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© 2001 American Society for Clinical Oncology Patients’ Perceptions of Receiving Bad News About CancerByFrom the Department of Psychology, Bucknell University, Lewisburg, PA; and Department of Radiation Oncology, Mary Greeley Medical Center, Ames, IA. Address reprint requests to J.T. Ptacek, PhD, Department of Psychology, Bucknell University, Lewisburg, PA 17837; email: ptacek{at}bucknell.edu
PURPOSE: The purpose of this investigation was to document patients’ recollections about what transpired during bad news interactions between physicians and themselves. PATIENTS AND METHODS: One hundred twenty cancer patients provided information about the most recent time they received bad cancer-specific news. Using a series of descriptive statements, patients reported on what the physician did while communicating the bad news. Patients also indicated the extent to which they were satisfied with the transaction and whether they believed that the interaction had any long-lasting impact on their adjustment or on their subsequent interactions with the physician who delivered the news. RESULTS: Overall, patients reported having similar experiences, with most physicians behaving in ways that were consistent with advice published in the medical literature. Satisfaction with the bad news transaction was high. Younger patients and women found the transaction to be more stressful, and older patients believed that the transaction was less important for subsequent interactions with the physician. Logistic regression analyses indicated that satisfaction with the transaction was uniquely predicted by factors related to the environment, to what the physician said, and to how the physician said it. CONCLUSION: Despite high levels of self-reported satisfaction by patients, some factors differentiated the most satisfied patients from patients who were less satisfied. The findings suggest that special attention should be given to making the environment comfortable, taking plenty of time with the patient, and attempting to empathize with the patient’s experiences.
". . . after a pelvic exam—he did not even let me be dressed—he just stood there—my legs still spread and blurted it out to me that I had cancer—no sympathy or feeling expressed at all. . . I should have been allowed off the exam table. He just worked between my legs and told me very cruelly—I wasn’t even lying flat—my legs were still in the stirrups—not even allowed to be covered." —Cancer Patient, Fall 1998 The past 5 years have been associated with sharp increase in interest among researchers, educators, and practitioners about how to most effectively communicate bad news to patients. Evidence indicates that good communication with patients is important. For instance, good communication and high satisfaction with one’s health care providers are associated with increased compliance, better emotional adjustment, and reduced likelihood of litigation.1-3 Of all communications that physicians and patients can have, perhaps none is more important than the informing interview. Writers have suggested that bad news signals the onset of a stressful time for patients,4 that receiving bad news poorly has a distressing impact on patients’ lives,5 and that delivering bad news is stressful for physicians.6 The bad news literature has been associated with two important limitations. First, it has been largely nonempirical. Content analyses of research efforts indicate that the vast majority of work in this area involves letters, opinion pieces, and reviews.4,7 From these nonempirical pieces, however, a common cluster of factors thought to be associated with high-quality bad news transmission has emerged. Specifically, results of consensus-seeking research suggest bad news can be delivered most effectively when practitioners attend to what news is transmitted (eg, convey some measure of hope), how the news is transmitted (eg, use simple, nontechnical language without euphemisms), and where the news is transmitted. Second, there has been a focus on physicians’ reports. However, because patients are typically more highly impacted by the bad news than are physicians, a focus on patients’ perceptions is warranted. Most research done with patients and families has focused on their preferences for bad news delivery,8 and recent data suggest that these preferences fall into domains similar to those provided by physicians: content (physician expertise), support (informational and emotional aid), and facilitation (where and when the news is communicated).9 Although information about patient preferences is informative, too little is still known about what happens during bad news transactions or whether delivery processes relate to patient adjustment. The goal of this investigation was to determine not what should be done or what patients would like to see done but rather to explore what is done when bad news is communicated. The approach taken was to gather information from persons with cancer about the most recent time they received bad cancer-specific news.
Participants Patients were 120 adults (70 men and 50 women) treated for cancer with radiation at a midwestern clinic in the United States. Patients were either currently undergoing treatment or had done so within the previous 6 months. Patients averaged 68 years of age (SD, 12.12 years) and most (97%) were white. More than 10 cancer sites were represented, with 26%, 20%, and 17% being treated for either breast cancer, prostate cancer, or lung cancer, respectively. The transactions involved more than 50 physicians who represented seven specialties, with 26%, 24%, and 10% receiving news from a surgeon, a urologist, or a family practice physician, respectively. The majority (66%) of patients provided information about a bad news transaction that had occurred less than 6 months in the past.
