As described above, cultural background greatly influences many aspects of the communication process. Although some cross-cultural descriptive studies have been conducted, especially on the views about disclosure of the diagnosis, relatively little is known about the specific influence of culture on the interaction between patients and their health care practitioners. How cultural variables might affect the information patients want, patients' preferred and assumed participatory styles, and other aspects of the interaction warrant future study.
The Patient's Family
Families can help patients make better decisions about their care. Some therefore believe that patient-centered approaches emphasizing patient autonomy in medical decision making should be shifted to family-centered approaches because most decision making in health care is carried out in the context of family care and obligation.
Health care professionals are valued when they establish a structured and ongoing dialogue with family members about treatment goals, plans of care, and expectations regarding patient outcomes. Caregivers report that specific and tailored direction is supportive and reduces the uncertainty they experience as they provide care. Family caregivers must be considered an integral part of the advanced cancer care partnership. In one investigation, being welcomed into the medical setting was a simple action, greatly appreciated by caregivers, allowing them to move on with unfolding events. In taking a legitimate place in the cancer scenario, caregivers may more easily attend to their own needs alongside those of the patient. Ideally, however, the physician should check with the patient to determine his or her desires about the level of involvement in making decisions that caretakers should have.
(Refer to the PDQ summary on Family Caregivers in Cancer: Roles and Challenges for more information.)
Other Communication Barriers
Unless directly invited, many patients are often reluctant to ask important questions about their disease and its treatment. Some researchers have found that indirect cues signaling informational and emotional needs are far more common from patients than direct requests for information or support. Concomitantly, doctors readily respond to direct expressions of need but find it difficult to detect and respond to indirect behaviors cueing patient needs. The indirect forms of communication that are particularly difficult for many doctors to apprehend are allusions, paraverbal expressions (e.g., auditory pitch and tone), and nonverbal behaviors (e.g., facial expression and posture). Patients may assume that their doctors will tell them whatever is relevant; others worry about appearing foolish if they reveal their ignorance by asking questions; and some feel guilty about taking too much of the busy doctor's time.[25,26] In the absence of explicit discussion, physicians may make incorrect assumptions and unilateral decisions about patients' information needs and preferences, incorrectly assessing their own information-giving behavior. Other barriers to communication may include the multiple specialists that patients see; the multiple clinicians and others that the patient may see within the treatment team (e.g., physician, mid-level practitioner, nurse, billing office clerk, patient advocate); the challenges posed by variations in education level, cultural differences, and ethnicity; and the anxiety that often accompanies an initial or high-stakes interview (e.g., disclosure of restaging results), which may affect patient comprehension and understanding.