Indian Journal of Palliative Care
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REVIEW ARTICLES
Nurses' workplace stressors and coping strategies
Vickie A Lambert, Clinton E Lambert
January-June 2008, 14(1):38-44
DOI:10.4103/0973-1075.41934  
Prior research has suggested that nurses, regardless of workplace or culture, are confronted with a variety of stressors. As the worldwide nursing shortage increases, the aged population becomes larger, there is an increase in the incidence of chronic illnesses and technology continues to advance, nurses continually will be faced with numerous workplace stressors. Thus, nurses, especially palliative care nurses, need to learn how to identify their workplace stressors and to cope effectively with these stressors to attain and maintain both their physical and mental health. This article describes workplace stressors and coping strategies, compares and contrasts cross-cultural literature on nurses' workplace stressors and coping strategies, and delineates a variety of stress management activities that could prove helpful for contending with stressors in the workplace.
  64,641 956 17
Adverse psychosocial consequences: Compassion fatigue, burnout and vicarious traumatization: Are nurses who provide palliative and hematological cancer care vulnerable?
Brenda M Sabo
January-June 2008, 14(1):23-29
DOI:10.4103/0973-1075.41929  
The work environment significantly affects the physical, psychological, emotional and/or spiritual wellbeing of individuals is unquestionable. Adverse effects have been noted among healthcare professionals working with clients experiencing pain and suffering often associated with cancer, palliative or end-of-life care; however, little is known about how or in which manner the nurse-patient-family relationship may affect the psychosocial health and wellbeing of nurses working in these areas. Three concepts have been highlighted as most frequently associated with the adverse consequences of caring work: these are compassion fatigue (secondary traumatic stress), burnout and vicarious traumatization. The following discussion investigates these concepts and their implications on palliative and hematological cancer nursing practice.
  31,650 682 16
PAIN
Pain management in cancer cervix
Gayatri Palat, MS Biji, MR Rajagopal
July-December 2005, 11(2):64-73
DOI:10.4103/0973-1075.19182  
Cancer of the cervix uteri is a common cause of pain among women. On the physical realm, the cancer may cause somatic [soft tissue and bone], visceral and neuropathic pain [lumbosacral plexopathy]. Radiotherapy and chemotherapy may cause neuropathy too. Psychological, social and cultural factors modify the pain. Evaluation of the individual type of pain and a patient-centred approach are fundamental requirements for rational management. Disease modifying treatment like radiotherapy and chemotherapy must be considered when applicable. Pain control is usually achieved by the use of WHO three-step ladder, remembering that possible association of renal dysfunction would necessitate caution in the use of NSAIDs and opioids. Side effects must be anticipated, prevented when possible, and aggressively treated; nausea and vomiting may already be present, and constipation can worsen pain when there is a pelvic mass. Pain emergencies can be treated by quick titration with intravenous morphine bolus doses. Neuropathic pain may warrant the use of usual adjuvants, with particular reference to cortico-steroids and the NMDA antagonist, ketamine. In intractable pain, many neurolytic procedures are tried, but a solid evidence base to justify their use is lacking. Continuous epidural analgesia with local anaesthetic and opioid may be needed when drug therapy fails, and desperate situations may warrant interventions such as neurolysis. Such physical measures for pain relief must be combined with psychosocial support and adequate explanations to the patient and the family.
  31,006 716 1
REVIEW ARTICLE
Sweating in advanced cancer
Robert Twycross
January-June 2004, 10(1):1-11
  30,868 526 -
PAIN
Cancer and treatment related pains in patients with cervical carcinoma
Saikat Das, Jenifer Jeba, Reena George
July-December 2005, 11(2):74-81
DOI:10.4103/0973-1075.19183  
Pain in carcinoma cervix is a multidimensional experience with sensory, affective and cognitive-evaluative components. Many patients do not receive adequate pain management because of a lack of proper assessment, misconceptions regarding the pharmacologic and non pharmacologic methods of pain management and failure to distinguish between different types of pain. In our audit pelvic and nodal recurrence were the commonest cause of pain presenting as as pelvic pain, [42%], lumbosacral plexopathy [40%] and abdominal pain [34%] [n = 30]. Pain on defaecation caused by rectal obstruction, and suprapubic pain due to pyometra can be relieved by colostomy and drainage. Very little literature is available on the pain syndromes associated with carcinoma cervix. The present article is a review of cancer and treatment related pains in carcinoma cervix.
