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Communication Along the Disease Trajectory

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    Diagnostic Disclosure and Discussions About Prognosis

    When there was little in the way of effective anticancer treatment, physicians shied away from disclosing the cancer diagnosis for fear it would send a patient into a mental tailspin.[10][Level of evidence: II] Disclosure of a cancer diagnosis progressed from the physician-centered paternalistic approach to doctor-patient communication in the 1950s and 1960s, to full disclosure by the late 1970s.[11] Improved treatment modalities, changing societal attitudes and, in the United States, legislation enforcing the patient's right to informed decision making drove physician-patient communication in a more open or disclosing direction.[12] Consequently, today in North America and many Western countries, there is total open disclosure regarding the presence of cancer, though physicians frequently do not discuss the prognosis unless a patient asks. The reluctance to truthfully disclose a terminal prognosis persists in southern Europe, including Italy and Spain.[13] For patients, however, not discussing the diagnosis may engender feelings of isolation, anxiety, lack of autonomy or control, psychological abandonment, mistrust, suspicion, and a sense of betrayal. On the other hand, open discussion of the diagnosis decreases uncertainty, improves participation in decisions about care, allows access to psychological support, encourages self-care, and allows the patient to begin planning for the future.[12]

    Although honest disclosure can have a negative emotional impact in the short term, most patients will adjust well over time. Gratitude and peace of mind, positive attitudes, reduced anxiety, and better adjustment are some of the benefits that patients report from having been told about a diagnosis of cancer. Because uncertainty is a major cause of emotional distress for patients, relief from uncertainty can, in itself, be therapeutic;[14] some believe that over time, patients achieve a psychosocial objective correlative of order within the context of chaos theory.[15] When bad news is given tactfully, honestly, and in a supportive fashion, the patient's experience of the conversation is less stressful. Not being told about the severity of their condition or not having the opportunity to express their fears and concerns may lead patients to believe that nothing can be done to help them or may prevent them from understanding their disease.[16];[17][Level of evidence: II] On the other hand, a patient who is told bad news bluntly by a practitioner who is trying to quickly complete the difficult task of sharing bad news will likely feel extremely frightened and unsupported. Being told that there is nothing more to be done can engender feelings of abandonment.[17] One study [18][Level of evidence: II] surveyed 497 cancer patients regarding their experiences receiving their cancer diagnoses. Significant predictors of patient satisfaction with the conversation included perceiving the physician as personally interested, being able to understand the information given, being informed in the proper environment (doctor's office), and having more time invested in discussing the information. Although most patients wish to have complete and accurate information regarding their condition, many patients feel that the news is forced upon them unless their right to have the news given according to their preferences is acknowledged by the physician (e.g., "Are you someone who wants to know all the details about your condition?").

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