Breaking bad news about cancer : the experiences of patients, patients' family/whānau members and healthcare professionals : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Clinical Psychology at Massey University, Wellington, New Zealand

Abstract

Breaking bad news is a reality of medical practice in oncology, and can be a challenging task for those receiving and delivering the news. For patients and their family members, ‘bad news’ is understandably accompanied by strong emotions and ongoing implications for their lives as they adjust to the news. For healthcare professionals (HCPs), there are numerous variables to consider and balance when having these difficult conversations, as well as managing the personal impact.

The current study aims to explore the subjective experiences of patients, patients’ family/whānau members, and HCPs when bad news was delivered to patients about their cancer within the surgical departments of MidCentral District Health Board. The study is designed to allow multiple perspectives to be gathered and compared, and recommendations for practice to be made that align with the goals of those involved in the project’s inception, as well as attend to the underrepresentation of family members’ perspectives and New Zealand-based data in the literature.

To achieve this, the current study utilised a qualitative approach with the epistemological and methodological basis informed by interpretative phenomenological analysis. The study also included a consumer perspective with the involvement of the Otaki advisory group to guide how the study was conducted and provide feedback on the study outcomes. Data was collected through semi-structured interviews with 10 patients, 6 family/whānau members, 5 surgeons, and 6 nurses. Interviews were analysed in two ways: by participant group (i.e., patients, family members, and HCPs) and by ‘linked case’ (i.e., direct comparisons of the perspectives of all those involved in the same patient’s case of breaking bad news).

The findings are presented as a series of superordinate and subordinate themes. The group-based analysis highlighted that patients understood their bad news experiences through the lens of their health beliefs and expectations of care, the relational and support needs they, and others, had during and following the encounter, and the ongoing shifts in perspective and priorities they experienced. Family members identified the patient as the focus of care, but also acknowledged their need for support in order to cope. HCPs recognised that breaking bad news was challenging based on the variation between instances of breaking bad news and patients’ needs, organisational constraints they had to work under, and the personal toll this task could take. The linked case-based analysis demonstrated that the receivers of bad news have a range of emotional and informational needs and that HCPs and family members fulfil important roles in accurately meeting patients’ needs.

Four conclusions can be drawn from the study as a whole about the process of breaking bad news. Firstly, there is variability in the situations, delivery approaches and needs of those involved in breaking bad news, requiring a flexible and tailored approach. Secondly, establishing an interpersonal connection between the deliverer and receiver of bad news is a central part of the process. Thirdly, breaking bad news is a challenge for all and receiving support in order to cope, is paramount. Lastly, there is a shared responsibility across healthcare organisations, training providers, HCP teams, and individual HCPs to make this process go as well as possible for all those involved. The current research makes an important contribution to understanding that, without doubt, breaking bad news is a complex process for those delivering and receiving the news, and improvements in this area require careful consideration, prioritising and resourcing as part of delivering effective cancer care.