Is it possible to improve the breaking bad news skills of residents when a relative is present? A randomised study.

BACKGROUND: Although patients with cancer are often accompanied by a relative during breaking bad news (BBN) consultations, little is known regarding the efficacy of training programmes designed to teach residents the communication skills needed to break bad news in a triadic consultation. METHODS: Residents were randomly assigned to a 40-h dyadic and triadic communication skills training programme (n=48) or a waiting list (n=47). A simulated BBN triadic consultation was audiotaped at baseline, and after training for the training group, and 8 months after baseline for the waiting list group. Transcripts were analysed using content analysis software (LaComm). A coder determined the moment of bad news delivery and the relative's first turn of speech regarding the bad news. A generalised estimating equation was used to evaluate residents' communication skills, BBN timing, and the relative's inclusion in the consultation. RESULTS: Ninety-five residents were included. After training, the duration of the pre-delivery phase was found to be longer for the trained residents (relative risk (RR)=3.04; P<0.001). The simulated relative's first turn of speech about the bad news came more often during the pre-delivery phase (RR=6.68; P=0.008), and was more often initiated by the trained residents (RR=19.17; P<0.001). Trained residents also used more assessment (RR=1.83; P<0.001) and supportive utterances (RR=1.58; P<0.001). CONCLUSION: This study demonstrates that a training programme that focuses on the practice of dyadic and triadic communication skills can improve the communication skills of the participating residents in a BBN triadic consultation. Such a training should be included in resident curriculum.

Is it possible to improve residents breaking bad news skills? A randomised study assessing the efficacy of a communication skills training program.

BACKGROUND: This study aims to assess the efficacy of a 40-h training programme designed to teach residents the communication skills needed to break the bad news. METHODS: Residents were randomly assigned to the training programme or to a waiting list. A simulated patient breaking bad news (BBN) consultation was audiotaped at baseline and after training in the training group and 8 months after baseline in the waiting-list group. Transcripts were analysed by tagging the used communication skills with a content analysis software (LaComm) and by tagging the phases of bad news delivery: pre-delivery, delivery and post-delivery. Training effects were tested with generalised estimating equation (GEE) and multivariate analysis of variance (MANOVA). RESULTS: The trained residents (n=50) used effective communication skills more often than the untrained residents (n=48): more open questions (relative rate (RR)=5.79; P<0.001), open directive questions (RR=1.71; P=0.003) and empathy (RR=4.50; P=0.017) and less information transmission (RR=0.72; P=0.001). The pre-delivery phase was longer for the trained (1 min 53 s at baseline and 3 min 55 s after training) compared with the untrained residents (2 min 7 s at baseline and 1 min 46 s at second assessment time; P<0.001). CONCLUSION: This study shows the efficacy of training programme designed to improve residents' BBN skills. The way residents break bad news may thus be improved.

[Fear of falling in older people]. / La peur de chuter et le "syndrome post-chute " de la personne âgée.

Fear of falling and poor physical performance are prominent symptoms in many older people. The prevalence of fear of falling in community-living elderly ranges between 12 % and 65 %, and is higher in women than men. It commonly occurs after falls, but it also occurs without a previous fall history. One of the major consequences of fear of falling is the restriction and avoidance of activities. However, not all elderly with fear of falling avoid activities in daily life. Some elderly only become cautious, which may be functional in preventing falls. Only a small percentage of elderly show a pattern of excessive fear and restriction of activities. The consequences of this pattern may, however, be debilitating and devastating. Excessive fear and avoidance may compromise the quality of life, and may result in a decline of physical capabilities and, ultimately, in an increased risk of falls, which may further fuel fear and avoidance. Future research should investigate whether individualised intervention strategies are efficient in preventing falls and activity-related fear of falling within this population in order to improve her quality of life.

Predictors of physicians' satisfaction with their management of uncertainty during a decision-making encounter with a simulated advanced stage cancer patient.

OBJECTIVES: To optimize their training, predictors of physicians' satisfaction with their management of uncertainty should be examined. This study investigated these predictors by using a simulated advanced stage cancer patient. METHODS: Physicians (n=85) rated their satisfaction with their management of uncertainty (Visual Analog Scale-100mm) after a decision-making encounter. Communication predictors were examined with the: Observing Patient Involvement scale (OPTION), Multidimensional analysis of Patient Outcome Predictions (MD.POP) and Communication Content Analysis Software (LaComm). Psychological predictors were assessed with the: Intolerance of Uncertainty Inventory (IUI), Physicians' Reactions to Uncertainty scale (PRU), Decisional Conflict Scale (DCS), and Jefferson Scale of Physician Empathy (JSPE). RESULTS: Physicians' satisfaction (mean=67mm; standard deviation=17mm) was not predicted by their communication, but by their anxiety due to uncertainty (PRU) (ß=-.42; p=<.001) and their perceived empathy (JSPE) (ß=.26; p=.009). These variables accounted for 25% of variance in physicians' satisfaction. CONCLUSIONS: Physicians' satisfaction with their management of uncertainty was not affected by their communication performance, but by their psychological characteristics. PRACTICE IMPLICATIONS: Training programs should increase physicians' awareness regarding the communication performance required in decision-making encounters under conditions of uncertainty.

