- Email: [email protected]
Breaking bad medical news in a dental care setting
CLINICAL
PRACTICE
Breaking bad medical news in a dental care setting Pelin Güneri, DDS, PhD; Joel Epstein, DMD, MSD, FRCD(C), FDS RCS(Edin); Ronald W. Botto, PhD
O
ral manifestations may be the first indication of a number of systemic conditions,1 and providing oral care treatment to these patients may result in significant and even life-threatening complications. Oral cancers—including oropharyngeal squamous cell carcinoma, Kaposi sarcoma, metastatic disease to the head and neck, and hematologic and lymphoproliferative disorders—may develop in the head, neck and oral cavity. They need to be diagnosed before dental treatment to prevent further complications and to facilitate early initiation of medical care. Furthermore, patients receiving cancer therapy, cancer treatment survivors (who represent 3.9 percent of the U.S. population2) and patients receiving palliative care or hospice care may be seen in dental offices owing to subsequent oral complications. Patients with sexually transmitted diseases such as syphilis, gonorrhea, human immunodeficiency virus, herpes virus infections, human papilloma virus–associated cancer and other viral-related diseases may seek care from a dental care provider. Patients with serious systemic conditions—including endocrine, neurological, mucocutaneous and gastrointestinal diseases; hemato-
AB STRACT Background. Dental care providers may diagnose diseases and conditions that affect a patient’s general health. The authors reviewed issues related to breaking bad medical news to dental practice patients and provide guidance to clinicians about how to do so. Methods. To help reduce the potentially negative effects associated with emotionally laden communication with patients about serious health care findings, the authors present suggestions for appropriately and sensitively delivering bad medical news to both patients and their families in a supportive fashion. Results. Preparing to deliver bad news by means of education and practice is recommended to help prevent or reduce psychological distress. One form of communication guidance is the ABCDE model, which involves Advance preparation, Building a therapeutic relationship or environment, Communicating well, Dealing with patient and family reactions, and Encouraging and validating emotions. An alternative model is the six-step SPIKES sequence—Setting, Perception, Invitation or Information, Knowledge, Empathy, and Strategize and Summarize. Using either model can assist in sensitive and empathetic communication. Conclusions. For both practitioners’ and patients’ well-being, empathetic and effective delivery of bad medical news should be included in dental school curricula and continuing education courses. Practical Implications. Dental care providers should be familiar with the oral manifestations of diseases and the care needed before the patient undergoes medical treatment and use effective communication necessary to share bad news with patients. Key Words. Communication; dental education; dentistry; dentists; diagnosis, oral; disclosure; lesions, oral; mouth mucosa. JADA 2013;144(4):381-386.
Dr. Güneri is a professor, Department of Oral and Maxillofacial Radiology, School of Dentistry, Bornova, Izmir 35100, Turkey. Address reprint requests to Dr. Güneri. Dr. Epstein is an adjunct professor, the director, a collaborative member, Samuel Oschin Comprehensive Cancer Institute, and a consulting staff member, Cedars-Sinai Medical Center, Los Angeles; and a consulting staff member, Division of Otolaryngology and Head and Neck Surgery, City of Hope National Medical Center, Duarte, Calif. Dr. Botto is an associate professor, Department of Oral Health Science, and the director, Interprofessional Education and Activities, College of Dentistry, University of Kentucky, Lexington.
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logic, cardiovascular and respiratory disorders; and autoimmune syndromes—may experience oral manifestations.3-16 Thus, oral findings could indicate significant local oral disease and represent manifestations of systemic conditions that must be recognized and diagnosed expeditiously,17 which can lead not only to a better prognosis but also to reduced morbidity and cost of care.18 Oral health care providers must recognize abnormalities, take steps to achieve diagnosis and be familiar with the treatment modalities for these conditions. In addition, the changing nature of the practice and evolution of disease and medical care management requires that oral health care providers be comfortable providing appropriate and necessary care to people with advanced disease and variable prognoses. This ability requires both competency in and comfort with assessing a complete medical and dental history, including habits such as tobacco, alcohol and illicit drug use; sexual history (owing to sexually transmitted diseases that have the possibility of oral involvement); and symptoms and diagnoses of potentially significant medical conditions, in a positive, nonjudgmental way.19 In doing so, the oral health care provider needs to avoid lecturing the patient about his or her behaviors, even if doing so is well intended.20 Using phrases such as “Now you know you should (should not) … ” are not conducive to encouraging behavior change and can result in resistance to change.21 Identifying the patient’s reasons for the behavior, assessing his or her current readiness for change and using motivational interviewing techniques are significantly more effective.20-22 If a life-threatening condition is suspected in a patient, the steps needed to arrive at a diagnosis, by means of testing or referral, need to be communicated in a sensitive and supportive manner, and they need to address any potential concerns regarding the diagnosis of the condition. Using communication to address potential concerns related to diagnosis will help ensure that the patient understands the importance of compliance with further testing and referrals. Taking this approach also will help the practitioner address the patient’s concerns regarding compliance. Breaking bad news is a difficult task for which most dental care practitioners often have received little or no education. Breaking Bad News
Information that produces a negative expectation can be considered bad news.23 Receiving and breaking bad news are difficult for both patients 382 JADA 144(4)
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and health care professionals.24-26 For example, a cancer diagnosis often is associated with fear of dying, exhausting treatment with significant complications and poor quality of life; therefore, the effect of receiving a diagnosis of cancer might be devastating.27 Despite advances in medicine and communication education, patients with cancer often are dissatisfied with the way the bad news is delivered.28,29 This dissatisfaction could be because receiving bad news can be influenced by a patient’s life experiences; personality; spiritual principles; philosophical, religious or cultural beliefs; perceived social support; and emotional stamina.30 The way that bad news is delivered can have a profound effect on both the recipient and the caregiver.28,31,32 Most clinicians are uncomfortable with breaking bad news because they may be reluctant owing to their own discomfort in doing so, as well as their concerns about their lack of knowledge and skills.25,32 Although nondisclosure is considered unethical, providing additional information in a manner that is overwhelming to the patient also is inappropriate.33,34 Patients prefer to be informed directly with sensitivity about the diagnosis of, prognosis of, treatment plans for, and potential adverse effects of and complications of the treatment for their conditions.34 A lack of effective communication during the delivery of bad news may cause the patient to become confused, distressed and angry, whereas an appropriate and sensitive interaction can help the patient adjust to the difficult situation.30 A patient’s need for and acceptance of information is of great concern throughout the continuum of disease treatment and survival.34 The ability to deliver bad news to a patient requires knowledge not only of the diagnosed condition and its treatment but also of the integration of fundamental communication competencies and professionalism. It is essential that all health care workers, including dental professionals, develop these skills.35,36 Educational curricula and continuing education programs need to address these communication skills, which also include sensitivity to the cultural background and sociocultural environment of both the health care practitioner and the patient, as ABBREVIATION KEY. ABCDE: Advance preparation, Building a therapeutic relationship or environment, Communicating well, Dealing with patient and family reactions, and Encouraging and validating emotions. CUDSH: Cork University Dental School and Hospital. SPIKES: Setting, Perception, Invitation or Information, Knowledge, Empathy, and Strategize or Summarize.
