Effective communication is a part and parcel of any successful patient care. Today we know that preserving hope is one of the factors, among many others, that play a crucial role in the healing process [1]. Physicians clearly have a huge impact on the patient’s level of hope, hence the need to create a set of guidelines to help them preserve hope even when bringing bad news is essential.

Disclosing a diagnosis of terminal illness may destroy hope, and therefore enhance suffering [2]. Nevertheless, even in the new era of shared decision-making, insufficient guidance continues to cause physicians difficulties in communicating with patients, particularly when disclosing bad news. Not long ago, in the 1960s, 90% of the oncologists surveyed in a study said they would not disclose cancer diagnosis to their patients. Two decades later, 97% of physicians preferred telling the truth to patients [2].

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Communication guidelines needed
I have conducted a literature review to gain a deeper understanding of existing knowledge regarding the importance of hope in the context of communicating bad news in advanced cancer care. My aim was to form an overarching view of the subject, allowing future researchers to develop communication guidelines for physicians, ultimately enhancing the quality of treatment and patient consultations.

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Exploring patients’ perceptions
The findings of the research demonstrate that exploring patient’s goals and perceptions of their disease is necessary for doctors to shape their communicative approach further down the line. Offering patients the opportunity to decide how much information they want to know enables them to practice autonomy while relieving the doctor’s sense of responsibly for making decisions solely on his own. The question, however, is how a patient can be expected to practice autonomy and have both realistic expectations and hope if he or she is not fully aware of the nature of the disease. This study shows for example that the discontinuation of anti-cancer treatment or referral to palliative care can cause confusion for advanced cancer care patients, as it has been traditionally associated with death, and thus with a complete loss of hope. As we know, palliative care or the withholding of treatment do not necessarily mean that doctors have given up on the healing process.

Helpful communication tools for doctors
The studies surveyed in this review suggest numerous tools that doctors should use in order to foster hope:
• Softening, sweetening information and giving hopeful information selectively by avoiding certain words. For example in a study conducted among American doctors working with dying patients a physician said the following:

“How we present the numbers to patients, will dictate how they hear it, so it makes sense, in other words, if I say 90% will die, or 1 in 10 do better, then I think patients hear different things […].”[3].

• Showing care was important especially for whom no further treatment was available.
• Acknowledging fear enables patients to feel more comfortable to talk about their concerns.
• Being open to alternative treatments was especially valued because it demonstrated to patients that their care provider did not give up on them.
• Using tools for demonstration such as diagrams, pictures, and credible websites was identified as helpful in order to understand information regarding the disease.

Raising patient empowerment and health literacy
In summary, this study makes a case for tailoring information to the given level of patients’ health literacy on a case by case basis, empowering them to know what they can realistically hope for. It also identifies the need for further research to investigate ways of raising patient empowerment and health literacy to a higher level. This would be instrumental in closing the gap between false perceptions and reality regarding cancer.

References:

[1] W.F. Baile, et al., SPIKES-A Six-Step Protocol for Delivering Bad News: Application to the Patient With Cancer, Oncologist, 5(4)(2000) 302-11.
[2] J. Coulehan, Deep Hope: A song Without Words. Theor. Med. Bioeth. 32(3)(2011) 143-60.
[3] N.T. Miyaji, Truth-telling among American Doctors in the Care of Dying Patients, Soc. Sci. Med.36(1993) 249-264.

Further references are available upon request. Please feel free to contact me at: pasztrai@farner.ch!