Don’t Always Expect Questions From Patients About Prognosis
Although most patients want to know about the potential outcome of their disease and whether treatment is likely to have a significant impact on it, the information needs of patients and how best to fulfill those needs are very variable, Walter F. Baile, MD, told The ASCO Post. Dr. Baile is Professor of Behavioral Science and Psychiatry and Director of the Interpersonal Communication and Relationship Enhancement (I*CARE) program at The University of Texas MD Anderson Cancer Center in Houston. He is also one of originators of the SPIKES six-step strategy for breaking news to patients with cancer (see article above).1
Cues From the Clinician
“Sometimes patients and families have information needs but may be afraid to ask because they don’t want to hear bad news. Others may assume that the physician or oncologist is going to tell them everything they need to know,” Dr. Baile noted. Whether or not patients ask questions “often depends on the behavior of the clinician,” Dr. Baile said. “If the clinician has the kind of relationship with the patient that indicates he or she is open to having questions asked, then the patient will pick up on that cue. But if the clinician has a hand on the door knob, or seems harried, that is a cue that can be interpreted by the patient as ‘I’m too busy.”
According to the SPIKES protocol, breaking bad news to patients should be done, whenever possible, in a setting with some privacy, but involving the patient’s significant other, with all seated. “If you sit down, it says, ‘I am available to you.’ If you stand up, it says, ‘I haven’t really got much time to give you.’ I think it is easy to underestimate the nonverbal messages that doctors give to patients about their willingness to answer questions,” Dr. Baile said.
One of the recommendations from a recent German study,2 using a variation of the SPIKES protocol, was to consider splitting the delivery of bad news over two visits, which Dr. Baile agreed could be useful. “Many patients, after you use the word cancer or talk about prognosis, may not hear the rest of what you say,” he noted. “So when they come back, there is an opportunity to say, ‘Did you have any questions about our conversation of last week? Is there anything that wasn’t clear to you?’”
‘Perpetual Possibility to Ask Questions’
Frequent reassurances of listeners’ understanding and the “perpetual possibility to ask questions” were also suggested by the German researchers. “Questions are always coming up,” Dr. Baile said, and clinicians should not to be dismissive of any questions posed by patients since it may leave them feeling foolish for having asked in the first place.
“Patients in search of answers may do an Internet research and find an obscure animal study that actually has no relevance for the patient’s outcome. We should not be dismissive of that and bluntly tell them it is an irrelevant study, because that demeans the patient’s quest for being a collaborator in finding answers to questions about the course of their disease,” Dr. Baile stated. “Many patients come with some knowledge from the Internet about their prognosis and treatment. These individuals, I think, are primed to ask questions.”
Other patients may be reluctant to ask questions. “If you want to stay patient-centered, you ask patients how much information they want about their disease. That is one of the steps of SPIKES, the invitation piece. Another really important piece that many doctors don’t address is to ask patients what they have been told or what they know. This is important because you can’t begin to give bad news until you know what the patient already knows,” he added.
Given the time constraints imposed on physicians, can so much information by imparted in the time allotted? “That’s the biggest complaint,” Dr. Baile said. “However, I can tell you that if you provide information accurately, and you check with the patient and family as to what they’ve understood, in the end it will save you time. If you are upfront with the patient who really wants to know about the likely outcome of the disease, it could save you a lot of grief later on. If you hide that information from a patient, and after the second chemotherapy, when the disease has progressed, the patient says, ‘Well, you didn’t tell me the chemo might not work,’ then you have to pick up a lot of pieces.”
Dr. Baile noted, “Some data show that patients consider their oncologist to be, if not the most important, then one of their two most valued sources of support. So what’s support? It is in a large part establishing the ‘connection’ by communicating effectively, acknowledging the patients’ emotions, and answering their questions.” ■
1. Baile WF, Buckman R, Lenzi R, et al: SPIKES—a six-step protocol for delivering bad news: Application to the patient. Oncologist 5:302-311, 2000.
2. Seifart C, Hofmann M, Bar T, et al: Breaking bad news—what patients want and what they get: Evaluating the SPIKES protocol in Germany. Ann Oncol 25:707-711, 2014.
When the prognosis is poor, breaking the bad news badly can exacerbate the distress experienced by cancer patients and their families. A lack of sensitivity to patient and family emotions and not being attuned to how individual patients would prefer to be informed about their prognoses can result...