Clinical communication is a multidimensional concept, which encompasses the core of effective clinical practice. Communication in cancer patients is particularly challenging and yet a less focused area in cancer care. Various barriers and challenges in communication may affect the management protocol of cancer patients. Challenges may arise in various dimensions of cancer care including breaking bad news to delivery of complex clinical information, determination of appropriate treatment strategies, dealing with uncertainties, end of life counseling as well as cultural and language barriers affecting the whole communication dynamics. Effective communication is the basic foundation for responsive treatment decisions, positive health outcome, patient driven compliance and overall high quality of care. Thus, there is a need for acknowledging and actively deciphering the challenges and developing and promoting various protocols of effective communication skills in cancer patients.
Communication can be defined as a voluntary and purposeful sharing of information between two or more participant in an attempt to convey or receive the included massage. Communication plays a vital role in the continuum of health care delivery system worldwide. Effective communication is the basic foundation and the priority pillar in the medical field due to its direct role in the safety, quality of the patient care, patient satisfaction and overall clinical outcome [
In most of the cases, physicians lack these communication skills or they respond to various emotional cues with strategies that block further disclosure by the patients [
Unlike patients with other medical conditions, the communication with cancer patients are unique due to the fact that there are certain level of uncertainties related to treatment, survival & cure, involvement of various treatment protocols & modalities, interaction of multiple clinicians & change in health care team over time [
All these challenges may play a vital role in the overall disease management and undermine the desired clinical outcome in cancer patients. Various studies looking at the effect of effective communication on good cancer care found that there are many drop outs in cancer care due to patients being unsatisfied or confused about the overall management plan, compliance & lack of confidence on the physicians [
Effective communication between clinician & patients related to consultation may play an important role and predict health outcomes in cancer patients [
Communicating | Challenges |
---|---|
Bad news | This is an essential part in the treatment of cancer patients. The impact of this communication affects patient’s emotional adjustments, treatment compliance and overall health outcome. |
Psychosocial & emotional aspects | Various emotions are at stake in cancer patients. The physicians need to elicit the emotional response, validate the concerns and be empathetic at the same time. |
Complex information & long-term trust | Physicians attitude regarding the understanding of the patients may emit various nonverbal cues of negative impact which might reduce the impact of verbal communication. |
Hope & overlapping uncertainties | Various inherent uncertainties regarding the treatment options and coupled with need for hope. |
Statistics related to the prognosis | Sharing quantitative information from patients perspective, framing information, using visual aids, misunderstanding and overly concrete misinterpreting of the numbers and statistics by the patients. |
Promoting heath & behavior | Patient navigators responsible for various health education and promotion faces the challenges of safety, setting boundary, facing and overcoming boundary, emotional turmoil, etc. |
Treatment decision | Various ethical aspects and patient expectations in treatment decision. |
Communication with grieving family | Death of a relative due to cancer is a devastating and life changing event for family members and challenge lies in comforting, being empathetic listener and rely on nonverbal cues. |
Family member of patient with hereditary cancer | Identifying the at risk family member of hereditary cancer patients and advocating the need for screening for similar cancer. |
Palliative & end-of-life care | Emotional nature of the communication, difficulty in differentiating emotions, structural aspects, etc. may affect communication. |
Children or elderly with cancer | Difficulty in explicating the level of understanding and emotional impact, differentiating self-emotion from those of patients. |
Patients of culture & language | Cultural and language barrier affects the whole communication dynamic between the physician and the patients. |
Patients in clinical trials | Recruitment of patients, expectation of patients, potential adverse effects, impact on quality of life, complexity of clinical trial protocol, unconscious biases, lack of cultural competence, etc. |
Thus, any intervention done to maximize the therapeutic effect of communication and overcome the challenges in communication should focus on achieving these proximal & intermediate outcomes.
Encounter with cancer patients are very emotion-laden and requires a great deal of clinical & communication skill on part of the health care team. Management of communication challenge in cancer patient include―
1) Patient-centered care: patient centered care is an interaction between patient, physician & health services and consists of three core attributes as [
・ Consideration of the need of the patients, their perspectives & experiences.
・ Providing opportunities to the patients to participate in their own care.
・ Effort to enhance & nourish physician-patient relationship.
A seamless equilibrium of these three components is integral to improved health outcome in cancer patients.
According to Institute of Medicine (IOM), an interaction of patient, physician & health services is crucial for maintenance of patient centered care [
2) Ethical consideration in patient communication: Ethical consideration is also an important factor in communication with cancer patients. The oncologists should be able to identify the spectrum of treatment options available and indicated for the patient; cost effectiveness of the management, understand the patient preference
& goal, respect patient autonomy, ensure appropriate patient situation & communicate properly with patient regarding the risk-benefit of the treatment & overall prognosis [
3) Communication skill training: Communication skill training focuses on training the health care providers, training in cultural competency & training of the patients [
4) Intervention of communication at health care settings: A tiered approach to health care setting including intervention at team, practice and health care setting is important to ensure continued care. Improved communication within treatment team of cancer patients; use of web based resources, care diaries, patient-held medical records or direct access to medical records by the patients in clinical practice; appropriate layout and training of staff in appropriate communication technique in health care setting will definitely help to improve patient satisfaction [
There are various specific protocols in place to enable health care workers to tackle communication challenges in cancer patients. Some of the protocols include-
“SPIKES” is a six steps protocol to deliver bad news in cancer patients [
・ Step 1: Setting up the interview and maintaining privacy, connecting with patients and minimizing interruption.
・ Step 2: Assessing patient perception through asking open-ended questions and tailoring communication accordingly.
・ Step 3: Obtaining patient invitation so that to get a cue about patients expectation about information disclosure.
・ Step 4: Giving knowledge to the patients while starting at the vocabulary level of the patients, avoiding technical terms and giving information in small chunks and checking back on patients understanding.
・ Step 5: Addressing patients emotions with empathy.
・ Step 6: Strategy and summary-ending the consultation by providing a disease summary and treatment plan.
This model provides a framework of sequence of strategies for the management of challenging situation in clinical practice for health care workers with different level of experience [
・ R―Recognizing and acknowledging that there is a problem to be dealt.
・ E―Expressing empathy, reflecting back and summarizing patients point of view.
・ B―Establishing clear professional, interpersonal and ethicolegal boundaries.
・ E―Emphasizing and putting patients at the center of interaction.
・ L―Using inclusive rather than distancing language.
・ S―Focusing on solutions after being empathic and highlighting the problem and patient’s best interest.
There are many other specific interventions like multimedia interventions, patient-patient communication intervention that are in place to manage challenging communications and also there might be other related evidences, which were beyond the scope of this paper.
Communication in cancer patients is a unique and challenging aspect, which strikes at the very foundation of clinical care, adherence and health outcome. These communications are embedded in multiple layers of the context that needs to be modulated so as to achieve a meaningful and proactive communication. Thus, there is a need to acknowledge the challenges and do further research to get an insight into the various underlying barriers to concordance in the patient-physician communication and design and implement various intervention protocols in cancer patients.
IrtizaHasan,TasnuvaRashid, (2016) Clinical Communication, Cancer Patients & Considerations to Minimize the Challenges. Journal of Cancer Therapy,07,107-113. doi: 10.4236/jct.2016.72012