Prevention of adjustment disorders and anticipatory nausea secondary to adjuvant chemotherapy: a double-blind, placebo-controlled study assessing the usefulness of alprazolam.

PURPOSE AND METHODS: Although a high prevalence of adjustment disorders and anticipatory nausea secondary to adjuvant chemotherapy (CT) has been reported, little has been done to develop strategies to prevent these problems. A double-blind, placebo-controlled study was therefore designed to assess the usefulness of adding low-dose alprazolam (0.5 mg to 2 mg per day) to a psychologic support program including progressive relaxation training designed to prevent the aforementioned conditions. Fifty-seven women undergoing adjuvant CT for stage II primary breast cancer agreed to participate in the assessment, which was conducted at four time points: before starting CT, 6 weeks after CT, before the fourth CT, and after the fourth CT. The Hospital Anxiety and Depression Scale (HADS), Montgomery and Asberg Depression Rating Scale (MADRS), Hamilton Anxiety Scale (HAS), Revised Symptom Checklist (SCL-90-R), Morrow Assessment of Nausea and Emesis (MANE), and World Health Organization (WHO) grading of acute and subacute toxicities were used to compare the alprazolam (AA) and placebo (PA) arms of the study. RESULTS: At the second evaluation, the results showed a higher rate of anticipatory nausea (18% v 0%) in the PA compared with the AA arm (P = .038). These differences were no more significant at each of the further assessments. Significant differences were found for the intake of hypnotics at each assessment visit, with the rate of hypnotic users being significantly higher in the PA (19%) compared with the AA (0%) arm at the fourth assessment (P < .05). Anxiety and depression scores of self- and observer-report were similar in the two arms. A significant relationship was found between the development of anticipatory nausea and the self-report of anxiety and depression score measured by HADS at baseline. The average HADS total score at baseline was 15.33 (SD = 6.56) for patients who developed anticipatory nausea and 11.23 (SD = 6.67) for other patients. CONCLUSION: The adjunct of alprazolam to a psychologic support program delays the occurrence of anticipatory nausea and controls sleeping problems secondary to adjunct CT. Although studies are needed to improve the efficacy reported here, physicians may already consider the use of alprazolam for cancer patients undergoing CT.

Communication skills and psychological training in oncology.

Preserving the best possible quality of life for cancer patients and their families has become a major goal in cancer care. However, the cumulative effect of stressors related to cancer care, many of which involve communicating with patients and relatives, may lead to the development of burnout in staff. Many health care professionals lack the psychosocial knowledge and communications skills needed to identify patients' problems because general professional training focuses on technical care. Teaching strategies known as psychological training programs (PTP) are therefore being developed to help improve health care professionals' sensitivity to communication problems with patients and relatives. Cognitive (e.g. theoretical information), experiential (e.g. case-history discussions), behavioural (e.g. role-playing exercise) and supportive (e.g. stressor identification) training techniques are used to teach the essential skills of good communication, i.e. listening, empathy, response to cues and appropriate use of reassurance. PTP range from one-day courses and residential workshops to full-time 1- or 2-year curricula. However, one of the main obstacles to implementing PTP is scepticism among health care professionals about its usefulness. Research on training effectiveness should therefore be developed to assess the impact of communication skills on quality of care and patients' quality of life.

The psychiatrist's perspective on quality of life and quality of care in oncology: concepts, symptom management, communication issues.

The important prevalence of psychosocial problems and psychiatric disturbances that have been reported in oncology, underlines the need for comprehensive psychosocial support for cancer patients and their families. Psychosocial support is designed to preserve, restore or enhance quality of life. Quality of life refers not only to psychosocial distress and adjustment-related problems but also to the management of cancer symptoms and treatment side-effects. Psychosocial interventions designed for this purpose should be divided into five categories: prevention, early detection, restoration, support and palliation. Firstly, preventive interventions are designed to avoid the development of predictable morbidity secondary to treatment and/or disease. Secondly, early detection of patients' needs or problems refers to the assumption that early interventions' could have therapeutic results superior to those of delayed support, both for quality of life and survival. Thirdly, restorative interventions refer to actions used when a cure is likely, the aim being the control or elimination of residual cancer disability. Fourthly, supportive rehabilitation is planned to lessen disability related to chronic disease, characterised by cancer illness remission and progression, and to active treatment. Fifthly, palliation is required when curative treatments are likely to no longer be effective, and when maintaining or improving comfort becomes the main goal. Psychological interventions are often multidisciplinary, with a variety of content. The type of psychological intervention ranges from information and education to more sophisticated support programmes including directive (behavioural or cognitive) therapies, or non-directive (dynamic or supportive) therapies. Social interventions usually include financial, household, equipment, and transport assistance depending on individual and family needs and resources. These interventions may be combined with the prescription of pharmacological (psychotropic, analgesic), physical, speech or occupational therapies, especially in rehabilitation programmes. Health care services devoted to delivery of these interventions are hospital, hospice or home-based and organised very differently depending on already available community resources and local practice.

