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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">A Synthesis of the Literature on Breaking Bad News or Truth Telling: Potential for Research in India</title><author><name sortKey="Martis, Lawrence" sort="Martis, Lawrence" uniqKey="Martis L" first="Lawrence" last="Martis">Lawrence Martis</name><affiliation><nlm:aff id="aff1">Social Aetiology of Mental Illness – CIHR Postdoctoral Fellow, Centre for Addiction and Mental Health, 455 Spadina Avenue, Toronto, Ontario, M5S 2G8, Canada</nlm:aff></affiliation></author><author><name sortKey="Westhues, Anne" sort="Westhues, Anne" uniqKey="Westhues A" first="Anne" last="Westhues">Anne Westhues</name><affiliation><nlm:aff id="aff2">Faculty of Social Work, Wilfrid Laurier University, 120 Duke Street West, Kitchener, Ontario, N2H 3W8, Canada</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">23766589</idno><idno type="pmc">3680834</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3680834</idno><idno type="RBID">PMC:3680834</idno><idno type="doi">10.4103/0973-1075.110215</idno><date when="2013">2013</date><idno type="wicri:Area/Pmc/Corpus">002E58</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">002E58</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">A Synthesis of the Literature on Breaking Bad News or Truth Telling: Potential for Research in India</title><author><name sortKey="Martis, Lawrence" sort="Martis, Lawrence" uniqKey="Martis L" first="Lawrence" last="Martis">Lawrence Martis</name><affiliation><nlm:aff id="aff1">Social Aetiology of Mental Illness – CIHR Postdoctoral Fellow, Centre for Addiction and Mental Health, 455 Spadina Avenue, Toronto, Ontario, M5S 2G8, Canada</nlm:aff></affiliation></author><author><name sortKey="Westhues, Anne" sort="Westhues, Anne" uniqKey="Westhues A" first="Anne" last="Westhues">Anne Westhues</name><affiliation><nlm:aff id="aff2">Faculty of Social Work, Wilfrid Laurier University, 120 Duke Street West, Kitchener, Ontario, N2H 3W8, Canada</nlm:aff></affiliation></author></analytic><series><title level="j">Indian Journal of Palliative Care</title><idno type="ISSN">0973-1075</idno><idno type="eISSN">1998-3735</idno><imprint><date when="2013">2013</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>The high incidence of fatal diseases, inequitable access to health care, and socioeconomic disparities in India generate plentiful clinical bad news including diagnosis of a life-limiting disease, poor prognosis, treatment failure, and impending death. These contexts compel health care professionals to become the messengers of bad news to patients and their families. In global literature on breaking bad news, there is very little about such complex clinical interactions occurring in India or guiding health care providers to do it well. The purpose of this article is to identify the issues for future research that would contribute to the volume, comprehensiveness, and quality of empirical literature on breaking bad news in clinical settings across India. Towards this end, we have synthesized the studies done across the globe on breaking bad news, under four themes: (a) deciding the amount of bad news to deliver; (b) attending to cultural and ethical issues; (c) managing psychological distress; and (d) producing competent messengers of bad news. We believe that robust research is inevitable to build an indigenous knowledge base, enhance communicative competence among health care professionals, and thereby to improve the quality of clinical interactions in India.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Heyse Moore, L" uniqKey="Heyse Moore L">L Heyse-Moore</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ptacek, Jt" uniqKey="Ptacek J">JT Ptacek</name></author><author><name sortKey="Eberhardt, Tl" uniqKey="Eberhardt T">TL Eberhardt</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Buckman, R" uniqKey="Buckman R">R Buckman</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Rogers, Em" uniqKey="Rogers E">EM Rogers</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Levetown, M" uniqKey="Levetown M">M 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Indian J Palliat Care</journal-id><journal-id journal-id-type="iso-abbrev">Indian J Palliat Care</journal-id><journal-id journal-id-type="publisher-id">IJPC</journal-id><journal-title-group><journal-title>Indian Journal of Palliative Care</journal-title></journal-title-group><issn pub-type="ppub">0973-1075</issn><issn pub-type="epub">1998-3735</issn><publisher><publisher-name>Medknow Publications & Media Pvt Ltd</publisher-name><publisher-loc>India</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">23766589</article-id><article-id pub-id-type="pmc">3680834</article-id><article-id pub-id-type="publisher-id">IJPC-19-2</article-id><article-id pub-id-type="doi">10.4103/0973-1075.110215</article-id><article-categories><subj-group subj-group-type="heading"><subject>Review Article</subject></subj-group></article-categories><title-group><article-title>A Synthesis of the Literature on Breaking Bad News or Truth Telling: Potential for Research in India</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Martis</surname><given-names>Lawrence</given-names></name><xref ref-type="aff" rid="aff1"></xref><xref ref-type="corresp" rid="cor1"></xref></contrib><contrib contrib-type="author"><name><surname>Westhues</surname><given-names>Anne</given-names></name><xref ref-type="aff" rid="aff2">1</xref></contrib></contrib-group><aff id="aff1">Social Aetiology of Mental Illness – CIHR Postdoctoral Fellow, Centre for Addiction and Mental Health, 455 Spadina Avenue, Toronto, Ontario, M5S 2G8, Canada</aff><aff id="aff2"><label>1</label>Faculty of Social Work, Wilfrid Laurier University, 120 Duke Street West, Kitchener, Ontario, N2H 3W8, Canada</aff><author-notes><corresp id="cor1"><italic><bold>Address for correspondence:</bold> Dr. Lawrence Martis; E-mail: <email xlink:href="lawrence.martis@utoronto.ca">lawrence.martis@utoronto.ca</email></italic></corresp></author-notes><pub-date pub-type="ppub"><season>Jan-Apr</season><year>2013</year></pub-date><volume>19</volume><issue>1</issue><fpage>2</fpage><lpage>11</lpage><permissions><copyright-statement>Copyright: © Indian Journal of Palliative Care</copyright-statement><copyright-year>2013</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-sa/3.0"><license-p>This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p></license></permissions><abstract><p>The high incidence of fatal diseases, inequitable access to health care, and socioeconomic disparities in India generate plentiful clinical bad news including diagnosis of a life-limiting disease, poor prognosis, treatment failure, and impending death. These contexts compel health care professionals to become the messengers of bad news to patients and their families. In global literature on breaking bad news, there is very little about such complex clinical interactions occurring in India or guiding health care providers to do it well. The purpose of this article is to identify the issues for future research that would contribute to the volume, comprehensiveness, and quality of empirical literature on breaking bad news in clinical settings across India. Towards this end, we have synthesized the studies done across the globe on breaking bad news, under four themes: (a) deciding the amount of bad news to deliver; (b) attending to cultural and ethical issues; (c) managing psychological distress; and (d) producing competent messengers of bad news. We believe that robust research is inevitable to build an indigenous knowledge base, enhance communicative competence among health care professionals, and thereby to improve the quality of clinical interactions in India.</p></abstract><kwd-group><kwd>Breaking bad news</kwd><kwd>Clinical communication</kwd><kwd>Life-limiting disease</kwd><kwd>Patient care in India</kwd><kwd>Truth telling</kwd></kwd-group></article-meta></front><body><sec id="sec1-1"><title>INTRODUCTION</title><p>India has a high rate of life-threatening diseases and consequently plenty of clinical bad news, but few empirical studies about communicating such information to patients and families. The purpose of this article is to identify questions requiring the attention of health researchers in India, and possibly other developing countries, to contribute to the volume, quality, and comprehensiveness of the knowledge base on “truth telling” in relation to patient care and the education of health care professionals. Pursuit of these studies will enrich the global clinical communication scholarship as well as scholarship in India. We begin with some definitions of “breaking bad news” or “truth telling,” the two phrases that appear most commonly in the literature and that we have used interchangeably. Next, we highlight the significance of the topic and its relevance to India. Then, we will present a synthesis of the global literature, including the sparse Indian literature, on this topic under four themes to point out the potential for more research in India.</p></sec><sec id="sec1-2"><title>THE CONCEPT OF CLINICAL BAD NEWS OR TRUTH TELLING</title><p>Any health issue, even a common cold, has some degree of bad news if it requires a visit to a clinic or disrupts plans for a few days. However, the kind of bad news that most concerns health researchers, clinical communication scholars, and health care professionals is associated with life-limiting, progressive, and advanced diseases, henceforth referred as “eventually fatal health conditions,” a phrase found in the Australian glossary of palliative care.[<xref ref-type="bibr" rid="ref1">1</xref>] The nature of bad news in these contexts differs drastically from unpleasant information and manageable disruptions of daily activities caused by common or chronic health conditions. Information about the diagnosis of a difficult disease, poor prognosis, failure of treatments, lack of viable treatment options, treatment consequences such as toxic chemotherapy, amputation, or loss of functioning, and even impending death is clinical bad news.