Patient-centered care: the key to cultural competence.

Much of the early literature on 'cultural competence' focuses on the 'categorical' or 'multicultural' approach, in which providers learn relevant attitudes, values, beliefs, and behaviors of certain cultural groups. In essence, this involves learning key 'dos and don'ts' for each group. Literature and educational materials of this kind focus on broad ethnic, racial, religious, or national groups, such as 'African American', 'Hispanic', or 'Asian'. The problem with this categorical or 'list of traits' approach to clinical cultural competence is that culture is multidimensional and dynamic. Culture comprises multiple variables, affecting all aspects of experience. Cultural processes frequently differ within the same ethnic or social group because of differences in age cohort, gender, political association, class, religion, ethnicity, and even personality. Culture is therefore a very elusive and nebulous concept, like art. The multicultural approach to cultural competence results in stereotypical thinking rather than clinical competence. A newer, cross cultural approach to culturally competent clinical practice focuses on foundational communication skills, awareness of cross-cutting cultural and social issues, and health beliefs that are present in all cultures. We can think of these as universal human beliefs, needs, and traits. This patient centered approach relies on identifying and negotiating different styles of communication, decision-making preferences, roles of family, sexual and gender issues, and issues of mistrust, prejudice, and racism, among other factors. In the current paper, we describe 'cultural' challenges that arise in the care of four patients from disparate cultures, each of whom has advanced colon cancer that is no longer responding to chemotherapy. We then illustrate how to apply principles of patient centered care to these challenges.

Communication training in oncology: results of intensive communication workshops for Italian oncologists.

The primary aim of this study was to evaluate the efficacy of a 3-day communication course model for senior Italian oncologists. The course, initially designed for US oncologists, was modified to address specific educational areas expected to be relevant to the targeted participants. Five 3-day intensive communication courses were held for oncologists from different geographical regions in Italy. The courses included formal lectures, small group work, role play and interviews with simulated patients. Participants completed questionnaires before and after the 3-day workshop. An improvement in self-efficacy, knowledge of communication skills, favourable changes in attitudes towards disclosure of medical information and assessing patients' concerns and fears were demonstrated at the end of the course. The course was feasible and succeeded in improving parameters associated with effective communication behaviours.

The psychologic distress in patients with cancer.

The psychologic distress in patients with cancer may be divided into three categories; depression, anxiety and neuro-cognitive changes including delirium. The supportive interventions of health care professionals along with the use of psychotropic medications have been shown to relieve depression, anxiety, and states of confusion in oncology patients. Oncology nurses are in a critical position to identify problems and intervene to provide appropriate symptom relief. The management of psychologic distress may improve adherence to treatment programs, reduce toxicity, achieve a better quality of life, and enhance grace and dignity at the end of life.

Communication skills: breaking bad news in the clinical setting.

Oncology nurses need to develop expert communication skills, especially when delivering bad news to patients and families. Patients and families differ in their needs for levels of information, interpretation of information delivered to them, and responses to unfavorable news. When bad news is delivered in a sensitive and caring manner, morale can be maintained, and the process of coming to terms with illness or death is possible through realistic expectations and hope. It is valuable for nurses to elicit patients' or family members' understanding of what is happening to them, and what they need is key in the process of communicating in a crisis time. Also, skill in responding to feelings and not the content of expression is necessary to the process of recovery. So many improved cancer treatments exist, but the goal of effectively communicating bad news with respect and caring is just as important as treating the person who happens to have cancer.

Breaking bad news about cancer: patients' preferences for communication.

PURPOSE: The goal of this study was to assess patients' preferences regarding the way in which physicians deliver news about their cancer diagnosis and management. PATIENTS AND METHODS: A sample of 351 patients with a variety of cancers completed a measure assessing their preferences for how they would like to be told news about their cancer. Patients rated characteristics of the context and content of the conversation as well as physician characteristics. RESULTS: Factor analysis indicated that patients' preferences for how they would like to be told news regarding their cancer can be grouped into the following three categories: (1) content (what and how much information is told); (2) facilitation (setting and context variables); and (3) support (emotional support during the interaction). Women (P =.02) and patients with higher education (P =.05) had significantly higher scores on the Content scale, women (P =.02) had higher scores on the Support scale, and younger patients (P =.001) and those with more education (P =.02) had higher scores on the Message Facilitation scale. Medical variables were not associated with patients' ratings of the importance of the three subscales. CONCLUSION: Patients rated items addressing the message content as most important, though the supportive and facilitative dimensions were also rated highly. Understanding what is important to patients when told news about their cancer provides valuable information that may help refine how this challenging task is best performed.

SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer.

We describe a protocol for disclosing unfavorable information-"breaking bad news"-to cancer patients about their illness. Straightforward and practical, the protocol meets the requirements defined by published research on this topic. The protocol (SPIKES) consists of six steps. The goal is to enable the clinician to fulfill the four most important objectives of the interview disclosing bad news: gathering information from the patient, transmitting the medical information, providing support to the patient, and eliciting the patient's collaboration in developing a strategy or treatment plan for the future. Oncologists, oncology trainees, and medical students who have been taught the protocol have reported increased confidence in their ability to disclose unfavorable medical information to patients. Directions for continuing assessment of the protocol are suggested.

Communication skills training in oncology. Description and preliminary outcomes of workshops on breaking bad news and managing patient reactions to illness.

BACKGROUND: Cancer clinicians do not receive routine training in the psychosocial aspects of patient care such as how to communicate bad news or respond to patients who have unrealistic expectations of cure. Postgraduate workshops may be an effective way to increase interpersonal skills in managing these stressful patient encounters. METHODS: The authors conducted 2 half-day workshops for oncology faculty, one on breaking bad news and one on dealing with "problem situations." Participants met in a large group for didactic presentations and then small groups in which they used role-play and discussion to problem-solve difficult cases from their practices. The small groups were assisted in their work by trained physician facilitators. The workshops were evaluated by means of a follow-up satisfaction questionnaire as well as a self-efficacy measure, which was administered before and after the workshops. RESULTS: Twenty-seven faculty and 2 oncology fellows participated in the training programs. Satisfaction questionnaires showed that the programs met the educational objectives and were considered to be useful and relevant by the participants. Self-efficacy questionnaires revealed an increase in confidence in communicating bad news and managing problem situation cases from before to after the workshop. The majority of attendees welcomed the opportunity to discuss their difficult cases with colleagues. A number resolved to implement newly learned approaches to common patient problems they encountered frequently. CONCLUSIONS: Communication skills workshops may be a useful modality to provide training to oncologists in stressful aspects of the physician-patient relationship. Further research is needed to assess whether long term benefits accrue to the participants.

Discussing disease progression and end-of-life decisions.

Because most patients now want to know the truth about their diagnosis and prognosis, the ability to discuss the cancer diagnosis, disease recurrence, or treatment failure, and to solicit patients' views about resuscitation or hospice care, are important verbal skills for oncologists and other oncology health care providers. Moreover, the ability to clearly articulate a treatment plan or elicit patient preferences for treatment are a prerequisite to informed consent. Despite these imperatives, clinicians do not routinely receive training in key communication skills that could enable them to accomplish these tasks. A body of literature is available, however, that identifies communication strategies that can (1) facilitate the establishment of a close rapport with the patient, (2) identify the patient's information preferences, (3) ensure comprehension of key knowledge and information, (4) address the patient's emotions in a supportive fashion, (5) elicit the patient's key concerns, and (6) involve the patient in the treatment plan. In this article, we use dialogues between a physician and a hypothetical patient with advanced ovarian cancer to illustrate how communication techniques can be applied to accomplish these goals. We identify important benefits of the use of these techniques for both the physician and patient, and pose several questions regarding the training of physicians in this area.

Intention to learn results of genetic testing for hereditary colon cancer.

INTRODUCTION: This report investigates the correlates of intention to find out genetic test results in colorectal cancer patients undergoing genetic counseling and testing for hereditary nonpolyposis colon cancer. Specifically, we investigated whether intention to learn genetic test results was associated with sociodemographic factors, medical history, psychosocial factors, attitudes, beliefs, and decisional considerations related to genetic testing. MATERIALS AND METHODS: Among 342 colorectal cancer patients who went through an informed consent process and gave blood for genetic testing and who were eligible for a psychosocial questionnaire study, 269 cases completed a baseline interview. Patients were contacted in person during a routine clinic visit or by letter and follow-up telephone call and were interviewed either in person or by telephone. RESULTS: In univariate analysis, intention to learn test results was positively associated with income, quality of life, a belief that being tested will help family members prevent cancer, being worried about carrying an altered gene, and a belief that one has the ability to cope with test results. It was negatively associated with a belief that genetic counseling is too much trouble relative to the benefits. Intention also was positively associated with scales measuring the pros of learning test results and the pros of informing relatives about test results; it was negatively associated with the cons of learning test results. In multivariable analysis, the belief that testing would help family members prevent cancer, being worried about carrying an altered gene, and the pros of learning test results remained statistically associated with intention when other variables were included in the model. CONCLUSIONS: Our findings showed that the positive aspects of genetic testing were more strongly associated with intention than were the negative aspects. They also showed that persons who stated an intention to learn their genetic test results were more likely than persons who did not to affirm both the benefits and the importance of such testing. These results are consistent with the literature on psychosocial aspects of genetic testing for breast cancer.