  26,855 570 2
REVIEW ARTICLES
Fatigue in cancer: A review of literature
Vijayakumar Narayanan, Cherian Koshy
January-June 2009, 15(1):19-25
DOI:10.4103/0973-1075.53507  PMID:20606851
Fatigue is a common symptom of advanced cancer limiting one's activity and affecting the quality of life. It is a multidimensional symptom complex with subjective and objective components. Hence, its definition and assessment seems arbitrary, incomplete, and elusive. Components of fatigue often merge with other 'disease states' as anemia, depression and so on, compounding difficulty to assess it separately. Fatigue has a high prevalence rate, and lasts longer in chronic diseases like cancer. Its association with treatment modalities like chemotherapy, radiotherapy alongside the primary disease process makes it seemingly ubiquitous in many cases. Systemic manifestation of cancer causes excess demand on body resources on cell repair, uncontrolled growth with metabolite accumulation causing fatigue. Co-morbid conditions of organic and psychological nature causes fatigue. There are many assessment tools for fatigue with different uses and objectives, simple and reproducible tools like Brief Fatigue Inventory, Edmonton Symptom assessment scale seem feasible in everyday practice. Management of fatigue is not straightforward and rewarding. Although treatment of cause appears to be an attractive option, it is not possible in all cases. Therapeutic agents targeting cytokine load is in early stages of study and available results are not favorable. Specific measures aimed at pain relief, prevention/treatment of sepsis, management of depression, avoidance of drugs causing fatigue, restoring the metabolic profile are important. Methyl phenidate, megestrol, and modafinil are some drugs with promising effect to treat fatigue, though confirmatory studies are yet to be established. Non-pharmacological methods are also helpful. Forewarning patients on upcoming fatigue, active regular exercise, and stress management are some of them. Fatigue being a multidimensional entity, single mode of therapy is insufficient. Combined modality tailored to individual patient need and understanding may be the right way to battle this ill-understood symptom. This review article examines the etiopathogenesis and management strategies of fatigue in cancer.
  23,859 583 6
ORIGINAL ARTICLES
Effective factors in providing holistic care: A qualitative study
Vahid Zamanzadeh, Madineh Jasemi, Leila Valizadeh, Brian Keogh, Fariba Taleghani
May-August 2015, 21(2):214-224
DOI:10.4103/0973-1075.156506  PMID:26009677
Background: Holistic care is a comprehensive model of caring. Previous studies have shown that most nurses do not apply this method. Examining the effective factors in nurses' provision of holistic care can help with enhancing it. Studying these factors from the point of view of nurses will generate real and meaningful concepts and can help to extend this method of caring. Materials and Methods: A qualitative study was used to identify effective factors in holistic care provision. Data gathered by interviewing 14 nurses from university hospitals in Iran were analyzed with a conventional qualitative content analysis method and by using MAXQDA (professional software for qualitative and mixed methods data analysis) software. Results: Analysis of data revealed three main themes as effective factors in providing holistic care: The structure of educational system, professional environment, and personality traits. Conclusion: Establishing appropriate educational, management systems, and promoting religiousness and encouragement will induce nurses to provide holistic care and ultimately improve the quality of their caring.
  22,724 303 -
REVIEW ARTICLES
Spiritual perspectives and practices at the end-of-life: A review of the major world religions and application to palliative care
S Bauer-Wu, R Barrett, K Yeager
July-December 2007, 13(2):53-58
DOI:10.4103/0973-1075.38900  
Palliative care professionals promote well-being and ease suffering at the end-of-life through holistic care that addresses physical, emotional, social and spiritual needs. The ways that individuals cope with serious illness and prepare for death are often done so within a religious context. Therefore, it is essential that palliative care practitioners are sensitive to and have an appreciation of different religious perspectives and rituals to meet the unique needs of their patients and families. This paper provides a brief overview of the five major world religions - Buddhism, Christianity, Hinduism, Islam and Judaism - with particular emphasis of the respective perspectives on suffering, death and afterlife. Despite wide variation in these traditions, an understanding of common rituals surrounding death, funerals and bereavement can improve care for patients, families and communities facing the end-of-life.
