Abstract
Background:
Breaking bad medical news is one of the most difficult tasks of physicians. In this regard, communication skills play a vital role.Objectives:
This study aimed to investigate patients’ preferences and attitudes toward receiving bad medical news in academic hospitals affiliated with Guilan University of Medical Sciences.Methods:
This cross-sectional descriptive study was conducted on patients over 18 years of age from March 2021 to December 2021. A questionnaire taken from Alrukban’s study regarding patients’ demographic characteristics, preferences, and tendencies while receiving bad news was filled out through a face-to-face interview.Results:
In this study, 600 patients were interviewed, 96% of which preferred to know their disease diagnosis, 76.2% preferred to be the first person to receive bad news, and employed individuals with younger ages and higher levels of education significantly preferred to be the recipients of illness news. Furthermore, 40.7% of patients preferred not to be accompanied by anyone when receiving bad news, 82.3% preferred to be broken bad news by the head of the medical team, and 50.8%, particularly female, younger, and employed patients, preferred the physician to start the conversation containing some information about the disease. Also, younger female patients significantly preferred the physician to stay with them and provide additional information after presenting the diagnosis in a completely private space.Conclusions:
Most patients preferred to know about their diagnosis. The impact of socio-demographical variables, including age, gender, level of education, and marital status, should be considered when breaking bad news.Keywords
1. Background
In modern healthcare, physicians’ communication skills are becoming increasingly valuable. Empathy, trust, and respect are crucial for doctor-patient communication, reducing patient anxiety and dissatisfaction and promoting patient’s better decision-making regarding their treatment process (1).
Patients increasingly prefer to receive comprehensive information about their disease, survival, treatment planning, complications, and the chance of cure. On the other hand, poor communication makes doctors distant from patients and negatively affects the doctor-patient relationship (2).
In this regard, one of the important issues is breaking bad news about the disease to patients. A successful doctor must be flexible enough to deal with various patients with different cultures and beliefs.
The bad news is defined as “any information which negatively affects the patient’s view of his/her future” (3). Bad news not only causes unpleasant reactions in the listener but also evokes unpleasant feelings in the speaker (4). Breaking bad news is the responsibility of physicians, although they find it very unpleasant and stressful (5). Studies have shown that the way of breaking bad news directly affects the patient-doctor relationship (6, 7). It also results in the patient’s adaptation and cooperation in the treatment process (4, 8, 9). Today, telling the truth and being honest with the patient is considered a doctor’s legal duty and also a patient’s right (10). Cultural, medical, moral, and legal factors play important roles in breaking bad news appropriately.
Therefore, the physician should primarily be aware of the patient’s willingness to receive the exact diagnosis and prognosis (11). Patients’ and doctors’ cultural and belief variations are among the significant influencing factors. For example, physicians in the East believe that informing patients about their life-threatening disease results in hastening their death. In contrast, Western societies appreciate patients' right to know the truth about their real medical conditions (12-14). Regarding the effect of cultural differences on the way of breaking bad news, Dias et al.’s research concluded that the presence of the patient's companions made it difficult to discuss the details of the disease (15). On the contrary, in Alrukban's study from Arabia, the presence of older family members while receiving bad news was considered positive (16).
Research has recently shown that patients mostly prefer to know about their disease and physical condition. In fact, they most desire to know how long they will survive, what the complications of their treatment are, and how much their chances for recovery are. Also, they want to gain more knowledge about the details of the disease (17). The results of Fujimori et al.’s study investigating 500 cancer patients in terms of their expectations on how to receive bad news showed that 90% of them preferred to be informed about their disease status in detail. They also expected the doctors to pay enough attention to their emotional reactions and also the emotional reactions of their families. Among the patients, 30% preferred not to know about their life expectancy (18).
Although there are limited studies on patients’ preferences and attitudes toward breaking bad news, due to obvious cultural and regional differences, it is not possible to generalize their results. Since each region’s beliefs, convictions, and culture are different and will definitely affect people’s judgment, perceptions, and tendencies, conducting this study independently in each region is necessary. For the first time, this study explored the patient’s preferences and attitudes toward breaking bad news. To the best of our knowledge, few studies were conducted in Iran, let alone in Guilan, and the main literature came from the West.
2. Objectives
This study aims to investigate patients’ preferences and attitudes toward receiving bad medical news. It should be noted that this is the first multi-center research at Guilan University of Medical Sciences on this subject. Based on the results of this research, a protocol can be formulated, and training courses can be planned to increase the abilities and skills of doctors in fulfilling this important task.