Procedure
Materials The stress experienced by patients while they received the news was assessed using a five-point scale (ranging from 1, not at all/none to 5, very/a lot). On the same scale, patients indicated their satisfaction with how the transaction had gone and rated the extent to which the recalled transaction influenced their psychologic adjustment. Patients who had returned to the physician after the transaction rated the extent to which they believed the transaction influenced these subsequent interactions.
Descriptive Findings Endorsement rates for each delivery statement are listed in Table 1. To provide a context in which to evaluate these numbers, we established consistency cut-scores derived from a binomial distribution, which assumed that the probability that the physician would engage in a given behavior was based on chance alone (thus, P = .50). Sample percentages above 67% or below 33% were associated with a two-tailed probability level of .0004 or less, which meant that the responses were notably consistent across patient reports.
Consistency across physicians was high for most, but not all, behaviors described in the statements. Specifically, someone accompanying the doctor while he or she gave the news, sitting near the patient, checking with the patient after the transaction, showing his or her true feelings to the patient, using words to let the patient know that bad news was forthcoming, and allowing the patient’s reaction to dictate the flow of the transaction were not consistently reported (using the 33% to 67% criteria). It was also highly uncommon for physicians to initiate any physical patient contact. Patients remembered experiencing moderate stress when receiving the news (median, 3.00) but reported being satisfied with how the transaction had proceeded, which had a median score of 5.00. Although some patients believed the transaction influenced their psychologic adjustment (median, 3.00), as a group they did not believe strongly that it influenced subsequent interactions with that physician (median, 1.00).
Associations Among Variables
Spearman rank-order correlations and Kruskal-Wallis tests were conducted to examine whether age and sex related to stress, satisfaction, and adjustment ratings. As compared with younger patients, older patients reported experiencing less stress (r = -0.31) and believed that the recalled transaction was less important in influencing subsequent interactions with physician (r = -0.32). In addition, women (mean rank, 75.05) recalled experiencing more stress than did men (mean rank, 55.83) (
Logistic Regression Analyses Wald tests, odds ratios, and 95% confidence intervals for the significant variables that emerged from each logistic regression analysis are presented in Table 2. The odds of being satisfied with the transaction were significantly higher when (1) the news was received in a comfortable location, (2) the transaction was free from interruptions, (3) physicians sat close to patients, (4) physicians tried to empathize with what patients were feeling, and (5) physicians let patients know in words that bad news was forthcoming. The odds of being satisfied were significantly lower when physicians rushed through the news and when they struggled to find the right words.
The goal of this investigation was to examine bad news transactions from the patient’s perspective. We found that for many specific aspects of these transactions, a significant majority of physicians were rated as having used objectively good behaviors or as not having used objectively poor behaviors, at least as defined by whether the behavior was consistent with recommendations in the medical literature. In addition, despite experiencing moderate stress, patients were satisfied with the transaction. Although patient satisfaction ratings were quite high, they were similar to other published reports and seem to be consistent with such ratings when survey methods are used.12,13 The apparent competence of these physicians at delivering bad news is consistent with physician-provided accounts of what transpired during a particular transaction, which also suggests a high level of competence at this task.10,11 Research using more objective video-taped assessments of interactions between residents and standardized patients, however, has lead some researchers to conclude that residents lack competence in communicating bad news.14 Physician experience and research methodology are explanations for different findings across studies. Research should move from documenting competence to understanding what makes physicians more or less effective at this type of communication. It is important to recognize, regardless of who is making the report, that engaging in a behavior does not guarantee that one has done it well. Physicians may use simple language but do so in a way that patronizes patients. Moreover, these generally positive findings should not obscure the fact that there were aspects of these transactions that could be improved on. More than 30% of physicians apparently maintained a fairly high level of control over the flow of the interaction, and sitting close to the patient was remembered as having occurred in just over 60% of the transactions. It was also uncommon for physicians to initiate physical contact with the patient, and in less than 30% of the transactions did the doctor seem to let other events in patients’ lives influence how the news was delivered. Several aspects of these bad news encounters were statistically significant independent predictors of satisfaction with the transaction. Physicians and medical centers should make certain that a comfortable room is available for such transactions. Giving bad news in a corridor, waiting room, or a typical examination room are not good alternatives. Physicians should also ensure that there are no interruptions while giving bad news. To help do so, they may want to either