- How to manage and support the delivery of bad news at the initial diagnosis of breast cancer
- Diagnosing medical complications is one of the most beneficial procedures that clinicians and physicians engage in as one of their routine activities in medical centres. Relaying not so pleasant news to any person is one of the hardest roles especially to patients who are under the threat of a deadly disease like cancer. Patients are constantly checked to determine the causes of their diseases and feedback of the tests given. This has to be done irrespective of the outcome and in most cases; it is always negative feedback (Bail, 2000). Baile et al note that a series of research done from 1950-1970s indicate that most physicians were reluctant in delivering bad news to cancer patients because the treatment prospects were still very uncertain. Despite the situation having changed to modern date where cancer treatment is easily accessible to patients, clinicians and nurses still struggle with the process of delivering bad news due to the skills that are wanting.
- Medical specialist have termed the delivery of bad news to patients as a necessary evil, meaning it is one of their duties that must still be done however discouraging it may be to the patients and their families. Jenkins and Fallowfield describe bad news in the medical field as any feedback or data given after a test or diagnosis that brings out a negative modification to the expectations of an individual regarding both their current health status and their prospective future. It is the type of information that causes a patient to experience emotional disturbance, after receiving feedback from doctors (Fallowfield & Jenkins, 2004). Some examples of bad news that medical professionals have to deliver include; letting a couple know that they cannot be able to have children, telling a patient that he/she is HIV positive, information another patient that the lump detecting indicates they have cancer among others. Medical practitioners have the task of diagnosing, treating, prescribing drugs and advising patients against illnesses. In the line of duty, we sometimes have results that needs to be shared with the patients but we fail to do the delivery in the professional way as we have not been trained on emotionally intelligence for such work. The process of delivering bad news involves the use of a person who is a specialist that understands patient’s psychological needs very well and takes care of them. Bad news is the kind of news that cause the patient depression or sorrowful feelings like anger, grief, despair, fear, hopelessness and anxiety. The patient may experience this for a considerable period of time and may take long time to get back on track (Schmid, Kindiman, and Langewitz, 2005). Others are never able to recover completely from such negative feelings. In my job as a breast cancer nurse, I deal with patients through helping the doctors in the process of bad news delivery. I spend most time with them than any other person who is working on their case like the surgeons or lab technicians. For this reason, I get to understand more on how they feel about the whole situation. It is painful when I have to break the results of screening tests done which may not be good.
- From my previous experience, others have always opted that the news to be told to a second party like a father, wife, husband or for them to be given in a manner that can be less stressful. For example if it is a husband, she can just hug his wife and let her cry and assure her that it will be fine, the same applies to a child and parent where the parent becomes the pillar of strength for the child as parents reduce the impact of the news. I have worked on several cases of breast cancer but this particular patient is unique because, she is a public figure and therefore confidentiality of the highest order is necessary. This paper is about the appropriate communication skills needed in delivering bad news to a patient who has been diagnosed with cancer. I examine her case as in the following section.
- My patient’s age (42) puts her at a risk of getting breast cancer. Recent trends of the disease imply that high risks of cancer development for breast cancer increases with age. There have been cases before where medical professionals have been accused of failing to inform patients of their actual medical status or giving reports of the diagnosis tests done on cancer patients, and most commonly in older clients like the patient in this case (Ptacek, 2001). While doctors have been the actual custodians required to break bad news to patients, nurses are also gradually finding their role in this process. Scientific research has demonstrated that nurses play a supportive role in the process, thus the need to have them on board during the process of breaking bad news (Schmid, Kindlimann, and Langewitz,2005)They take part through; assisting the diagnosed patients come to actual terms with the news given, they are always present in most cases when the doctor is delivering the news to patients, prepare the patients and their relatives in advance of receiving bad news, and providing more opportunities to the patients through which they can discuss the bad news delivered. Despite their role in this process, nurses are often ignored and less training and effective communication training is done in this regard. The current experience is thus from the daily common experience that have promoted the nurses to learn while on the job (Parker, 2001).
- My patient has a malignancy and is eager to know as much medical information about the feedback test of the screening that has been done. Her family has constantly been calling me with the intention to find out the test results from me. Even though I know the results, my concern is how I should let them know over the phone. Again, I am strongly convinced that it is the doctor who is best placed to break the news to her on face –face basis and an appointment has been secured. I am also concerned on about how I shall prepare her psychologically to receive the bad news from the doctor. This according to my medical practise is however not advisable as the patient’s medical health information must be handled with high levels of privacy and confidentiality.
- This means that I cannot disseminate any information of the patient to the relatives without her consent before she even knows her own medical condition. In the past, it was a common practise for doctors to withhold such crucial information from cancer patients with the belief that it was the best decision made for the sake of the clients. Nevertheless, during my practise as a medical practitioner, the code of ethics outlined the honestly and being transparent with the clients about their medical conditions is essential. From my daily experience with other patients, I have observed a rising trend that modern patients always want the truth of their health status, regardless of the effect. Some always want to know about the causes and effects of cancer, how it has been treated before and their chances of living. Others who detected about their conditions in other centres became very annoyed with doctors who conducted screening on them without telling them the truth about their conditions. My mind struggles with several issues like her possible expectations regarding her medical condition, how to give the feedback without making her lose hope and her possible reaction. I am not the only one who is afraid of the outcome, my other colleagues in the hospital have always shared with me that delivering bad news is one of their greatest fears because they dread miscommunication challenges (Department of Health, Social Services and Public Safety, 2003).
