I have been consulted on multiple occasions to evaluate terminally ill
patients for depression and denial of their advanced disease.
In many of these instances, I encountered communication gaps between the
patient and the medical staff.
Most patients are not familiar with medical terminology and do not know
how to navigate the medical system. They see their oncologist in the outpatient
clinic, but when they get hospitalized, they are seen by the covering medical
team at the hospital. When that happens, patients often feel like foreigners.
They hope to see their regular outpatient oncologist and have difficulty
understanding why their regular doctor cannot see them.
Ive seen residents struggle trying to fill in communication gaps.
An orientation with minimal use of technical language could decrease a
patients level of distress.
Patients must be guided and told about the responsibilities of the
treating medical team. For example, residents could explain their role, as well
as their relationship with the outpatient oncologist.
The effort to inform a patient that someone at the hospital is helping
to coordinate their care could minimize their concerns and help to set more
It can be difficult for patients to reveal their thoughts and feelings
in a place that may make them uncomfortable. Clinicians can facilitate the
creation of an environment in which patients feel safer to share their
Clinicians should strive to earn their patients trust by
preserving the dignity of patients and their families. Allowing a patient to
tell his or her life story can go a long way toward doing that, helping them
feel like more than just a body with a cancer.
Harvey M. Chochinov, MD, and colleagues developed a treatment
called dignity therapy that allows patients to tell their life stories and pass
them on as a legacy to their loved ones. This practice helps patients and their
families to preserve dignity and prepare for death.
William Breitbart, MD, and colleagues developed meaning-centered
group psychotherapy, designed to help patients with advanced cancer enhance
their sense of meaning, peace, purpose, hope and spiritual well-being, even as
they are confronted with death. The approach demonstrated reductions in
patients anxiety and their desire for hastened death.
Clinicians also can preserve their patients dignity by treating
them with respect and using good manners. These efforts include practices such
as knocking on the door and asking permission to interrupt a patients
meal before speaking with them.
Assessing patients understanding of their disease helps to
determine whether they are ready and willing to have an end-of life discussion.
A study by Ramirez, Graham, Richards and colleagues found that 10% to
30% of patients with terminal and recurrent cancer were not aware of or had
difficulties admitting the seriousness of their disease.
Finding out what patients know can help determine whether they can
tolerate an end-of-life conversation. If a patient is in denial, the clinician
could ask the patient to give a history of what has happened since his or her
cancer diagnosis and assess to what extent the patient is able to cope with it.
The clinician then should ask the patient if he or she knows what is
wrong, then point out any inconsistencies between the patients
perceptions and what actually is happening. If the patient is ambivalent or
reluctant to talk about it, the clinician could ask the patient about the
reason for the ambivalence or the conflict.
If clinicians must deliver bad news even if appropriate
conditions for doing so are met it is important that they pause and give
patients the opportunity to comprehend what is communicated. The clinician then
could acknowledge the patients likely fears, saying something like,
I can imagine how difficult this is for you.
This statement could indicate to patients that it is OK to talk about
their feelings, and they may use it as an opportunity to tell clinicians why
they are distressed and mention something that could be done to help them.
Other behaviors can impair good communication between clinicians and
- Giving advice or reassurance before the patient has the opportunity
to express their concerns prevents them from disclosing what is causing them to
- Assuming the source of a patients stress. For example, some
patients could be more worried about their children than the dying process.
- Not giving patients time to process what they have been told. It is
not uncommon to unintentionally change the topic during a conversation,
preventing the patient from fully processing what was said. This may deprive
patients from being able to express or address the issue that is causing them
Good communication is essential when treating patients. With good
communication, patients can make more informed consent choices.
Fallowfield and colleagues found that patients who received inadequate
information either too much or too little are at higher risk of
developing psychiatric illness such as depression or generalized anxiety
Good communication also affects the loved ones who must prepare for the
patients eventual death. Research has shown family members who were not
prepared for the loss of a relative are more likely to suffer from complicated
grief or depression.
Workshops have been developed to help clinicians improve their
A valuable online resource is the Oncotalk program, sponsored by the
NCI. It can be found at http://depts.washington.edu/oncotalk.
Topics include fundamental communication skills, delivering bad news,
managing the transition to palliative care, talking about advance care plans,
conducting family conferences and how clinicians should handle requests for
therapies that they believe are futile.
Maria Rueda-Lara, MD, is an assistant professor of clinical
psychiatry and behavioral sciences at the Sylvester Comprehensive Cancer Center
and the University of Miamis Miller School of Medicine.
Disclosure: Dr. Rueda-Lara reports no relevant financial
For more information:
- Breitbart W. Psychooncology. 2010;19:21-28.
- Chochinov HM. J Clin Oncol. 2005;23:5520-5525.
- Fallowfield L. Br J Cancer. 2003;89:1445-1449.
- Ramirez AJ. Lancet. 1996;347:724-728.