Art of breaking bad news: A qualitative study in Indian healthcare perspective.

Background: Health-care communication is essential for amiable provider-recipient relationship. This study explored various health-care experiences and expectations of service recipients and providers in private clinical establishments of West Bengal, India, while breaking difficult news, bad news, and death. Aim: The current study was framed with the following research question: What are the varying perceptions, experiences, and expectations of healthcare recipients and their providers while seeking/delivering support in situations of breaking bad news and communications on death? Materials and
Methods: The data were collected through individual in-depth interviews-31 respondents that included 16 patients and their families (recipient) and 15 medical practitioners (provider). Inductive thematic analysis was used.
Results: Three main themes and nine sub-themes were identified highlighting livid experiences and perceptions of respondents. The findings suggest that interpersonal communications involve language barriers, health literacy and COVID-19 pandemic, situations of sudden unexplained death, perceptual negativity surrounding healthcare, empathy as well as emotions and multiple affiliations leading to ethical moral conflicts to influence individual perception. Regarding treatment attributes, factors of inaccessibility misconceived as incompetence and waiting and contact time are involved. The behavior and personality dimensions include attitude and robustness of the patient party and capability to handle emotions that affect provider-recipient relationship during communications of bad news and death.
Conclusion: This study provided a local perspective about the experiences and expectations of healthcare recipients and their providers. Understanding this critical realm shall help in bridging the gap between recipient expectations and provider practices. It will also attempt towards possible alignment to improve patient satisfaction. Copyright:

INTRODUCTION

Communication is an inherent entity to all encounters. Facets of care are unimaginable without communication. In healthcare settings, information content and communication style hold prominence. The communication intricacies exhibit a triad relationship between the healthcare personnel, the patient, and the next of kin.[1] However, dynamic elements of life and death often cause difficulty in comprehension, and irrespective of the cause of death or criticality of the patient, effective communication strands serve as the only bridge of hope and solace.

Healthcare establishments are institutions where timely intervention and decision are integral to clinical practice. Although, conveying bad news is a perpetual practice in most medical establishments, breaking difficult or bad news call for detailed justifications that physicians find increasingly stressful.[2] This “difficult news” or “bad news” create cognitive, emotional or/and behavioral deficit on the recipient prompting a negative change in their life processes. Therefore, many physicians avoid or underperform it.[3]

Open, clear, and concise communication is required to discuss disease diagnosis and prognosis. Sometimes minimal knowledge, different expectations, and perceptual gaps amongst providers and recipients create dissatisfaction and conflicts linked to lack of clarity, context, content, soft skills, and empathy.[45] Apart from underlying stress and discomfort, these interactions decide not only the impact of the disease/death on the lives of patients and families but also their relationship with the physician. Thus, health professionals must demonstrate competent communication attributes for high-quality care.

Since communication as a skill can be taught, it opened strategic vistas of teaching communication to medical students and physicians.[6] Established protocols like SPIKES, BREAKS, ABCDE have redefined ways of breaking bad news and death.[789] However, in the absence of proper training, continuous evaluation, and feedback, this learnable skill is not optimally developed amongst all practitioners.

The advantages and limitations of different teaching methodologies such as didactic lectures, small group discussions, and simulations with situation handling have been highlighted.[10] The impact of nonverbal communication on the quality of healthcare interactions has been identified by researchers that closely monitored the healthcare interactions amongst medical practitioners, patients, and their families.[7] Various protocols and standard communication guidelines have been designed considering the need of cancer patients, palliative care personnel, and stakeholders involved in breaking bad news including communications on death.[11]

Indian scenario

India with approximately 1.3 billion individuals reflects socioeconomic and cultural diversity. The Indian healthcare system is complex, bureaucratic, and variable. Access to efficient healthcare services gets dwarfed due to the poor physician-patient ratio. Cancer and kidney ailments/complications resulting in death have escalated due to failures of accessing healthcare services during emergencies generating higher proportions of otherwise preventable “bad news” and “death.”[12]

