Physician challenges in communicating bad news.

Communicating bad news is never easy and for physicians these interactions may be a significant source of stress. To examine the characteristics that make delivering of bad news stressful, two studies were conducted. In the first study, 37 physicians generated 192 responses describing the characteristics that influence how difficult it is to break bad news. After sorting the responses in terms of common themes, six categories were identified: Physician, Patient, Institutional, Illness, Relationship, and Mishap. In Study 2, 115 physicians rated the degree of stress associated with each factor. Using principle component and reliability analyses, empirical support was found for six categories. A higher-order factor analysis suggested the existence of one over-arching factor. Items in the Mishap category were rated on average as the most stressful. Stress scores were largely unrelated to years in practice, experience delivering bad news or training.

Coherence and transituational generality in coping: the unity and the diversity.

We investigated the transituational coherence of coping strategy use by collecting coping data on multiple occasions, and assessing the effects of aggregation over varying numbers of occasions. Study 1 examined the effects of aggregating daily coping reports over three- and six-day periods. Study 2 extended the results of Study 1 by assessing the extent to which aggregation increased the correlation between a dispositional coping measure and daily coping reports. Both studies strongly supported the hypothesis that aggregation would enhance the consistency of coping preferences, suggesting some degree of coherence within the domain of coping strategy used. Aggregated coping reports correlated with each other at significantly higher levels (ranging from 0.46 to 0.77 in Study 1 and from 0.65 to 0.95 in Study 2), than unaggregated coping reports (ranging from -0.12 to 0.30 in Study 1 and from 0.12 to 0.53 in Study 2). Study 2 also showed that aggregated daily reports were better predictors of subsequent coping than scores derived from a standard dispositional coping survey.

Coping, distress, and marital adjustment in couples with cancer: an examination of the personal and social context.

We examined the links between coping and psychological outcomes in 53 patients who had undergone radiotherapy for cancer. Patients completed a coping survey and a measure of perceived support during a six-week course of radiation therapy and reported about their mental health and marital satisfaction one month following treatment. The prospective associations between coping and psychological distress and martial satisfaction depended upon the supportive context in which patients were coping. Seeking emotional support and using positive reappraisal were more effective (i.e., were significantly and positively correlated with marital satisfaction) for people low in spousal support than for people high in such support. Although men and women reported coping similarly with the cancer and had similar levels of adjustment, the association between coping and outcomes differed by gender; the associations for women were significantly stronger than they were for men. Results thus suggest that both individual and environmental characteristics moderate the associations between coping and outcomes in cancer survivors.

Self-reports of anxiety in burn-injured hospitalized adults during routine wound care.

The purpose of this investigation was to examine the amount of anxiety patients believed tolerable and the amount of anxiety experienced during routine burn wound care. Participants included 47 hospitalized adults who provided data for four consecutive assessment periods. Patients (mean TBSA, 16%; range, 2-70%) were primarily Caucasian (87%) and had an average hospital stays of 23 days (range, 11-130). Reports of what level of anxiety they would be able to tolerate and what level of anxiety had been experienced were assessed using 10-point Graphic Rating Scales. The use of anxiolytic was recorded, and patient suggestions for reducing anxiety were obtained. The single most commonly endorsed anxiety treatment goal was 0, although 53% consistently chose a treatment goal other than 0 (range, 1-6). Two repeated-measure analyses of variance indicated that the amount of anxiety patients could tolerate and the amount they reported experiencing did not change over the course of time. Paired t-tests revealed that patients routinely reported more anxiety than they considered tolerable. Analyses of anxiety reports of patients treated with anxiolytics (n = 6) vs patients receiving no anxiolytics (n = 41) revealed inconsistent differences in actual anxiety and treatment goals across time. In general, patient suggestions for lessening anxiety included requests for education, communication, additional medications, and manipulation of the hospital environment. Anxiety for burn-injured, hospitalized adults remains a concern. Our findings are consistent with the literature indicating that adult patients hospitalized for burn wound care report appreciable anxiety, over and above what they consider "tolerable." Continued research is needed and should include investigations into the relationship between pain and anxiety during routine wound care.

Comparison of patient satisfaction and self-reports of pain in adult burn-injured patients.

