Patients and caregivers may present with different needs, making it difficult to decide whose needs take priority. This situation is especially common when it comes to truth-telling, with family members asking the health care team to keep bad news a secret from the cancer patient, or vice versa.
The level of evidence required for informed decision making about genetic testing depends on the circumstances of testing. Evidence from a sample of high-risk families may be sufficient to provide useful information for testing decisions among people with similar family histories but is likely to be insufficient to make early recommendations for, or decisions about, testing in families with less dramatic histories or in the general population. Even among people with similar family histories, however,...
Cultural differences can profoundly affect communication with the patient and family. For example, some Asian Americans believe that talking about death or dying is bad luck. Such differences complicate discussions about prognosis, treatment choices, and even the use of terms such as chemotherapy, radiation, and hospice. Keeping a life-threatening diagnosis a secret from the patient and avoiding discussions of disease progression further add to a caregiver's sense of burden, isolation, and responsibility.
Breaking Bad News
Delivering bad news to patients and caregivers is an essential skill for oncologists, palliative care physicians, and other members of the health care team. To do this well, the physician should:
Become comfortable with end-of-life issues.
Understand the range of options available for families.
Let caregivers know what can, rather than what cannot, be done for the patient.
Share and receive information in a compassionate manner.
Oncotalk is a teaching program designed to improve communication skills for postgraduate medical trainees. The program covers essential communication skills such as the "Ask-Tell-Ask" principle and the "Tell me more" principle, and communication tasks are linked to the illness trajectory:
The first visit.
Making anticancer treatment decisions.
Offering clinical trials.
Completing anticancer therapy.
Discontinuing palliative chemotherapy.
Responding to Difficult Situations
Family caregivers may believe that their concerns are inevitable and their needs cannot be met. In an ideal setting, the social worker or psychologist should be present at meetings with family caregivers to assist with follow-up and support.
Just as a patient's family can appoint a spokesperson, the oncology team can designate a family liaison. However, most family caregivers prefer direct access to the treating oncologist; in fact, active listening by physicians may reduce caregiver burden. One study found that caregivers experienced less burden and distress if they felt that the treating physician listened to their needs and opinions. The oncology team should maintain frequent communication to ensure that messages and other information delivered to the family are consistent and that treatment goals are clear to all concerned.
Responding to Family Conflict
Some families may have less-than-optimal internal relationships, which may lead to communication difficulties within the family and with health care professionals. Many families are not happy, tight-knit units, and the stress of caring for a relative with cancer can reignite unresolved conflicts or create new conflicts. It may be beyond the scope of the oncology team to resolve long-standing family conflict. Use of the family meeting and one family-appointed spokesperson as a communication liaison with the oncology team can help to ameliorate some of these difficulties.