Declaring death is predominantly the physician’s responsibility but limited training, individual abilities, and other constraints often result in vandalism, maladjustment, and violence to which there is hardly any preparedness.[81314] Furthermore, practitioners have few provisions to address their concerns while conveying bad news. There is a correlation between length of medical service and the ability to effectively communicate bad news though many experienced practitioners and senior nurses feel the need of communication training for better management.[15] Paradoxically, junior doctors with little experience declare more deaths than their seniors.[16]

Medical education in India has set higher precedence on technical proficiency than soft skills. Patient satisfaction and expectations often take a backseat as availing treatment are paramount. However, medical practitioners need optimal “hard” and “soft” skills for greater patient engagement.[17] The previous medical education curriculum lacked elements of health communication. Recent modifications in undergraduate medical courses introduced a foundation course emphasizing on professional and ethical behavior. This course has been positively perceived by medical students, but actual long-term outcomes need further elucidation.

Furthermore, the pandemic spiked COVID-19 cases and deaths thereby challenging the already overburdened Indian healthcare machinery.[18] Significant caseloads, mortality figures, fear of self-infection, and acute stress lessened empathetic interpersonal dealings. In addition, the vulnerability of the common man and positive COVID cases being equated to bad news further complicate matters. As opposed to other conventional diseases, instances of sudden dissociation of kin from the patient were reported.

A large body of evidence on communicating bad news or death is available globally.[811] While diverse values, socio-cultural dynamics, disease incidence, and significant deaths make India one of the best laboratories to comprehend the complexities of breaking difficult/bad news or death, very few empirical studies have been done.[19] Considering these points, this study attempted to highlight the patient/next of kin perceptions and expectations on breaking difficult news, bad news, and communications involving death. It also discussed the challenges faced by medical practitioners while doing so. These findings will assist healthcare providers/practitioners to design practically viable patient-centric/family-centric interventions that will lessen patient/next of kin dissatisfaction thereby strengthening the provider-recipient relationship.

METHODOLOGY

Design

Data collection, analysis, and interpretation exploring perceptions and expectations of healthcare recipients and challenges and experiences of medical practitioners on difficult news, bad news, and death communications were done through in-depth interviews and inductive thematic analysis. The theoretical explanation was developed by analyzing experiences and expectations of patients/next of kin and medical practitioners.

Sample

We recruited only adult (>18 years) patients/next of kin that had the experience of receiving bad news and death communications. Similarly, medical practitioners who admit patients and directly communicate such news were considered for the study. Purposive sampling was used to select samples for subsequent interviews. With exception of the respondent’s sociodemographic details, no personal information was collected. Finally, 15 doctors and 16 patients/families were considered and 31 interviews are included in the present study [Figure 1]. Respondents, that disagreed, didn’t meet the inclusion criteria and medico-legal cases were excluded. Socio-demographic details of participants are provided in Table 1.

Figure 1

Process used to select participants for the study

Table 1

Sociodemographic details of the respondents

Description	Healthcare recipients		Total	Healthcare providers Medical practitioners
	Patients	Next of kin
Sample size	6	10	16	15
Gender
Male	5	6	11	13
Female	1	4	5	2
Education
High school	1	Nil	1	Nil
Graduation	4	6	10	5
Postgraduation	1	3	4	7
Above postgraduation	0	1	1	3
Monthly income (INR 1 USD=75 INR approx)
Below 20,000	1	2	3	0
20,000-50,000	3	4	7	5
Above 50,000	2	4	6	10

INR: Indian rupee, USD: United State dollar

Ethical considerations

All measures to maintain ethics were considered. Ethical clearance from the institutional ethics committee and respondent’s consent for interviewing and recording was taken. The detailed study process was explained and they were assured about the confidentiality of their responses.

