Syed Hamza Abbas  ( Norfolk and Norwich University Hospital, Norwich, United Kingdom )
Syed Qamar Abbas  ( St Clare Hospice, Hastingwood, Essex, United Kingdom )
Syed Muhammad Mubeen  ( Department of Community Health Sciences, Hamdard College of Medicine & Dentistry, Hamdard University, Karachi, Pakistan. )
Syed Muhammad Mubashir  ( Final Year MBBS Student, Jinnah Sindh Medical University, Karachi, Pakistan. )
Aliya Zaman  ( Department of Pathology, Muhammad Medical College, Mirpurkhas, Pakistan. )

Objective: To assess the perception and attitude of physicians related to breaking bad news.

 

Methods: The cross-sectional study was conducted at three teaching hospitals in Karachi and Mirpurkhas, Pakistan, from April 2019 to February 2020, after approval from Hamdard University, Karachi, and comprised physicians of either gender having direct patient contact. Data was collected using a questionnaire based on literature. The questionnaire was pilot-tested before distribution among the subjects. The responses were categorised with respect to age, gender and professional experience. Data was analysed using SPSS 25.

 

Results: Of the 230 subjects, 119(51.7%) were females. The overall mean age was 34.5±8.8 years and mean professional experience was 9.1±8.2 years. Overall, 19(8.3%) subjects believed they had a very good ability to deliver bad news, while 26(11.3%) avoided telling the patient the truth about diagnosis, prognosis and treatment. Age had a significant association with correctly defining breaking bad news (p<0.05).

 

Conclusion: The skill level related to breaking bad news was found to be deficient. Key Words: Breaking bad news, Communication, Pakistan.

 

(JPMA 73: 487; 2023) DOI: 10.47391/JPMA.5249

 

Submission completion date: 05-11-2021 — Acceptance date: 26-09-2022

 

Introduction

 

Communication skills are an integral element of medicine practice¹. Examples of this skill in practice vary from the initial patient encounter taking medical histories to imparting a patient’s diagnosis and management strategy. Examples of such diagnoses include chronic and terminal illnesses. If clinicians are not able to practice good communication skills due to a lack of training, this can lead to challenging patient interactions².

The subjects of breaking bad news (BBN) has been extensively researched, and dimensions vary widely across cultural contexts around the world^3-7. There is evidence that the ability to convey news to a patient can have a significant effect on patient experience, which, in turn, can lead to improved patient outcomes⁸. One way to explain how bad news is viewed by physicians is to use the awareness, attitudes and actions paradigm.

The benefits of integrating BBN training has been documented well in studies from around the world⁹. In many countries, medical schools and hospitals require the teaching of these communication skills as part of the core curriculums¹⁰. Physicians also encounter this in postgraduate training¹¹. However, despite options that do exist, opportunities can exist asymmetrically within cultural contexts and in resource-limited settings. Even if there are resources, the uptake will differ considerably across institutions and countries. The current study was planned to assess the perception and attitude of physicians related to BBN.

 

Subjects and Methods

 

The cross-sectional descriptive study was conducted from April 2019 to February 2020 at one public-sector and two private tertiary care hospitals in Karachi and Mirpurkhas, Pakistan, after approval from the ethics review committee of Hamdard University, Karachi. The survey was conducted outside the premises of two hospitals and only verbal consent was obtained from the participants, whereas written permission was obtained from the third institution and data was collected on the premises.

The sample was raised using non-probability convenience sampling method, and those included were physicians of either gender having direct patient contact. Data was collected using a self-administrated questionnaire developed in the light of Setting and listening skills; Patients perception; Invitation to give information; Knowledge; Explore emotions and empathise; Strategy and summarise (SPIKES)¹², Background; Rapport; Explore; Announce; Kinding; Summarise (BREAKS)¹³ and the Calgary-Cambridge framework¹⁴. The questionnaire included demographic information as well as questions related to physicians’ BBN knowledge, awareness and practices. The questionnaire was initially piloted with 8 participants comprising colleagues and peers to check for possible inconsistencies in question comprehension. After necessary modifications, the questionnaire was finalised and distributed among the study participants (Annexure). The sample size was calculated using Raosoft sample size calculator at 95% confidence level, 5% margin of error, and 20% expected awareness of SPIKES protocol¹⁵. The sample was inflated by 10% to cover for refusals or dropouts.