3. Methods
After the approval of the study protocol by the Research Ethics Committee of Guilan University of Medical Sciences, this cross-sectional study was conducted in academic hospitals of the city of Rasht, Guilan, affiliated with Guilan University of Medical Sciences from March 2021 to December 2021.
Inclusion criteria: Having above 18 years of age, being admitted to the academic hospitals affiliated with Guilan University of Medical Sciences, having proper communication, and living in Guilan province.
Exclusion criteria: Being unwilling to participate in the study, not providing informed consent, not having the ability to communicate due to a different language or other reasons, and not living in Guilan and moving from other areas.
First, the research objective and method were explained to the patients, and informed consent was obtained from them. Then, a responsible medical student filled out a questionnaire via a direct interview. The questionnaire taken from Alrukban et al.’s study (16) consisted of two sections and 15 questions. The corresponding author of the original article was informed by e-mail about planning similar research in Northern Iran. The questionnaire was translated into Persian and reviewed by ten expert faculty members. The first part belonged to demographic data, including age, gender, marital status, level of education, and occupation. The second part reflected individuals’ preferences and attitudes toward receiving bad news. Questions 1 - 4 were related to participants' preferences while receiving bad news, and questions 5 - 9 were related to participants' attitudes toward receiving bad news. The questionnaire was scored according to the frequency of the answers.
3.1. Sample Size
According to Alrukban et al.’s study (16), 50% preferred to hear bad news in a private space with the presence of a supporter.
p = 0.50, q = 0.50, ∝ = 0.05, d = 0.04.
3.2. Statistical Analysis
The data were analyzed by SPSS software (INC .21 Chicago, II, USA). Quantitative variables are reported as mean ± standard deviation and qualitative variables are presented as frequencies and percentages. Chi-square and Fisher’s exact tests were used to observe the association between qualitative variables. A P-value less than 0.05 was considered significant.
4. Results
During the study period, a total of 839 patients were interviewed to reach the determined sample size, and 239 people were excluded. Among them, 105 were unwilling to participate for personal reasons, and 134 did not meet the inclusion criteria, such as having different languages. Finally, the data of 600 patients were analyzed (mean age = 44.73 ± 17.26 years; 50% (n = 300) = male). Patient demographic information is shown in Table 1. Among the patients, 96% preferred to know their disease diagnosis, 76.2% preferred to be the first person to receive bad news, employed individuals with younger ages and higher levels of education significantly preferred to be the recipients of illness news, 40.7% preferred not to be accompanied by anyone when receiving bad news, and 33.5%, particularly females, preferred to be accompanied by their spouse (P > 0.0001). Also, the majority of patients (82.3%) preferred to be broken bad news by the head of the medical team, and 50.8% of patients preferred the physician to start the conversation with an introduction containing some information about the disease, which was significantly preferred by female, younger, and employed patients (Table 2). Furthermore, female patients at younger ages significantly preferred a completely private space while receiving bad news and preferred the doctor to stay with them and provide additional information after presenting the diagnosis (Table 3). The frequency of the answers to the questions about attitudes and preferences is presented in Table 2.
