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Journal of Clinical Oncology, Vol 25, No 21 (July 20), 2007: pp. 3181 © 2007 American Society of Clinical Oncology. DOI: 10.1200/JCO.2007.11.6814
Truth Telling: Yes, but How?Princess Margaret Hospital, Medical Oncology, University of Toronto, Toronto, Ontario, Canada; and The University of Texas M.D. Anderson Cancer Center, Houston, TX
Departments of Behavioral Science and Faculty Development, The University of Texas M.D. Anderson Cancer Center, Houston, TX To the Editor: Many of our discussions with patients or relatives are extremely difficult and even heartbreaking. The Rockwell et al1 article superbly described such a moment spent with the devoted father of a young man dying of leukemia as the physician realized that no other members of the medical team had yet talked with the patient or family about the patient's imminent death. Most likely, many physicians in this case had genuinely wanted to hold such discussions but did not know how. As teachers of communication skills, we often hear statements from colleagues such as, "I don't know what to say," "I don't know to put it into words," or "Yes, I want to do this, but how?" These feelings can be a major obstacle to communication and may also explain why many professionals feel unable to hold these difficult discussions, and thus, do not attempt them. Fortunately, there are several communication strategies and techniques that are relatively easy to learn and to use for these difficult situations. There is no universal script to soothe all anguish and reduce all stress. However, there are relatively simple and practical techniques that can substantially change the outcome of difficult interactions. Our six-step Setting Perception Invitation Knowledge Emotion Strategy and Summary (SPIKES) protocol for breaking bad news has been shown to be easily learned and taught2 and mirrors what patients have said they want from their physicians.3,4 Setting—don't try to have important conversations in awkward places, such as the hallway. Turn your pager to silent. First impressions count: greet the patient in a friendly manner and make eye contact. Perception—while seated, listen without interruption while the patient talks. Assess the patient's perception of the medical situation (the patient usually knows more than you think). You may say, "What have you been told so far?" or "What do you understand about your medical problem?" Invitation—explain to the patient your goals for the interview and obtain their agreement. Knowledge—give the information in clear and simple language (without jargon) and in small chunks. Ask the patient periodically about his or her understanding and whether you are being clear. Emotions—the key to handling emotions, the most important component of the interview, is to acknowledge every strong emotion (yours or the patients) as it appears. The easiest way to accomplish this is with the empathic response, described below. Strategy and summary—describe the management plan. This gives the patient a roadmap for the future. Close with a brief summary ending with a clear contract for the next contact (eg, next appointment).5 This three-step empathic response can lower the emotional level and improve the patient's ability to listen and ask questions. (1) Identify to yourself the emotion as you perceive it (eg, shock, distress, upset, feeling awful, anger, or frustration). (2) Identify the immediate cause of the emotion (almost always the news you have just given). (3) Respond in a way that shows you have made the connection between steps 1 and 2 (eg, "I realize this news comes as quite a shock" or "This must be very tough right now"). Use of the empathic response shows that you have perceived the emotions that the patient is feeling; that you are "tuned in" to him; and changes the topic of conversation from the bad news or the management plan to the way the patient is feeling and allows a moment for the feelings to abate. During such interviews, physicians, too, often experience intense emotions, including anxiety, sadness, or guilt.6 You can use an empathic response on your own feelings ("This is not easy for me either"), and because an empathic response describes an emotion, as opposed to displaying it, the response should not escalate that emotion during the interview. It can also be used to acknowledge the difficulty of the interview itself, while reducing rising tension (eg, "These are difficult things to talk about, aren't they?" or even "I know this isn't easy—for either of us"). It is also worth remembering that wish statements are known to be helpful and are well received because they align the physician with the patient (eg, "I wish things had turned out differently") and gently affirm the bad news.7 Discussions such as those in the article by Rockwell et al are of major importance and have a considerable effect on the patient's (and family's) overall assessment of the standard of care. These relatively straightforward strategies and techniques can greatly improve support of the patient and family, reinforcing the oft-repeated comment—it isn't just what you say; it's the way you say it and—more importantly—the way you listen that count. AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author(s) indicated no potential conflicts of interest. REFERENCES
1. Rockwell LE: Truthtelling. J Clin Oncol 25:454-455, 2007 2. Back AL, Arnold RM, Baile WF, et al: Efficacy of communication skills training for giving bad news and discussing transitions to palliative care. Arch Int Med 167:453-460, 2007 3. Hagerty RB, Butow PN, Ellis PA, et al: Cancer patient preferences for communication of prognosis in the metastatic setting. J Clin Oncol 22:1721-1730, 2004 4. Parker PA, Baile WF, deMoor C, et al: Breaking bad news about cancer: Patient preferences for communication. J Clin Oncol 19:2049-2056, 2001 5. Buckman R, Baile WF: A Practical Guide to Communication Skills in Cancer Care. Toronto, Ontario, Cinemedic Productions, 2002 (CD-ROM set) 6. Wallace JA, Hlubocky FJ, Daugherty CK: Emotional responses of oncologists when disclosing prognostic information to patients with terminal disease: Results of qualitative data from a mailed survey to ASCO members. J Clin Oncol 24:473s, 2006 (abstr 8520) 7. Quill TE, Arnold RA, Platt F: "I wish things were different": Expressing wishes in response to loss, futility, and unrealistic hopes. Ann Intern Med 135:551-555, 2001 Related Reply
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Copyright © 2007 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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