Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0973-1075.150172
Source of Support: None, Conflict of Interest: None
Objective: In a regional hospital, many patients are newly diagnosed with cancer. Breaking the bad news in these patients and their relatives is a tough task. Many doctors are not experienced in talking to patients about death or death-related diseases. In recent years, there have been great efforts to change the current situation. The aim of this study was to investigate the experience and education of medical personnel in breaking bad news in a secondary hospital.
Keywords: Breaking bad news, Cancer, Communication skills, Greece, Oncology, Truth telling
Giving bad news to patients delicately is not an optional requirement for doctors but an essential part of professional practice.  In regional hospitals, many patients are newly diagnosed with cancer. Informing these patients and their relatives of bad news is a tough and challenging task. Most doctors do not have previous experience in talking to patients about death or death-related diseases and are required almost daily to give unwelcomed news without being prepared properly for such instances.  It is unforgivable if it is done without tact, understanding or compassion. If it is done well, patients may feel somewhat less hopeless and walk away with hope.  Bad news drastically and negatively alters the patients' view of their future. 
Delivering bad news is a stressful moment for physicians and patients too. , Patients' satisfaction and perceptions of receiving bad news has been investigated. There is evidence that good communication of health care providers can improve patients' compliance with treatment and emotional adjustment. ,,
Unfortunately, communication skills are not an essential part of medical studies in many countries. This fact has a great impact on the way doctors approach patient when bad news delivered. During the last few years, there have been great efforts from universities and other institutions to change the current situation. There are many courses, forums and available printed materials that can help doctors improve their abilities and their knowledge in this challenging area. , Besides that, there are structured guidelines for breaking bad news. Baile/SPIKES framework guidelines by Regnard and Kindren and the ABCDE mnemonic are some useful tools that can help doctors to improve their ability to deliver bad news. ,,,
The aim of this study was to investigate the experience and education of medical personnel in delivering bad news to cancer patients and the observance of some basic rules mentioned in the latest guidelines. In addition, this study proposes solutions to improving the everyday practice in a regional hospital.
59 doctors from The General Hospital of Komotini in north Greece (26 specialists and 33 residents only of clinical specialties) were included in the study from October until December 2010. These doctors are involved in delivering bad news in everyday practice and often treat patients with cancer. Doctors of laboratory specialties (radiologists, microbiologists and pathologists) that are not directly delivering bad news were excluded from the study to avoid bias. Doctors who did not answer all the items of the questionnaire were further excluded (6 specialists and 4 residents).
Based on a literature review, an anonymous questionnaire developed. The questionnaire consisted of 20 items that measure education and some basic rules mentioned in the latest guidelines on breaking bad news. ,,, In addition, two demographic questions (sex and grade) were included. Yes/No responses were required for all questions, except six. Training, time, space characteristics and doctors' knowledge of current guidelines were registered. The final item of the questionnaire was an open comment on possible solutions to the current situation. Minitab 15.1.1 program was used for statistical analysis.
26 specialists and 33 residents answered all items of the questionnaire. Residents delivered bad news less frequently than specialists did. 27 residents (81.82%) delivered bad news less than five times a month and 17 specialists (65.38%) five to ten times a month [Figure 1]. 42 doctors (64.41%) had not had specific training in breaking bad news. 21 doctors had specific training during undergraduate or postgraduate studies and through discussions and interviews with more experienced colleagues [Figure 2]. 47 doctors (79.66%) had a consistent plan for breaking bad news and 45 doctors (76.27%) answered that they do not deliver bad news the same way to all patients. 57 doctors (96.61%) choose a quiet place and 53 (89.83%) allocate ample time without any interruptions. Only 23 doctors sit close to patients (38.98%) and 34 of the doctors (57.63%) allow physical contact with them. 53 doctors (89.83%) use simple words, ensure patient understanding and do not rush through the news. In oncology cases, 51 doctors (86.44%) choose patients' relatives as first recipients of bad news. 46 doctors (77.97%) allow relatives to determine whether patients are informed fully about the disease. 33 doctors (55.93%) answered that they do not try to convince patients' relatives that the patient needs to know everything about the disease. 21 doctors (35.59%) answered that the diagnosis is the most difficult part in the discussion with oncology patients and their relatives. 26 doctors (44.07%) found that the most difficult task is to discuss the prognosis, 3 doctors (5.08%) about remission and 9 (15.25%) discussing the end of active treatment and start of palliative care [Figure 3]. 39 doctors (66.10%) had not heard about techniques and guidelines on breaking bad news and 36 (61.02%) had not tried to find out information about it. Finally, 57 doctors (96.61%) considered that training in breaking bad news is essential for their clinical practice.