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well as an awareness of both the practitioner’s and patient’s beliefs regarding the disclosure of bad news.37,38 In medicine, almost one-half of the practitioners who break bad news more than one to two times weekly have received no formal education regarding this task,39 and such education is even more rare in dentistry.26,40 Education regarding the Delivery of Bad News
PRACTICE
TABLE 1
Guide for preparing the setting and the clinician for breaking bad news.* STEP Advance Preparation
DESCRIPTION Arrange for adequate time, privacy and no interruptions Review relevant clinical information and test results as appropriate; review current general recommendations for treatment and general outcomes (may consult potential referral source for information) Mentally rehearse and identify words or phrases to use and avoid Be prepared intellectually and emotionally
Building a Therapeutic Relationship or Environment
Find a quiet and private setting
In a study conducted in the Determine what and how much the patient wants to know United Kingdom, investigators Have family or support people present, if appropriate found that most medical schools Introduce yourself to everyone have had some form of educaWarn the patient that bad news is coming tion relating to communication, Use touch when appropriate death and dying or both for at Arrange next steps, follow-up appointments or referrals, as 41 least 20 years. However, teachindicated ing of these topics has varied Communicating Ask what the patient and his or her significant others considerably in both duration Well already know and content, there has been Ask directly how much and what kind of information will be helpful to them no interdepartmental coordiTake into account their preferred learning styles and need nation or collaboration,39 and for information instructors mostly used nonBe frank but gentle and compassionate; avoid euphemisms standardized models and apand medical and dental jargon 30,42,43 proaches. Developing skills Allow for silence and breaks; proceed at the patient’s pace for communicating with patients Have the patient describe his or her understanding of the who have serious medical condinews; repeat this information when summarizing the discussion and at subsequent visits tions requires emphasis on its Allow time for questions; write things down and provide importance in the curriculum so written information that the necessity and value of Conclude each visit with a summary and a follow-up plan its being taught are similar to Dealing With Assess and respond to the patient’s and other people’s those of other aspects of health Patient and emotional reactions; repeat at each visit 23 care. Although the importance Family Be empathetic Reactions of education regarding breakDo not argue with or criticize colleagues ing bad news effectively and Encouraging Explore what the news means to the patient sensitively is acknowledged and Validating Offer realistic hope according to the patient’s goals and education in the necessary Emotions When appropriate, provide positive information, a basic or communication skills may be initial approach to treatment and a prognosis (such as, in included in the curricula of medigeneral, early diagnosis allows less complex, less costly and more successful outcomes) cal schools, it also is important 44,45 Use interdisciplinary resources and advice regarding finding in dental education. However, reliable online resources we found only one reference of Take care of your own needs; be attuned to the needs of its inclusion in a dental school involved house staff members and office or hospital 46 personnel curriculum. This lack of inclusion may be due to an erroneous * Source: VandeKieft. presumption that dental professionals commonly do not provide vational interviewing to address the relevant bad news to patients. However, many oral and issues.45-47 In addition, communication skills systemic conditions may be recognized in the courses need to include the importance of and dental practice environment. To improve the methods for working collaboratively with those provision of information related to a serious oral in other dental and medical disciplines. finding, courses should be developed regarding Communication skills. To prevent the negainterviewing techniques, communication skills tive effects associated with poor communication associated with breaking bad news and motiwith patients, as well as with their resistance 48
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TABLE 2
Setting, Perception, Invitation or Information, Knowledge, Empathy, and Strategize and Summarize model.* STEP
DESCRIPTION
Setting
Find a quiet and private setting Avoid interruptions
Perception
Establish how much the patient knows and his or her perceptions about the medical situation
specific programs regarding this topic in U.S. and Canadian dental schools. Tables 1 and 2 may serve as preparation guidelines for improving communication with patients when delivering bad news. The Impact of Delivering Bad News
Although there is information in the medical literature regarding patients’ emotions after receiving Take preferred learning styles and need for information into bad news,27,34,35,43 there is little consideration about health care practitioners’ Knowledge Share bad news with the patient using gentle, nonclinical feelings regarding providing news language in small segments; when appropriate, provide positive information and basic information regarding the of a serious diagnosis and prognonext steps involved in the diagnosis, treatment and sis to patients.23 We were not able prognosis; in general, early diagnosis allows for less complex, to identify any research about less costly and more successful outcomes this topic regarding dental profesEmpathy Acknowledge the patient’s emotions and reactions with appropriate responses sionals. Fear of the unknown, unleashing an emotional or physiSummarize Summarize in language that the patient can understand and Strategize easily and provide a strategic plan for further intervention; cal reaction, expressing emotion, ask the patient to repeat or summarize the information not knowing all the answers, and received and the next steps personal fear of illness and death * Source: Kaplan. have been reported as some of the difficulties that health care or noncompliance, we provide the skills necesproviders may have when disclosing unfavorable diagnoses and prognoses to patients.23 Bearsary for adequate transmission of bad news and ing this responsibility may create a sense of steps for delivering distressing information to helplessness,32,53 a fear of being blamed for the patients and their families in Table 1.26-28,31,45,48-53 This guide is referred to as the ABCDE model, illness or a wish to shield the patient from the which involves Advance preparation, Buildreality of the situation.32 ing a therapeutic relationship or environment, Receiving education in effective communiCommunicating well, Dealing with patient and cation skills can help clinicians deliver bad family reactions, and Encouraging and validatmedical news, and although learning the skills ing emotions.48 for breaking bad news within a supportive An alternative to the ABCDE model is framework may diminish the feeling of helplessSPIKES,54 which is a six-step protocol for deness,53,55 it may not reduce the stress of doing 52 livering bad news to patients (Table 2). Each so.55,56 Dentists who detect a suspicious oral muletter in the name represents a phase in the sixcosal lesion or symptoms that are highly suggesstep sequence: Setting, Perception, Invitation or tive of a malignant or serious disease and have Information, Knowledge, Empathy, and Stratbasic knowledge regarding