The effects of a 24-h psychological training program on attitudes, communication skills and occupational stress in oncology: a randomised study.

The usefulness of psychological training programs (P.T.P.) in health care settings devoted to cancer care is beginning to be recognised but their content, form and effectiveness need further investigation. Seventy-two oncology nurses were randomly assigned to a 24-h P.T.P. or to a waiting list period. Attitudes were assessed by a semantic differential questionnaire, occupational stress was assessed by the Nursing Stress Scale and communication skills were assessed by standardised videotaped role-playing exercises. These were used to compare trained (T.S.) and control subjects (C.S.). The results show a significant training effect on attitudes (P = 0.05), especially on those related to self concept (P = 0.004), and on the level of occupational stress related to inadequate preparation (P = 0.02). Limited changes were found regarding post-training communication skills. T.S. were significantly more in control of the interview than C.S. (P = 0.02). The results indicate that 24-h P.T.P. assessed here are effective. The data also demonstrate the need to consolidate the skills acquired by regular post-training sessions.

Screening for psychiatric disorders in a lymphoma out-patient population.

The Hospital Anxiety and Depression Scale (HADS), a four-point, 14-item self-assessment questionnaire, was tested as a screening method for psychiatric disorders in a sample of 117 Hodgkin's lymphoma and non-Hodgkin lymphoma consecutive out-patients. A receiver operating characteristic (ROC) analysis was performed, giving the relationship between the true positive rate (sensitivity) and the false positive rate (1--specificity). This makes it possible to choose an optimal cut-off score that takes into account the costs and benefits of treatment of psychiatric disorders (mainly adjustment, depressive and anxiety disorders) in a lymphoma out-patient population. A cut-off point of 10 gave 84% sensitivity and 66% specificity. HADS appears in this study to be a well accepted, simple, sensitive and specific tool.

Caring About Women and Cancer (CAWAC): a European survey of the perspectives and experiences of women with female cancers.

This paper reports on the findings of the largest ever European survey of female patients' perceptions of their cancer treatment. It has provided clarification of what women consider important in relation to their management and has identified several areas where more research is needed. It has shown that women's knowledge about cancer before diagnosis is poor and the number undergoing regular screening could be improved. Women are not being adequately prepared and educated about what to expect from treatment and steps should be taken as a matter of urgency to redress this shortcoming. It was revealed that whilst families were the primary source of support to female cancer patients, women also derive considerable support from healthcare professionals, particularly senior doctors; more attention should be paid by specialists and nurses to developing psychological skills to cope with this. In this context, further research is needed into how support groups may best meet patient needs.

Brief psychological training for health care professionals dealing with cancer patients: a one-year assessment.

The usefulness of psychological training for health professionals dealing with terminally ill cancer patients is becoming more widely recognized, but little has been done to elaborate its content and form. Of special interest is the study of the effectiveness of brief psychological training groups and the quality of treatment to be achieved. The principal aim of the training group assessed here was to develop a better understanding of death and dying issues and ways to cope with them. The present study reports the attitudes of participants, assessed 1 year after the end of training in order to investigate the possible consolidation of the immediate posttraining effectiveness reported previously. Subjects (n = 78) who attended the training groups were compared to a control group (n = 42). Attitudes about oneself, illness and death, occupation, personal growth, and professional relationships were assessed with a semantic differential questionnaire before training, after training, and 1 year later. Results show a significant reduction of the positive effect assessed just after the training. While attitudes moved significantly to the positive pole immediately after the end of the training, 1 year later the reverse phenomenon is noted. These data suggest the necessity for improving the effectiveness of short psychological training proposed to help health care professionals dealing with terminally ill cancer patients.

Cancer care--a stress for health professionals.

Literature related to health care professionals dealing with stress of cancer care is still in its infancy. The authors distinguish papers of general interest (the most frequent), papers identifying stressors, and papers about stress consequences. Most of them recognize death of the patients as a major stressor for health care professionals. There are also additional stressors specific to health care and work. Consequences of stressors have another important dimension: working with cancer patients is often a chronic stress which may lead to the development of burnout and poor quality of care. Little also is actually known about how coping strategies and/or support are influencing adaptation and stress consequences. The authors suggest that an important effort should be made to evaluate stress, and its consequences on poor staff communication with cancer patients and their families. Training interventions aimed at a better quality of care should be designed and their usefulness investigated. The effectiveness of training for health care professionals dealing with cancer patients is reviewed.