  22,299 652 5
CASE REPORTS
Palliative management of malignant bowel obstruction in terminally Ill patient
Darshit A Thaker, Bruce C Stafford, Luke S Gaffney
May-August 2010, 16(2):97-100
DOI:10.4103/0973-1075.68403  PMID:21811356
Mr. P was a 57-year-old man who presented with symptoms of bowel obstruction in the setting of a known metastatic pancreatic cancer. Diagnosis of malignant bowel obstruction was made clinically and radiologically and he was treated conservatively (non-operatively)with octreotide, metoclopromide and dexamethasone, which provided good control over symptoms and allowed him to have quality time with family until he died few weeks later with liver failure. Bowel obstruction in patients with abdominal malignancy requires careful assessment. The patient and family should always be involved in decision making. The ultimate goals of palliative care (symptom management, quality of life and dignity of death) should never be forgotten during decision making for any patient.
  19,159 276 1
ORIGINAL ARTICLE
Depression and demoralization as distinct syndromes: Preliminary data from a cohort of advanced cancer patients
Juliet C Jacobsen, Lauren C Vanderwerker, Susan D Block, Robert J Friedlander, Paul K Maciejewski, Holly G Prigerson
January-June 2006, 12(1):8-15
DOI:10.4103/0973-1075.25913  
The term demoralization has been used to describe existential distress and despair of patients with advanced disease. Aim: This study sought to determine whether a cluster of symptoms interpreted as demoralization could be identified and distinguished from a cluster of depressive symptoms. Materials and Methods: As part of the Coping with Cancer Study, a federally funded multi-site study of advanced cancer patients, 242 patients were interviewed on a broad range of mental health parameters related to depression, grief, quality of life, self-efficacy, coping and religiousness/spirituality. Results: A principal components analysis revealed separate depression and demoralization/despair factors. Seven symptoms constituted the demoralization/despair factor: loss of control, loss of hope, anger/bitterness, sense of failure, feeling life was a burden, loss of meaning and a belief that life's meaning is dependent on health and were found to be internally consistent (Cronbach's a = 0.78). Only 14.8% of subjects with "syndromal demoralization" met DSM-IV criteria for Major Depression (MDD); 7.4% for Minor Depression. Of those with MDD only 28.6% had syndromal level demoralization. Prior history of MDD predicted current MDD, but not syndromal demoralization. Demoralization, not MDD, was significantly associated with the patient's reported level of inner peacefulness. When compared with MDD, syndromal demoralization was more strongly associated with wish to live and wish to die and equally predictive of mental health service use. Conclusion: The symptoms of demoralization are distinct from depressive symptoms and appear to be associated with the patient's degree of inner peacefulness.
  18,201 507 24
REVIEW ARTICLES
Keeping hospice palliative care volunteers on board: Dealing with issues of volunteer attrition, stress, and retention
Stephen Claxton-Oldfield, Jane Claxton-Oldfield
January-June 2008, 14(1):30-37
DOI:10.4103/0973-1075.41933  
This article explores the issues of hospice palliative care volunteer attrition and retention (i.e., why volunteers leave and how to keep them interested). In addition, common sources of stress for volunteers will be identified and suggestions for alleviating stress will be offered. Volunteers are special people; patients and families greatly appreciate the care and support they provide and the other staff members' (e.g., nurses) jobs are often made easier because of them. Thus, maintaining a committed group of volunteers is an extremely important task for volunteer coordinators. The literature reviewed in this article focused mostly on North American studies and was limited to research that specifically involved hospice palliative care volunteers as participants.
  18,382 308 6
Palliative care and spirituality
Aru Narayanasamy
July-December 2007, 13(2):32-41
DOI:10.4103/0973-1075.38897  
Critical junctures in patients' lives such as chronic illnesses and advanced diseases may leave the persons in a state of imbalance or disharmony of body, mind and spirit. With regard to spirituality and healing, there is a consensus in literature about the influence of spirituality on recovery and the ability to cope with and adjust to the varying and demanding states of health and illness. Empirical evidence suggests that spiritual support may act as an adjunct to the palliative care of those facing advanced diseases and end of life. In this article, the author draws from his empirical work on spirituality and culture to develop a discourse on palliative care and spirituality in both secular and non-secular settings. In doing so, this paper offers some understanding into the concept of spirituality, spiritual needs and spiritual care interventions in palliative care in terms of empirical evidence. Responding to spiritual needs could be challenging, but at the same time it could be rewarding to both healthcare practitioner (HCP) and patient in that they may experience spiritual growth and development. Patients may derive great health benefits with improvements in their quality of life, resolutions and meaning and purpose in life. It is hoped that the strategies for spiritual support outlined in this paper serve as practical guidelines to HCPs for development of palliative care in South Asia.