potential treatment, egize and Summarize, and this model applies common complications and the prognosis of the to health care issues, including dentistry.40,52 disease inevitably experience both psychologiCurtin and McConnell40 stated that they had cal and physical stress. Research results have “identified only three articles addressing the shown that staff members working in oncology interpersonal components in breaking bad news and infectious disease clinics have a high risk of in dentistry,” and none of the articles addressed experiencing burnout57-59 because they encounhow to teach the needed skills to dental stuter multiple stressors that may influence the dents. Curtin and McConnell40 then discussed quality of their lives negatively across time.60 how the SPIKES model was introduced to the Delivering bad news to patients is considered an dental curriculum at Cork University Dental acute stressor that may, in turn, lead to proSchool and Hospital (CUDSH), Ireland, in found psychological and physiological changes, 2010.40 They stated that “research is currently such as increases in sympathetic nervous ongoing to assess how patients perceive stusystem activity (including blood pressure, heart dents’ delivery of bad news.” We are not aware of rate and catecholamine secretion), as well as Invitation or Information
Ask the patient and significant others how much and what kind of information will be helpful to them
52
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platelet aggregation and changes in the number and function of a variety of immune cells.24,25,61,62 Cohen and colleagues24 reported that delivering both bad and good medical news produced an acute stress response consisting of significant increases in self-reported distress and cardiovascular responses. Breaking only bad news, however, led to a significant increase in natural killer cell function. Health care providers who experience intense emotional response when they are working under “unpleasant” conditions could benefit from receiving education in addressing difficult issues regarding both their patients’ and their own emotions, as well as receiving professional psychological support to decrease the level of work-related stress.56 Considering that dental care providers may experience psychological distress when delivering bad news, we recommend education for dental care providers. Furthermore, considering that the burden of this situation on dentists is underestimated, more interpersonally oriented approaches in dental education (such as those at CUDSH) and continuing education are necessary to improve the well-being of dental care providers and, ultimately, the quality of patient care. Using the ABCDE and SPIKES models can help dental care providers prepare for the delivery of bad medical news and can be of benefit to both the patient and the provider. Although the impact of using the SPIKES model in dental patient care is being evaluated as part of a dental curriculum, both the ABCDE and SPIKES models have relevance to dentistry and are good models to use when addressing difficult situations associated with the delivery of dental care. The importance of the ABCDE and SPIKES models is that they each address patient and practitioner issues, comfort and well-being associated with the stress of communicating about bad news. CONCLUSIONs
Health care education needs to include teaching practitioners to address the stressors associated with a health care practice, including delivering difficult information to patients. Bearing in mind that clinicians have the responsibility to communicate with patients about numerous scenarios regarding various treatment options, the need to educate oral health care professionals regarding the assessment of clinical care for patients is clear.47 As observed during delivery of medical bad news, patients need to be communicated with and receive information in an effective and sensitive manner when they feel overwhelmed.31 Thus, dental education should
PRACTICE
address these needs by including education regarding communication skills and methods for sensitive and supportive delivery of bad news to patients,40 which is a crucial aspect of patient care in dental practice, in curricula and in continuing education. The dental care provider must be familiar with the conditions and general principles of care associated with medical conditions and be familiar with and be able to discuss oral and dental care needed before, during and after the patient receives medical treatment and acute care. To maximize effective treatment, dental care practitioners need to receive the appropriate education regarding the skills necessary to address both the patient’s and their own needs, as well as the issues involved in delivering bad news. n Disclosure. None of the authors reported any disclosures. 1. Frydrych AM, Slack-Smith LM. Dental attendance of oral and oropharyngeal cancer patients in a public hospital in Western Australia (published online ahead of print Aug. 11, 2011). Aust Dent J 2011;56(3):278-283. doi:10.1111/j.1834-7819.2011.01343.x. 2. Centers for Disease Control and Prevention. Cancer Survivors: United States, 2007. www.cdc.gov/mmwr/preview/mmwrhtml/ mm6009a1.htm. Accessed Feb. 21, 2013. 3. Chi AC, Neville BW, Krayer JW, Gonsalves WC. Oral manifestations of systemic disease. Am Fam Physician 2010;82(11):1381-1388. 4. Reichart PA, Phillipsen HP. Betel chewer’s mucosa: a review. J Oral Pathol Med 1998;27(6):239-242. 5. Scully C, Porter S. ABC of oral health: swellings and red, white, and pigmented lesions. BMJ 2000;321(7255):225-228. 6. Scully C, Felix DH. Oral medicine: update for the dental practitioner—aphthous and other common ulcers. Br Dent J 2005; 199(5):259-264. 7. Scully C, Felix DH. Oral medicine: update for the dental practitioner—mouth ulcers of more serious connotation. Br Dent J 2005;199(6):339-343. 8. Scully C, Felix DH. Oral medicine: update for the dental practitioner—dry mouth and disorders of salivation. Br Dent J 2005; 199(7):423-427. 9. Scully C, Felix DH. Oral medicine: update for the dental practitioner—oral malodour. Br Dent J 2005;199(8):498-500. 10. Scully C, Felix DH. Oral medicine: update for the dental practitioner—oral white patches. Br Dent J 2005;199(9):565-572. 11. Scully C, Felix DH. Oral medicine: update for the dental practitioner—red and pigmented lesions. Br Dent J 2005;199(10): 639-645. 12. Scully C, Felix DH. Oral medicine: update for the dental practitioner—disorders of orofacial sensation and movement. Br Dent J 2005;199(11):703-709. 13. Scully C, Felix DH. Oral medicine: update for the dental practitioner—lumps and swellings. Br Dent J 2005;199(12):763-770. 14. Scully C, Felix DH. Oral medicine: update for the dental practitioner—oral cancer. Br Dent J 2006;200(1):13-17. 15. Scully C, Felix DH. Oral medicine: update for the dental practitioner—orofacial pain. Br Dent J 2006;200(2):75-83. 16. Kragelund C, Reibel J, Hadler-Olsen ES, et al. Scandinavian Fellowship for Oral Pathology and Oral Medicine: statement on oral pathology and oral medicine in the European Dental Curriculum (published online ahead of print Sept. 1, 2010). J Oral Pathol Med 2010;39(10):800-e1. doi:10.1111/j.1600-0714.2010.00939.x. 17. Vandevanter N, Combellick J, Hutchinson MK, Phelan J, Malamud D, Shelley D. A qualitative study of patients’ attitudes toward HIV testing in the dental setting (published online ahead of print Feb. 16, 2012). Nurs Res Pract 2012;2012:803169. doi:10.1155/2012/ 803169. 18. Jacobson JJ, Epstein JB, Eichmiller FC, et al. The cost burden of oral, oral pharyngeal, and salivary gland cancers in three groups: commercial insurance, Medicare, and Medicaid (published online