Data was analysed using SPSS 25. Descriptive results were tabulated as frequencies and percentages, and logistic regression model was used to assess association of responses with age, gender and professional experience. P<0.05 was considered statistically significant.

 

Results

 

Of the 243 doctors approached, 230(94.6%) participated; 119(51.7%) females and 111(48.3%) males. The overall mean age was 34.52±8.8 years, and mean professional experience was 9.1±8.2 years.  The majority was associated with Medicine and allied fields 129(56%), and 154(67%) had professional experience up to 10 years. Overall, 19(8.3%) subjects said they had a very good BBN ability, while 26(11.3%) avoided telling the truth about diagnosis, prognosis and treatment to patients. Further, 11(4.8%) subjects felt insecure dealing with BBN, while 100(43.5%) felt the duty was fulfilled. A large majority 184(80%) believed BBN is important enough to be incorporated in the curriculum (Table 1). Awareness level related to various standard BBN protocols was also assessed (Figure).

 

 

 

Bivariate logistic regression of the responses showed age was a significant predictor of defining BBN (p<0.05) (Table 2).

 

 

Of the total, 193(83.9%) participants said they preferred BBN communication in clear, understandable language that avoided technical words, 152(67%) learned it from colleagues, seniors and consultants, while 173(75%) mentioned high expectation of patients or their relatives about the possible medical outcome was the biggest BBN barrier (Table 3).

 

 

Discussion

 

To the best of our knowledge, the current study is the first to assess the BBN perception and attitude of physicians working in tertiary care hospitals in Pakistan’s southern province of Sindh.

BBN is the process of providing negative information to a person. It is an emotionally stressful situation for doctors as well as for patients and their families. To achieve patient satisfaction, it is necessary to know BBN awareness, attitudes and behaviours in medical settings among those delivering medical care to patients. This is because adequate communication training increases patient satisfaction¹⁶. It is critical that Pakistani clinicians develop the capacity to provide this knowledge, as the global burden of chronic diseases is increasing. These increases are similarly expressed in the developed world¹⁷.

Previous BBN research in Pakistan remains limited. However, some literature has appeared over the last decade. This provides a contextual model for the subject¹⁸. The findings of Baig et al. included a general recognition of the value of presenting bad news among clinicians. The findings highlighted the need to develop the skills of Pakistani clinicians in this regard¹⁸. However, Jameel et al.¹⁹ found that clinician’s uptake of BBN training was low, but the study, done in 2012, may not represent the current situation. There is a need for re-evaluating the situation, which the current study tried to address.

Considering how the past may have influenced present realities, Sarwar et al.¹⁵ found that medical residents were dissatisfied when it came to BBN, but, again, it may not be truly representative of the entire country because the study was conducted in a tertiary hospital in Lahore.

There were notable key themes that emerged in the current study. On the topic of delivering bad news, many doctors were able to correctly define it (63%). Also, only 43% respondents felt their individual BBN ability was good or better. This value is comparable to 49.5% reported earlier¹⁵, and a marked improvement on perceived ability among 85% respondents¹⁹. Time since graduation was significant for perceived BBN ability (p<0.01), which was in contrast to literature¹⁵.

When practising, clinicians’ feelings varied, with common responses being duty fulfilled (43%), pitiful (17%) and sadness (27%). Besides, 20% respondents said BBN should be done by giving hope even if the basis for the said hope may not exist.

Different questions asked in the questionnaire focussed on different elements of knowledge, attitudes, and behaviour (KAB), and showed that clinicians were slowly gaining BBN aptitude. In addition, some behaviours reflected an appreciation of the BBN value.

In the current cohort, 29% respondents agreed that patients do not want to know a serious diagnosis. In terms of what the respondents viewed as challenges in practice, 75.5% cited high standards of care as an obstacle to BBN. Also, 25.8% subjects shared concerns that they might be blamed. This sentiment is not new in literature¹⁸. It may be of interest to conduct studies on patients’ expectations in Pakistan. In addition, BBN training will benefit from concentrating on managing expectations to facilitate the doctor-patient interaction. Training in ethical patient communication should also be considered in the light of such findings.

