Hospital consultants breaking bad news with simulated patients: an analysis of communication using the Roter Interaction Analysis System.

OBJECTIVE: To explore how experienced clinicians from wide ranging specialities deliver bad news, and to investigate the relationship between physician characteristics and patient centredness. METHODS: Consultations involving 46 hospital consultants from 22 different specialties were coded using the Roter Interaction Analysis System. RESULTS: Consultants mainly focussed upon providing biomedical information and did not discuss lifestyle and psychosocial issues frequently. Doctor gender, age, place of qualification, and speciality were not significantly related to patient centredness. CONCLUSION: Hospital consultants from wide ranging specialities tend to adopt a disease-centred approach when delivering bad news. Consultant characteristics had little impact upon patient centredness. Further large-scale studies are needed to examine the effect of doctor characteristics on behaviour during breaking bad news consultations. PRACTICE IMPLICATIONS: It is possible to observe breaking bad news encounters by video-recording interactions between clinicians and simulated patients. Future training programmes should focus on increasing patient-centred behaviours which include actively involving patients in the consultation, initiating psychosocial discussion, and providing patients with opportunities to ask questions.

Pilot study to assess the credibility of acupuncture in acute exacerbations of chronic obstructive pulmonary disease.

BACKGROUND: Exacerbation of chronic obstructive pulmonary disease (COPD) is a common reason for hospital admission, and adjunctive non-pharmacological treatments would be welcomed. A pilot study was undertaken to assess the feasibility of conducting a study of acupuncture during an acute exacerbation of COPD. We also examined the credibility of a sham device in this setting and assessed the effect of acupuncture on breathlessness and anxiety. METHODS: A prospective, randomised, patient- and assessor-blinded, sham controlled study was conducted on three consecutive days in a district general hospital. Credibility of both acupuncture and the Park sham device were assessed using the Borkovec and Nau questionnaire. Dyspnoea was measured on the modified Borg score and a 10 cm visual analogue scale, while anxiety was measured on a 10 cm visual analogue scale. RESULTS: 11 patients were recruited and nine completed the study. There were no adverse events with either intervention. Acupuncture was well tolerated and credibility scores were similar before and after real and sham acupuncture. Symptoms improved after both treatments, with no significant difference between groups. CONCLUSION: In this pilot study acupuncture was well tolerated by subjects experiencing an acute exacerbation of COPD. Acupuncture treatment and the Park sham device were both credible. Although recruitment was slow, a further trial with a larger sample size is feasible and recommended.

Breaking bad news: consultants' experience, previous education and views on educational format and timing.

CONTEXT: Breaking bad news is a difficult task for health professionals. Senior hospital doctors acknowledge the importance of breaking bad news well, but previous surveys have found them to be sceptical of formal training and disinclined to seek courses in this area. We sought to ascertain if this view was still held. METHODS: A postal questionnaire was sent to 285 consultants across 3 acute hospital trusts in the Midlands, UK. Questions included items on the frequency and types of breaking bad news situations encountered, and the timing and modality of previous training. Open comment on what forms of education would be useful, and when, was requested. RESULTS: Eleven consultants were no longer in post. Of the remainder, 173/274 (63%) replied; 153 (56%) returned questionnaires of which 150 (55%) were useable. Respondents represented 32/33 (97%) of the surveyed specialties. The majority reported breaking bad news frequently (> 1-2 times weekly); however, almost half (49%) had received no formal training in this specific area, although 53% described having received experiential training in either clinical, training or management contexts. Of 118 respondents who commented, only 5 believed no form of training was useful, whereas 47 specifically recommended some form of role play. Regarding timing, 72 thought it desirable at postgraduate level or at all stages of training, with 44 explicitly stating at consultant level. CONCLUSIONS: Consultants in clinical specialties break bad news frequently. Although many have not received formal training, the majority believe it is useful and are increasingly willing to undertake experiential approaches. This augurs well for future training programmes.

Continuing Professional Development (CPD) in palliative medicine: a survey.

All doctors are required to undertake Continuing Professional development (CPD)--for good practice and for the purposes of annual appraisal and re-validation. The medical workforce in palliative medicine is diverse. Many doctors work on a part time basis, with the same CPD requirements as those working fulltime. This survey was undertaken: to establish whether doctors had fulfilled their CPD requirements in the year 2001-2002 and to identify problems or difficulties experienced by doctors in undertaking CPD. A questionnaire was sent to all doctors known to be working in non-training posts within palliative medicine in October 2002, requesting information on CPD undertaken between 1 April 2001 and 31 March 2002. Questions were also asked regarding knowledge and understanding of appraisal and revalidation. The response rate was 53% (381/721). Palliative medicine was the main post for 276 (72%) respondents and 169 were on the specialist register (44%). The subgroup most likely to have fulfilled CPD requirements were those on the Specialist Register (64%), and those least likely were those holding a contract with a charitable organisation (33%). Less than half of those not on the specialist register understood CPD and revalidation requirements. Overall, only 43% of respondents were meeting CPD requirements (median 25 credits; range 5-375 hours). This study has highlighted widespread barriers to the successful planning, participation in, and recording of, CPD for palliative medicine doctors, with those who are not on the specialist register appearing to be particularly disadvantaged. Individual doctors' information needs need to be addressed, but organisational support for CPD is also required. We believe many of these issues also apply in other specialities.