- Communication skills become vital in the process of delivering bad news to patients. Both clinicians and nurses have to be trained on how to; create an enabling environment for effective communication to take place, use the best non verbal cues and verbal choices of words to address patients during such times of bad news delivery, and how these professionals may express their empathy to the patients. This only means that the clinicians and the nurses must have prior knowledge on how to engage the patient in effective discussions so as to avert the danger of getting them unaware. Nevertheless, good communication skills and training will enable both parties involved to effectively engage each other with expected better results which will greatly satisfy the patient’s concerns and promote their perception on undertaking effective treatment measures after the news have been delivered. Good communication also reduces the stigmatization levels. On the contrary, poor communication may cause more devastation to the patients and their relatives with high chances of eventually affecting their psychological process of absorbing the bad news given and the treatment process of their medical conditions. This means that in order to succeed in delivering bad news, a patient centered approach in communication has to be adapted. This means attention will be shifted by the doctors, nurses, patients and the relatives to find common grounds that may act as the starting points in engaging the diagnosed cancer patient. This approach gives clear guidelines on how to manage both verbal and non verbal communication activities in order to enhance a smooth exchange of information and enhance trust building the contributes towards the process recover
- I must commend my patient for coming to the hospital after she detected a lump in her right breast; this shows that the patient has some knowledge about breast cancer even though not adequate thus the visit will enlighten her more. Having had the tumour for the past one year without seeking medication is alarming and creates the perception that the patient may have had cancer awareness when it was a bit late and had already started experiencing signs and symptoms or she had the information but chose to ignore. Information is very crucial in fighting cancer, those who are aware of the signs and symptoms of breast cancer will always get to see a doctor and get checked thus reducing their chances of developing the cancer or being at a better position of being cured. My patient’s situation can worsen due to the delay in time periods from discovery and seeking medical checkups.
- My patient is married and a mother to two children thus her anxiety and fear are common for those with families as they worry about welfare of their children. A mother is the cornerstone of a family thus her greatest fear might be how her health issue will eventually affect her family. The things she might fear are; the cost of treatment for her new condition might drain away her finances sending her and her family into financial crisis, the emotional trauma she will put her family through by telling them of her health condition, the sudden stop of her career and being a very influential person, she minds what people will say about her and the worse that can ever happen is death. Her fear levels are so high that she makes prior conclusion that she actually has cancer even before the results of the tests are released and openly prefers a mastectomy. The patient has had appointment with the surgeon and awaiting results from radiologist before they can decide on the next step based on the screening results. The most obvious fact with delivering bad news to a cancer patient is that it could involve two possible outcomes of either the results of abnormal images from screening done and that will require a biopsy to be done or either regarding the results of the diagnosis given. Scientists recommended that in the case of an abnormal imaging that requires biopsy, and then communication of the bad news should be done during the ultrasound process or at the time of diagnosing the mammography. The best they suggest is during the diagnostic time when the cancer patient is still around. It is at this point that the patient is most suitable to be introduced to a person who can always be contacted from the hospitals breast cancer centre, and mostly is the nurse who takes over to make further discussions, provide any other details of the procedure involves and possible book appointment for next visits. Such an inititiative promotes a relationship of radiologist-nurse-patient that will be vital in the whole process. The bad news could either be delivered by phone or on a face-face basis. Most patients find it difficult to return to the facility thus the frequent call follow ups done by the family of the patient. In most cases, the telephone results delivery is done by the nurse if the results are positive but with radiologist if the outcome indicates cancer presence. The nurse’s role will be to make follow ups the next day to determine the extent of the bad news on the patient. Often, the patients leave with contact cards indicating that phone calls will be made directly rather than through short messages. Still, even on phone certain rules need to be followed like considering the patient’s current environment before bad news delivery. For bad news, we often ensure the recipients are in a safe environment and making the privacy. The main reason why the bad news have to be delivered on cancer is so that a diagnosis is may be provided, the prognosis discussed and a plan for treatment done in order to provide support to the patient. The process could also be used to foster a physician-patient relationship that could be strengthened for subsequent management of the cancer condition. There is no properly outlined medical formula but I would adopt the sex steps procedure that has been commonly used to break bad news to cancer patients. These include; setting the ample environment for the interview to take place, analysing and predicting the possible patient’s reactions upon receiving the news, setting and scuring an appointment with her, giving background information and more knowledge on cancer, responding to her emotions and making a summary with her case. I will use these six steps to communicate the results and try to convince her on the importance of the biopsy, these include; getting started, patient’s knowledge, how much she wants to know, sharing the information, responding to feelings and planning and follow up(Dwamena, Han, Smith).