Clinicians showed increased trust in practice on the subject as 57% respondents reported BBN training from their undergraduate/postgraduate studies. Another study found that 95% of its respondents had not had any training at the undergraduate level¹⁹. Additionally, 66.7% of respondents referred to training by observing seniors at work compared to 66% reported earlier.¹⁹ Just 10% clinicians responded learning of skills from relevant courses. Regarding the use of protocols, only 44% and 43% of the respondents said they were aware of the SPIKES protocol and BREAKS approach, respectively. In literature, 20% knew of SPIKES and 33% knew of BREAKS¹⁵. Of the total, 80% respondents said it was “very important” that BBN training be included in the curriculum. This mirrors earlier findings¹⁵.

With respect to BBN, if the relative of the patient asked to withhold the diagnosis from the patient, 45% clinicians indicated their intention to comply with such a request. In an earlier cohort, the corresponding statistics was 59.5%¹⁵. If the patient directly asked about the diagnosis, 40% doctors would only then provide the details. Just 12% of the respondents decided that they should always warn the patient of bad news, regardless of the family’s wishes. Nevertheless, 3% said they would suggest the relative to see another doctor straightaway. This demonstrates the need to provide graduates with proper BBN training. Patients should be aware of their diagnoses, and this heterogeneity between the answers to this question is a major ethical issue, in addition to the practical concern of good communication in doctor-patient relationship.

The importance of addressing these issues is further underscored by the fact that guidance exists in countries, such as the United Kingdom, on patient details relevant to certain clinical diagnoses²⁰. Considering that there are many doctors trained in Pakistan who practise abroad²¹, there is a further practical case to help standardise practice between southern Pakistan and the rest of the world.

As regards the use of protocols in practice, only 50.4% respondents said they were aware of SPIKES. This is an improved value compared to 20% and <10% reported earlier^15,19. This improvement is seen against the backdrop of current protocols to strengthen BBN willingness of clinicians^12,15. As a result, intensive training in these approaches as part of medical curricula and short-term courses can both provide a structure for clinicians while also improving personal perceptions on the matter. Although Pakistan’s specific work on SPIKES is limited, adopting a universal approach that has evidence from elsewhere is the most feasible way to further improve these skills in the region. Once it has been developed as a standard, future work could be done to optimise the approach that is ideally moulded to the cultural context.

Although our research focused on the clinician’s viewpoint on BBN in Pakistan, the patient’s perspective was not addressed whereas other countries have investigated this aspect^22,23. This is one of the limitations of the current study. Another limitation is that the sample was selected from three hospitals only, and no testing for its validity and reliability was performed.

 

Conclusions

 

The skill level related to BBN was found to be deficient. Emphasis should be on improving such skills in a resource-limited environment.

 

Disclaimer: None.

 

Conflict of Interest: None.

 

Source of Funding: None.

 

References

 

1.      Makoul G. Communication Skills Education in Medical School and Beyond. JAMA. 2003; 289:93. doi: 10.1001/jama.289.1.93.

2.      Dosanjh S, Barnes J, Bhandari M. Barriers to breaking bad news among medical and surgical residents. Med Educ. 2008; 35:197-205. doi: 10.1046/j.1365-2923.2001.00766.x.

3.      Fallowfield L, Jenkins V. Communicating sad, bad, and difficult news in medicine. Lancet. 2004; 363:312-9. doi: 10.1016/S0140-6736(03)15392-5.

4.      Bumb M, Keefe J, Miller L, Overcash J. Breaking Bad News: An Evidence-Based Review of Communication Models for Oncology Nurses. Clin J Oncol Nurs. 2017; 21:573-80. doi: 10.1188/17.CJON.573-80.

5.      Rajasooriyar C, Kelly J, Sivakumar T, Navanesan G, Nadarasa S, Sriskandarajah M, et al. Breaking Bad News in Ethnic Settings: Perspectives of Patients and Families in Northern Sri Lanka. J Glob Oncol. 2017; 3:250-6. doi: 10.1200/JGO.2016.005355.