Data collection

Semi-structured interviews were done with patients/next of kin and medical practitioners. Interview schedule [Appendix 1] was developed from extant literature on breaking bad news and piloted before use. Telephonic interviews were done with respondents from a prominent tertiary care hospital chain in Kolkata, West Bengal from August 2019 to June 2020 by MS. She is an experienced doctoral researcher who has prior training in qualitative interview techniques. The focus of patient/next of kin interviews was reflection of their experiences, beliefs, and expectations to receive bad news and death communications whereas the focus of the medical practitioner’s interviews included descriptions of practical settings, perceptions, and experiences while breaking bad news and conveying death. All interviews were audio-recorded and lasted around 25–60 min. The interviews were done in English and Bengali. Vernacular interviews employed the back translation method for content accuracy.[20]

Data analysis

Data collection and analysis happened iteratively and concomitantly. This created provisions for additional dialogue and newer insights that influenced subsequent interviews and analyses. The interviews continued until the authors considered that sufficient information is obtained satisfying the research aim and no new concepts or themes were recorded.[21] Interview audio recordings were anonymized for maintaining confidentiality, transcribed verbatim, and analyzed after each completion. Analysis of data was done through inductive thematic analysis;[22] a six-step approach that begins with identifying commonalities and differences, preliminary generation of numerous codes, and final categorization of larger themes iteratively by re-reading transcripts and refining the thematic idea aligning with qualitative description. Transcripts were manually coded by MS and AR. They independently coded the interviews before comparing their concepts and codes. To have a deeper understanding of the viewpoints of healthcare service recipients and their providers, initial interview analyses for patients/kin and practitioners were done separately. Relevant themes and sub-themes for each category were generated, a comparison of which is presented in Table 2. Final themes with definition and nomenclature were agreed by all authors and clubbed for both the respondent sets. Selective illustrative quotes from transcripts have been provided as evidence for each theme in Table 3.

Table 2

A comparison of viewpoints of patients/kin and medical practitioners

Patients/next of kin	Medical practitioners
Interpersonal communication
Language barriers and low health literacy	Language barriers and low health literacy
Communication constraints	Disproportionate doctor-patient ratio
No dialogue on death cause	Practical limitations
Negative mindset about the health system and practitioners
Lack of empathy and emotions	Fear of violence
Patient care quality issues	Trust issues
Treatment attributes
Inaccessibility perceived as incompetence	Practically impossible to be in the hospital 24/7
Long queue and short contact time	Time allocation based on condition and seriousness
Attitude, behavior, and personality dimensions
Nonredressal of emotional vulnerability	Negative experiences with next of kin

