Abstract
Breaking bad news is a global challenge for all types of health providers. Our study assessed the attitude and practice from the doctors’ perspective in a patriarchal society. A descriptive cross-sectional hospital-based study was conducted, involving doctors from both medical and surgical departments. Almost half of the respondents believed that Sudanese patients do not like to know their diagnosis, and a slightly higher proportion had no previous training on how to break bad news. Some 20% indicated that they would conceal the diagnosis from a patient if his or her relatives so requested. Less than one-quarter of respondents followed a standard protocol. Although most of the doctors subscribed to the notion that patients have the right to know everything about their illnesses, not all of them held this attitude towards their local patient population.
Introduction
‘Bad news’ defined by Buckman is ‘any information which adversely and seriously affects an individual’s view of his or her future’. 1 Since early history, professionals were recommended not to divulge bad news. This strategy was followed until the 20th century. Hippocrates recommended ‘concealing most things from the patient while you are attending to him … revealing nothing of the patient's present or future condition’. 2 In 1847, the American Medical Association’s first code of medical ethic stated that: ‘The life of a sick person can be shortened not only by the acts but also by the words or the manner of a physician …’. 3 While treatment prospects, especially for cancer, were bleak, most physicians believed it is destructive to the patient to hear bad news about the diagnosis. 4 Nevertheless, by the late 1970s, the majority of doctors were open to telling cancer patients about their diagnosis. 5 A survey of 1251 Americans in 1982 found that 96% of respondents wished to be told if they had a diagnosis of cancer, and 85% of those who had a grave prognosis ‘wished to be given a realistic estimate of how long they had to live’. 6 The cause of this shift in practice may be attributed to advances in cancer treatment 7 and may also be to a change regarding the domineering paternal attitudes of doctors. 8 Healthcare professionals should protect patients’ confidentiality and privacy while they are breaking the bad news. By doing so, this facilitates the task of truth-telling and this is emphasised in breaking bad news protocols.7,9
Although no one likes breaking bad news, 10 the task could be improved by approaching it in a stepwise manner and applying well-established principles of communication and counselling. 7 Three major sequence protocols exist for breaking bad news: SPIKES; 7 BREAK; 11 and ABCDE. 9
A majority of the respondents at an American Oncology meeting stated that the SPIKES protocol was easy to understand, 7 but when it comes to patients’ opinion, a scarce number of studies have been conducted. 12 There are no clear guidelines in Sudan. Many cultural and social factors may influence the process. For example, whereas death may be accepted, being pregnant and unmarried might not.
Material and methods
A descriptive cross-sectional hospital-based study was conducted in October 2014 in Khartoum Teaching Hospital, the largest in the country. A statistically adequate sample total of 291 consenting doctors, whose representation was proportionate to their actual weight in the study population, working in both medical and surgical departments of all grades, were targeted. Privacy and confidentiality were maintained throughout by anonymising responses.
The personal and professional characteristics of the study population.
The attitude of breaking bad news across the respondents.
The practice of breaking bad news across the respondents.
The total percentage of the responses to this question = 100.1%, because of rounding.
Ethics approval was issued by the Department of Community Medicine, University of Khartoum, Hospital Research Committee and Khartoum State Ministry of Health.
Results
Slightly more than half (51%) of respondents had received training in breaking bad news. The majority (81.8%) thought that the patient should be told everything about his or her serious illness, but 39.9% thought that Sudanese patients do not like to know about their diagnosis, nor about the prognosis of a serious illness. When challenged by relatives wanting to hide a serious diagnosis, 49% said that they would disclose the diagnosis if the patient was interested to know and 20.4% indicated that they would submit to relatives’ wishes and conceal the diagnosis (Table 2). Only one-quarter of the respondents followed a standardised protocol for breaking bad news, of whom 55.6% followed the SPIKES protocol, while 52.5% used their own approach.