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ahead of print April 26, 2012). Head Neck Oncol 2012;4(1):15. doi:10.1186/1758-3284-4-15. 19. Greenberg BL, Kantor ML, Jiang SS, Glick M. Patients’ attitudes toward screening for medical conditions in a dental setting (published online ahead of print Oct. 10, 2011). J Public Health Dent 2012;72(1):28-35. doi:10.1111/j.1752-7325.2011.00280.x. 20. Yevlahova D, Satur J. Models for individual oral health promotion and their effectiveness: a systematic review (published online ahead of print Aug. 24, 2009). Aust Dent J 2009;54(3):190-197. doi: 10.1111/j.1834-7819.2009.01118.x. 21. Koerber A. Health behavior and helping patients change. In: Mostofsky DI, Forgione AG, Giddon DB, eds. Behavioral Dentistry. Ames, Iowa: Blackwell; 2006:149-160. 22. Rubak S, Sandbaek A, Lauritzen T, Christensen B. Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract 2005;55(513):305-312. 23. Buckman R. Breaking bad news: why is it still so difficult? Br Med J (Clin Res Ed) 1984;288(6430):1597-1599. 24. Cohen L, Baile WF, Henninger E, et al. Physiological and psychological effects of delivering medical news using a simulated physician-patient scenario. J Behav Med 2003;26(5):459-471. 25. Hulsman RL, Pranger S, Koot S, Fabriek M, Karemaker JM, Smets EM. How stressful is doctor-patient communication? Physiological and psychological stress of medical students in simulated history taking and bad-news consultations (published online ahead of print April 23, 2010). Int J Psychophysiol 2010;77(1):26-34. doi:10.1016/ j.ijpsycho.2010.04.001. 26. Newton JT. Reactions to cancer: communicating with patients, family and carers (published online ahead of print April 8, 2010). Oral Oncol 2010;46(6):442-444. doi:10.1016/j.oraloncology.2010.03.015. 27. Chiu LQ, Lee WS, Gao F, Parker PA, Ng GY, Toh CK. Cancer patients’ preferences for communication of unfavourable news: an Asian perspective (published online ahead of print Feb. 16, 2006). Support Care Cancer 2006;14(8):818-824. doi:10.1007/s00520-0050911-7. 28. Horwitz N, Ellis J. Paediatric SpRs’ experiences of breaking bad news. Child Care Health Dev 2007;33(5):625-630. 29. Brown VA, Parker PA, Furber L, Thomas AL. Patient preferences for the delivery of bad news: the experience of a UK Cancer Centre (published online ahead of print Feb. 9, 2010). Eur J Cancer Care (Engl) 2011;20(1):56-61. doi:10.1111/j.1365-2354.2009.01156.x. 30. Fallowfield L, Jenkins V. Communicating sad, bad, and difficult news in medicine. Lancet 2004;363(9405):312-319. 31. Chernus-Mansfield N. Breaking the news: the role of the physician. In: Wright KW, Spiegel PH, Thompson LS, eds. Handbook of Pediatric Retinal Disease. New York City: Springer; 2006:82-95. 32. Sciubba JJ. End of life considerations in the head and neck cancer patient (published online ahead of print Sept. 18, 2008). Oral Oncol 2009;45(4-5):431-434. doi:10.1016/j.oraloncology.2008.06.001. 33. Farber NJ, Urban SY, Collier VU, et al. The good news about giving bad news to patients. J Gen Intern Med 2002;17(12):914-922. 34. Hoff L, Tidefelt U, Thaning L, Hermerén G. In the shadow of bad news: views of patients with acute leukaemia, myeloma or lung cancer about information, from diagnosis to cure or death. BMC Palliat Care 2007:6:1. 35. Friedrichsen MJ, Strang PM, Carlsson ME. Breaking bad news in the transition from curative to palliative cancer care: patient’s view of the doctor giving the information. Support Care Cancer 2000;8(6):472-478. 36. Bowyer MW, Hanson JL, Pimentel EA, et al. Teaching breaking bad news using mixed reality simulation (published online ahead of print May 20, 2009). J Surg Res 2010;159(1):462-467. doi: 10.1016/j.jss.2009.04.032. 37. Baile WF, Lenzi R, Parker PA, Buckman R, Cohen L. Oncologists’ attitudes toward and practices in giving bad news: an exploratory study. J Clin Oncol 2002;20(8):2189-2196. 38. Fujimori M, Uchitomi Y. Preferences of cancer patients regarding communication of bad news: a systematic literature review (published online ahead of print Feb. 3, 2009). Jpn J Clin Oncol 2009;39(4):201-216. doi:10.1093/jjco/hyn159.
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39. Barnett MM, Fisher JD, Cooke H, James PR, Dale J. Breaking bad news: consultants’ experience, previous education and views on educational format and timing (published online ahead of print Aug. 22, 2007). Med Educ 2007;41(10):947-956. doi:10.1111/j.13652923.2007.02832.x. 40. Curtin S, McConnell M. Teaching dental students how to deliver bad news: S-P-I-K-E-S model. J Dent Ed 2012;76(3):360-365. 41. Field D, Wee B. Preparation for palliative care: teaching about death, dying and bereavement in UK medical schools 2000-2001. Med Educ 2002;36(6):561-567. 42. Dosanjh S, Barnes J, Bhandari M. Barriers to breaking bad news among medical and surgical residents. Med Educ 2001;35(3): 197-205. 43. Ammann RA, Baumgartner L. Bad news in oncology: which are the right words? (published online ahead of print Jan. 28, 2005). Support Care Cancer 2005;13(5):275-276. doi:10.1007/s00520-0040712-4. 44. Chiodo GT, Tolle SW. Delivering bad news to dental patients. Gen Dent 1997;45(3):228-234. 45. Newton JT, Fiske, J. Breaking bad news: a guide for dental healthcare professionals. Brit Dent J 1999;186(6):278-281. 46. Farrand P, Clover H, Hutchison IL. GDPs’ self-perceived confidence and anxiety in their clinical and communication skills used when screening for oral cancer: UK variations. Prim Dent Care 2003;10(3):81-86. 47. Glick M. The numbers game. JADA 2008;139(5):528-530. 48. VandeKieft GK. Breaking bad news. Am Fam Physician 2001; 15:64(12):1975-1978. 49. Billson A, Tyrrell J. How to break bad news. Curr Paediatr 2003;13(4):284-287. 50. Hull SK, Broquet K. How to manage difficult patient encounters. Fam Pract Manag 2007;14(6):30-34. 51. Becze E. Strategies for breaking bad news to patients with cancer. ONS Connect 2010;25(9):14-15. 52. Kaplan M. SPIKES: a framework for breaking bad news to patients with cancer (published online ahead of print Aug. 2, 2010). Clin J Oncol Nurs 2010;14(4):514-516. doi:10.1188/10.CJON.514-516. 53. Wakefield A, Cocksedge S, Boggis C. Breaking bad news: qualitative evaluation of an interprofessional learning opportunity. Med Teach 2006;28(1):53-58. 54. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES: a six-step protocol for delivering bad news—application to the patient with cancer. Oncologist 2000;5(4):302-311. 55. Ptacek JT, McIntosh EG. Physician challenges in communicating bad news (published online ahead of print March 26, 2009). J Behav Med 2009;32(4):380-387. doi:10.1007/s10865-009-9213-8. 56. Moores TS, Castle KL, Shaw KL, Stockton MR, Bennett MI. ‘Memorable patient deaths’: reactions of hospital doctors and their need for support. Med Educ 2007;41(10):942-946. 57. Grunfeld E, Zitzelsberger L, Coristine M, Whelan TJ, Aspelund F, Evans WK. Job stress and job satisfaction of cancer care workers. Psychooncology 2005;14(1):61-69. 58. Glasberg J, Horiuti L, Novais MA, et al. Prevalence of the burnout syndrome among Brazilian medical oncologists. Rev Assoc Med Bras 2007;53(1):85-89. 59. Alacacioglu A. Burnout in nurses and physicians working at an oncology department (published online ahead of print Oct. 22, 2008). Psychooncology 2009;18(5):543-548. doi:10.1002/pon.1432. 60. Cashavelly BJ, Donelan K, Binda KD, Mailhot JR, ClairHayes KA, Maramaldi P. The forgotten team member: meeting the needs of oncology support staff. Oncologist 2008;13(5):530-538. 61. Glaser R, Kiecolt-Glaser JK, Bonneau RH, Malarkey W, Kennedy S, Hughes J. Stress-induced modulation of the immune response to recombinant hepatitis B vaccine. Psychosom Med 1992; 54(1):22-29. 62. Kiecolt-Glaser JK, Cacioppo JT, Malarkey WB, Glaser R. Acute psychological stressors and short-term immune changes: what, why, for whom, and to what extent? Psychosom Med 1992;54(6):680-685.