Table 3

Final themes and subthemes during communication of bad news and death

Themes	Sub-themes	Excerpts
Interpersonal communication	Language barriers, health literacy, and COVID-19 pandemic	“My son had low-grade fever. We went to three hospitals including government hospital (names the hospital). The private hospital near our house wanted COVID testing and asked to contact health department. I could not get through and came back to the hospital. By this time, the condition had deteriorated and I begged hospital authorities. They did not pay and heed. Lastly, we went to (names the facility) where the doctors were discussing something in Bengali. I could not follow much but I pleaded to save my son. When they connected the oxygen and took him inside, my son lay there, lifeless. I can’t forgive myself” (starts crying profusely) (next of kin F1)
		“I don’t know much about medicines. I tried to explain what medicine my mother takes for blood pressure though I couldn’t name it. But they were unable to follow.” (Next of Kin F2)
	Communication gaps in cases of sudden unexplained deaths	“I have every right to know what happened . My daughter who was stable, lost her life in sleep. Being a mother, I expect the doctor to tell me what went wrong.” (starts crying) (Next of Kin F3)
		“Sometimes, sudden deaths like cardiac arrest or pulmonary embolism do not present any prior symptoms. We lose patient even after trying our best. But many patient parties don’t want to listen” (Consultant Doctor P1)
	Perceptual negativity surrounding healthcare	“The doctors of today are only bothered about money. This test that test, when they know what medicine will work. Slightest of something, and they will name some deadly disease. They will ask for hospitalization, and then so much cost…. On top of this, they don’t even talk properly.” (Patient PAT 13)
		“We pay whatever they ask for, let them do whatever they want to, …still, if the results are not guaranteed, what is the point of spending so much money ” (Next of Kin, F7)
	Empathy and emotionality	“My daughter was diagnosed with leukaemia. We went to renowned Dr. X at Z hospital. We arranged money for treatment. After a series of tests, the doctor straight away said, “she will not make it beyond 2-3 months”. Being a doctor of that stature, I expected some amount of gentleness but ….it didn’t matter” (Next of Kin F7)
		“Most deaths are largely corroborated as wrong treatment. We tend to remain little hostile as the vulnerable patient party often considers our emotional support as wrong treatment or delayed response” (Consultant Doctor P3)
	Multiple associations and ethical moral conflicts	“I am associated with a few hospitals. While I am sure that my team at respective hospitals is giving the best possible care, I cannot be there all the time. I have a personal life too. If there is an emergency, I definitely go.” (Consultant Doctor P 7)
		“I was asked to sign the papers. They were in a hurry. I didn’t ask. They didn’t tell. Found out later that it was permission for operation and complication details were mentioned. I would have asked other family members had they told me.” (Next of kin F 4)
		“The problem is, sometimes patient or their families feel that we are prescribing procedures unnecessarily. In reality, we perform what is best for the patient in that scenario; Sometimes when patient or their families don’t consent to it, we have no option and the condition deteriorates despite knowing what works best” (Consultant Doctor P 4)
		“Sometimes patient parties don’t follow instructions. They question the treatment regimen and interfere in our duty. We are already stressed and it further increases our woes” (Resident Doctor P 15)
		“I requested the doctor to admit my father. His condition deteriorated in the last 3 days. The doctor said, “The medicines will work”. He gave some tests and didn’t admit him. He finally expired after 2 days of struggle.” (Next of kin F11)
Treatment attributes	Inaccessibility misconceived as incompetence	“It is impossible to reach the hospital at late hours to declare death, when I am sure that my ITU/ICU team is proficient and strong with the job. The RMO on duty is capable enough to declare death” (Consultant Doctor P 9)
		“We regularly deal with death and related events. While I understand that patient party is emotionally vulnerable, it needs to be understood that we are human beings too, and being present at the hospital 24/7 is no one’s cup of tea” (Consultant Doctor P8)
		“I come to this hospital twice a week for the night shifts and sometimes, patients die despite our best efforts and intentions. We discuss with the treating physician and act likewise. At times, we declare death too”. (Junior Resident doctor P 14)
		“Dr.XXX has been treating my father since the last 8 years. Even for any minor health issues, we always consulted him. That night, I couldn’t connect as his phone was off. I went to the hospital and requested the receptionist, but she asked me to wait until morning. What is the point? I didn’t want to talk to junior doctors. I paid such hefty sum. At least, he could have spoken once over phone.” (Next of Kin F 10)
	Waiting time and contact time	“I waited for about 4 h to see the doctor. I was right in time for my appointment but still had to wait. When I finally entered his chamber, he checked the test reports and wrote some medicines…he didn’t even bother to ask anything, he was in a hurry”(Next of kin F8)
		“I had so many questions regarding my condition. But the doctor always came with a huge team. Sometimes I even forgot to ask …he never really probed anything or explained. Later on, if my son went to his secretary, he would wait for 2 h before he could see the doctor.” (Patient PAT 6)
		“We see so many patients daily. We cannot spend endless hours with everyone. Our aim is to diagnose patients and give treatment. Sometimes, urgent care is also needed and we leave everything and provide the attention to the patient that requires the most.” (Consultant Doctor P 13)
Behavior and personality dimension	Attitude and robustness of the patient party	“Now days, it is indeed risky…You read newspapers, right! How, doctors are beaten, even killed, for a fault which was never theirs. What do we do? When it is 2 or 3 of us versus 50-60 odd people… I have personally faced such a situation before. We are mostly blamed for deaths as we are the face of the hospital. But, things are not always under our control. So the current protocol at this hospital is that the death will be declared by the on call/on duty doctor” (Consultant Doctor P1)
		“I know there are many who use muscle power. However, as a patient party I have every right to know what happened and how a death occurred. For security, it is hospital’s duty to shield their staff. But, often there are miscommunications and aggressions because we cannot talk or meet the treating doctor” (Next of Kin F9)
	Capability to handle emotions	“It is so easy for doctors to declare death. It is equally tough for the family members to accept it. They must give some hint so that we are prepared mentally” (Next of Kin, F 5)
		“I will always remember Dr. (names the doctor). I was a young college student and my father was his patient. That evening, dad went to the hospital after having breathing troubles and expired in the hospital. Dr. (names the doctor), took the initiative to not only inform me but also ensure a smooth passage of my late father to the morgue since I stayed at a different city. The next day I was handed over everything and I am indebted for the emotional support Dr.(names the doctor) gave me’ (Next of Kin F 6)