- Figure 1 Steps in Delivering Bad News using SPIKES- by Baile et al
- 1- Step one: organize for a meeting with her especially on a day that my schedule is flexible to provide for an ample time for discussion I will also review her medical files and any other information in advance that will be useful during our meeting. Prepare for any emotional outbreak by having some facial tissue available just in case she needs them, request any colleagues to take up my tasks during the time for the meeting to prevent interruptions and get from her who else she would like to be present during the meeting, and the meeting will be held in my office because it has a conductive environment.
- 2- Step two: start the discussion by establishing what the patient knows about her health; with the information given, I will ascertain whether the patient will be able to comprehend the dreadful news I have for her. Some of the questions will include; what she knows about her illness, how she describes her medical condition, her reaction towards the situation, what other doctors told her about her condition and when she first noticed the symptoms.
- 3- Step three: Establish her background knowledge of this condition and how much more information she would like to know because people have various capabilities of handing information, depending on their race, ethnicity and culture, religion and socioeconomic class. In relation to this it is evident that every individual patient has the freedom of choice to decline the reception of any medical information. One therefore has a choice of appointing another party, in this case a close family member to get the details on their behalf. I will thus inquire on whether she would prefer receiving the information on a personal basis and respect her decision. Chances are that she will prefer getting firsthand information, basing on her eagerness of receiving the results of the two weeks screening.
- 4- Step four: Deliver the information in a sensitive, honest and charismatic manner choosing my words carefully and using those that emphasize in her situation. My voice will be steady and slow giving her time to absorb and digest the information. I plan to use the following words’’ I am afraid the feedback may not be quite encouraging. From the screening that was conducted, a lump was found in your left breast thus you will need to take a biopsy to determine the problem.’’ During that time, I will maintain eye contact and be particularly keen to study and evaluate her- non-verbal communication. Her reaction will tell what she feels now.
- 5- Step five: I will acknowledge her emotions and give her time to react and sett le down. The patients and their families have differing mechanisms of receiving bad medical news and reports. Some portray immediate emotional response with bitterness, elf denial, anger, anxiety, tears, sadness and other emotions that are much that are much stronger. Others express denial, blame, guilt, disbelief, fear or a sense of loss or shame, a few may go to extremes to fight, flight from the room or completely switch off their minds to something else (The Robert Wood Johnson Foundation).
- 6- Step sex: establishing a plan for the next steps which will dwell more on performing further tests (biopsy), discuss with her potential sources of emotional and practical support e.g. Family, friends, counselor and professional therapy. I will reassure her of my active engagement in the plan to help and privacy and confidentiality of the information, give her my business card with contact details for my additional questions and establish a time a follow- up appointment.
- The discovery of another mass in the left breast of the by the radiologist is worrying although it does not mean that the lump are cancerous until they are proven to be so. However the only way to do so is to take a biopsy of from the lump and test for presence of cancer cells. Before taking the biopsy it is important to ensure that the patients understand the entire procedure of determining the presence of cancerous cells in a tissue. After the determination of her medical condition, it will be an inevitable task for me to tell her the bad news even though it is mentally demanding for me as a nurse in charge of preparing her psychologically before the actual delivery from the doctor. Spilling of out the result before the actual delivery of the news by the doctor would be unprofessional since patient are supposed to get such information from the doctors. Proper delivery of the distressing news to the patient is extremely valuable. This is because poor delivery of the news especially life threatening to the patient may result to adverse effect. After the doctor delivers news to the patient it is my responsibility as a nurse to ensure that emphasize the details of the bad news to her. In order to ensure that the patient accept the information I will use the patient centered approach to explain to the patient the bad news. Using this approach I will be able to deliver the bad news to her and at the same time boost her self-esteem. Cancelling the patient can help the patient and the family involved to adopt better ways of coping with news. In order to break the cancer news I will adopt the six steps that are commonly used by the break the bad news to cancer patient.
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- Organize a meeting with her and at the same time prepare her medical files.
- Establishing what the patient knows about her health
- Establishing the background knowledge of this condition
- Deliver the information
- Acknowledge her emotion
- Establishing a plan for her perform further test to determine the seriousness of the condition.
- Proper following of the above steps to deliver the bad news would therefore help to ensure that she is able to accept the result and be move on with her life.
- Conclusion
- From the above it is evident that breaking of bad news is one of the hardest tasks that the medical practitioners face especially when the news is life threat. This is because in the event that the bad news is not delivered effectively it may have adverse side effect on the patient. Communication skills are vital in the delivery of the bad news to the patient. In this case proper use of the verbal and non-verbal communication skills can help to prepare the patient psychologically and therefore enable the patient to absorb the bad news. One of the best approaches that need to be applied in the delivery of the news to the patient is the patient centered approach since it can help to boost the self-esteem of the patient. Analysis of the above case presented it is evident that the nurses play a critical role in the delivery of bad news to the patient. Considering the case I have presented it is important to note after using the patient centered approach to counsel the patient, she was able to accept news and move on with her life. I therefore propose that the nurses should adopt such approach when delivery the news and at the same time ensure that they demonstrate professionalism.
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