Breaking Bad News - Wirklichkeit und Patientenpräferenzen

Breaking bad news, for example disclosing the diagnosis of cancer to a patient, is a frequent task for physicians. There exists only few data from studies about this topic both nationally and internationally. The American SPIKES protocol, a guideline how to break bad news to a patient, is being used in medical teaching in Germany, but evaluation of the SPIKES protocol is sparse and insufficient. In Europe the SPIKES protocol has never been evaluated before. Information is missing about the quality of the bad news delivery in Germany and about patients’ preferences regarding that conversation. Thus it was the intention of this study to examine the way in which bad news are being told in Germany and patients’ preferences for that. The recommended steps of the SPIKES protocol were evaluated, each concerning patients’ preferences and the perception of how they had been realized in bad news delivery. Moreover, the correlation between patient’s emotional state and quality of bad news delivery should be examined. A questionnaire based on the items of the SPIKES protocol was generated. Via this questionnaire 350 oncological patients at two different hospitals in Marburg were asked how the bad news had been broken to them and what preferences they had regarding the conversation. Additionally the patients were asked to complete the “Hospital Anxiety and Depression Scale – German version” (HADS-D). The patients indicated clear preferences for the bad news disclosure. When comparing the preferences and reality, significant differences were found. The patients’ preferences weren’t fulfilled in reality. This could be a reason for the high percentage of dissatisfaction with the bad news delivery among the patients. Only 46.1 percent of the patients stated that they were satisfied with the way the bad news had been broken to them. In relation to the SPIKES protocol it can be shown that some items of the protocol were more important for the patients than others. Many of the most important preferences for example were informative aspects, while emotional aspects seemed to be less important for the patients. The overall quality of the bad news delivery was significantly related to the emotional state after receiving bad news both directly after bad news delivery and at the time evaluating this questionnaire. This study provides the first actual-theoretical comparison of a “breaking bad news” guideline. It offers important findings about the way bad news are being told in Germany and the patients’ preferences regarding such conversation. It can be stated that there is a high need for improvement when disclosing bad news. A modification of the SPIKES protocol in Germany in a way that considers the patients’ preferences is being suggested. Patients should be involved more actively in discussing the bad news and patients’ needs for prerequisites (for example undisturbed surrounding, adequate time) should be more respected and realized by physicians and hospital management. Furthermore the conception of the bad news delivery in a two-step procedure should be strongly recommended. There is a need for further studies to confirm the results and findings of this survey. Clinical trials should be carried out to examine, if the use of guidelines influences the quality of the bad news delivery and especially, if the adherence to these guidelines can improve patients’ satisfaction and success of the bad news delivery.