Participants’ Socio-Demographic Characteristics
| Variables and Status | Values a |
|---|---|
| Gender | |
| Male | 300 (50) |
| Female | 300 (50) |
| Age (y) | |
| Mean ± SD | 44.73 ± 17.26 |
| Min-max | 13 - 93 |
| Marital status | |
| Married | 142 (23.7) |
| Single | 458 (76.3) |
| Education | |
| Illiterate | 34 (5.7) |
| Elementary school | 48 (8) |
| High school | 77 (12.8) |
| Diploma | 292 (48.7) |
| University degree | 149 (24.8) |
| Occupation | |
| Employed | 306 (51) |
| Unemployed | 294 (49) |
| Preference to know about the disease condition | |
| Yes | 576 (96) |
| No | 24 (4) |
Participants’ Preferences and Attitudes Toward Receiving Bad News
| Questions and Status | No. (%) |
|---|---|
| Question 1: If your physician has bad news for you, who would you like to be the first person to receive it? | |
| One of my parents | 24 (4) |
| My wife/husband | 73 (12.2) |
| One of my kids | 23 (3.8) |
| One of my siblings | 19 (3.2) |
| Myself | 457 (76.2) |
| Others | 4 (0.7) |
| Question 2: Are you willing to tell another person about your diagnosis? | |
| Yes | 168 (31) |
| No | 414 (69) |
| Question 3: Who would you like to accompany you when receiving bad news? | |
| One of my parents | 61 (10.2) |
| My wife/husband | 201 (33.5) |
| One of my kids | 66 (11) |
| One of my siblings | 17 (2.8) |
| No one | 244 (40.7) |
| Others | 11 (1.8) |
| Question 4: Who would you prefer to break the bad news to you? | |
| The head of the medical team | 494 (82.3) |
| Any member of the medical team | 22 (3.7) |
| The psychologist or social worker | 15 (2.5) |
| My best friend | 10 (1.7) |
| One of my family members | 52 (8.7) |
| Spiritual counselor | 7 (1.2) |
| Question 5: Which method would you prefer when receiving bad news? | |
| Face-to-face | 540 (90) |
| Telephone | 23 (3.8) |
| By mail | 7 (1.2) |
| Medical report | 30 (5) |
| Question 6: What is the best way of breaking bad news for you? | |
| Directly without warning or introduction | 219 (36.5) |
| Start with Allah’s will, grace, and remembrance | 76 (12.7) |
| Start with an introduction containing information about the disease | 305 (50.8) |
| Question 7: In which of these places would you prefer to receive bad news? | |
| Private place | 343 (57.2) |
| Public place | 12 (2) |
| The place is not important | 245 (40.8) |
| Question 8: What do you prefer from the person telling you the bad news to do? | |
| Leave you alone immediately | 122 (20.3) |
| Stay with you and support you | 155 (25.8) |
| Stay and give you more information about the disease | 272 (45.3) |
| Inform one of your family/friends and ask them to come | 51 (8.5) |
| Question 9: What are the main characteristics you expect from the person breaking bad news to you? | |
| Polite with good manners | 166 (27.7) |
| Medical expert with good knowledge | 367 (61.2) |
| Good manager | 21 (3.5) |
| Experienced in psychological treatment | 46 (7.7) |
The Association Between Participants’ Socio-Demographic Characteristics and Preferences, and Attitudes Toward Receiving Bad News a
| Variables | Marital Status | P-Value | Gender | P-Value | Occupation | P-Value | Age | P-Value | |||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Single | Married | Male | Female | Employed | Unemployed | ||||||
| 1- If your physician has bad news for you, who would you like to be the first person to receive it? | < 0.0001 | < 0.0001 | < 0.0001 | ||||||||
| One of my parents | 12 (6.2) | 12 (2.9) | 13(4.3) | 11 (3.7) | 11 (3.6) | 13 (4.4) | 0.026 | 37.83 ± 14.5 | |||
| My wife/husband | 0 (0) | 68 (16.7) | 23 (7.7) | 50 (16.7) | 39 (12.7) | 34 (11.6) | 43.86 ± 13.98 | ||||
| One of my kids | 14 (7.3) | 9 (2.2) | 13 (4.3) | 10 (3.3) | 4 (1.3) | 19 (6.5) | 74 ± 17.96 | ||||
| One of my siblings | 7 (3.7) | 17 (4.2) | 9 (3) | 10 (3.3) | 11 (3.6) | 8 (2.7) | 43.21 ± 12.95 | ||||
| Myself | 155 (80.7) | 302 (74) | 238 (79.3) | 219 (73) | 240 (78.4) | 217 (73.8) | 43.82 ± 16.57 | ||||
| Others | 4 (2.1) | 0 (0) | 4 (1.3) | 0 (0) | 1 (0.3) | 3 (1) | 44.5 ± 31.41 | ||||
| 2- Who would you like to accompany you when receiving bad news? | < 0.0001 | < 0.0001 | < 0.0001 | < 0.0001 | |||||||
