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Doctors could do a better job of breaking bad news: study

By Andrew M. Seaman

NEW YORK (Reuters Health) - Less than half of German people who are told they have cancer through a set and accepted protocol for breaking bad news are satisfied with the conversation, according to a new study.

Researchers found that may be due to gaps in what patients considered important during that process and what they report actually happened when they got the news.

The study's lead author told Reuters Health that traditionally doctors thought they were aware of their patients' preferences and breaking bad news hadn't been a focus during their training.

"The idea was somehow that physicians will ‘naturally' have the ability to communicate," Dr. Carola Seifart wrote in an email.

She is from Philipps-University of Marburg in Marburg, Germany.

Doctors of all kinds break bad news to their patients, but it's especially common among oncologists, who diagnose and treat cancer, Seifart and her colleagues write in Annals of Oncology.

For example, the diagnosis of a new cancer or a negative development with an existing cancer can significantly change a person's view of the future.

In many countries, the so-called SPIKES protocol is widely accepted as the standard for breaking bad news.

The protocol is based on six steps that involve finding an appropriate setting, determining what the patient already knows or suspects, understanding what the patient wants to know, knowing how to deliver information the patient understands, being sympathetic and summarizing the information at the end of the meeting.

While SPIKES has been tested in the U.S., the researchers write that it has not been tested in Germany and there is little information on how bad news is broken there.

They surveyed 350 people who were patients at two medical centers in Germany and had cancer.

The surveys focused on how patients felt the news of their cancer was first broken to them based on the SPIKES protocol and which parts of the protocol were most important to them, out of 37 items.

Overall, only about 46 percent of the participants were completely satisfied with the way the bad news was broken to them.

Of the 10 parts of SPIKES that the patients rated most important, five addressed how doctors provide information or knowledge, three pertained to how doctors conclude the meeting and two were about the setting where the news is delivered.

The researchers compared those preferences to what the participants actually experienced when they received bad news.

The greatest difference was between the information participants wanted on their prognosis and what the doctors actually told them.

Based on their findings, the researchers suggest doctors ask about what information patients want and focus on the disease's prognosis and how it will impact daily life. Doctors should also routinely ask whether patients understand the information and offer them the opportunity to ask questions.

The researchers also suggest that the process of breaking bad news be split over two visits, because many of the participants felt unable to make decisions during the first visit.

Seifart cautioned that the new findings can't be generalized to all countries.

Dr. Walter Baile also cautioned that the study's findings are limited, because what the participants reported happening during their visit may be different from what actually happened.

Baile, from The University of Texas MD Anderson Cancer Center in Houston, is an expert on the SPIKES protocol but was not involved with the new study.

"Patients don't often remember at the time of diagnosis what they've been told," he said, adding that the request for a second visit is important.

"From our work, what we found is that patients need to have these conversations over and over again," Dr. Juliet Jacobsen, who was also not involved with the study, said.

She is a specialist in palliative care at the Massachusetts General Hospital Cancer Center in Boston.

"I think they (the authors) recognize that by saying even a two-step process would be an improvement," she said.

Baile said the finding that a lot of patients were unhappy with the way bad news was given is significant.

"Patients really need a lot of information and that's what other studies have shown," he said.

SOURCE: http://bit.ly/1gf51en Annals of Oncology, online February 6, 2014.

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