COVID-19: Coronavirus disease-2019, ICU :Intensive care unit, ITU: Intensive treatment unit, RMO: Resident medical officer

The major findings on perceptions, experiences, and expectations of patients/next of kin and practitioners on communicating bad news and death have been categorized into three main themes and 9 sub-themes [Figure 2]. The main themes were interpersonal communication, treatment attributes and attitude, behavior, and personality dimension [Table 3]. The consolidated criteria for reporting qualitative research (COREQ) guidelines have been followed for the design and reporting of data.

Figure 2

(a-c) The thematic map showing themes and sub-themes. (a) Sub-themes associated with interpersonal communication. (b) Sub-themes associated with treatment attributes. (c) Sub-themes associated with behavior and personality dimension

RESULTS

We analyzed 31 interviews of patients/next of kin and medical practitioners. 3 main themes and 9 sub-themes were generated. Respondent’s views were elaborated through examination of personal factors, context, perception, experiences, and other external factors. The viewpoints of respondents were compared while examining these themes. Results are summarized.

Interpersonal communication

Language barriers, health literacy, and COVID-19 pandemic

Indian healthcare endorses a good provider-recipient relationship. Current COVID-19 pandemic accompanied by low health literacy, language diversity, absence of interpreters, higher patient loads, and time constraints posed dire challenges in healthcare communications. Excerpts from interviews are cited

One respondent noted:

‘My son had low grade fever…………I can’t forgive myself’ (Starts crying profusely) (Next of kin, F1)

Another respondent commented,

‘I don’t know much about medicines……But they were unable to follow.’ (Next of Kin, F2)

Communication gaps in cases of sudden unexplained deaths

There is minimal research on death communications where prognosis or cause of death is unexplainable. Communication lapses as perceived by the next of kin have been highlighted below.

‘I have every right to know what happened ….what went wrong.’ (Starts crying) (Next of Kin, F3)

Effective communication skills are individualistic. Perceptual differences, lack of awareness, and limited soft skill training visualize this gap manifold and create complications.

A doctor asserted,

‘Sometimes, sudden deaths like cardiac arrest…….don’t want to listen’ (Consultant Doctor, P1)

Physicians share a close relationship with their patients and sudden death causes burnout for them,[23] but different insights often obstruct effective communication.

Perceptual negativity surrounding Indian healthcare

Negative experiences have contributed toward blame games, dissatisfaction, and interpersonal communication. Perceived negative environment frequently limits dialog that creates fragility in the patient-provider relationship.

As commented by one of the patients:

‘The doctors of today………., they don’t even talk properly.’ (Patient PAT13)

Another family member reflected

‘We pay whatever they ask for,………….so much money ‘ (Next of Kin F7)

Healthcare challenges, exorbitant health expenses, lower degrees of tolerance, and negative assumptions are corroborated with insufficient quality of care.

Empathy and emotionality

The practitioners regularly experience poor prognosis and death, prompting them to assimilate such situations and deal practically and professionally. Consequently, they sometimes fail to address the emotional needs of the next of kin. Patient and their families perceive such interactions as lack of empathy and emotional support.

Excerpts from the next of kin interview:

‘My daughter was diagnosed with leukaemia.….it didn’t matter’ (Next of Kin, F7)

Practitioner’s view on emotions and empathy depicted a different experience.