| One of my parents | 47 (24.5) | 14 (3.4) | 17 (5.7) | 44 (14.7) | 21 (6.9) | 40 (13.6) | 28.63 ± 8.97 | ||||
| My wife/husband | 0 (0) | 192 (47.1) | 76 (25.3) | 125 (41.7) | 105 (34.3) | 96 (32.7) | 44.88 ± 12.78 | ||||
| One of my kids | 25 (13) | 41 (10) | 36 (12) | 30 (10) | 14 (4.6) | 52 (17.7) | 89.83 ± 15.53 | ||||
| One of my siblings | 19 (9.9) | 7 (1.7) | 6 (2) | 11 (3.7) | 9 (2.9) | 8 (2.7) | 38.41 ± 18.16 | ||||
| No one | 94 (49) | 150 (36.8) | 157 (52.3) | 87 (29) | 151 (49.3) | 93 (31.6) | 42.55 ± 15.16 | ||||
| Others | 7 (3.6) | 4 (1) | 8 (2.7) | 3 (1) | 6 (2) | 5 (1.7) | 38.54 ± 21.28 | ||||
| 3- Who would you prefer to break the bad news to you? | 0.033 | 0.139 | 0.135 | 0.002 | |||||||
| The head of the medical team | 157 (81.7) | 337 (82.6) | 258 (86) | 236 (78.7) | 256 (83.7) | 238 (81) | 44.09 ± 16.43 | ||||
| Any member of the medical team | 6 (3.12) | 16 (3.9) | 10 (3.3) | 12 (4) | 16 (5.2) | 6 (2) | 40.72 ± 12.5 | ||||
| The psychologist or social worker | 2 (1) | 13 (3.2) | 3 (1) | 12 (4) | 5 (1.6) | 10 (3.4) | 38.06 ± 14.57 | ||||
| My best friend | 3 (1.5) | 7 (1.7) | 4 (1.3) | 6 (2) | 4 (1.3) | 6 (2) | 48.5 ± 22.7 | ||||
| One of my family members | 21 (10.9) | 31 (7.6) | 22 (7.3) | 30 (10) | 22 (7.2) | 30 (10.2) | 53.69 ± 23.39 | ||||
| Spiritual counselor | 3 (1.5) | 4 (1) | 3 (1) | 4 (1.3) | 3 (1) | 4 (1.4) | 44.42 ± 13.59 | ||||
| 4- Which method would you prefer when receiving bad news? | 0.511 | 0.215 | 0.131 | 0.619 | |||||||
| Face‑to‑face | 175 (91.1) | 365 (89.5) | 276 (92) | 264 (88) | 274 (89.5) | 266 (90.5) | 45.03 ± 17.53 | ||||
| Telephone | 6 (3.1) | 17 (4.2) | 7 (2.3) | 16 (5.3) | 12 (3.9) | 11 (3.7) | 42.95 ± 17.17 | ||||
| By mail | 3 (1.5) | 4 (1) | 4 (1.3) | 3 (1) | 1 (0.3) | 6 (2) | 40.14 ± 16.97 | ||||
| Medical report | 8 (4.1) | 22 (5.4) | 13 (4.3) | 17 (5.7) | 19 (6.2) | 11 (3.7) | 41.76 ± 11.99 | ||||
| 5- What is the best way of breaking bad news for you? | 0.006 | 0.007 | 0.045 | < 0.0001 | |||||||
| Directly without warning or introduction | 75 (39) | 144 (35.3) | 126 (42) | 93 (31) | 112 (36.6) | 107 (36.4) | 45.61 ± 18.33 | ||||
| Start with Allah’s will, grace, and remembrance | 17 (8.9) | 59 (14.5) | 29 (9.7) | 47 (15.7) | 29 (9.5) | 47 (16) | 52.97 ± 19.29 | ||||
| Start with an introduction containing information about the disease | 100 (52.1) | 205 (50.2) | 145 (48.3) | 160 (53.3) | 165 (53.9) | 140 (47.6) | 42.04 ± 15.15 | ||||
| 6- In which of these places would you prefer to receive bad news? | 0.157 | < 0.0001 | 0.744 | 0.013 | |||||||
| Private place | 121 (63) | 223 (54.7) | 147 (49) | 196 (65.3) | 178 (58.2) | 165 (56.1) | 42.94 ± 16.71 | ||||
| Public place | 4 (2) | 8 (2) | 8 (2.7) | 4 (1.3) | 5 (1.6) | 7 (2.4) | 46.41 ± 13.3 | ||||
| The place is not important | 67 (34.9) | 177 (43.4) | 14 5 (48.3) | 100 (33.3) | 123 (40.2) | 122 (41.5) | 47.15 ± 17.93 | ||||
| 7- What do you prefer from the person telling you the bad news to do? | 0.002 | < 0.0001 | < 0.0001 | < 0.0001 | |||||||
| Leave you alone immediately | 47 (24.2) | 75 (18.4) | 81 (27) | 41 (13.7) | 63 (20.6) | 59 (20.1) | 43.82 ± 18.5 | ||||
| Stay with you and support you | 50 (26) | 105 (25.7) | 61 (20.3) | 94 (31.3) | 77 (25.2) | 78 (26.5) | 44.23 ± 17.35 | ||||
| Stay and give you more information about the disease | 77 (40.1) | 195 (47.8) | 133 (44.3) | 139 (46.3) | 154 (50.3) | 118 (40.1) | 42.64 ± 13.97 | ||||
| Inform one of your family/friends and ask them to come | 18 (9.3) | 33 (8.1) | 25 (8.3) | 26 (8.7) | 12 (3.9) | 39 (13.3) | 59.5 ± 22.49 | ||||
| 8- What are the main characteristics you expect from the person breaking bad news to you? | 0.007 | 0.219 | 0.269 | 0.336 | |||||||
| Polite with good manners | 56 (29.1) | 110 (27) | 74 (24.7) | 92 (30.7) | 74 (24.2) | 92 (31.3) | 46.27 ± 19.52 | ||||
| Medical expert with good knowledge | 120 (62.5) | 247 (60.5) | 196 (65.3) | 171 (57) | 196 (64.1) | 171 (58.2) | 44.58 ± 16.52 | ||||
| Good manager | 4 (2.1) | 17 (4.2) | 9(3) | 12 (4) | 12 (3.9) | 9 (3.1) | 42.38 ± 14.15 | ||||