When the care giver needs care.

Case studies are used to illustrate family dysfunction that can occur when the wife and/or mother who has assumed the role of primary care giver is diagnosed and treated for cancer. These women were treated by the liaison psychiatrist and social workers at a large cancer center. The cases are discussed from a framework of family systems theory. Treatment implications for social workers in health care are also presented.

Improving physician-patient communication in cancer care: outcome of a workshop for oncologists.

BACKGROUND: Physicians caring for cancer patients receive little formal training in difficult communications such as breaking bad news, discussing life support, and addressing patients' emotional concerns. METHODS: The authors conducted a three-day workshop in communication skills for nine oncology attendings and three fellows. Topics for the workshop were selected by participants by a pre-workshop questionnaire. Small groups of four to five participants interviewed simulated patients who role-played scripts based on the selected topics. Sessions on self-awareness and one on planning for continuing the work of the group after the workshop were included. RESULTS: Responses to pretest and posttest questionnaires showed that the workshop increased the participants' confidence in a number of communication areas and also in managing physician burnout. Process issues such as patient death and expectations for cure were also discussed. CONCLUSION: Interactive workshops offer a promising way of teaching communication skills and aspects of the physician-patient relationship to oncologists. Conclusions regarding outcome, however, are preliminary and tentative, and long-term results are uncertain.

An ovarian cancer support group.

PURPOSE: Because of the low rate of cure and high rate of relapse, the disease course of ovarian cancer can be emotionally devastating. Using psychological interventions to support patients emotionally and to enhance their quality of life should therefore be considered an important complement to medical care. OVERVIEW: The authors describe a support group for patients with ovarian cancer, which was conducted over a 2-year period. The group consisted of patients with poor prognoses whose experience ranged from initial medical treatment, remission, and relapse to the dying experience. Key themes that arose during the sessions are identified, and differences between psychotherapy groups and support groups are highlighted. In contrast to psychotherapy groups, existential issues stood out as the most important therapeutic factor in this support group. CLINICAL IMPLICATIONS: Because it is widely acknowledged that support groups have unique value in the total care of women with ovarian cancer, this description of issues related to group process hopefully will assist others who may plan to offer this type of psychological intervention for patients. With increasing technology and the resulting extension of life for patients with ovarian cancer, support groups like this may become an important aspect of care to enhance quality of life. The multidisciplinary team, including psychiatry, social work, nursing, and chaplaincy, is essential in expanding support groups in healthcare settings.

Terminally ill cancer patients. Their most important concerns.

PURPOSE: When the goal of treatment is palliative, the most important outcome is improving patient quality of life. The authors describe the major concerns of terminally ill cancer patients with a prognosis of 6 months of less. OVERVIEW: In phase I of this three-part study, 74 terminally ill patients were interviewed to identify their major concerns. In phase II, interviews with 120 terminally ill cancer patients showed that their most important concerns encompass existential, spiritual, familial, physical, and emotional issues. Phase III will determine the validity and reliability of a quality-of-life scale based on these patients' most important concerns. The information presented here summarizes the results of interviews from phases I and II. CLINICAL IMPLICATIONS: Patients were receptive to being interviewed and remarked on the relevance and importance of these issues to their own experience. Several patients commented that although their disease was assessed and reassessed throughout their care, the existential, spiritual, familial, and emotional aspects of their illness rarely were a focus of their care. Healthcare professionals can create an atmosphere in which these patients feel comfortable exploring the quality-of-life issues that are most important to them. The systematic assessment of patient concerns about quality of life may complement disease assessment and facilitate referrals to appropriate members of the healthcare team. The wide range of concerns reported suggests that a team approach, including physicians, nurses, social workers, psychiatrists, psychologists, and chaplains, is the most effective way to meet the needs of terminally ill patients.

