Communication in Cancer Care (PDQ®): Supportive care - Health Professional Information [NCI] - Communication Along the Disease Trajectory
Patients facing death have myriad concerns that include leaving children and other loved ones behind; decline in the socially based aspects of one's identity; the end of being able to fulfill normal roles; fear of burdening loved ones; loss of control; deterioration in personal appearance; needing help with intimate personal care and routine activities of daily living; worries about mental awareness; pain and management of symptoms; quality of life; dignity; achieving a sense of completion; having a good death; and abandonment. During transitions, patients want their oncologists to provide biomedical information, show that they care about them as individuals, and balance hope with realism. One study  identifies several communication strategies to accomplish this, including "ask-tell-ask" and "hope for the best, prepare for the worst." A number of patients are grateful for the opportunity to talk about questions of death, though they often have few opportunities because many patients find that the medical staff is afraid of or uncomfortable with talking about death and dying, which exacerbates feelings of isolation and separation.
Saying goodbye to patients is an area discussed in an article that provides practical suggestions for communicating with the patient at the end of life. The authors suggest that saying goodbye is an important way for the oncologist to achieve closure with the patient by acknowledging the importance of the relationship and expressing appreciation to the patient.
Strategies for Breaking Bad News
When existential concerns are translated to the clinical setting, the optimal method of breaking bad news becomes a primary concern. Breaking bad news abruptly has been found to increase its negative impact. Patients also report particularly negative reactions as a result of the following circumstances:
- News delivered over the telephone or in the recovery room.
- Doctors withholding information.
- Clinicians' failure to provide information about the availability of additional help.
- Information given bluntly and factually (e.g., "You have a terminal cancer and you have 6 months to live").
Patients also report that letters and tapes of the bad news consultation are helpful and may increase their level of satisfaction with and retention of the information provided.
One survey found that most physicians do not have a consistent plan or strategy for breaking bad news to their patients. Among a sample of physicians who attended an annual meeting of the American Society of Clinical Oncology, 22% reported that they did not have a consistent approach to the task of breaking bad news to patients, and 51.9% reported that they had several techniques or tactics but did not have an overall plan. Determining what patients believe to be important in the interaction may help refine the current guidelines and yield specific, evidence-based recommendations for facing this challenging task.