Some 60% reported that they felt sad and frustrated after breaking bad news. Slightly more than half (55.3%) reported giving clues to their patients about an expected serious outcome before establishing a definitive diagnosis. When it came to talking about prognosis and/or life expectancy, 48.7% did volunteer an estimation, but a high proportion (70.4%) delivered this information to family members (Table 3). Half obtained consent from their patients before divulging a diagnosis and 90.6% assessed the patients’ foreknowledge (Table 3).
The frequency of medical conditions perceived as bad news by the respondents.
The most frequently reported barrier for breaking bad news was the ‘high expectation of a good outcome by patients or their relatives’, followed by ‘fear of not knowing all the answers to the patients or their relatives’ questions’ and ‘personal fear of illness or death’. ‘Fear of being blamed’ was the least reported barrier (11.9%) (Table 2).
The relationship between ‘Do you think the patient should be told everything about their serious illness?’ and gender, specialty and previous training in breaking bad news.
Values are presented as n (%).
P value has been calculated using the Chi-square test.
The relationship between ‘Do you think the patient should be told everything about their serious illness?’ and years of experience in the medical field.
P value has been calculated using the Kruskal–Wallis test.
Discussion
Breaking bad news is an important task for every healthcare professional. Almost half of the respondents had received training in breaking bad news; despite this, there was no demonstrated significant difference in attitude between those thus trained and those not. A Sudan government report stated that only 25% of patients were told their true diagnosis, 13 and the notion by doctors that most patients do not want this to be divulged is not unique to Sudan (found among 94.3% of doctors in an Indian study). 14 However, most patients in Sudan actually seem to be interested in knowing their diagnosis. 15 The nuclear family unit is willing to take on responsibility for their family member and doctors accept this decision. As discussed thoroughly by Salem et al., there are many differences between Western and Muslim cultures when it comes to breaking bad news. In Sudan, the process of taking a healthcare decision is family-led, in contrast to the patient-led approach in Western countries. 16 Hence family members are sometimes informed of a serious diagnosis before or independently of the patients themselves. 17 In such countries, patient’s rights must be re-interpreted, but the need to respond sensitively to both family members’ and patients’ concerns remains. 18
Protocol-based approaches to breaking bad news were followed by a minority of doctors and only a small proportion of these followed techniques of their seniors, in contrast to the practice of oncologists. 19 The SPIKES protocol was the most popular, but still utilised by few, and indeed very few studies have been carried out assessing patients’ acceptability of each of the established protocols.12,20 Nonetheless, most doctors incorporated components of the SPIKES protocol steps, namely obtaining a patient’s invitation and assessing the patient’s perception. 7
A majority of respondents expressed feelings of depression and frustration after breaking bad news, consistent with findings elsewhere. 14 Failing to meet high patient expectations may easily explain this phenomenon. Obviously non-curable conditions are least welcomed, but conditions with a social stigma carry an even higher burden. Concealing information may, however, be harmful to others, for example regarding the infectious nature of HIV disease or leprosy.
Respecting patients’ autonomy and their right to know any information about their health status, without patronising them, should be mandatory. Their informed consent should be sympathetically ascertained, within the context of their family relationships. Patients’ faith and religious beliefs often deeply influence patients’ perspective on how they can receive bad news and doctors are encouraged to consider these sensitively. 21
Limitations
Our study sample was from only one university health facility. In addition, the proportion of the senior doctors was small compared to the juniors, according to their total numbers.
Conclusion
Most Sudanese doctors appear to believe that patients, in general, have the right to know all information related to their illness. However, not all of them maintained this attitude towards their own patients. Training in breaking bad news is not yet available to all healthcare workers. Unrealistically high expectations of patients or their relatives constituted the major barrier for breaking bad news.
Footnotes
Acknowledgements
The authors thank the Khartoum Teaching Hospital for facilitating communication with working doctors and the department of community medicine. They also thank Professor Siddig E Muneer, Dr. Mohammed Nimir and Dr. Alaa Abir for their critical revision and checking of the English language, style and grammar.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.