Is it appropriate to use Western guidelines for breaking bad news in non-Western emergency departments? A patients’ perspective

Abstract

Objective

To find whether Western guidelines on breaking bad news in a nonemergency department are appropriate for an emergency department of a non-Western country; according to patients’ preferences.

Method

We designed a 19 items questionnaire of Likert-type scale and interviewed 156 patients in the emergency department of a referral hospital in Iran.

Results

The patients’ preferences in 9 out of 19 statements were similar to the guidelines. “Using the maternal language” received the strongest agreement. The strongest disagreement was on “encouraging the patients to talk after receiving bad news.” The summative scores of subsection indicated strong agreement for cultural issues, followed by communication skills, breaking bad news session, and privacy.

Conclusion

The patients’ preferences were not completely consistent with the guidelines. We could not determine if it was a situational or cultural issue. However, it is reasonable to design a new guideline for breaking bad news, considering these factors.

Keywords

Truth disclosure death notification culture

Introduction

Receiving a bad news is a life-changing event and potentially harmful for both patients and physicians.¹ Patients’ characteristics (e.g., age, education, religion, previous life experiences, and personality) and the gap between patients’ expectations and medical reality, affect the impact of bad news.^2,3 The subjective nature of most of these factors is the weakest link in the process of breaking bad news, which makes the patients’ emotional reactions unpredictable.

Experts have designed guidelines to minimize the impact of bad news. Most guidelines are based on physician-oriented studies that had focused on “disclosure of cancer diagnosis” or “death notification” in oncology departments and according to Western cultures. To generalize the recommendations of these guidelines, we need to know if they are appropriate for: (1) a nononcology department, (2) a non-Western culture, (3) other type of bad news, and (4) if they are aligned with patients’ preferences. Despite cultural globalization and studies that claim these guidelines are consistent with patients’ preferences in different parts of the world, a growing body of evidence suggests consideration of cultural differences in breaking bad news.^4–9 We could not find any study investigating the effects of different type of bad news or situational factors on the process of breaking bad news.

We conducted this cross-sectional study on breaking bad news from the patients’ point of view with emphasis on cultural issues (such as language, social etiquette, and religious beliefs). Emergency department (ED) has a complex situation and different type of bad news compared with nonemergency departments. Therefore, it is an excellent field for studies on situational differences. Through this study we want to evaluate the similarity of our patients’ preferences about receiving bad news in the ED and the recommendations of the Western guidelines. The eventual aim of this study is to help reducing the impact of receiving bad news in emergency departments, by proposing a new guideline that covers both cultural and situational factors.

Methods

Setting

We conducted this study in the emergency department of a tertiary referral hospital affiliated to Tehran University of Medical Sciences.

Patients

One hundred and eighty-three of Iranian patients who were admitted to our emergency department between October of 2011 and April of 2012 were included in this study. Because we generally refer nontraumatized children to the pediatric department, admitted patients are usually older than 14 years of age. We selected the patients who were in odd/even numbered beds only on odd/even days, respectively and excluded 27 (14.75%) out of 183 patients by following exclusion criteria: (1) unconsciousness, (2) unwilling or unable to participate, (3) inability to speak and understand Persian, (4) aphasia, and (5) non-Iranians.

Material

Making the preliminary questionnaire

We developed a preliminary questionnaire based on common items in SPIKES, ABCDE, PEWTER, and TALK guidelines and translated it into Persian. This questionnaire had two sections:

Sociodemographic (SD) section

Scaled statements (SSs) section: A set of 5-point discrete visual analog SSs ranging from 0 (strongly disagree) to 4 (strongly agree).

Islam is the most prevalent religion in Iran. Because of Islamic limitations on cross-gender physical contact and to consider the religious beliefs of Muslim population, we added the explanatory phrase of “within Islamic limits” at the end of SS4, which is about “expressing empathy through physical contact.” To consider cultural issues in this questionnaire, we added two more statements about using religious phrases and patients’ native language. The preliminary questionnaire contained 6 SD and 25 SS items.

Content validity

We asked a group of experts on breaking bad news to evaluate the content validity of the questionnaire. They examined the compatibility of the questionnaire to the study aims independently and described each item as relevant, need revision (major or minor), or irrelevant. We analyzed the results and excluded any statement that more than 50% of experts had described it as irrelevant (Content validity index < 0.75). We asked the experts to decide whether to exclude or change the “major revision” items, but we performed “minor revisions” such as changes in wording for clarity (2 items) ourselves. At the end of this stage, the questionnaire contained 6 SD and 21 SS items.