‘Most deaths are largely corroborated as wrong treatment. ……………or delayed response’ (Consultant Doctor, P3)

The empathic assertion seems to be a possible answer to strengthen the provider-recipient relationship.

Multiple affiliations and ethical-moral conflicts

Poor communication and misunderstanding promote dysfunctional conflicts.[24] Associations and practice at different hospitals, work pressure, and time restrictions create dissatisfaction.

A senior Doctor reported:

‘I am associated with a few hospitals.…….I definitely go.’ (Consultant Doctor, P7)

A patient’s family noted:

‘I was asked to sign the papers.……………….family members had they told me.’ (Next of kin, F4)

Relevant information and process clarity help patients and their families to understand and cope with the demands of situation.

Clinical practice is intensive and demands attention, support, and intervention from practitioners and their teams.[25] Disagreements on end-of-life care or informed consent delay decision-making and create ethical-moral conflicts.

A senior consultant noted:

‘The problem is ….…despite knowing what works best’ (Consultant Doctor, P4).

Regarding agreement to following instructions, another doctor noted:

‘Sometimes patient parties …………………….it further increases our woes’ (Resident Doctor P15)

Perspectives varied with the experiences of patient families as one of them noted:

‘I requested……………. He finally expired after 2 days of struggle’.(Next of kin F11)

Treatment attributes

Inaccessibility misconceived as incompetence

Patients and families expect positive interactions and immediate redressal with the treating physician.[26] While the practitioners are tremendously occupied with patient load, work pressure, and stress. Many corporate hospitals ensure quality care through designated teams, but lack of regulatory compliance on communication or support can lead to emotional harm and dissatisfaction when expectations do not match reality. Excerpts of doctor’s experiences are highlighted below.

‘It is impossible to ……………………is capable enough to declare death’ (Consultant Doctor P9)

‘We regularly deal …………………………present at the hospital 24/7 is no one’s cup of tea’ (Consultant Doctor P8)

‘I come to this hospital twice a week.……….At times, we declare death too’.(Junior Resident doctorP14)

A narrative from one of the family members:

‘Dr. XXX has been treating my father ……….once over phone’.(Next of Kin F10)

Perceived lacunae in physician’s communication and pre-decided mindset end up in confrontational and aggressive environments. Each of these respondents sets has their own challenges while declaring death or dealing with difficult news.

Waiting time and contact time

The average time to see a doctor in Indian settings has always attracted the wrath of patients/next of kin. Mostly, the average wait varies across services and is between 30 min to 2 h.[27] Interestingly, the approximate time spent with the doctor (contact time) is much less when compared to waiting time.[28]

‘I waited for about 4 hours………………, he was in a hurry.’(Next of kin F8)

‘I had so many questions ………………he could see the doctor’.(Patient PAT 6)

As narrated by a practitioner,

‘We see so many patients daily.…………………the patient that requires the most.’ (Consultant Doctor P13)

The doctor–patient ratio and seriousness of the patient’s condition are important decisive factors for time allocation. However, disproportionate waiting time and shorter interactive spans with practitioners result in ambiguity, overlooking the psychosocial needs of the patient/next of kin.

Behavior and personality dimension

Attitude and robustness of the patient party

Communication inadequacy, emotional distress, and alienation endanger the good doctor-patient relationship.[29] Numerous incidences in the past have resulted in violence and threat to life and property prompting medical practitioners to occasionally remain passive in events of death.

Explaining a similar situation, one of the consultants noted:

‘Now days, it is indeed risky…. by the on call/on duty doctor’ (Consultant Doctor P1).

Regarding this concern, one of the patient family members commented:

‘I know there ………………….we cannot talk or meet the treating doctor’ (Next of Kin F9)

Death of patients can be attributed to infrastructure limitations, health status of the patient during hospital entry, comorbid conditions, unknown reasons, and host of other factors. Next of kin, in a state of vulnerability often blame the doctors for the end result instigating disagreements and violence.

Capability to handle Emotions

Self-awareness, empathy, and effective communication are integral social skills.[30] In healthcare settings, these induce patient satisfaction and reduce discrepancies, perceptual discriminations, and negative experiences.