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PRACTICE
Breaking bad medical news in a dental care setting Pelin Güneri, DDS, PhD; Joel Epstein, DMD, MSD, FRCD(C), FDS RCS(Edin); Ronald W. Botto, PhD
O
ral manifestations may be the first indication of a number of systemic conditions,1 and providing oral care treatment to these patients may result in significant and even life-threatening complications. Oral cancers—including oropharyngeal squamous cell carcinoma, Kaposi sarcoma, metastatic disease to the head and neck, and hematologic and lymphoproliferative disorders—may develop in the head, neck and oral cavity. They need to be diagnosed before dental treatment to prevent further complications and to facilitate early initiation of medical care. Furthermore, patients receiving cancer therapy, cancer treatment survivors (who represent 3.9 percent of the U.S. population2) and patients receiving palliative care or hospice care may be seen in dental offices owing to subsequent oral complications. Patients with sexually transmitted diseases such as syphilis, gonorrhea, human immunodeficiency virus, herpes virus infections, human papilloma virus–associated cancer and other viral-related diseases may seek care from a dental care provider. Patients with serious systemic conditions—including endocrine, neurological, mucocutaneous and gastrointestinal diseases; hemato-
AB STRACT Background. Dental care providers may diagnose diseases and conditions that affect a patient’s general health. The authors reviewed issues related to breaking bad medical news to dental practice patients and provide guidance to clinicians about how to do so. Methods. To help reduce the potentially negative effects associated with emotionally laden communication with patients about serious health care findings, the authors present suggestions for appropriately and sensitively delivering bad medical news to both patients and their families in a supportive fashion. Results. Preparing to deliver bad news by means of education and practice is recommended to help prevent or reduce psychological distress. One form of communication guidance is the ABCDE model, which involves Advance preparation, Building a therapeutic relationship or environment, Communicating well, Dealing with patient and family reactions, and Encouraging and validating emotions. An alternative model is the six-step SPIKES sequence—Setting, Perception, Invitation or Information, Knowledge, Empathy, and Strategize and Summarize. Using either model can assist in sensitive and empathetic communication. Conclusions. For both practitioners’ and patients’ well-being, empathetic and effective delivery of bad medical news should be included in dental school curricula and continuing education courses. Practical Implications. Dental care providers should be familiar with the oral manifestations of diseases and the care needed before the patient undergoes medical treatment and use effective communication necessary to share bad news with patients. Key Words. Communication; dental education; dentistry; dentists; diagnosis, oral; disclosure; lesions, oral; mouth mucosa. JADA 2013;144(4):381-386.
Dr. Güneri is a professor, Department of Oral and Maxillofacial Radiology, School of Dentistry, Bornova, Izmir 35100, Turkey. Address reprint requests to Dr. Güneri. Dr. Epstein is an adjunct professor, the director, a collaborative member, Samuel Oschin Comprehensive Cancer Institute, and a consulting staff member, Cedars-Sinai Medical Center, Los Angeles; and a consulting staff member, Division of Otolaryngology and Head and Neck Surgery, City of Hope National Medical Center, Duarte, Calif. Dr. Botto is an associate professor, Department of Oral Health Science, and the director, Interprofessional Education and Activities, College of Dentistry, University of Kentucky, Lexington.
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logic, cardiovascular and respiratory disorders; and autoimmune syndromes—may experience oral manifestations.3-16 Thus, oral findings could indicate significant local oral disease and represent manifestations of systemic conditions that must be recognized and diagnosed expeditiously,17 which can lead not only to a better prognosis but also to reduced morbidity and cost of care.18 Oral health care providers must recognize abnormalities, take steps to achieve diagnosis and be familiar with the treatment modalities for these conditions. In addition, the changing nature of the practice and evolution of disease and medical care management requires that oral health care providers be comfortable providing appropriate and necessary care to people with advanced disease and variable prognoses. This ability requires both competency in and comfort with assessing a complete medical and dental history, including habits such as tobacco, alcohol and illicit drug use; sexual history (owing to sexually transmitted diseases that have the possibility of oral involvement); and symptoms and diagnoses of potentially significant medical conditions, in a positive, nonjudgmental way.19 In doing so, the oral health care provider needs to avoid lecturing the patient about his or her behaviors, even if doing so is well intended.20 Using phrases such as “Now you know you should (should not) … ” are not conducive to encouraging behavior change and can result in resistance to change.21 Identifying the patient’s reasons for the behavior, assessing his or her current readiness for change and using motivational interviewing techniques are significantly more effective.20-22 If a life-threatening condition is suspected in a patient, the steps needed to arrive at a diagnosis, by means of testing or referral, need to be communicated in a sensitive and supportive manner, and they need to address any potential concerns regarding the diagnosis of the condition. Using communication to address potential concerns related to diagnosis will help ensure that the patient understands the importance of compliance with further testing and referrals. Taking this approach also will help the practitioner address the patient’s concerns regarding compliance. Breaking bad news is a difficult task for which most dental care practitioners often have received little or no education. Breaking Bad News
Information that produces a negative expectation can be considered bad news.23 Receiving and breaking bad news are difficult for both patients 382 JADA 144(4)
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and health care professionals.24-26 For example, a cancer diagnosis often is associated with fear of dying, exhausting treatment with significant complications and poor quality of life; therefore, the effect of receiving a diagnosis of cancer might be devastating.27 Despite advances in medicine and communication education, patients with cancer often are dissatisfied with the way the bad news is delivered.28,29 This dissatisfaction could be because receiving bad news can be influenced by a patient’s life experiences; personality; spiritual principles; philosophical, religious or cultural beliefs; perceived social support; and emotional stamina.30 The way that bad news is delivered can have a profound effect on both the recipient and the caregiver.28,31,32 Most clinicians are uncomfortable with breaking bad news because they may be reluctant owing to their own discomfort in doing so, as well as their concerns about their lack of knowledge and skills.25,32 Although nondisclosure is considered unethical, providing additional information in a manner that is overwhelming to the patient also is inappropriate.33,34 Patients prefer to be informed directly with sensitivity about the diagnosis of, prognosis of, treatment plans for, and potential adverse effects of and complications of the treatment for their conditions.34 A lack of effective communication during the delivery of bad news may cause the patient to become confused, distressed and angry, whereas an appropriate and sensitive interaction can help the patient adjust to the difficult situation.30 A patient’s need for and acceptance of information is of great concern throughout the continuum of disease treatment and survival.34 The ability to deliver bad news to a patient requires knowledge not only of the diagnosed condition and its treatment but also of the integration of fundamental communication competencies and professionalism. It is essential that all health care workers, including dental professionals, develop these skills.35,36 Educational curricula and continuing education programs need to address these communication skills, which also include sensitivity to the cultural background and sociocultural environment of both the health care practitioner and the patient, as ABBREVIATION KEY. ABCDE: Advance preparation, Building a therapeutic relationship or environment, Communicating well, Dealing with patient and family reactions, and Encouraging and validating emotions. CUDSH: Cork University Dental School and Hospital. SPIKES: Setting, Perception, Invitation or Information, Knowledge, Empathy, and Strategize or Summarize.