  16,778 887 4
REVIEW ARTICLE
Palliative radiotherapy in head and neck cancers: Evidence based review
Kaustav Talapatra, Tejpal Gupta, Jai Prakash Agarwal, Sarbani Ghosh Laskar, Shyam Kishore Shrivastava, Ketayun Ardeshir Dinshaw
July-December 2006, 12(2):44-50
DOI:10.4103/0973-1075.30244  
Squamous cell carcinoma of head and neck (SCCHN) is one of the commonest cancers seen in India, constituting up to 25% of their overall cancer burden. Advanced SCCHN is a bad disease with a poor prognosis and patients usually die of uncontrolled loco-regional disease. Curative intent management of loco-regionally advanced SCCHN has become more evidence-based with active clinical research in the form of large prospective randomized controlled trials and meta-analyses. However, little has been written about palliative radiotherapy (PRT) in head and neck cancers. It is widely recognized that PRT provides effective palliation and improved quality-of-life in advanced incurable malignancies. It is in this context that this study proposes to review the existing literature on palliative radiotherapy in advanced incurable SCCHN to help formulate consensus guidelines and recommendations.
  16,713 935 5
REVIEW ARTICLES
Spiritual issues at end of life
Santosh K Chaturvedi
July-December 2007, 13(2):48-52
DOI:10.4103/0973-1075.38899  
Spirituality is multifaceted. The various beliefs regarding the concept of spirituality, spiritual needs of terminally ill patients and the methods of spiritual assessment are discussed here. There is a close association between demoralization, distress, spiritual pain and spiritual distress. Standardised clinical methods to assess spiritual distress and provide spiritual care and healing are available. Spiritual well-being is a significant dimension of overall health-related quality of life. Although there seems to be traditional and natural spiritual care in our society and especially in palliative care settings, hardly any formal training or interventions are available. This paper aims to encourage soul searching in the end-of-life care.
  16,430 710 3
ONCOLOGY
The oncologic management of carcinoma cervix after primary treatment failure
Lee Hsueh Ni, Firuza Patel, Santam Chakraborty, Suresh Sharma
July-December 2005, 11(2):82-93
DOI:10.4103/0973-1075.19184  
  16,191 581 1
ORIGINAL ARTICLES
Breast self-examination: Knowledge, attitude, and practice among female dental students in Hyderabad city, India
Dolar Doshi, B Srikanth Reddy, Suhas Kulkarni, P Karunakar
January-April 2012, 18(1):68-73
DOI:10.4103/0973-1075.97476  
Aim: The aim was to assess the knowledge, attitude, and practice (KAP) regarding breast self-examination (BSE) in a cohort of Indian female dental students. Materials and Methods: A cross-sectional descriptive questionnaire study was conducted on dental students at Panineeya Institute of Dental Sciences, Hyderabad, Andhra Pradesh, India. Data were analyzed using SPSS software (version 12). Chi-square test was used for analysis of categorical variables. Correlation was analyzed using Karl Pearson's correlation coefficient. The total scores for KAP were categorized into good and poor scores based on 70% cut-off point out of the total expected score for each. P-value of <0.05 was considered statistically significant. Results: This study involved a cohort of 203 female dental students. Overall, the total mean knowledge score was 14.22 ± 8.04 with the fourth year students having the maximum mean score (19.98 ± 3.68). The mean attitude score was 26.45 ± 5.97. For the practice score, the overall mean score was 12.64 ± 5.92 with the highest mean score noted for third year 13.94 ± 5.31 students. KAP scores upon correlation revealed a significant correlation between knowledge and attitude scores only (P<0.05). Conclusion: The study highlights the need for educational programs to create awareness regarding regular breast cancer screening behavior.
