Doctor patient communication and psychosocial care
Cancer is the most feared disease in most communities, and all age groups are at risk. Cancer is life threatening, but potentially curable. Cancer treatments are feared because of their distressing side effects. For many types of cancer, patients can participate in choosing between treatments which have different side effects and similar outcomes. Fear of recurrence after cancer treatment is a concern for many patients. Some cancers are preventable, and for many patients, early diagnosis is important for the best outcomes. These features of cancer and its treatment generate particular information needs for patients and their families which are compounded by the multitude of health practitioners who participate in cancer care and control.
Pamphlets prepared for cancer patients describing aspects of cancer care according to cancer type, disease extent and treatment goals are widely available, and these can improve patient understanding of their situation. Pamphlets describing different cancer treatments and their side effects may reduce patient misunderstanding and fear, and prompt question-asking. Doctors caring for cancer patients should be aware of the information contained in these widely available pamphlets.
Communication in the cancer care setting must inform and support patients receiving a diagnosis of a life-threatening illness. Patients frequently misunderstand or forget important information they need to participate in decisions about their care. Patient misunderstanding may be compounded by inconsistent information given by different members of the cancer care team. Patient denial is a coping strategy which enables living with uncertainty, and may underpin hope. These considerations should guide communication with cancer patients and their families. Tables 1-2 summarise clinician behaviours and the value of communication aids in cancer care consultations. Table 3 outlines the range of topics which are important in different phases of a cancer journey.
The substance of information given to cancer patients should be documented in patient records and this information should be communicated to the general practitioner and members of the hospital-based treatment team.
Patients with advanced cancer want information about its effects on their life expectancy. Most oncologists find it difficult to estimate and explain survival time, and frequently they are reluctant to discuss prognosis. Recent research has found that most people with advanced cancer judge presentation of best case, worst case and typical survival scenarios preferable and more helpful and reassuring than presentation of just the median survival time.
Cancer patients commonly receive chemotherapy and/or invasive investigations in the last days of their life, and sometimes are inappropriately intubated/admitted to intensive care. Discussing end of life (EOL) care preferences with incurable cancer patients is frequently not undertaken until the last days of life or at all. Patients who report talking with their oncologist of their EOL care preferences have a better quality of death. Facilitating the preparation of an Advance Care Plan to document patient’s EOL care preferences is a valuable means of promoting patient discussion with their close family about their EOL preferences.
Table 1: Some patient-centred clinician behaviours which enhance the quality of a cancer patient consultation
|Non-verbal behaviours||Verbal behaviours|
|Maintaining eye contact||Reviewing purpose of the consultation|
|Forward leaning to indicate attentiveness||Asking patient understanding of their situation|
|Nodding to indicate understanding||Encouraging patient participation and suggesting questions|
|Use of diagrams to inform understanding||Acknowledging uncertainty and options for care|
|Reviewing images and results with the patient||Checking patient understanding|
Table 2: Communication aids developed and studied in cancer patient care
|Communication aids in cancer patient care|
|Communication skills training courses change doctor and nurse consultation behaviours at least in the short term, but improved patient outcomes are not convincingly documented.|
|Providing question prompt lists increases patient participation in oncology consultations, and increases question asking about the outcomes of care.|
|Patients do not recall most information provided during oncology consultations. Consultation audio-recordings enable patients to review information provided. Studies report that most consultation recordings are listened to by patients and their families, and recordings are valued particularly by patients from a non-English speaking background.|
|Decision aids have been developed for and evaluated in patients considering chemotherapy for advanced and incurable cancer, and for those considering adjuvant chemotherapy.|
|Providing patients with copies of letters from cancer specialists to the referring doctors is valued by patients and enhances their recollection of consultations.|
Table 3: Context of doctor patient communication during the cancer experience
|Fear of cancer||* Relevance of family history|
* Guilt related to smoking, ignoring early signs of cancer
|Diagnosis of cancer||* Fear of treatment|
* Why me?
|Staging||* Fear of incurability|
* Fear of treatment
|Treatment||* What is the goal?|
* When do I know if I am cured?
* How do I know if treatment is working?
* Choosing between treatment options
|Recurrence||* Can the cancer be cured/controlled?|
* Is treatment worthwhile?
* Do I need treatment now when I am well?
|End of life||* How long have I got?|
* How will I die?
* Will I be in pain?
* What should I tell the family?