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well as an awareness of both the practitioner’s and patient’s beliefs regarding the disclosure of bad news.37,38 In medicine, almost one-half of the practitioners who break bad news more than one to two times weekly have received no formal education regarding this task,39 and such education is even more rare in dentistry.26,40 Education regarding the Delivery of Bad News
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TABLE 1
Guide for preparing the setting and the clinician for breaking bad news.* STEP Advance Preparation
DESCRIPTION Arrange for adequate time, privacy and no interruptions Review relevant clinical information and test results as appropriate; review current general recommendations for treatment and general outcomes (may consult potential referral source for information) Mentally rehearse and identify words or phrases to use and avoid Be prepared intellectually and emotionally
Building a Therapeutic Relationship or Environment
Find a quiet and private setting
In a study conducted in the Determine what and how much the patient wants to know United Kingdom, investigators Have family or support people present, if appropriate found that most medical schools Introduce yourself to everyone have had some form of educaWarn the patient that bad news is coming tion relating to communication, Use touch when appropriate death and dying or both for at Arrange next steps, follow-up appointments or referrals, as 41 least 20 years. However, teachindicated ing of these topics has varied Communicating Ask what the patient and his or her significant others considerably in both duration Well already know and content, there has been Ask directly how much and what kind of information will be helpful to them no interdepartmental coordiTake into account their preferred learning styles and need nation or collaboration,39 and for information instructors mostly used nonBe frank but gentle and compassionate; avoid euphemisms standardized models and apand medical and dental jargon 30,42,43 proaches. Developing skills Allow for silence and breaks; proceed at the patient’s pace for communicating with patients Have the patient describe his or her understanding of the who have serious medical condinews; repeat this information when summarizing the discussion and at subsequent visits tions requires emphasis on its Allow time for questions; write things down and provide importance in the curriculum so written information that the necessity and value of Conclude each visit with a summary and a follow-up plan its being taught are similar to Dealing With Assess and respond to the patient’s and other people’s those of other aspects of health Patient and emotional reactions; repeat at each visit 23 care. Although the importance Family Be empathetic Reactions of education regarding breakDo not argue with or criticize colleagues ing bad news effectively and Encouraging Explore what the news means to the patient sensitively is acknowledged and Validating Offer realistic hope according to the patient’s goals and education in the necessary Emotions When appropriate, provide positive information, a basic or communication skills may be initial approach to treatment and a prognosis (such as, in included in the curricula of medigeneral, early diagnosis allows less complex, less costly and more successful outcomes) cal schools, it also is important 44,45 Use interdisciplinary resources and advice regarding finding in dental education. However, reliable online resources we found only one reference of Take care of your own needs; be attuned to the needs of its inclusion in a dental school involved house staff members and office or hospital 46 personnel curriculum. This lack of inclusion may be due to an erroneous * Source: VandeKieft. presumption that dental professionals commonly do not provide vational interviewing to address the relevant bad news to patients. However, many oral and issues.45-47 In addition, communication skills systemic conditions may be recognized in the courses need to include the importance of and dental practice environment. To improve the methods for working collaboratively with those provision of information related to a serious oral in other dental and medical disciplines. finding, courses should be developed regarding Communication skills. To prevent the negainterviewing techniques, communication skills tive effects associated with poor communication associated with breaking bad news and motiwith patients, as well as with their resistance 48
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TABLE 2
Setting, Perception, Invitation or Information, Knowledge, Empathy, and Strategize and Summarize model.* STEP
DESCRIPTION
Setting
Find a quiet and private setting Avoid interruptions
Perception
Establish how much the patient knows and his or her perceptions about the medical situation
specific programs regarding this topic in U.S. and Canadian dental schools. Tables 1 and 2 may serve as preparation guidelines for improving communication with patients when delivering bad news. The Impact of Delivering Bad News
Although there is information in the medical literature regarding patients’ emotions after receiving Take preferred learning styles and need for information into bad news,27,34,35,43 there is little consideration about health care practitioners’ Knowledge Share bad news with the patient using gentle, nonclinical feelings regarding providing news language in small segments; when appropriate, provide positive information and basic information regarding the of a serious diagnosis and prognonext steps involved in the diagnosis, treatment and sis to patients.23 We were not able prognosis; in general, early diagnosis allows for less complex, to identify any research about less costly and more successful outcomes this topic regarding dental profesEmpathy Acknowledge the patient’s emotions and reactions with appropriate responses sionals. Fear of the unknown, unleashing an emotional or physiSummarize Summarize in language that the patient can understand and Strategize easily and provide a strategic plan for further intervention; cal reaction, expressing emotion, ask the patient to repeat or summarize the information not knowing all the answers, and received and the next steps personal fear of illness and death * Source: Kaplan. have been reported as some of the difficulties that health care or noncompliance, we provide the skills necesproviders may have when disclosing unfavorable diagnoses and prognoses to patients.23 Bearsary for adequate transmission of bad news and ing this responsibility may create a sense of steps for delivering distressing information to helplessness,32,53 a fear of being blamed for the patients and their families in Table 1.26-28,31,45,48-53 This guide is referred to as the ABCDE model, illness or a wish to shield the patient from the which involves Advance preparation, Buildreality of the situation.32 ing a therapeutic relationship or environment, Receiving education in effective communiCommunicating well, Dealing with patient and cation skills can help clinicians deliver bad family reactions, and Encouraging and validatmedical news, and although learning the skills ing emotions.48 for breaking bad news within a supportive An alternative to the ABCDE model is framework may diminish the feeling of helplessSPIKES,54 which is a six-step protocol for deness,53,55 it may not reduce the stress of doing 52 livering bad news to patients (Table 2). Each so.55,56 Dentists who detect a suspicious oral muletter in the name represents a phase in the sixcosal lesion or symptoms that are highly suggesstep sequence: Setting, Perception, Invitation or tive of a malignant or serious disease and have Information, Knowledge, Empathy, and Stratbasic knowledge regarding