Correlates of psychologic distress in colorectal cancer patients undergoing genetic testing for hereditary colon cancer.

In this article the authors describe the demographic and psychosocial correlates of 2 measures of psychologic distress among 200 colorectal cancer patients undergoing genetic testing for hereditary nonpolyposis colon cancer. The prevalence of symptoms of depression on the Center for Epidemiologic Studies Depression (CES-D) Scale was 24%. In multivariate analysis, female sex, less formal education, fewer sources of social contacts, and less satisfaction with them were associated with high scores on the CES-D Scale. Characteristics associated with high scores on the State-Trait Anxiety Inventory were younger age, less formal education, non-White race, local-regional stage of disease, fewer social contacts, and less satisfaction with them. Information on psychosocial correlates of psychologic distress may prove useful in guiding genetic counseling sessions, in identifying subgroups that need more intensive follow-up, and in developing interventions to facilitate adjustment to genetic test results.

A retrospective study of the psychiatric management and outcome of delirium in the cancer patient.

This report describes the evaluation and treatment of delirium in the cancer patient in a major comprehensive cancer center. Ninety consecutive cases of delirium seen by the inpatient psychiatry consultation/liaison service were analyzed in a retrospective fashion to evaluate demographic information, alcohol use, central nervous system disease, coexisting medical disease, and past psychiatric history. Delirium cases were divided into hyperalert, hypoalert, and mixed subtypes. For these three subtypes, medication profiles including dose of medication, duration of delirium, outcome, and the venue where the delirium began were also evaluated. The hyperalert subtype of delirium was the commonest type observed (71%) and had the shortest duration (P < 0.0001) and best outcome (P < 0.001). The patients with a hyperalert delirium subtype were treated with the least amount of haloperidol (P < 0.0001). Patients were delirious for longer when the delirium began in the intensive-care units (P < 0.04). In general, patients who received no haloperidol experienced delirium of longer duration (P < 0.02) than those receiving haloperidol. Since the data represent patients who were referred for psychiatric treatment, this may explain the increased number of hyperalert deliriums and, therefore, the generalizability of the results is limited. Delirium in the cancer patient is particularly problematic given the coexisting medical problems these patients experience. Because the outcome of delirium is better when the duration is shorter, it is important for clinicians to be sensitive to early symptoms so that treatment can be implemented faster, leading to less morbidity and mortality.

Neuropsychiatric disorders in cancer patients.

Cancer and cancer treatments can directly affect the central nervous system and cause acute and chronic cognitive and emotional disturbances that have important implications for the quality of life of the patient. The literature in this area, however, has suffered from a lack of sound prospective studies and because clinical trials of cancer treatments have rarely incorporated formal neuropsychiatric assessments. This review describes recent findings on the central nervous system effects of cancer chemotherapy and treatment with immunologic agents. It also discusses several neuropsychiatric disorders seen in cancer patients that often represent diagnostic and therapeutic dilemmas.

Influence of physician communication on newly diagnosed breast patients' psychologic adjustment and decision-making.

BACKGROUND: Physician-patient communication is of critical importance when a breast cancer diagnosis is made, because the emotionally overwhelmed patient must be educated about her disease and available treatments so she can participate in decisions about her care. A research study addressed the hypothesis that patients whose surgeons used psychotherapeutic techniques during the cancer diagnostic interview would have better psychologic adjustment to their cancer. METHODS: One hundred women surveyed 6 months after surgery completed the Cancer Diagnostic Interview Scale (CDIS) and the SCL-90-R, a measure of psychologic well being. RESULTS: Factor analysis of the CDIS revealed that the physician's caring attitude was perceived by the women as most important, with information-giving as a much weaker component. Multiple regression analysis supported the hypothesis that psychologic adjustment was predicted by physician behavior during the cancer diagnostic interview. Other significant predictors of adjustment were a history of psychiatric problems and premorbid life stressors. CONCLUSIONS: Provision of information needed for decision-making appears to be valued largely within the context of a caring physician-patient relationship. Specific surgeons' behaviors believed to facilitate patient adjustment include expressing empathy, allowing sufficient time for patients to absorb the cancer diagnosis, providing information, and engaging the patient in treatment decision-making.