Clarity and reliability

To examine the clarity of the questionnaire, we asked a heterogeneous group of patients to review it. It was understandable and no changes were necessary.

To test the reliability of SS items by Cronbach’s alpha, we interviewed 20 patients as a pretest. The Cronbach’s alpha was 0.72 and by deleting two weak statements increased to 0.79; which is satisfactory. We did not include pretest interviews in the final results.

The final questionnaire

The Appendix presents the English translation of the final questionnaire (6 SD and 19 SS items). According to the content of the statements, we divided the SS items into four subsections:

Privacy (SS1, 2, and 10)

Breaking bad news session (SS5, 6, 7, 14, and 16)

Communication skills (SS3, 4, 8, 9, 11, 12, 13, 17, and 18)

Cultural issues (SS15 and 19).

Interview

After designing the final questionnaire, we obtained approval from the ethics committee of Tehran university of Medical Sciences. We administered the face-to-face interviews after an explanation regarding study aims and information anonymity to the patients. All of the patients gave verbal consent to be interviewed. To maintain consistency, the same researcher conducted all 156 interviews and asked the SSs in the order of 1–19, no matter in what subsection they were.

Statistical data analysis

We analyzed the collected data using descriptive statistics and the results expressed as frequency and percentages. We measured the central tendency and spread of responses by using the median and quartiles, respectively.

Results

Results of SD section

Table 1 presents SD information about the patients. The patients had spent on average 9.4 hours in ED before the interview (median = 8 hours, minimum/maximum = 2/48 hours).

Table 1.

Results of sociodemographic section (n = 156).

	N	Percentage
Gender
Male	80	51.3
Female	76	48.7
Age (mean = 45.1, male/female = 45.6/43.5)
20–30 y.o.	35	22.4
30–40 y.o.	36	23.1
40–50 y.o.	34	21.8
50–60 y.o.	26	16.7
>60 y.o.	25	16.0
Marital status
Single	34	21.8
Married	110	70.5
Widowed/divorced	12	7.7
Religion
Muslim	155	99.4
Christian	1	0.6
Education
>12 years	54	34.6
<12 years	87	55.8
Uneducated	15	9.6

Results of SS section

Analysis of SS items

Table 2 presents the results of SS items. The median in nine statements was four, the highest point on this Likert scale. The strongest agreement was on SS19 (89.1%) and the strongest disagreement on SS13 (57.1%). Although SS section has an ordinal arrangement, we also calculated mean score of each statement and rated them as strong agreement (≥3), neutral (1.5–2.5), and strong disagreement (≤1). Based on mean scores, patients rated SS1, 3, 12, 17, and 19 as “strong agreement” and did not rate any statement as “strong disagreement.” SS19 had the highest mean score (3.66) and SS13 the lowest (1.36).

Table 2.

Results of SS items (N = 156).

	Answers (%)					Median	Mean	Interquartile range
	0	1	2	3	4	Median	Mean	Interquartile range
SS1	16.7	3.8	9.0	3.2	67.3	4	3.01	2–4
SS2	44.9	10.3	11.5	3.8	29.5	1	1.63	0–4
SS3	8.3	4.5	16.0	6.4	64.7	4	3.15	2–4
SS4	26.3	9.0	19.2	9.6	35.9	2	2.20	0–4
SS5	41.7	6.4	18.6	7.1	26.3	2	1.70	0–4
SS6	15.4	5.8	14.7	9.0	55.1	4	2.83	2–4
SS7	14.1	3.8	14.1	8.3	59.6	4	2.96	2–4
SS8	21.2	1.3	21.2	8.3	48.1	3	2.61	2–4
SS9	43.6	5.1	10.3	5.1	35.9	2	1.85	0–4
SS10	50.0	5.1	9.6	7.7	27.6	0.5	1.58	0–4
SS11	17.3	4.5	17.9	9.6	50.6	4	2.72	2–4
SS12	7.1	3.2	19.9	7.7	62.2	4	3.15	2–4
SS13	57.1	2.6	12.8	1.9	25.6	0	1.37	0–4
SS14	32.7	2.6	16.0	7.7	41.0	2	2.22	0–4
SS15	21.8	7.1	15.4	7.7	48.1	3	2.53	1–4
SS16	18.6	4.5	22.4	7.1	47.4	3	2.60	2–4
SS17	9.0	3.8	20.5	10.9	55.8	4	3.01	2–4
SS18	21.8	2.6	9.6	13.5	52.6	4	2.72	2–4
SS19	5.8	1.9	1.9	1.3	89.1	4	3.66	4–4

Note: SS, scaled statement.