6.      Sexton D. ‘As Good as it’s Going to Get’. Bad News Conversations in Neurology: Challenges for Occupational Therapists. Br J Occup Ther. 2013; 76:270-9.DOI: doi.org/10.4276/030802213X137061699328

7.      Geeta M, Krishnakumar P, Gupta A, Kapil U. Research Letters. Indian Pediatr. 2017; 54:685-7.

8.      Manary M, Boulding W, Staelin R, Glickman S. The Patient Experience and Health Outcomes. N Engl J Med. 2013; 368:201-3. doi: 10.1056/NEJMp1211775.

9.      Carrard V, Bourquin C, Stiefel F, Mast MS, Berney A. Undergraduate training in breaking bad news: A continuation study exploring the patient perspective. Psychooncology. 2019; 29:398-405. doi: 10.1002/pon.5276

10.    Vermylen J, Wood G, Cohen E, Barsuk J, McGaghie W, Wayne D. Development of a Simulation-Based Mastery Learning Curriculum for Breaking Bad News. J Pain Symptom Manage. 2019; 57:682-7. doi: 10.1016/j.jpainsymman.2018.11.012.

11.    Barnett M. Effect of Breaking Bad News on Patients’ Perceptions of Doctors. J R Soc Med. 2002; 95:343-7.

12.    Buckman R. Breaking bad news: the S-P-I-K-E-S strategy. Community Oncol. 2005; 2:138-42.

13.    Narayanan V, Bista B, Koshy C. 'BREAKS' Protocol for Breaking Bad News. Indian J Palliat Care. 2010; 16:61-5. doi: 10.4103/0973-1075.68401.

14.    Silverman JD, Kurtz SM, Draper J. Skills for Communicating with Patients. Oxford, UK: Radcliffe Medical Press, 1998.

15.    Raosoft, Inc. Sample size calculator. [Online] 2004 [Cited 2022 September 10]. Available from: URL: http://www.raosoft.com/samplesize.html

16.    Boissy A, Windover A, Bokar D, Karafa M, Neuendorf K, Frankel R, et al. Communication Skills Training for Physicians Improves Patient Satisfaction. J Gen Intern Med. 2016; 31:755-61. doi: 10.1007/s11606-016-3597-2.

17.    Remais J, Zeng G, Li G, Tian L, Engelgau M. Convergence of non-communicable and infectious diseases in low- and middle-income countries. Int J Epidemiol. 2012; 42:221-7. doi: 10.1093/ije/dys135.

18.    Baig L, Tanzil S, Ali S, Shaikh S, Jamali S, Khan M. Breaking Bad News: A contextual model for Pakistan. Pak J Med Sci. 2018; 34:1336-40. doi: 10.12669/pjms.346.15663.

19.    Jameel A, Noor SM, Ayub S. Survey on perceptions and skills amongst postgraduate residents regarding breaking bad news at teaching hospitals in Peshawar, Pakistan. J Pak Med Assoc. 2012; 62:585-9.

20.    General Medical Council UK. Consent: patients and doctors making decisions together Guideline 9. [Online] [Cited 2020 June 26]. Available from: URL: https://www.gmc-uk.org/-/media/documents/gmc-guidance-for-doctors---consent---english_pdf-48903482.pdf?la=en&hash=588792FBA39749E57D881FD2E33A851918F4CE7E

21.    Qureshi AZ, Rathore FA. Number of Pakistani physicians working abroad; Do we really need to know? J Pak Med Assoc. 2014; 64:1410-2.

22.    Azzopardi J, Gauci D, Parker P A, Calleja N, Sloan J A, Zammit R. Breaking bad news in cancer: an assessment of Maltese patients’ preferences. Malta Medical School Gazette, 2017;1:36-45.

23.    Hanratty B, Lowson E, Holmes L, Grande G, Jacoby A, Payne S, et al. Breaking bad news sensitively: what is important to patients in their last year of life? BMJ Support Palliat Care. 2011; 2:24-8. doi: 10.1136/bmjspcare-2011-000084.

 

 

Annexure

Breaking Bad News – Pakistani Doctor’s Perspective

 

Questionnaire

Mark a tick  or fill in the blanks as appropriate. Please attempt all questions.

