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Journal of Clinical Oncology, Vol 24, No 19 (July 1), 2006: pp. 3217 © 2006 American Society of Clinical Oncology. DOI: 10.1200/JCO.2006.06.2935
Breaking Bad News: More Than Just GuidelinesThe University of Texas, M.D. Anderson Cancer Center, Houston, TX
Princess Margaret Hospital, Toronto, Canada
Massachusetts General Hospital, Boston, MA
The University of Texas, M.D. Anderson Cancer Center, Houston, TX To the Editor: We appreciate the consideration given by Eggly and her colleagues regarding the techniques, settings, and difficulties involved in giving bad news. In their article, Eggly et al1 challenge aspects of several guidelines suggested for this purpose. It is clear, as they mention, that the main task in giving bad news is providing information to the patient and caregivers using verbal and nonverbal techniques, which enhance patient and family understanding. However, because bad news conversations can be emotionally charged, not only for the patient and family, but also for the clinician, a mindful approach2 in preparing for the encounter can be quite useful for avoiding pitfalls that can occur. Specifically, it is quite common for strong patient emotion such as crying, blaming, or anger to provoke feelings of sympathy, anxiety, guilt, failure, and disappointment in the physician,3,4 which can lead the physician to give false hope, provide premature reassurance or prescribe unnecessary therapies.5 Our own experience in teaching this subject6,7 has shown that (for both new and experienced clinicians) reflecting on one's own feelings is an essential element in overcoming these unhelpful behaviors. When the clinician becomes aware of his or her own attitudes, it is then possible to avoid communication pitfalls and support the patient. This kind of preparation for the bad news encounter would seem to be quite important.8 The central and most important principle of breaking bad news is the fact that this set of communication skills can be taught and learned.9,10 Furthermore, they are not innate abilities which every clinician possesses or does not possess. This is more important than any debate about the current validity of proposed guidelines, which are basically templates for clinicians, helping them to approach the task and employ their communication skills and techniques optimally. As Eggly et al rightly point out, these interviews rarely proceed in a linear, orderly, or planned fashion, and this makes it even more difficult to teach the techniques using only written material (which is fundamentally a linear medium). Our own experience in conducting successful workshops (including those sponsored and offered by the American Society of Clinical Oncology) strongly suggest that while guidelines can be explained, physicians benefit most by seeing examples of valuable communication strategies and demonstration of skills in realistic clinical situations, in order to understand how strategies and plans can be useful in preparing for the clinical encounter (whether the bad news had been predicted and anticipated or not). These workshops also provide participants with opportunities to practice new skills and receive personalized feedback and coaching—helping them to develop a skill set that they feel is effective.11 Just as pilots gain experience in simulators, so learning and being comfortable with communication skills in advance allows their use when the need arises, and even more so when that need was anticipated or expected. We also agree that caregivers are an essential component of patient support and similar skills are required to deal not only with developing a therapeutic alliance with the family, but also in handling tense situations which might arise when the family objects to the patient being told the bad news or the patient does not want caregivers to know information about the illness. Whether research evidence, such as that from videotaped encounters, will lead us to find ways to more effectively communicate with patients is still an open question. Such data undoubtedly demonstrate the uniqueness of each patient, and challenge the clinician to acquire and use techniques and skills that can be effectively employed within a template provided by proposed guidelines. In the future, it is likely that widespread teaching of and research into these skills will dramatically improve the outcome from the patient's point of view and reinforce the value of such skills to the clinician. Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest. REFERENCES
1. Eggly S, Penner L, Albrecht TL, et al: Discussing bad news in the outpatient oncology clinic: Rethinking current communication guidelines. J Clin Oncol 24:716-719, 2006 2. Zoppi K, Epstein RM: Is communication a skill? Communication behaviors and being in relation. Fam Med 34:319-324, 2002[Medline] 3. Buckman R: Breaking bad news: Why is it still so difficult? BMJ 288:1597-1599, 1984 4. Baile WF, Buckman R, Lenzi R, et al: SPIKES-A six-step protocol for delivering bad news: Application to the patient with cancer. Oncologist 5:302-311, 2000 5. Maguire P, Pitceathly C: Key communication skills and how to acquire them. BMJ 325:697-700, 2002 6. Lenzi R, Baile WF, Berek J, et al: Design, conduct and evaluation of a communication course for oncology fellows. J. Cancer Educ 20:143-149, 2005[CrossRef] 7. Back AL, Arnold RM, Tulsky JA, et al: Teaching communication skills to medical oncology fellows. J Clin Oncol 21:2433-2436, 2003 8. Meier DE, Back AL, Morrison RS: The inner life of physicians and care of the seriously ill. JAMA 286:3007-3014, 2001 9. Fallowfield L, Jenkins V, Farewell V, et al: Efficacy of a cancer research UK communication skills training model for oncologists: A randomised controlled trial. Lancet 359:650-656, 2002[CrossRef][Medline] 10. Delvaux N, Razavi D, Marchal S, et al: Effects of a 105 hours psychological training program on attitudes, communication skills and occupational stress in oncology: A randomised study. Br J Cancer 90:106-114, 2004[CrossRef][Medline] 11. Baile WF, Fryer-Edwards K, Back A, et al: Teaching communication skills to oncology fellows: The ABCs of using psychodynamic principles. Psychooncology 14:IV-1, 2005 (suppl 12)
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Copyright © 2006 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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