In the comments section on possible solutions, doctors proposed role model groups, special courses and further training on current guidelines.
The goal of this investigation was to examine the experience of medical personnel in breaking bad news in a regional Greek hospital.
Similar to other published reports, a significant majority of doctors had not received specific training in breaking bad news. Residents have higher rates of undergraduate training because of promising efforts by many universities in order to change the current situation. ,,,
Most doctors have a consistent plan, do not treat all patients the same way and focus on patients' perceptions and preferences. Although doctors are not aware of the latest guidelines and techniques, in most of the cases they select a quiet place and allocate enough time, similar to the findings in other reports.  There are low rates of doctors who sit next to patients and allow physical contact with them. According to the SPIKES protocol and other guidelines, this behavior can have a negative effect in the establishment of a good doctor-patient relationship.  The majority of doctors use simple words and they check for understanding in similar rates to that described in other reports. These attitudes can lead to higher rates of satisfaction among the patients. 
This investigation indicates that in cancer patients, doctors very often prefer to share information with relatives and not directly with the patient. Probably as a result of past theories about a patient's best interest.  Furthermore, it can indicate doctors lack of confidence on their role as bearers of bad news or inability to respond to a patient's reactions and emotions. ,
In our study, the majority of the doctors felt uncomfortable discussing diagnosis or prognosis and have less difficulty discussing about the end of treatment and remission of cancer. In a regional hospital, there are many newly diagnosed patients with cancer and the discussion of the diagnosis and prognosis are the most difficult issues that concern a physician prior to patient's referral to an oncology department.
All participants identified the difficulties in breaking bad news and considered specific training as essential.
A few limitations of this study must be noted. First of all, most questions required a "Yes" or "No" answer, which restricts the collected data to these two categories. Secondly, the sample was relatively small and obtained from only one regional hospital, so there was statistical bias and no comparison between different hospitals. The timescale was short and had no possible modifications as this audit performed as an assessment for a postgraduate course. As a result, it was difficult to expand the sample with data from other regional hospitals. Aside from that, in a regional hospital without an oncology department, patients with cancer are not the majority. Many doctors probably answered many items of the questionnaire with poor experience. Finally, because of the self-report method, there may be a respondent reporting bias.
There are many training courses with proven effectiveness in breaking bad news, organized in hospitals worldwide, as mentioned in various research papers.  To improve the current situation, medical schools should introduce obligatory lectures and workshops with the aim to improve future doctors' communication skills.
In our hospital, there are low rates of specific training in communication skills and awareness of protocols and techniques on breaking bad news. However, the selected location, the physician's speech and plan for breaking bad news are followed according to current guidelines. In oncology patients, doctors prefer to deliver bad news to patients' relatives who determine patient knowledge. Possible solutions to improve the current situation include the:
• Development and publication of regional guidelines
• Organization of local groups responsible for training in the use of the guidelines and their implementation in practice
• Training in communication skills during undergraduate studies in medical schools
• Regular meetings in hospitals and interviews with specialized professionals in breaking bad news
• Hospital-based training workshops.
[Figure 1], [Figure 2], [Figure 3]