A patient family noted:

‘It is so easy for doctors ………we are prepared mentally’ (Next of Kin F5)

Another kin responded:

‘I will always remember Dr.(names the doctor).………Dr.(names the doctor) gave me’ (Next of Kin F6)

Better services can be delivered by healthcare organizations with emotional training that will further help them achieve constructive outcomes. The patient-physician relationship is positively affected with the optimum capability to handle emotions.

DISCUSSION

This study examined the mindset of both respondent sets–patients, their families, and medical practitioners, to gain insights on their perceptions, challenges, and experiences in Indian healthcare settings. Conventionally, it is believed that doctors must be knowledgeable, skillful, and expert for better patient satisfaction, thus stressing on the importance of updated technical knowledge and expertise in Indian medical education pedagogy. While technical expertise is absolutely essential, this study has highlighted the fundamental role of effective communication and contributory soft skills for medical practitioners.

Our study has emphasized the positive impact of communicating difficult news, bad news, and death with understanding, accountability, and empathy for better patient experience, management, and satisfaction. Formative courses on healthcare communications, especially on breaking difficult and bad news or communicating death alongside technical skills are needed for an amiable doctor–patient relationship.

The results have been categorized into three main themes and subsequent subthemes. The first theme of interpersonal communication includes five subthemes-(a) language barriers, health literacy, and COVID-19 pandemic, (b) communication gaps in cases of sudden unexplained deaths (c) Perceptual negativity surrounding Indian healthcare (d) empathy and emotionality (e) multiple affiliations and ethical-moral conflict.

Interpersonal communication-verbal, non-verbal, and para-verbal (voice, words, and intonation) is integral to diagnosis and treatment.[31] It takes place in mixed environments containing favorable and adverse factors.[32] One major challenge faced by the medical fraternity and patients/next of kin is language-associated barriers. Similar instances are reported in other countries too where interpreter services have enhanced understanding among patients, better health-care utilization, and overall satisfaction of practitioners and recipients.[33] In India, at least 22 different languages are spoken in innumerable dialects other than English that is the official “lingua franca.”[34] Internal immigration, huge patient load, low health literacy; which is the ability to comprehend and follow prescription instruction amongst others[35] and lack of awareness magnify difficulties for both healthcare providers and recipients. In addition, COVID-19 onset has impacted the health infrastructure, economy, and increased burden on health services. Our study has identified that the use of simple explanations and basic knowhow of other languages shall give an extra edge to the physician team in the absence of interpreters thereby instilling confidence and satisfaction on the health-care system.

Physicians mostly work in teams following standard protocols for routine and emergency cases though; sometimes their best of efforts do not yield fruitful results. Informing the family regarding the sudden death of their loved ones can trigger extreme responses of denial, shock, anger, or guilt.[16] Physicians find it highly stressful to declare unexpected death and they look forward to experimental approaches since they feel inadequate.[2] Our findings suggest utilizing one or more communication forms to lessen the vulnerability of the patient’s family and comfort them elaborating the emergency steps taken. Since there is little or no formalized training, physicians normally avoid or underperform it prompting trust issues, dissatisfaction, and bereavement within service recipients. Most importantly, out of fifteen healthcare providers interviewed, only two of them have reportedly received formal training on effective communication as a part of their specialization course in community medicine. The respondents (medical practitioners) highlighted learning on the job through practical experience and observing their peers and seniors.

Being empathetic and emotional to the cause of grieve and a humane touch will not only console the next of kin but also inculcate satisfaction with long-lasting effect. However, perceptual negativity and media trials create additional misconceived pressure creating communication delays thereby requiring awareness strategies and responsible reporting.

There is the dearth of trained medical professionals. Many doctors work in various polyclinics/chambers and also practice in multiple locations. The timing and location options address the patient/next of kin needs and convenience.[36] It is challenging for the doctors to physically cater to the individual needs of patients/next of kin and they rely on their teams at dispersal. The teams often struggle to meet the technical and bureaucratic demands and also convince the patient families. Patient families sometimes perceive this as a lack of doctor’s commitment. Inter-professional clinical ethics support for healthcare professionals during difficult situations of care is important, especially in communication and reflection.[37] We found that time restrictions with limited fruitful interactions, protocol explanations, and implications, resulting in treatment delays or ethical-moral conflicts.