turn off their pagers or give them to another staff member while speaking to the patient. Physicians should also sit close to the patient, allow the patient to respond in his or her own unique way, and check back with the patient at some later point in time. Physicians can also enhance satisfaction if they give a verbal warning shot about the fact that bad news was forthcoming and if they use a warm and caring tone. Finally, every effort should be made to empathize with what the patient is feeling. Cegala et al15 have suggested that competent communication by physicians includes two elements: relational communication and information exchange. This investigation focused primarily on socially related, relational outcomes. Our belief was that the nature of these specific transactions would set the stage, positively or negatively, for subsequent interactions between the patient and the physician. The findings did not, however, bear out this expectation. Subsequent research efforts should explore other variables that might influence the quality of patient-doctor relationships after bad news and assess both relational and informational factors. It should be noted that the present investigation suffered from several limitations. First and foremost was the reliance on retrospective self-report patient data about these transactions. Although authors16 have argued that more data should be collected from the patients themselves, as opposed to physicians, patient data are not without their own set of difficulties. Just as physicians have been shown to be poor judges of patients’ emotional experiences,17 it is likely, given the circumstances, that patients are just as bad at reading their physicians’ emotions and reporting about their behaviors. However, it is precisely these memories, however inaccurate or biased they might be, that will influence emotional adjustment and subsequent interactions with physicians and the medical system. Second, the sample was relatively small and obtained from one clinic in the Midwest. Thus, despite the fact that more that 50 physicians were represented in the reports, care should be taken not to generalize too far beyond this specific sample. Moreover, given the self-report methodology used, it is possible that only those patients who had had relatively positive experiences participated. Our sample was therefore biased toward a particular type of patient (in terms of area of the country and treatment modality) and may have been biased toward the most satisfied patients. Additional research should include large-scale, multicenter prospective designs and use of several data sources (eg, patients, physicians, and objective observers). Other data types should also be collected (including videotapes or audiotapes), because these data may reveal important predictors of satisfaction that are missed with paper-and-pencil measures.12 Given the potential importance of this topic to both patient and physician well-being, expending the effort to collect these types of data is warranted.
1. Cameron C: Patient compliance: Recognition of factors involved and suggestions for promoting compliance with therapeutic regimens. J Adv Nurs 24: 244-250, 1996[Medline] 2. Roberts CS, Cox CE, Reintgen DS, et al: Influence of physician communication on newly diagnosed breast patients’ psychologic adjustment and decision-making. Cancer 74: 336-341, 1994 (suppl 1)[Medline] 3. Safran DG, Taira DA, Rogers WH, et al: Linking primary care performance to outcomes of care. J Fam Pract 47: 213-220, 1998[Medline]
4.
Ptacek JT, Eberhardt TL: Breaking bad news: A review of the literature. JAMA 276: 496-502, 1996 5. Fallowfield LJ: Giving sad and bad news. Lancet 341: 476-478, 1993[Medline] 6. Buckman R: Breaking bad news: Why is it still so difficult. BMJ 288: 1597-1599, 1984
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Girgis A, Sanson-Fisher RW: Breaking bad news: Consensus guidelines for medical practitioners. J Clin Oncol 13: 2449-2456, 1995
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Parker PA, Baile WF, de Moor B, et al: Breaking bad news about cancer: Patients’ preferences for communication. J Clin Oncol 19: 2049-2056, 2001 8. Girgis A, Sanson-Fisher RW, Schofield MJ: Is there consensus between breast cancer patients and providers on guidelines for breaking bad news? Behav Med 25: 69-77, 1999[Medline] 10. Ptacek JT, Fries EA, Eberhardt TL, et al: Breaking bad news to patients: Physicians’ perceptions of the process. Support Care Cancer 7: 113-120, 1999[Medline] 11. Ptacek JT, Ptacek JJ, Ellison NM: "I’m sorry to tell you...": Physician’s reports of breaking bad news. J Behav Med 24: 205-217, 2001[Medline] 12. Hall JA, Irish JT, Roter DL, et al: Gender in medical encounters: An analysis of physician and patient communication in a primary care setting. Health Psychol 13: 384-392, 1994[Medline] 13. Hall JA, Dornan MC: What patients like about their medical care and how often they are asked: A meta-analysis of the satisfaction. Soc Sci Med 27: 935-939, 1988 14. Eggly S, Afonso N, Rojas G, et al: An assessment of residents’ competence in the delivery of bad news to patients. Acad Med 72: 397-399, 1997[Medline] 15. Cegala DJ, McGee DS, McNeilis KS: Components of patients’ and doctors’ perceptions of communication competence during a primary care medical interview. Health Communication 8: 1-27, 1996 16. Hinds C, Streater A, Mood D: Functions and preferred methods of receiving information related to radiotherapy. Cancer Nurs 18: 374-384, 1995[Medline]
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Passik SD, Dugan W, McDonald MV, et al: Oncologists recognition of depression in their patients with cancer. J Clin Oncol 16: 1594-1600, 1998 Submitted February 12, 2001; accepted June 22, 2001.
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Copyright © 2001 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
2 (1, N = 127) = 8.46; P < .01). 