| Experienced in psychological treatment | 12 (6.3) | 34 (8.3) | 21 (7) | 25 (8.3) | 24 (7.8) | 22 (7.5) | 41.45 ± 15.41 | ||||
5. Discussion
According to the results of this study, the majority of the patients preferred to be informed about their disease and to be the first person to know about the diagnosis and also the main physician to perform this task. Contrary to this study, Alrukban et al. reported that young female patients preferred the physician to leave them alone immediately after breaking bad news. In our study, a small percentage of patients preferred their siblings to accompany them, but in their study, the majority of male patients preferred to be accompanied by their siblings. In contrast, our findings revealed that male participants preferred the physician to stay by them and not leave them after breaking bad news. Another difference was that they preferred a psychologist or social worker to break the bad news to them and begin the dialogue with the name of Allah. Regarding the preferred way of breaking bad news, the telephone was the most acceptable option, while in our study, breaking bad news by the head of the medical team face-to-face and by beginning the conversation with an introduction containing information about the disease were the preferred options, respectively (16). Similar to our study, Bongelli et al. reported that the majority of their patients preferred to know the truth, younger patients supported the rule of informing the patient all about the disease, and older people had a fear of receiving the truth (19).
In Mirza et al.’s study, most respondents disagreed that empathetic physical touch was helpful when receiving bad news; even some described it as apprehensive. The most important components for patients were physicians' empathy, considering enough time to explain the disease diagnosis and its implications, and finally asking them if they perceived (20). Bongelli et al. reported that the majority of their respondents preferred to know the truth about their health conditions; however, a polarization was observed between those who elected that the truth should be fully disclosed and those who argued that the truth should be communicated in a personalized manner. They found that younger patients decidedly rejected concealment of breaking bad news, while more fear of knowing the truth was observed among older ages. They concluded that incomprehensible language, lack of empathy, and scarcity of time were three main defects in doctor-patient communication (19).
Searching the literature reveals discrepancies among the results of studies in different areas. Of course, socio-demographic favors, psychological variables, individuals’ expectations, physicians’ communication skills, cultural beliefs, patient-doctor communications, biomedical, psychological, and cultural beliefs, and ethnic differences are among the influential factors which are not the same in different studies (8, 21). However, despite the different findings of the studies, they share one common result: The necessity of holding professional ethics training courses and acquiring communication skills with the patient. It should be noted that academic centers focus on technical proficiency and medical practices rather than communication skills (22, 23).
5.1. Strengths
This multi-center study was the first survey in Guilan investigating patients’ preferences and attitudes toward the way of breaking bad medical news.
5.2. Limitations
We acknowledge that the current research was restricted to academic and governmental hospitals, and the investigated topic was not explored in the private sector.
5.3. Conclusions
Based on the results of this study, most patients prefer to know about their disease diagnosis. It was also found that younger female patients with higher levels of education needed more consideration in receiving bad news. A better perception of patients’ preferences regarding breaking bad news in Guilan could be useful in improving doctor-patient communication and adopting more appropriate medical practices.
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