The treatment attributes theme includes sub-themes (a) Inaccessibility misconceived as incompetence (b) waiting time and contact time.

Indian healthcare is significantly affected due to overstretched work hours promoting stress, anger, and anxiety among medical professionals.[38] It affects the communication and performance of the front-line medical personnel.[39] We found that trust and high expectations of recipients on the healthcare machinery upset them terribly when they are unable to access the physician. It is often perceived as patronizing and condescending superiority by the next of kin. Patient outcomes and effective delivery system can be achieved through strategic human resource planning and resource allocation.

Delayed appointments, cancellations, long waiting time, and short contact time, challenge healthcare interactions.[28] Notably, physicians are the ones that patients or families want to meet. Long waiting times result in frustration, emotional outbursts, and psychological reflections on patients and next of kin.[40] Our results highlight that insufficient time for patient interaction/consultation and high patient load, affect the working ability of physicians who rush through “not so serious” cases. It creates a feeling of trivial interaction thus brooding dissatisfaction amongst the patient/next of kin.

The behavior and personality themes include (a) attitude and robustness of patient party (b) capability to handle emotions as the two sub-themes.

Technological advancements have eased the process of finding treatment alternatives or information.[41] Furthermore, cynical attitude, power-mongering, and mob fury result in violence against healthcare providers. Preconceived notion on disease or treatment creates different insights. Expressions range from seeking another opinion, questioning, or ignoring the physician’s diagnosis/treatment plan to violence. In India, till a decade ago, these things were unheard of.[42] Violent episodes ranging from verbal abuse and aggression to physical damage towards life and property were also identified.[14] Our study has highlighted first account experiences of physicians that were at the receiving end of such ire of patients/next of kin. There are various limitations in health-care settings that are beyond the capacity of the treating physician or their team. Expectation management of next of kin is paramount since such experiences of aggression definitely interfere with the physician’s ability and communication skills. Constructive discourse by physicians further motivates patients and their families to feel confident about treatment protocol.

Emotional intelligence is pivotal in patient-centered care.[30] Emotionally intelligent physicians are self-aware, socially skilled, empathetic, self-regulated, and motivated with few episodes of disruptive behavior. Our results indicate that emotionally intelligent physicians understand patient vulnerability and need much better than others. Healthcare conflicts, violence, and dissatisfaction can be curbed using emotion handling capabilities.

A comparison of different perspectives of patients, their families, and medical practitioners suggested that effective communication and soft skills are necessary for better patient satisfaction.

CONCLUSION

Communications on bad news and death are tough to accept. All circumstances except situations where disease prognosis or death is predictable have underlying disagreements. Such incidents demand extremely well-crafted communication channels that will assist the patient or their families to deal with grief. The results of this study have reflected what patients and their families expect when they are apprised of such news. There are numerous established protocols for bad news and death communications; however, the medical practitioners have varied experiences and face challenges in practical settings.

There are three main contributions of the current study. Firstly, it is probably the only study that has explored the views of patients/next of kin and also medical practitioners on breaking bad news and death-related communications. It has successfully compared and contrasted the different grounds on which they reflect regarding the communication adequacy of such news. Secondly, it is the only study that targeted only those patients and their families who have some experience of receiving such news. Finally, this study has been a pioneer to identify the importance of good communication skills while breaking such news for better management thereby reflecting upon the immediate need to work on formative courses that enhance teaching-learning.

Limitations

We conducted all interviews with patients, families, and practitioners visiting tertiary care private healthcare facilities. The patients and families secured at least basic formal education and belong to middle-income and high-income strata. The inclusion of illiterate patients and government healthcare facilities could have broadened our understanding of preferences and perceptions on bad news and death along with the experiences of practitioners in government hospitals.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.