Procedural and background pain scores were assessed prospectively and compared with treatment goals and satisfaction scores in 84 adult (67 men and 17 women) burn-injured patients treated at a single, tertiary care medical center. We hypothesized that patient satisfaction with pain management plans would be highest among those patients who were experiencing the least pain and also among patients whose experiences most closely matched their treatment analgesic goals. Twice-weekly patient self-reports of worst and average procedural pain, background pain, treatment goals (the level of procedural pain and background pain patients reported that they would be satisfied as experiencing), and overall satisfaction with pain management plans were assessed using 10-point Graphic Rating Scales. Data concerning adjunctive treatments were also obtained. Opioid equivalents, representing pain medications administered, were compared. The majority of patients perceived that "no pain" during burn wound care was an unrealistic goal, a perception that was consistent throughout hospitalization. As hypothesized, average procedural pain levels demonstrated a negative association with patient satisfaction, indicating that patients with the highest levels of procedural pain also reported the lowest level of satisfaction. Opioid analgesic dosing was not significantly associated with ratings of procedural pain or treatment goals. Our findings support the hypothesis that patient satisfaction with pain management is highest in those who experience the least amount of burn care pain and do not support the hypothesis that satisfaction is highest in those whose pain experiences most closely match treatment analgesic goals.

The 2002 Lindberg Award. PRN vs regularly scheduled opioid analgesics in pediatric burn patients.

Very little has been published on treating acute pain in children younger than the age of 3 for burns or any other trauma etiology. This study prospectively monitored the pain behavior and opioid analgesic intake of 31 pediatric burn patients (mean age = 23.71 months; SD = 15.75). Twelve of those children were randomized to conditions in which they either received opioid analgesics pro re nata (ie, as needed, pain contingent) or on a regular basis. The two groups did not show differences in demonstrable pain but, interestingly, they received equivalent does of opioid analgesics. As such, the pro re nata group was likely medicated largely on a regularly scheduled basis. For most of the remaining (nonrandomized) subjects, physicians ordered regularly scheduled opioid analgesics, suggesting that this practice has become largely institutionalized in the study setting. Information on pediatric opioid analgesic dosing and pain measurement strategies for nonverbal subjects can be derived from the findings.

Acute stress disorder after burn injury: a predictor of posttraumatic stress disorder?

OBJECTIVES: The principal goals of this study were to determine whether ASD predicted chronic PTSD and whether dissociation is more characteristic of the acute-trauma period than PTSD symptoms. METHODS: Eighty-three hospitalized adult burn patients were assessed with structured interviews and self-report measures within 2 weeks of injury and again at least 6 months postburn. RESULTS: Nineteen percent had ASD. Dissociative symptoms were not more common or more severe than PTSD symptoms. Thirty-six percent had chronic PTSD. While ASD predicted chronic PTSD, meeting the symptom criteria for PTSD within 2 weeks postburn also predicted chronic PTSD. CONCLUSIONS: Our data support the inclusion of an ASD diagnosis in the DSM, which would allow the diagnosis of symptoms in the first month posttrauma as a psychiatric disorder but questions whether dissociation is more characteristic of the acute trauma period than the PTSD symptom clusters.

Physician interactions with families and caregivers after a patient's death: current practices and proposed changes.

There are little objective data concerning physician bereavement or other supportive interactions with the families and caregivers of deceased patients. We surveyed the physician staff of a large tertiary rural referral center in central Pennsylvania. We asked about current practices in attending former patients' funerals, family condolence visits, letter or phone contacts, as well as the desire of physicians to participate in these activities. The database consisted of 143 questionnaires that were returned from 286 physicians initially mailed the survey. Only 119 of the 143 had experienced patient deaths in their practices. Most of these 119 physicians did not participate in any type of planned contact with a former patient's family after the patient's death. Phone calls were used 39.6% after an inpatient death, and condolence notes were sent by about 40% of physicians. There was no correlation between these activities and number of deaths in the practice per year or if death occurred as an inpatient or outpatient. Physicians practicing at the medical center more than 10 years were more likely to contact the grieving family or caregivers. There was significant desire by the physicians to have an easy way to identify deceased patients' caregivers or loved ones, to have condolence notes available for the physicians' use, and to have bereavement service information sent to the families or caregivers.

Inpatient depression in persons with burns.

In this investigation the authors collected data regarding trait anxiety, well-being, and depression from 209 men and women who had been screened for prior psychiatric diagnosis and treated in an acute-care setting for burn injuries. Well-being was measured in reference to the month before the burn injury, whereas level of depression was self-rated by patients within 2 days of hospitalization, 5 days later, and 5 days after that. Ratings of depression were also obtained 1 month after hospital discharge. Results indicated that few patients rated their depression as severe at any point in time. Depression scores decreased significantly across the hospitalization period and were correlated with burn size, trait anxiety, and well-being. Depression ratings after discharge were significantly related to depression scores obtained at the end of the inpatient phase of the study. Although most patients did not report experiencing severe levels of depression, the stability of scores across time suggests the usefulness of early screening procedures. Catching such problems early may head off longer-term difficulties.

Patients' perceptions of receiving bad news about cancer.