  15,827 616 4
REVIEW ARTICLES
Communication with relatives and collusion in palliative care: A cross-cultural perspective
Santosh K Chaturvedi, Carmen G Loiselle, Prabha S Chandra
January-June 2009, 15(1):2-9
DOI:10.4103/0973-1075.53485  PMID:20606848
Handling collusion among patients and family members is one of the biggest challenges that palliative care professionals face across cultures. Communication with patients and relatives can be complex particularly in filial cultures where families play an important role in illness management and treatment decision-making. Collusion comes in different forms and intensity and is often not absolute. Some illness-related issues may be discussed with the patient, whereas others are left unspoken. Particularly in palliative care, the transition from curative to palliative treatment and discussion of death and dying are often topics involving collusion. Communication patterns may also be influenced by age, gender, age, and family role. This paper outlines different types of collusion and how collusion manifests in Indian and Western cultures. In addition, promising avenues for future research are presented.
  15,609 820 9
Physical therapy in palliative care: From symptom control to quality of life: A critical review
Senthil P Kumar, Anand Jim
September-December 2010, 16(3):138-146
DOI:10.4103/0973-1075.73670  PMID:21218003
Physiotherapy is concerned with identifying and maximizing movement potential, within the spheres of promotion, prevention, treatment and rehabilitation. Physical therapists practice in a broad range of inpatient, outpatient, and community-based settings such as hospice and palliative care centers where as part of a multidisciplinary team of care, they address the physical and functional dimensions of the patients' suffering. Physiotherapy treatment methods like therapeutic exercise, electrical modalities, thermal modalities, actinotherapy, mechanical modalities, manual physical therapy and assistive devices are useful for a range of life-threatening and life-limiting conditions like cancer and cancer-associated conditions; HIV; neurodegenerative disorders like amyotrophic lateral sclerosis, multiple sclerosis; respiratory disorders like idiopathic pulmonary fibrosis; and altered mental states. The professional armamentarium is still expanding with inclusion of other miscellaneous techniques which were also proven to be effective in improving quality of life in these patients. Considering the scope of physiotherapy in India, and in palliative care, professionals in a multidisciplinary palliative care team need to understand and mutually involve toward policy changes to successfully implement physical therapeutic palliative care delivery.
  14,885 1,001 16
REVIEW
The management of terminal delirium
AD Macleod
January-June 2006, 12(1):22-28
DOI:10.4103/0973-1075.25915  
Delirium is a distressing and disturbing clinical event. Palliation of the symptoms by multi-component interventions can be effective. The goal of interventions is to raise the deliriant threshold by combined symptom relief, environmental, psychological and pharmacological interventions. Haloperidol remains the drug of choice for delirium. For intractable delirious symptoms at the end of life terminal sedation may be indicated.
  15,183 566 6
REVIEW ARTICLES
End-of-life care in the Indian context: The need for cultural sensitivity
R Shubha
July-December 2007, 13(2):59-64
DOI:10.4103/0973-1075.38901  
End-of-life care requires dealing with challenging issues along various dimensions - physical, psychological, social and cultural. In addition to physical care, the importance of mental healthcare for patients at the end of life is now clearly recognised. However, there is much less awareness about the cultural factors that are involved in end-of-life care. Sensitivity to these factors is essential to providing high quality care and satisfaction to patients. In India, patients come from varied backgrounds. Their end-of-life needs differ according to their belief systems and values relating to life and death in general. In turn, these are influenced by the position they occupy along various dimensions, such as class, religion, caste, community, language, gender, to name a few. Moreover, cultural variations in attitudes and values have important practical implications for individuals making crucial medical decisions. It is therefore important for medical, paramedical and mental health professionals to be cognizant of these factors so as to provide effective and satisfying end-of-life care to patients. This paper discusses some of the issues in providing culture-sensitive care, using examples from the Indian context.