Analysis of SS items according to their subsections

Privacy

Most patients preferred to hear the bad news in a private place (67.3%) and 44.9% of them did not need any support person. Fifty percent of the patients did not like the idea of receiving bad news through a relative or friend.

Breaking bad news session

Forty percent of patients preferred telling them only the diagnosis and 55.8% wanted their responsible physician to be the breaker of bad news. Most of the patients preferred the idea of asking them whether they want to hear the bad news (59.6%) and what they already knew about it (55.1%), before telling them the bad news. A breaking bad news session with no time limits was preferred by 41.7% of the patients.

Communication skills

Patients wanted the physicians to introduce themselves (62.2%) and maintain eye contact (64.7%) when they break the bad news. They also preferred the physicians to summarize the bad news at the end of the session (50.6%), give them enough time for their questions (55.8%), and not to encourage them to talk about their feelings after breaking the bad news (57.1%). Other preferences were “giving them a warning shot” (48.1%) and “telling them the bad news all at once” (43.6%). Only one third of the patients preferred the physician to express his empathy by physical contact (35.9%).

Cultural issues

About half of the patients wanted the physicians to use religious phrases when they deliver the bad news (48.1%) and a significant majority of them preferred using their maternal language for breaking bad news (89.1%). The only non-Muslim participant strongly disagreed with the statement of using religious phrases for breaking bad news.

The summative scores of each SS subsection indicated strong agreement for cultural issues, followed by communication skills, breaking bad news session, and privacy subsections.

Discussion

We conducted this study to find if it is appropriate to use Western guidelines that are designed for a nonemergency situation, in a non-Western country and emergency situation. Comparing with the report of “Iranian Institute of Statistics,” the demographic distribution of the participants was similar to the general population, with the exception of higher mean age in the patients that may be explained by increased prevalence of diseases in older age.¹⁰

Breaking bad news in ED

Most original studies on breaking bad news have been conducted by oncologists and under controlled conditions of nonemergency departments. Almost all of them suggest “step-by-step” approach, which may be impractical in uncontrolled and time-deficient situation of ED. A time-deficient emergency physician usually cannot develop a satisfying communication with patients, which is necessary for a trustful physician–patient relationship and effective breaking bad news according to current guidelines.^11–13

The nature of bad news in the ED is also different from nonemergency departments. Bad news in oncology departments is usually associated with a terminal disease, but severe nonterminal diseases, mild diseases interfering with patients job (e.g., Welder’s keratitis), and any condition at an inappropriate time (e.g. Ankle sprain on the wedding day) are frequent bad news in ED.¹⁴

The length of stay in Iranian EDs is higher than developed countries.¹⁵ Consequently, it is more probable for emergency physicians in Iran to get a diagnosis in ED and deliver a bad news, comparing with their counterparts in developed countries. To minimize the impact of breaking bad news on patients and physicians, it is reasonable to use a guideline that is tailored to the special situation of ED.

Breaking bad news guidelines

A few decades ago, medical universities had no formal program for breaking bad news and the medical students had to learn it by observing experienced physicians.¹⁶ Physicians, who have not been trained for breaking bad news, may feel anxious, helpless, or guilty when delivering bad news regardless of their expertise.^17–19 The stress increases whenever there is an inexperienced physician, a young patient, limited successful treatments, or an emergency situation.^3,20 Experts recommend using one of the published guidelines to minimize patient’s reactions and improve physician’s comfort e.g. SPIKES, ABCDE, TALK, PEWTER and BREAKS.^3,21–24 Although some studies claim that health care professionals experience less stress by using these guidelines, but few of the guidelines have an evidence-based clinical efficacy and using them does not necessarily mean the bad news have been delivered effectively.^25–27

