Communication preferences and needs of cancer patients: the importance of content
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- Surbone, A. Support Care Cancer (2006) 14: 789. doi:10.1007/s00520-006-0027-8
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This issue of Supportive Care in Cancer features an article by Drs. Chiu, Lee, Gao, Parker, Ng and Toh on “Cancer patients’ preferences for communication of unfavourable news: an Asian perspective” . The authors report the results of a questionnaire survey of 200 cancer patients awaiting treatment or attending follow-up appointments at the National Cancer Center in Singapore. Patients agreed to complete the Measure of Patients’ Preference questionnaire developed by a team of four oncologists, a psychiatrist, a clinical psychologist and a health psychologist, with additional input from five cancer patients . The questionnaire consisted of 32 statements concerning different aspects of the patient–doctor interaction during communication of bad news. These statements, originally formulated in English, had been translated into Mandarin by two bilingual research assistants for the Mandarin-speaking patients. In addition to standard expert translation, the questionnaire was modified to be culturally sensitive. The questionnaire was especially mindful of the widespread use of euphemisms in some cultures , including the culture in Singapore, and the word “cancer” was at times replaced by the term “condition” . To assure comprehension of the questionnaire, research assistants were available on-site to clarify questions to patients when necessary. Patients were asked to rate the importance of each statement on a 1 to 4 scale .
The results of this study of Asian patients’ preferences regarding receiving troubling news show that of the ten items receiving the highest ratings, seven were related to the expertise of the physician and to the content of the information provided. On the contrary, only three items were related to the facilitative and supportive aspects of communication. According to the authors’ principal factor analysis, the statement “Doctor is honest about the severity of my condition” had the largest loading on the first factor and all items loaded onto the first factor related to content and facilitation of the communication process, rather than to its supportive dimension. The authors found that female gender was a predictor for the support subscale, and that women in the study rated the supportive aspects of patient–doctor communication regarding bad news higher than men did .
These results are in keeping with published data showing that patients from diverse cultural contexts tend to consistently rate at the highest level of importance physicians’ expertise and honesty in delivering detailed information, and in answering their patients’ questions about diagnosis, result of tests, treatment options and prognosis . As the authors state, their results do not imply that patients would dismiss the supportive elements of communication of bad news as “irrelevant”. However, their results clearly tell us what counts the most for today’s cancer patients: the ability to trust their doctor’s professional competence and honesty. From this study, we also learn that patients’ preferences in the matter of receiving communication of bad news seem to be very similar across cultures, at least for those patients treated at major institutions worldwide who are already acquainted with being told the truth about their cancer and with informed consent procedures.
Since the early 80s and early 90s, when the first reports of different truth-telling attitudes and practices worldwide were published in the international medical and bioethics literature, we have witnessed the proliferation of empirical and theoretical studies on the subjects of truth telling to cancer patients and of delivering bad news. We have learned about the evolution of truth-telling attitudes and practices worldwide and about the persistence of partial or non-disclosure in different cultural contexts [16, 20]. We have read extensively the importance of acquiring communication skills and of developing cultural competence [4, 9]. We have been taught by the insightful words of many of our colleagues worldwide that cultural sensitivity is made of respect and curiosity about different ways of communicating with patients in different cultural contexts. In particular, we have come to understand that there is no right to any form of cultural hegemony and no room for being judgemental or for stereotyping [14, 19]. We have read that words do not have the same meaning and resonance in all cultures, that uttering a “bad word” is considered to negatively affect patients in certain cultures, and that in other cultures, words such as “cancer “ or “depression” do not even exist [6, 15]. We have become acquainted not only with different communication styles but also with different views of the roles that family and physicians assume in different cultures with respect to cancer patients [1, 8, 12, 17]. We have learned that in specific clinical circumstances, we can use euphemisms, and that we can’t always ignore families’ requests to withhold or to mitigate the truth about a cancer diagnosis or prognosis . In fact, we need to constantly negotiate cross-cultural issues with patients and their families . We have learned that there are individual differences in communication preferences, which go beyond cultures and are rather related to gender, age and education, and that individual patients’ needs and preferences may vary over the course of their illness [5, 10]. We have explored specific gender-related differences in patterns and styles of communication, and found that women tend not only to appreciate more detailed information but also to value the supportive elements of communication more than men do . We have understood from reports worldwide that cancer patients treated at large specialised institutions are more likely to request full disclosure of their diagnosis, treatment options and prognosis from their physicians than patients whose care occurs in non-specialised or rural centres [2, 3, 21, 22]. We have established that an appropriate level of information is necessary to foster patients’ understanding of their illness and thus to enhance their cooperation with standard oncologic treatments and experimental therapies, leading to better quality of care and to better quality of life for them [3, 9, 11].
Along the way, however, we may have underestimated that, once our patients choose to be told the truth, first they demand and expect from their physicians the highest degree of expertise and thoroughness about the content of communication. Reminding us of the importance of “content” is a major contribution of the study published in this issue of the Journal Supportive Care in Care by Drs. Chiu et al. The patient–doctor relationship arises when a person experiencing symptoms and signs of an illness consults a fellow human being as a professional expert to help her in decoding and interpreting her suffering. Through their knowledge and expertise, physicians establish the diagnosis, formulate the prognosis and prescribe the appropriate treatment measures. In the patient–doctor relationship, the cognitive dimension runs parallel with an equally important dimension of caring that is based on empathy, respect and justice. Proper communication of the truth with one’s patients involves both expertise and empathy. Content and supportive aspects of communication influence each other reciprocally and thus need to be properly balanced, according to the patient’s individual and cultural preferences and contexts.