  14,783 642 6
SECTION 2: OBSERVATIONAL STUDIES IN PALLIATIVE CARE - ORIGINAL ARTICLES
Professional quality of life among professional care providers at cancer palliative care centers in Bengaluru, India
Amanpreet Kaur, Mahendra P Sharma, Santosh K Chaturvedi
April-June 2018, 24(2):167-172
DOI:10.4103/IJPC.IJPC_31_18  PMID:29736119
Context: Being a professional care provider at cancer palliative care settings is demanding and stressful. Literature has indicated the prevalence of high burnout (BO) and distress; however, there is a dearth of studies in India, with no study available on professional quality of life in the field of palliative care. Aims: The aim of the present study was to explore the professional quality of life, namely-compassion satisfaction [CS], burnout [BO], and secondary traumatic stress [STS] among professional care providers at cancer palliative care centers. Settings and Design: A cross-sectional, descriptive, and quantitative study was carried out at four cancer palliative care centers in Bengaluru after the permissions and ethical approvals. Subjects and Methods: The tools used were brief sociodemographic datasheet and professional quality of life (ProQoL)-Version 5 administered with 65 participants (mean age = 32.5 and standard deviation = 11.78) with work experience of at least 6 months. Analysis: A descriptive, correlational, and inferential analysis of the quantitative data was undertaken. Results: The results revealed that an average level of CS and BO was reported by 32 (49.2%) and 35 (53.8%) study participants, respectively, while 62 (95.4%) participants reported higher STS on ProQoL scale-Version 5. Significant differences in levels of CS, BO, and STS were found based on additional training taken in palliative care (P = 0.01), designation type (P < 0.001), and workplace type (P = 0.01). Conclusion: The overall results strongly suggest that a short intervention targeting STS and BO can help the study population and further enhance their CS and patient care.
  15,081 164 -
ORIGINAL ARTICLES
Breaking bad news in cancer patients
Apostolos Konstantis, Triada Exiara
January-April 2015, 21(1):35-38
DOI:10.4103/0973-1075.150172  PMID:25709183
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. Materials and Methods: 59 doctors from General Hospital of Komotini, Greece were included in the study. All the doctors were in clinical specialties that treated cancer patients. A brief questionnaire was developed based on current guidelines such as Baile/SPIKES framework and the ABCDE mnemonic. Results: Residents are involved in delivering bad news less frequently than specialists. Only 21 doctors (35.59%) had specific training on breaking bad news. 20 doctors (33.90%) were aware of the available techniques and protocols on breaking bad news. 47 doctors (79.66%) had a consistent plan for breaking bad news. 57 (96.61%) delivered bad news in a quiet place, 53 (89.83%) ensured no interruptions and enough time, 53 (89.83%) used simple words and 54 (91.53%) checked for understanding and did not rush through the news. 46 doctors (77.97%) allowed relatives to determine patient's knowledge about the disease. Conclusions: There were low rates of specific training in breaking bad news. However, the selected location, the physician's speech and their plan were according to current guidelines.
  14,555 284 -
NURSING PRACTISES
"Special foot massage" as a complimentary therapy in palliative care
Vijaya Puthusseril
July-December 2006, 12(2):71-76
DOI:10.4103/0973-1075.30249  
Terminal illness often throws up challenges that conventional treatments fail to address satisfactorily. Complimentary therapies such as foot massages are being rediscovered for their particular benefits in palliative care. This article includes a brief description of the process and discusses the author's experience with it's use.
  14,139 648 2
REVIEW ARTICLES
'BREAKS' protocol for breaking bad news
Vijayakumar Narayanan, Bibek Bista, Cheriyan Koshy
May-August 2010, 16(2):61-65
DOI:10.4103/0973-1075.68401  PMID:21811349
Information that drastically alters the life world of the patient is termed as bad news. Conveying bad news is a skilled communication, and not at all easy. The amount of truth to be disclosed is subjective. A properly structured and well-orchestrated communication has a positive therapeutic effect. This is a process of negotiation between patient and physician, but physicians often find it difficult due to many reasons. They feel incompetent and are afraid of unleashing a negative reaction from the patient or their relatives. The physician is reminded of his or her own vulnerability to terminal illness, and find themselves powerless over emotional distress. Lack of sufficient training in breaking bad news is a handicap to most physicians and health care workers. Adherence to the principles of client-centered counseling is helpful in attaining this skill. Fundamental insight of the patient is exploited and the bad news is delivered in a structured manner, because the patient is the one who knows what is hurting him most and he is the one who knows how to move forward. Six-step SPIKES protocol is widely used for breaking bad news. In this paper, we put forward another six-step protocol, the BREAKS protocol as a systematic and easy communication strategy for breaking bad news. Development of competence in dealing with difficult situations has positive therapeutic outcome and is a professionally satisfying one.
  13,960 632 3
REVIEW ARTICLE
Itch
Robert Twycross
July-December 2003, 9(2):47-61
  13,894 594 -
Online since 1st October '05
Published by Wolters Kluwer - Medknow