PURPOSE: The purpose of this investigation was to document patients' recollections about what transpired during bad news interactions between physicians and themselves. PATIENTS AND METHODS: One hundred twenty cancer patients provided information about the most recent time they received bad cancer-specific news. Using a series of descriptive statements, patients reported on what the physician did while communicating the bad news. Patients also indicated the extent to which they were satisfied with the transaction and whether they believed that the interaction had any long-lasting impact on their adjustment or on their subsequent interactions with the physician who delivered the news. RESULTS: Overall, patients reported having similar experiences, with most physicians behaving in ways that were consistent with advice published in the medical literature. Satisfaction with the bad news transaction was high. Younger patients and women found the transaction to be more stressful, and older patients believed that the transaction was less important for subsequent interactions with the physician. Logistic regression analyses indicated that satisfaction with the transaction was uniquely predicted by factors related to the environment, to what the physician said, and to how the physician said it. CONCLUSION: Despite high levels of self-reported satisfaction by patients, some factors differentiated the most satisfied patients from patients who were less satisfied. The findings suggest that special attention should be given to making the environment comfortable, taking plenty of time with the patient, and attempting to empathize with the patient's experiences.

"I'm sorry to tell you ..." physicians' reports of breaking bad news.

In this investigation the authors assessed what physicians do when planning for and delivering bad news to patients. Seventy-three physicians responded to a series of statements about the behaviors, thoughts, and feelings they might have had while preparing for and delivering bad medically-related news. Data were also obtained about how well they thought the transaction had gone, how much stress they had experienced, and what they thought the experience was like from the patient's perspective. Physicians reported that these transactions were only moderately stressful, with 18.1% and 18.7% indicating that preparation stress or delivery stress, respectively, were above the midpoint on the scale. Slightly over 42% of the sample indicated that the stress they experienced lasted from several hours to three or more days. Thirty-six delivery-related statements were typical (with endorsement rates of at least 80% in a given direction) for at least one of the two recall groups.

Community integration after burn injuries.

Evaluation of community integration is a meaningful outcome criterion after major burn injury. The Community Integration Questionnaire (CIQ) was administered to 463 individuals with major burn injuries. The CIQ results in Total, Home Integration, Social Integration, and Productivity scores. The purposes of this study were to determine change in CIQ scores over time and what burn injury and demographic factors predict CIQ scores. The CIQ scores did not change significantly from 6 to 12 to 24 months postburn injury. Home integration scores were best predicted by sex and living situation; Social Integration scores by marital status; and Productivity scores by functional outcome, burn severity, age, and preburn work factors. The data demonstrate that individuals with burn injuries have significant difficulties with community integration due to burn and nonburn related factors. CIQ scores did not improve over time but improvement may have occurred before the initial 6-month postburn injury follow-up in this study.

Time off work and return to work rates after burns: systematic review of the literature and a large two-center series.

The literature on time off work and return to work after burns is incomplete. This study addresses this and includes a systematic literature review and two-center series. The literature was searched from 1966 through October 2000. Two-center data were collected on 363 adults employed outside of the home at injury. Data on employment, general demographics, and burn demographics were collected. The literature search found only 10 manuscripts with objective data, with a mean time off work of 10 weeks and %TBSA as the most important predictor of time off work. The mean time off work for those who returned to work by 24 months was 17 weeks and correlated with %TBSA. The probability of returning to work was reduced by a psychiatric history and extremity burns and was inversely related to %TBSA. In the two-center study, 66% and 90% of survivors had returned to work at 6 and 24 months post-burn. However, in the University of Washington subset of the data, only 37% had returned to the same job with the same employer without accommodations at 24 months, indicating that job disruption is considerable. The impact of burns on work is significant.

Rates, trends, and severity of depression after burn injuries.

It is commonly assumed that patients hospitalized for burn treatment will experience some level of depression. However, little is known about the trends in severity of depression over time. The purpose of this study was to determine the rates and severity of depression over a 2-year period. The Beck Depression Inventory was administered at 1 month (N = 151), 1 year (N = 130), and 2 years (N = 125) after discharge. At 1 month, 54% of patients showed symptoms of moderate to severe depression, and at 2 years, 43% of the patients responding still reported moderate to severe depression. The average correlation between scores over time was high. Women had higher depression scores than men at each time period. An interaction between gender and having a head or neck injury was also observed at 1 month and 1 year after discharge. Results suggest that routine outpatient screening for depression is warranted.

Masking effects of social desirability response set on relations between psychosocial factors and sport injuries: a methodological note.

Social desirability has long been viewed as a potential source of error variance in self-report measures. We suggest that social desirability (whether in the form of impression management or self-deception) has the capacity to mask relations between psychosocial variables and sport-related outcome or criterion measures that are not measured by selfreport. To illustrate what can occur, we present data from a longitudinal study in which life stress and psychological coping skills were studied as predictors of behaviorally-defined athletic injuries. When data from the entire sample of 352 athletes were analyzed, virtually no injury variance was accounted for by life stress, psychological coping skills, or their interaction. In contrast, deletion from the sample of athletes with high social desirability response set scores resulted in significant predictive relations involving both life stress and coping skills, as well as a significant moderator effect for coping skills. We propose that social desirability masking effects can significantly increase the likelihood of Type II errors in sports medicine research that involves self-report measures, and that social desirability responding needs to be controlled or minimized.