potential treatment, egize and Summarize, and this model applies common complications and the prognosis of the to health care issues, including dentistry.40,52 disease inevitably experience both psychologiCurtin and McConnell40 stated that they had cal and physical stress. Research results have “identified only three articles addressing the shown that staff members working in oncology interpersonal components in breaking bad news and infectious disease clinics have a high risk of in dentistry,” and none of the articles addressed experiencing burnout57-59 because they encounhow to teach the needed skills to dental stuter multiple stressors that may influence the dents. Curtin and McConnell40 then discussed quality of their lives negatively across time.60 how the SPIKES model was introduced to the Delivering bad news to patients is considered an dental curriculum at Cork University Dental acute stressor that may, in turn, lead to proSchool and Hospital (CUDSH), Ireland, in found psychological and physiological changes, 2010.40 They stated that “research is currently such as increases in sympathetic nervous ongoing to assess how patients perceive stusystem activity (including blood pressure, heart dents’ delivery of bad news.” We are not aware of rate and catecholamine secretion), as well as Invitation or Information
Ask the patient and significant others how much and what kind of information will be helpful to them
52
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platelet aggregation and changes in the number and function of a variety of immune cells.24,25,61,62 Cohen and colleagues24 reported that delivering both bad and good medical news produced an acute stress response consisting of significant increases in self-reported distress and cardiovascular responses. Breaking only bad news, however, led to a significant increase in natural killer cell function. Health care providers who experience intense emotional response when they are working under “unpleasant” conditions could benefit from receiving education in addressing difficult issues regarding both their patients’ and their own emotions, as well as receiving professional psychological support to decrease the level of work-related stress.56 Considering that dental care providers may experience psychological distress when delivering bad news, we recommend education for dental care providers. Furthermore, considering that the burden of this situation on dentists is underestimated, more interpersonally oriented approaches in dental education (such as those at CUDSH) and continuing education are necessary to improve the well-being of dental care providers and, ultimately, the quality of patient care. Using the ABCDE and SPIKES models can help dental care providers prepare for the delivery of bad medical news and can be of benefit to both the patient and the provider. Although the impact of using the SPIKES model in dental patient care is being evaluated as part of a dental curriculum, both the ABCDE and SPIKES models have relevance to dentistry and are good models to use when addressing difficult situations associated with the delivery of dental care. The importance of the ABCDE and SPIKES models is that they each address patient and practitioner issues, comfort and well-being associated with the stress of communicating about bad news. CONCLUSIONs
Health care education needs to include teaching practitioners to address the stressors associated with a health care practice, including delivering difficult information to patients. Bearing in mind that clinicians have the responsibility to communicate with patients about numerous scenarios regarding various treatment options, the need to educate oral health care professionals regarding the assessment of clinical care for patients is clear.47 As observed during delivery of medical bad news, patients need to be communicated with and receive information in an effective and sensitive manner when they feel overwhelmed.31 Thus, dental education should
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address these needs by including education regarding communication skills and methods for sensitive and supportive delivery of bad news to patients,40 which is a crucial aspect of patient care in dental practice, in curricula and in continuing education. The dental care provider must be familiar with the conditions and general principles of care associated with medical conditions and be familiar with and be able to discuss oral and dental care needed before, during and after the patient receives medical treatment and acute care. To maximize effective treatment, dental care practitioners need to receive the appropriate education regarding the skills necessary to address both the patient’s and their own needs, as well as the issues involved in delivering bad news. n Disclosure. None of the authors reported any disclosures. 1. Frydrych AM, Slack-Smith LM. Dental attendance of oral and oropharyngeal cancer patients in a public hospital in Western Australia (published online ahead of print Aug. 11, 2011). Aust Dent J 2011;56(3):278-283. doi:10.1111/j.1834-7819.2011.01343.x. 2. Centers for Disease Control and Prevention. Cancer Survivors: United States, 2007. www.cdc.gov/mmwr/preview/mmwrhtml/ mm6009a1.htm. Accessed Feb. 21, 2013. 3. Chi AC, Neville BW, Krayer JW, Gonsalves WC. Oral manifestations of systemic disease. Am Fam Physician 2010;82(11):1381-1388. 4. Reichart PA, Phillipsen HP. Betel chewer’s mucosa: a review. J Oral Pathol Med 1998;27(6):239-242. 5. Scully C, Porter S. ABC of oral health: swellings and red, white, and pigmented lesions. BMJ 2000;321(7255):225-228. 6. Scully C, Felix DH. Oral medicine: update for the dental practitioner—aphthous and other common ulcers. Br Dent J 2005; 199(5):259-264. 7. Scully C, Felix DH. Oral medicine: update for the dental practitioner—mouth ulcers of more serious connotation. Br Dent J 2005;199(6):339-343. 8. Scully C, Felix DH. Oral medicine: update for the dental practitioner—dry mouth and disorders of salivation. Br Dent J 2005; 199(7):423-427. 9. Scully C, Felix DH. Oral medicine: update for the dental practitioner—oral malodour. Br Dent J 2005;199(8):498-500. 10. Scully C, Felix DH. Oral medicine: update for the dental practitioner—oral white patches. Br Dent J 2005;199(9):565-572. 11. Scully C, Felix DH. Oral medicine: update for the dental practitioner—red and pigmented lesions. Br Dent J 2005;199(10): 639-645. 12. Scully C, Felix DH. Oral medicine: update for the dental practitioner—disorders of orofacial sensation and movement. Br Dent J 2005;199(11):703-709. 13. Scully C, Felix DH. Oral medicine: update for the dental practitioner—lumps and swellings. Br Dent J 2005;199(12):763-770. 14. Scully C, Felix DH. Oral medicine: update for the dental practitioner—oral cancer. Br Dent J 2006;200(1):13-17. 15. Scully C, Felix DH. Oral medicine: update for the dental practitioner—orofacial pain. Br Dent J 2006;200(2):75-83. 16. Kragelund C, Reibel J, Hadler-Olsen ES, et al. Scandinavian Fellowship for Oral Pathology and Oral Medicine: statement on oral pathology and oral medicine in the European Dental Curriculum (published online ahead of print Sept. 1, 2010). J Oral Pathol Med 2010;39(10):800-e1. doi:10.1111/j.1600-0714.2010.00939.x. 17. Vandevanter N, Combellick J, Hutchinson MK, Phelan J, Malamud D, Shelley D. A qualitative study of patients’ attitudes toward HIV testing in the dental setting (published online ahead of print Feb. 16, 2012). Nurs Res Pract 2012;2012:803169. doi:10.1155/2012/ 803169. 18. Jacobson JJ, Epstein JB, Eichmiller FC, et al. The cost burden of oral, oral pharyngeal, and salivary gland cancers in three groups: commercial insurance, Medicare, and Medicaid (published online