The original studies of the guidelines were physician oriented and have been focused on skills rather than patient benefits, and even interfering factors have been studied from the physicians’ point of view.²⁸ This fact highlights the need for future studies on patients’ preferences.^20,29,30

The structure of these guidelines makes them difficult to perform in ED. One of the most accepted guidelines is SPIKES, an acronym for Setting up, Perception, Invitation, Knowledge, Emotions, and Strategy. Performing all these six steps in an overcrowded ED, if not impossible, is impractical. For example, preparation before breaking bad news is an important step in these guidelines, but emergency physicians usually have no sufficient time to prepare themselves or their patients. Some factors that may interfere with effective breaking bad news by physicians are: (1) lack of emotional support from other health professionals, (2) personal fears of the physician, (3) inadequate time for breaking bad news session, (4) inability in responding to patients’ emotions, and (5) difficulty in being honest without causing distress.^1,18,28 These factors are frequently encountered in ED.

Studies on breaking bad news in Iran

As far as we know, few studies have been published on “Breaking bad news in Iran”.^31–33 These studies have shown that physicians and nurses need to be trained on delivering bad news to patients³¹ and have proposed to integrate breaking bad news techniques into the Iranian medical education curriculum.³² In the present time, most of Iranian medical universities have courses on the techniques of breaking bad news, but because there is no culture-based guideline, the western guidelines are still the best and only option for these courses. Recent studies have evaluated the quality of breaking bad news courses and their impacts on health care providers, but none of them have evaluated the patients’ preferences.

Subsections

In our study, we found that the most preferred subsection of our questionnaire by Iranian patients in ED was cultural issues, followed by communication skills, breaking bad news session, and privacy subsections. Because the effects of cultural issues and privacy seem obvious, most studies in this filed have investigated the communication skills and breaking bad news sessions.

Patients’ privacy

Medical literature have shown that patient’s will about the presence of another person during breaking bad news session, depends on the cultural issues.^34–36 Most of our patients preferred to receive the bad news in a private place and this is same as what guidelines recommend. Approximately half of our patients did not like the idea of inviting a support person to be present in breaking bad news session or receiving the bad news through a relative or friend. The cultural tendency to keep everything private and secret may be partly responsible for this attitude in Iran, but the idea of “supporting the family and not harming them” and “being in an emergency situation” are other factors to consider, which need further studies.

Breaking bad news session

Tailoring the process of breaking bad news to patients’ preferences can help them to cope better with the stress of bad news. Medical literature has shown that guidelines meet patient’s expectations for receiving bad news.³⁰ But the subjects of these studies were oncology patients, who have different priorities. For example, oncology patients prefer to be informed about their prognosis in a breaking bad news session. This is quite reasonable, because during the usually long process of diagnosing cancer, patients prepare themselves for an unpleasant diagnosis and when they ask for more information, they usually want to know the prognosis. But in ED and because of the acute nature of the diseases, the patients prefer to know more about the diagnosis. One third of our patients, like oncology patients, wanted to know more about the outcome and prognosis of their disease. Because we conducted this study in a tertiary referral hospital, many patients already knew their diagnosis and their requirements were similar to oncology patients.

Guidelines recommend to discuss about patients’ feelings and emotions after delivering bad news. Our study demonstrated that immediately after receiving bad news, Iranian patients prefer not to talk anymore about their condition. As the patients also preferred the physician to summarize the information, regardless of their emotional status, we think it is a latent time before expressing emotions and contrary to breaking bad news guidelines, we recommend not to insist on talking during this period. We cannot determine how long it takes them to feel ready to talk again, but we suggest leaving them in a private room to think and decide when they want to talk. This recommendation requires a breaking bad news session with no time limits, which was also preferred by our patients and is against the recommendation of guidelines. It is quite possible, even for a time-deficient emergency physician, to frequently check whether the patient is ready to talk about his feelings or ask any questions.

Communication skills

When the time for establishing a trustful relationship is not enough, communication skills and body language may help to gain the patients’ trust more rapidly. The guidelines recommend putting the patient in a sitting position and maintaining eye contact during breaking bad news, which was also preferred by our patients. In medical literature, sitting beside the patient is controversial^3,37 and we cannot recommend any particular position for the breaker of bad news based on this study. Although right angle orientation when sitting is recommended as a nonverbal communication skill, our patients preferred confrontation position and a face-to-face orientation to receive a bad news.