Does it hurt to know the worst?--psychological morbidity, information preferences and understanding of prognosis in patients with advanced cancer.

BACKGROUND AND METHOD: Many doctors, while offering open discussion of diagnosis and treatment to cancer patients, still express concern about the psychological impact of discussing a poor prognosis. In this study, 106 advanced cancer patients were interviewed at home. The interview included open discussion and structured questionnaires: the Hospital Anxiety Depression Scale and Rotterdam Symptom Checklist. Participants were asked about information preferences, worries and unanswered questions. The interviewer (M.B.) rated "Understanding of diagnosis and of prognosis". RESULTS: A majority of participants (78%) demonstrated a good understanding of their diagnosis and were consistent with their information preference. On prognosis, 54% of those desiring information (49% of overall group) were fully aware; a further 22% were aware but unrealistic about time-scale. Although most were satisfied with their level of knowledge, 28% had further questions, particularly concerning "mode of disease progression" (n=25), "mode of death" (n=13) and prognosis (n=18). When understanding of prognosis was compared with psychological distress, a significant difference was observed between those with realistic versus unrealistic time-scales. However, this could be explained by increasing physical symptoms. CONCLUSIONS: Patients with advanced cancer have a good understanding of their diagnosis but many do not fully understand their prognosis. Although patients with deteriorating health are more likely to be psychologically distressed, awareness of prognosis does not itself cause depression. Doctors should be aware of patients' ongoing but often unvoiced concerns and prepared to explore these with them.

Aspects of caring for dying patients which cause anxiety to first year student nurses.

AIM: To examine what aspects of caring for dying patients cause anxiety in student nurses during their first year of training. DESIGN: Qualitative descriptive study. SETTING: A university in the UK delivering preregistration nurse education. METHOD: A purposive sample of 38 student nurses who had just completed their first year of their programme consented to participate in the study. Data triangulation was employed, with data collected from students' reflective diaries and two focus group meetings. FINDINGS: Eight themes emerged relating to students' anxiety about caring for dying patients: coping with the physical suffering of patients: what to do or say; the severing of the relationship with the patient; the type of death; cardiopulmonary resuscitation; last offices; coping mechanisms; and interventions that would improve the student experience. CONCLUSION: Findings from the study suggest that it is aspects of the caring role, rather than personal fear of death, that form the source of much of students' anxiety.

Effect of breaking bad news on patients' perceptions of doctors.

The breaking of bad news is a routine but difficult task for many health professionals. There are numerous anecdotes of insensitive practice but the subject has attracted little systematic research. We therefore interviewed 106 patients with advanced cancer (from an original sample of 195) to assess their perceptions of the doctors involved in their care. Aspects of the 'breaking bad news' event were recorded during discussion of the illness history and were subsequently rated. Participants were also asked to nominate doctors under the headings 'most helpful' and 'less helpful', and completed standardized psychological screening questionnaires. In 94 of the 106 cases the bad news had been given by a doctor, usually a surgeon. Of the 13 doctors categorized as 'most helpful' when breaking bad news, 8 were general practitioners; of the 7 categorized as 'less helpful' all were surgeons. 69% of patients were neutral or positive about the bad-news consultation, but 20% were negative and 6% very negative. Doctors in surgical specialties were significantly more likely to be rated poorly than non-surgical specialists or general practitioners. Surgeons were the group of doctors most likely to break bad news, but non-surgical doctors were rated more positively in performance of the task. This finding has implications for training.

Out-of-hours palliative care in the UK: perspectives from general practice and specialist services.

Palliative care within the community requires well coordinated multidisciplinary teamworking, involving both primary and secondary care practitioners. 'Out-of-hours' periods are a potentially problematic time for delivery of high quality care. We report on two national surveys-one of medical directors of out-of-hours general practitioner cooperatives, the other of medical directors of specialist palliative care units. The aim was to describe general practitioners' and specialists' perspectives on the availability and scope of community nursing and specialist palliative care services. The results point to wide variation in service provision within the community. The two groups differed strikingly in their perceptions, the general practitioners being much less positive than the specialists about the availability of specialist advice and admission to specialist units out of hours. Equitable out-of-hours palliative care services of high quality are unlikely to be achieved without dialogue between primary and secondary care based providers, local needs assessment and adequate resourcing.