Communication Skills in an Oncology Setting- Making ‘Breaking Bad News’ Better

Communication skills are the cornerstone of comprehensive cancer care. To communicate means 'to bring together'. It implies that at least two people- a clinician and a patient, relate and share something in common. Attaining communication skills as an aspect of patient care can expand the supportive role of the Oncologist, especially at crucial times for the patient and family, such as diagnosis, disease recurrence, and transition to palliative care. Evidence is mounting that effective and empathic communication with the cancer patient and family can influence desirable outcomes in cancer care, which affect patient quality of life, patient satisfaction, and medical outcomes. Evidence also exists that communication and interpersonal skills can be taught and learned.

In clinical care, communication is essential for all physicians and nurses to provide effective treatment for all patients, not just cancer care. Even though communication is a core clinical skill, studies have shown that only a few have received much formal training.

Active listening is the key to effective communication when communicating with patients and caregivers in clinical settings. Therefore, excellent and effective communication is not optional but mandatory in patient care. To enhance listening skills following methods may be helpful.

1. Greeting patients warmly and being hospitable, making them comfortable and offering seats and privacy are essential steps.

2. Asking open-ended questions that give the patient freedom to decide what and how much he/she should tell and wait for the cues.

3. Encouraging patients to speak about their concerns and clear their doubts and uncertainties while at the same time making sure that patients do not deviate from the central theme of discussion.

4. Maintaining eye contact gives confidence to the patient that he/she is being attentively listened.

5. There can be a period of brief silence when patients are relating their stories. It has to be understood that patients can become emotional as they narrate their past and describe a sensitive event or situation. They also need time to recollect certain events while telling their story. Tolerate their ‘brief ‘silence.

6. It is essential to avoid unnecessary interruption.

7. Show active listening by verbal and non-verbal means. This can be done by Repetition, reiteration (paraphrasing) and reflection.

8. Summarise & prioritise the agenda.

9. Empathise & give realistic hope.

How do we break the bad news to patients?

Breaking bad news is an essential aspect of communication and takes time. Oncologists are often the bearers of bad news, which can be stressful and uncomfortable for the Oncologist, patient, and relatives. Improper breaking of bad news can result in immediate and long-term damage to the patient and caregivers, so it is essential to acquire the skill of doing it. A 6-step protocol (SPIKES) by Robert Buckman can be used to communicate with cancer patients when breaking bad news. It should be tailored to patient needs, empathy, and respect.

Steps in Breaking Bad News

Step 1.S - Setting the context:  Choose a quiet room where privacy and comfort of patient and family can be maintained. Begin with an informal introduction; the patient can be seated at a comfortable place and allow family members to be included in person or on the phone. Avoid interruptions by turning off the phone or pager.

             Acquire all information possible about the patient and family. A family tree can help know the important people in the patient's life and the kind of relationship with them.

• Oncologists should be thorough with patient’s
• Diagnosis
• Patient’s clinical history, investigation results
• Plan of care and prognosis.
• Support system for the individual.

Step 2.P –Perception:

How much does the patient already know? “What do you know about your disease?” or, “What did the doctor tell you?” Ask a few questions, probe just enough to gather as much information as possible to

assess the patient's understanding of his/her disease."

Step 3.I –Invitation:

Studies have shown that when there is bad news to be transmitted, most patients indicated that they would want disclosure, while few indicated that they would want the news withheld from them but passed on to their family members. So, it is crucial to determine how much the patient wants to know. Moreover, what kind of information do they prefer to receive?

“Would you like me to explain further about your disease?”

Some patients may want to talk in detail, and others in summary. 

Step 4. K – Giving Knowledge and information:

Give the news in small, easily digestible chunks using words that fit the patient's level of comprehension. Allow them to process the information given to them before proceeding further.

First, give a warning shot to help the patient to prepare himself.

Examples of warning shots:

"You seem to have a swelling (or "wound") which is not the usual type."

Or

"It looks like the swelling you have is not a simple one."

Sometimes the patient at this point may come forward with a question ... “not simple or serious, does it mean it is cancer/?"Then the answer should be, "The test results show that it is cancer." Pause, observe the patient's expression/wait for the response and proceed.

Pause again after saying the word “cancer”.

Try to be brief, sensitive and precise. Do not be either too abrupt or too long.

Avoid technical language and "short- forms", which are easily misunderstood.

Step 5 E –Empathy:

Be sensitive to the patient’s emotional reactions. Encourage the patient to speak by listening carefully and responding empathically. Allow silence or questions. Acknowledge emotions of anger/ grief/ denial if expressed. Address the patient's concerns, which may differ significantly from the expected ones. Do not give false hopes by saying,

 "Do not worry; everything will be all right!".

a. Acknowledge the patient’s feelings:

The reactions are often directed to the situation rather than not at the Healthcare Personnel. Hence it is helpful to acknowledge that the patients and carers are distressed. Learn to respond rather than react, and when responding, evaluate with a calm mind and do whatever is most appropriate. This will help in controlling actions.

Identify the emotion as 'anger'.

Example: Patient says, "I knew it! I knew when I was not getting better while the doctor was giving me only medicines all the time!”

The following response may help

"I can see how angry you feel that your disease should have been diagnosed much earlier.

It can be explained later what may be the best thing to do without going into further details of what happened in the past.

b. Allow the patients to express feelings:

This will help to vent feelings to relieve the stress he/she is undergoing.

c. Help the patient to take a decision:

Give options and explain what can be done to suit his needs, respecting his agenda rather than imposing on the patient.

d. Remain silent if there is no answer. Do not always try to find solutions:

There is a natural tendency to search for answers when the patient asks a difficult question. Rather than preaching philosophy or quoting moral stories to pacify the patient, it is better to realise that these will not be taken up well by the patients.

For example, "Why did God do this to me?

Silence is the best answer here, as the patient only wishes someone to listen to his concerns and is not looking for answers. Oncologist's task should be to help the patient to find a solution rather than to suggest one. Solutions offered may not be acceptable for the patients in most situations as they may not conform to their beliefs and thoughts

Step 6.S – Strategy and Summary:

Before discussing a treatment plan or recommendations, ensure the patient is ready. Ensure that he/she has understood what was told. Clarify as follows

“Are there any points which you would like me to explain more?

Give clear and precise information about the next steps or available options. If no further treatment options are available or the patient declines further therapy, discuss referral to palliative care or hospice. Patients have less anxiety when they know all their options, are involved in decision-making and have a clear plan.

Summarize the key points again. Identify any support group which may behelpful and make concrete plans for the future.

Delivering bad news is never easy, but it can become a smoother process with practice and self-reflection. Using the SPIKES protocol can help make oncologist or physician conversations successful and give patients the dignity they deserve.

Written by:

Dr. Gautam Sarma,
Associate Professor,
Dept. of Radiation Oncology,
All India Institute of Medical Sciences- Guwahati.

Ng. Saniiru Lanah,
Nursing officer,
All India Institute of Medical Sciences- Guwahati.

Sources:

1. Break Bad News to patients with this step-by-step guide. January 13, 2022, by Aileen Anglin, APRN,ACNP-BC,AOCNP.
2. Indian Association of Palliative Care. (2017).  Certificate course in essentials of palliative care. Fifth edition. IAPC.