Describing and predicting the nature of procedural pain after thermal injuries: implications for research.

A prerequisite for studying and treating burn-related pain is the establishment of a good understanding of the nature of burn-related pain. However, in most investigations of pain, researchers have failed to examine pain over time or to create summary scores that capture differences in the nature of the pain experiences of individual patients. For 10 consecutive days, 47 patients treated for burn injuries reported on three aspects of procedural pain: worst pain, sensory pain, and affective pain. Three summary pain scores were constructed for each pain dimension: average pain, variability in pain, and linear change in pain. The authors found considerable variability in pain reports from the same patient and from different patients. Analyses indicated that pain reports decreased over time and that patients who had more trait anxiety reported more pain. Patients with larger burn injuries tended to report more affective pain and tended to have a pattern of high and low pain reports that differed from patients with less severe burn injuries. These findings suggest that adequate assessment of burn pain must occur frequently over the course of a single day, as well as for the duration of each patient's care.

The 2000 Clinical Research Award. Describing and predicting distress and satisfaction with life for burn survivors.

We investigated ratings of emotional distress and satisfaction with life at discharge from the hospital and at a 6-month follow-up in a multisite sample of 295 adults hospitalized for the care of a major burn injury. Several psychosocial variables (history of alcohol abuse, marital status, and previous mental health) and some medical variables (days of intensive care, pulmonary complications, and hand burns) accounted for significant variance in the prediction of outcomes. Brief Symptom Inventory (distress) scores were higher and Satisfaction With Life Scale scores were significantly lower than those of a normative population at both measurement points. The results show the utility of biosocial models in which psychological and physical variables interact to influence adjustment and quality of life.

Health care providers' perspectives on breaking bad news to patients.

This article reports the results of an investigation designed to obtain descriptive information about what typically transpires in bad news transactions between patients and physicians. A sample of 115 health care providers who were attending a 1-day workshop on palliative care issues responded to questions regarding bad news transactions between physicians and patients. Results indicated that giving the news in person, giving the news in a private place, having patient support providers present, and using a warm and caring tone are highly typical of bad news transactions, whereas exploring patient emotional reactions, relying on touch, delivering the news at the patient's pace, and providing written information are less typical. Nurses and physicians diverged in the perceptions about what typically transpires, suggesting that studies focusing only on physician reports or recommendations may be misleading. These data also point to the need to obtain other views of bad news transactions, and they argue for research designed to assess the relation between actual patient-physician encounters and subsequent patient-related outcomes.

Breaking bad news to patients: physicians' perceptions of the process.

The goal of this investigation was to gain a better understanding of the processes associated with communicating bad news to patients. A convenience sample of 38 physicians recalled a time when they delivered bad news and then answered a series of questions about what transpired. Data were also obtained about how well they thought the transaction had proceeded, how much stress they had experienced, and what they thought the experience was like from the patient's perspective. The majority of physicians reported following most of the published recommendations for delivering bad news. However, the number of recommendations followed was not correlated with self-reported stress and effectiveness in news delivery or with physicians' estimates of patients' distress. The number of recommendations followed could not be accounted for by the closeness of the relationship between physician and patient or by the gender composition of the bad news encounter. Overall, physicians reported that the transaction was moderately stressful for themselves, that the stress lasted beyond the recalled transaction, and that they were effective in delivering the news in a way that reduced patient distress. These findings suggest that the sampled physicians are generally following a substantial number of published recommendations when delivering very stressful news to patients. The primary weaknesses in the delivery process occur while preparing for the encounter. The fact that many of the physicians reported that their stress lasted beyond the transaction itself suggests that training in the delivery of bad news should include guidance on cognitive and behavioral coping strategies to help physicians deal with their own discomfort.

Parental relationships and coping with life stress.

Abstract The primary goal of this investigation was to explore how the quality of parent-student relationships relates to coping style by examining multiple aspects of this relationship-including support and conflict-and by examining the contribution that both parents' and students' perceptions of their relationship make to students' coping reports. We found that perceptions of conflict and depth in the parent-child relationship were each associated with different styles of coping. Moreover, parents' and students' perceptions each accounted for unique variance in students' coping reports. Greater perceived depth (both parent and student reports) predicted higher problem-focused scores, while students' perceptions of conflict predicted higher emotion-focused coping scores. Specific support provisions reported by students and parents also related differentially to the specific coping styles. Finally, the extent to which parents and students reported coping in a similar fashion was predicted by the quality of their relationship.