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ahead of print April 26, 2012). Head Neck Oncol 2012;4(1):15. doi:10.1186/1758-3284-4-15. 19. Greenberg BL, Kantor ML, Jiang SS, Glick M. Patients’ attitudes toward screening for medical conditions in a dental setting (published online ahead of print Oct. 10, 2011). J Public Health Dent 2012;72(1):28-35. doi:10.1111/j.1752-7325.2011.00280.x. 20. Yevlahova D, Satur J. Models for individual oral health promotion and their effectiveness: a systematic review (published online ahead of print Aug. 24, 2009). Aust Dent J 2009;54(3):190-197. doi: 10.1111/j.1834-7819.2009.01118.x. 21. Koerber A. Health behavior and helping patients change. In: Mostofsky DI, Forgione AG, Giddon DB, eds. Behavioral Dentistry. Ames, Iowa: Blackwell; 2006:149-160. 22. Rubak S, Sandbaek A, Lauritzen T, Christensen B. Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract 2005;55(513):305-312. 23. Buckman R. Breaking bad news: why is it still so difficult? Br Med J (Clin Res Ed) 1984;288(6430):1597-1599. 24. Cohen L, Baile WF, Henninger E, et al. Physiological and psychological effects of delivering medical news using a simulated physician-patient scenario. J Behav Med 2003;26(5):459-471. 25. Hulsman RL, Pranger S, Koot S, Fabriek M, Karemaker JM, Smets EM. How stressful is doctor-patient communication? Physiological and psychological stress of medical students in simulated history taking and bad-news consultations (published online ahead of print April 23, 2010). Int J Psychophysiol 2010;77(1):26-34. doi:10.1016/ j.ijpsycho.2010.04.001. 26. Newton JT. Reactions to cancer: communicating with patients, family and carers (published online ahead of print April 8, 2010). Oral Oncol 2010;46(6):442-444. doi:10.1016/j.oraloncology.2010.03.015. 27. Chiu LQ, Lee WS, Gao F, Parker PA, Ng GY, Toh CK. Cancer patients’ preferences for communication of unfavourable news: an Asian perspective (published online ahead of print Feb. 16, 2006). Support Care Cancer 2006;14(8):818-824. doi:10.1007/s00520-0050911-7. 28. Horwitz N, Ellis J. Paediatric SpRs’ experiences of breaking bad news. Child Care Health Dev 2007;33(5):625-630. 29. Brown VA, Parker PA, Furber L, Thomas AL. Patient preferences for the delivery of bad news: the experience of a UK Cancer Centre (published online ahead of print Feb. 9, 2010). Eur J Cancer Care (Engl) 2011;20(1):56-61. doi:10.1111/j.1365-2354.2009.01156.x. 30. Fallowfield L, Jenkins V. Communicating sad, bad, and difficult news in medicine. Lancet 2004;363(9405):312-319. 31. Chernus-Mansfield N. Breaking the news: the role of the physician. In: Wright KW, Spiegel PH, Thompson LS, eds. Handbook of Pediatric Retinal Disease. New York City: Springer; 2006:82-95. 32. Sciubba JJ. End of life considerations in the head and neck cancer patient (published online ahead of print Sept. 18, 2008). Oral Oncol 2009;45(4-5):431-434. doi:10.1016/j.oraloncology.2008.06.001. 33. Farber NJ, Urban SY, Collier VU, et al. The good news about giving bad news to patients. J Gen Intern Med 2002;17(12):914-922. 34. Hoff L, Tidefelt U, Thaning L, Hermerén G. In the shadow of bad news: views of patients with acute leukaemia, myeloma or lung cancer about information, from diagnosis to cure or death. BMC Palliat Care 2007:6:1. 35. Friedrichsen MJ, Strang PM, Carlsson ME. Breaking bad news in the transition from curative to palliative cancer care: patient’s view of the doctor giving the information. Support Care Cancer 2000;8(6):472-478. 36. Bowyer MW, Hanson JL, Pimentel EA, et al. Teaching breaking bad news using mixed reality simulation (published online ahead of print May 20, 2009). J Surg Res 2010;159(1):462-467. doi: 10.1016/j.jss.2009.04.032. 37. Baile WF, Lenzi R, Parker PA, Buckman R, Cohen L. Oncologists’ attitudes toward and practices in giving bad news: an exploratory study. J Clin Oncol 2002;20(8):2189-2196. 38. Fujimori M, Uchitomi Y. Preferences of cancer patients regarding communication of bad news: a systematic literature review (published online ahead of print Feb. 3, 2009). Jpn J Clin Oncol 2009;39(4):201-216. doi:10.1093/jjco/hyn159.
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39. Barnett MM, Fisher JD, Cooke H, James PR, Dale J. Breaking bad news: consultants’ experience, previous education and views on educational format and timing (published online ahead of print Aug. 22, 2007). Med Educ 2007;41(10):947-956. doi:10.1111/j.13652923.2007.02832.x. 40. Curtin S, McConnell M. Teaching dental students how to deliver bad news: S-P-I-K-E-S model. J Dent Ed 2012;76(3):360-365. 41. Field D, Wee B. Preparation for palliative care: teaching about death, dying and bereavement in UK medical schools 2000-2001. Med Educ 2002;36(6):561-567. 42. Dosanjh S, Barnes J, Bhandari M. Barriers to breaking bad news among medical and surgical residents. Med Educ 2001;35(3): 197-205. 43. Ammann RA, Baumgartner L. Bad news in oncology: which are the right words? (published online ahead of print Jan. 28, 2005). Support Care Cancer 2005;13(5):275-276. doi:10.1007/s00520-0040712-4. 44. Chiodo GT, Tolle SW. Delivering bad news to dental patients. Gen Dent 1997;45(3):228-234. 45. Newton JT, Fiske, J. Breaking bad news: a guide for dental healthcare professionals. Brit Dent J 1999;186(6):278-281. 46. Farrand P, Clover H, Hutchison IL. GDPs’ self-perceived confidence and anxiety in their clinical and communication skills used when screening for oral cancer: UK variations. Prim Dent Care 2003;10(3):81-86. 47. Glick M. The numbers game. JADA 2008;139(5):528-530. 48. VandeKieft GK. Breaking bad news. Am Fam Physician 2001; 15:64(12):1975-1978. 49. Billson A, Tyrrell J. How to break bad news. Curr Paediatr 2003;13(4):284-287. 50. Hull SK, Broquet K. How to manage difficult patient encounters. Fam Pract Manag 2007;14(6):30-34. 51. Becze E. Strategies for breaking bad news to patients with cancer. ONS Connect 2010;25(9):14-15. 52. Kaplan M. SPIKES: a framework for breaking bad news to patients with cancer (published online ahead of print Aug. 2, 2010). Clin J Oncol Nurs 2010;14(4):514-516. doi:10.1188/10.CJON.514-516. 53. Wakefield A, Cocksedge S, Boggis C. Breaking bad news: qualitative evaluation of an interprofessional learning opportunity. Med Teach 2006;28(1):53-58. 54. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES: a six-step protocol for delivering bad news—application to the patient with cancer. Oncologist 2000;5(4):302-311. 55. Ptacek JT, McIntosh EG. Physician challenges in communicating bad news (published online ahead of print March 26, 2009). J Behav Med 2009;32(4):380-387. doi:10.1007/s10865-009-9213-8. 56. Moores TS, Castle KL, Shaw KL, Stockton MR, Bennett MI. ‘Memorable patient deaths’: reactions of hospital doctors and their need for support. Med Educ 2007;41(10):942-946. 57. Grunfeld E, Zitzelsberger L, Coristine M, Whelan TJ, Aspelund F, Evans WK. Job stress and job satisfaction of cancer care workers. Psychooncology 2005;14(1):61-69. 58. Glasberg J, Horiuti L, Novais MA, et al. Prevalence of the burnout syndrome among Brazilian medical oncologists. Rev Assoc Med Bras 2007;53(1):85-89. 59. Alacacioglu A. Burnout in nurses and physicians working at an oncology department (published online ahead of print Oct. 22, 2008). Psychooncology 2009;18(5):543-548. doi:10.1002/pon.1432. 60. Cashavelly BJ, Donelan K, Binda KD, Mailhot JR, ClairHayes KA, Maramaldi P. The forgotten team member: meeting the needs of oncology support staff. Oncologist 2008;13(5):530-538. 61. Glaser R, Kiecolt-Glaser JK, Bonneau RH, Malarkey W, Kennedy S, Hughes J. Stress-induced modulation of the immune response to recombinant hepatitis B vaccine. Psychosom Med 1992; 54(1):22-29. 62. Kiecolt-Glaser JK, Cacioppo JT, Malarkey WB, Glaser R. Acute psychological stressors and short-term immune changes: what, why, for whom, and to what extent? Psychosom Med 1992;54(6):680-685.
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