Despite being recommended by most guidelines as a nonverbal skill, physical contact during breaking bad news is a point of controversy. Islamic and cultural beliefs in Iran limit cross-gender contact, even as a nonverbal solution for expressing empathy. In our study, agreement and disagreement on physical contacts during breaking bad news were almost equal. We did not measure the patients’ religiosity, so we could not analyze whether nonreligious patients preferred physical contact or vice versa. Because of the delicacy of this situation, physicians are better to be cautious in touching a Muslim patient for empathy. Although it is possible to use “before you tell, ask” technique to know the patients’ preferences, but asking them about the physical contact may defeat the purpose because nonverbal communication is more effective when the subject person is not conscious about it.

Cultural issues

The first step of an effective breaking bad news is a good communication, and a common language between sender and receiver of the message is the cornerstone of it. Iran is a multiethnic and multicultural country that people speak different languages in different provinces. Our patients stated that using their maternal language is the most important step in breaking bad news and the responsible physician was the most preferred person for delivering it. Therefore, it is reasonable for a physician to learn the local language or ask a translator for help, rather than asking someone else to break bad news directly. Being familiar with local language and culture may facilitate the process of breaking bad news for physicians, but it is not enough. In some provinces, physicians also need a good knowledge of subcultures for successful communication. Comparing patients’ preferences between different ethnic and cultural groups in a multiethnic and multicultural country like Iran can demonstrate the effect of subcultures.

It has been suggested in the literature that religion and spirituality can provide emotional support for the patients, but this idea needs further study to be confirmed.³⁸ Although asking about the patients’ personal, cultural, or religious context before breaking bad news is recommended, guidelines do not recommend using religious phrases to deliver bad news. In our study, almost all of our patients were Muslim and have a high level of agreement on using religious phrases to deliver bad news. We concluded that from our patients’ point of view, the supportive effect of religious phrases is more than a support person that they not preferred inviting him. We could not find any study about using religious phrases for breaking bad news in other cultures or situations; therefore, we cannot determine whether this finding is the result of Iranian culture or the situation of ED. Only one non-Muslim (Christian) had participated in this study, whose opinion, which was disagreed, cannot represent the opinion of all non-Muslim Iranians.

Limitations

In this study, we found some differences between our patients’ preferences and the guidelines, but we cannot determine whether they are cultural or situational based. It would be better to conduct a qualitative study for collecting patients’ preferences in emergency and nonemergency situations and compare them with the guidelines and each other. Small sample size limits the generalizability of our study. Nevertheless, this study can be considered as the first step into the subject of designing a new guideline for breaking bad news in ED.

Conclusion

Current guidelines on breaking bad news are so detailed that it is hard to use them completely in a time-deficient ED, and cultural differences make it more complicated. We recommend designing a comprehensive but compact guideline for breaking bad news in ED, which considers both cultural and situational issues. It is obviously a long way to design a guideline, but as a short-term solution, we suggest refining the existing guidelines according to the cultural characteristics of each country or situational specifications of each department. Based on this study, we sorted our patients’ preferences in the order of the most to the least desired items (Table 3) and recommend to deliver bad news in a time-deficient ED based on this “first things first” design. This approach needs to be evaluated against the formal “step by step” guidelines.

Table 3.

“First things first” approach for delivering bad news to an Iranian patient.

	Must do	Better to do	Do not
Before BBN	• Find a private setting • Introduce yourself • Ask the patient whether he wants to hear the bad news	• Ask the patient about what he already knows about the bad news	• Set a time limit for the session • Invite anyone as a support person without the patient’s permission
During BBN	• Deliver the bad news in patient’s maternal language • Maintain eye contact • Give a warning shot • Tell them the bad news frankly and straightforward	• Individualize physical contact with a Muslim patient • Deliver all of the information at once • Use religious phrases	• Deliver the bad news through one of the patient’s relatives or friends
After BBN	• Leave the patient in a private room • Give the patient enough time to ask all of his questions • Summarize all of the information you gave	• Ask the patient if he wants to know more about the outcome and prognosis	• Encourage the patient to talk about his feelings

Footnotes

Acknowledgement

We gratefully thank the patients who participated in this study and their family members for their patience and understanding.

Declaration of conflicting interests

None declared.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Appendix

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