 

1) Age:  ___________ (in years)                                 2). Sex: i) Male           ii) Female 

3). Department/Speciality: ___________________  4). Experience after graduation (in yrs) :____________

5). How do you define BAD NEWS?

i)            News about physical harm/life threatening disease to the patient.

ii)           News of death.

iii)          Any information transmitted that implies any negative change and would be capable of affecting the individual's view of life or their outlook for the future e.g., any disease  

6). How often do you deliver BAD NEWS?

i)   Less than once a month   ii)   1 – 4 times a month        iii)   5 – 10 times a month             iv)   More than 10 times a month

7). How do you consider your ability to give bad news?

            i)  Comprehensive  ii)   Very Good      iii)  Good     iv)  Acceptable

8).  Where do you usually give bad news?

            i)   Find a private and cosy place                  ii)   Report in an available office      

            iii)   Inform informally in the hallway/ward or some other place outside the office

9)  Do you ASK your patients whether they want to know their diagnosis of a serious illness before you tell them?

i)     Yes                      ii)     No         

10)  Do you assess your patients’ knowledge about their condition or situation before you tell them the diagnosis?

i)     Yes                      ii)     No         

11).  How do you provide the bad news? (May have more than one answer)

            i)      With clear, understandable language, avoiding technical words

            ii)     I explain in detail

            iii)    I give hopes even that they don’t exist

            iv)    I establish a trust relationship

            v)     I explain in detail and technical

            vi)    I put myself in the patient's place

            vii)   I clarify doubts

viii)   I don’t think doctors should tell all details about poor prognosis as it will make patients/relatives depressed

ix)   I delay telling them and, in the meantime, families/patients recognise themselves that patient is dying

            x)   Any other, please specify: _____________________________________________________

12).  When giving the bad news, do you always tell the truth about diagnosis, prognosis and treatment?

            i)     Never.     ii)   Avoid telling the truth                 iii)   Speak everything at once.

            iv)   Carefully, carefully, according to the request of the patient and / or family members.

13).  Do you think the patient should be told everything about their serious illness?

i)   Yes                        ii)   No            iii)   Not sure

14)  To whom do you tell the truth?

                        i)    Only to the patient          ii)   Only the family   iii)   The patient and his / her companion, at the same time                     iv)   Preferably, first to the patient, then to the family

            v)   Preferably, first to the family, then to the patient

15)  How do you feel about giving bad news?

            i)    sad                      ii)   With pity                iii)   Feeling of duty fulfilled

iv)    Relieved v)    Insecure                  vi)    Afraid     vii)   Others

16)  What fears do you have in giving bad news? (May have more than one answer)

i)    Fear of being blamed      ii)   Fear of ending the patient's hope           iii)  Fear of patient reactions

    iv)   Fear of death and disease itself         v)    Fear of their own emotional reactions

vi)   Others: ______________________________________________

17)  How did you learn to give bad news (Tick more than one answers if needed)?

            i)    During under/post graduate studies       ii)    By trial and error method

            iii)   Through specific courses            iv)    Seeing/follow other specialists/senior or colleague

            v)    Any other (pl specify) ______________________________________________

 

 

18)  How important do you think is incorporation of "How to give bad news" in the course of graduation?

i) Very important        ii) More or less important       iii) Important   iv) Little important      v)  Not important

19)  Do you think Pakistani patients do not want to know about their diagnosis and prognosis of a serious illness?

i)    Yes                       ii)    No           iii)    Not sure

20)  If the relative wants to hide the diagnosis of a serious illness from their patients what will you do?

i)      Agree with the relatives and avoid telling the diagnosis to the patient

ii)     Tell them to go to another doctor

iii)    Tell them: if the patient asks me I will tell the truth

iv)   Disagree with the relatives and tell the diagnosis to the patient

v)    Others, please specify__________________________________________

21)  What do you see as a barrier for breaking bad news? (May have more than one answer)

i)     High expectation of the outcome of the patients or their relatives

ii)    Fear of not knowing all the answers to the patients or the relatives’ questions

iii)   Personal fear of illness or death

iv)   Fear of being blamed

v)   Others, please specify__________________________________________

22)  Are you aware of the following standard protocols? Which one do you follow for breaking the bad news

SPIKES i)   No             ii)   Yes           iii)   Follow

BREAKS            i)   No             ii)   Yes           iii)   Follow

ABCDE i)   No             ii)   Yes           iii)   Follow

 

Thank you for your participation.