Immediate effectiveness of brief psychological training for health professionals dealing with terminally ill cancer patients: a controlled study.

The usefulness of a psychological training for health professionals dealing with terminally ill cancer patients is beginning to be widely recognized, but little has been done to elaborate its content and form. The study of the effectiveness of brief psychological training groups is of special interest for the quality of treatment to be achieved. The principal aim of the training group, assessed here, was to develop a better understanding of death and dying issues and ways to cope with them. Subjects (n = 122) who attended the training groups were compared to a control group (n = 43). Attitudes about oneself, toward illness and death, occupation, personal growth, and professional relationship were assessed with a semantic differential questionnaire before and after training. Results show a significant change in attitudes for the trained subjects. Subjects reporting more negative attitudes at the beginning of the training were those which benefit the most. The attitude change is a first step aimed at assessing the effectiveness of psychological training; it will be completed by the assessment of long term attitudes and behavior modifications of the health care professionals trained.

[Improving doctor's communication skills in oncology: review and future perspectives]. / Améliorer les stratégies de communication des médecins en oncologie: état des lieux et perspectives futures.

The aim of this review is to discuss the different communication skills training designed to physician interactions with cancer patients. The development of medicine and chronic cancer treatments indicates the need to improve communication skills that combine appropriate assessment, information and support. Literature shows however that numerous factors may jeopardize the mastery of those skills. As a consequence, initiatives have been made to improve oncologists' communication skills. The objectives of those training programs are to improve patients' as well as the medical staffs' quality of life. A critical review of objectives and used techniques (theorical information, case discussion, role playing, feed-back) is presented here. This review includes also the discussion about training module integrating several techniques. This review shows the efficacy of experiential techniques as well as participative techniques. The results of available studies are finally emphasizing two difficulties: the maintenance and the consolidation of the various skills acquired over time and their successful transfer to the clinical practice.

Comparative study of the efficacy and safety of trazodone versus clorazepate in the treatment of adjustment disorders in cancer patients: a pilot study.

The efficacy of trazodone (mean once-daily dose 111.5 +/- 36.3 mg) versus clorazepate (mean once-daily dose 17.5 +/- 7.5 mg) to relieve anxious and depressive symptoms in 18 patients undergoing treatment for breast cancer was investigated in a 28-day randomized, double-blind study. Efficacy was evaluated using the Hospital Anxiety and Depression Scale, the Revised Symptom Checklist and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire. A successful response to treatment was achieved in 91% (10/11) of patients who received trazodone and 57% (four of seven) of patients who were administered clorazepate (P = 0.1373). Bayesian analysis revealed that the prior probability of making a wrong decision in prescribing trazodone rather than clorazepate reduced from 26% to 8%. Assessment of the clinical scales suggested a benefit of trazodone compared with clorazepate, although the differences were not significant. Safety of both treatments was similar. Trazodone is devoid of an abuse risk and dependence and, therefore, could be a valuable alternative to clorazepate in the treatment of adjustment disorders in cancer patients.

[Psychological adaptation to bone marrow transplantation]. / Adaptation psychologique à la greffe de moelle.

Bone marrow transplantation, used with increasing success over the past ten years, is recognized as highly stressful. Physiological and psychological rehabilitation after treatment is often difficult. This paper outlines the psychological issues encountered by adult patients with haematological malignancies through a review of the adjustment disorders associated with bone marrow transplantation, their prevalence, symptomatology and predictive factors. Some guidelines are proposed for the prevention of the stresses associated with hospitalization.

[Factors limiting and favoring communication and information in oncology]. / Facteurs limitant et favorisant la communication et l'information en oncologie.

The authors discuss actual concepts about the transmission of information to the patient and his family in oncology. After the discussion of problems related to the emission and reception of information, they introduce the useful strategies designed in order to achieve an optimal transmission of information, and to improve doctor-patient communication.

[The psychosocial impact of illness and death in children: current concepts]. / L'impact psychosocial de la maladie et de la mort de l'enfant: conceptions actuelles.

The authors review actual concepts about the psychosocial impact of the fatal illness and the death of a child. The conceptualization of death and the psychological consequences of illness with a fatal prognosis--particularly those affecting the children themselves, their parents, and health care professionals--are developed and discussed.

[Euthanasia: interaction of bioethical and psychological aspects]. / Les euthanasies: intrications des dimensions bioéthiques et psychologiques.

The authors develop the interactions of psychological and ethical issues of euthanasia. After a brief recall of the historical background, they discuss the concept of euthanasia and analyse the distinction between active and passive euthanasia focusing either on patient-doctor relationship and ethics.