[<xref ref-type="bibr" rid="ref2">2</xref>] In situations of eventually fatal health conditions, bad news is seldom singular, because a series of disturbing events is likely to unfold as the boundary between the state of living and dying blurs.</p><p>The above description relates to a piece of unfavorable medical information, and therefore, it is called objective bad news. It is important to recognize the subjective dimension of bad news by understanding the diverse ways in which people perceive and respond to such health information. In this regard, Ptacek and Eberhardt[<xref ref-type="bibr" rid="ref3">3</xref>] pointed out psychological outcomes of bad news in defining it as the health information that “results in cognitive, behavioral, or emotional deficit in the person receiving the news and this lasts beyond the bad news encounter.” Similarly, Buckman[<xref ref-type="bibr" rid="ref4">4</xref>] contextualized bad news in the life prospects of a patient and defined it as “any news that drastically and negatively alters the patient's view of her or his future.” Many other nuances of bad news would emerge if health researchers examine this topic in various countries, cultures, and clinical contexts.</p></sec><sec id="sec1-3"><title>SIGNIFICANCE OF STUDYING CLINICAL BAD NEWS OR TRUTH TELLING</title><p>Clinical communication, also called patient–physician, consumer–provider, client–clinician, or patient–practitioner communication, refers to the interactions among health care professionals, patients, and families to achieve better health outcomes.[<xref ref-type="bibr" rid="ref5">5</xref>] It is the “foundation of the therapeutic relationship and the most common procedure” in all forms of patient care.[<xref ref-type="bibr" rid="ref6">6</xref>] Schofield goes to the extent of equating it to a prescription drug.[<xref ref-type="bibr" rid="ref7">7</xref>] The level of knowledge, sensitivity, and skill required for clinical interactions differs according to disease type, its severity, consequences, and the psychosocial characteristics of persons involved in the situation. Perhaps no other clinical situation tests the communicative competence of health care professionals as does an eventually fatal disease because such situations always have some degree of bad news.</p><p>The task of “breaking bad news” differs from other kinds of clinical communication and necessitates specialized skills because patients and families expect more information than in the case of curable or manageable health conditions.[<xref ref-type="bibr" rid="ref8">8</xref>] They tend to ask a lot of questions about prognosis but estimating survival, level of functionality, and treatment outcomes is difficult and uncertain.[<xref ref-type="bibr" rid="ref9">9</xref>] Bad news causes higher levels of emotional disturbance and reduces the capacity of patients and families both to absorb and to retain information.[<xref ref-type="bibr" rid="ref4">4</xref>] Dealing with multiple family members, deciding whether and how much of the bad news needs to be disclosed to patients, involving them in planning care,[<xref ref-type="bibr" rid="ref10">10</xref>] and identifying potential misunderstandings about prognosis and treatment goals add to the complexities of breaking bad news.[<xref ref-type="bibr" rid="ref11">11</xref>] No one likes to be a messenger of bad news, and all health care professionals would want the “pleasurable experience of confirming that all is well,” but many a times they are forced to state the opposite “even before they have had time to form a trusting relationship with patients and their families.”[<xref ref-type="bibr" rid="ref12">12</xref>] In short, health care professionals cannot avoid truth telling or be content with insensitive interaction. The capacity and ideas necessary to break bad news in a caring manner do not come naturally, but can be developed and nurtured by producing evidence-based theoretical frameworks and training programs.</p></sec><sec id="sec1-4"><title>RELEVANCE OF RESEARCH ON BAD NEWS IN INDIA</title><p>Perspectives and practices concerning truth telling are not immune from the health-seeking behaviors, traditions, beliefs, values, and social structures of any society and the socioculturally variegated India is one of the best laboratories to study the complexities of breaking bad news. Although it is a promising power house of the global economy, India is still a country of plentiful clinical bad news because it is among the top 10 countires in the world with the highest incidence of disease.[<xref ref-type="bibr" rid="ref13">13</xref>] Among its 1,029 million people,[<xref ref-type="bibr" rid="ref14">14</xref>] India has 2.5 million people with HIV or AIDS,[<xref ref-type="bibr" rid="ref15">15</xref>] 3.2 million people with cancer,[<xref ref-type="bibr" rid="ref16">16</xref>] about 150,000 persons with end stage renal disease,[<xref ref-type="bibr" rid="ref17">17</xref>] and 3.3 million tuberculosis patients[<xref ref-type="bibr" rid="ref13">13</xref>] at any given time. About 60% of the global coronary disease cases will soon be in India.[<xref ref-type="bibr" rid="ref18">18</xref>]</p><p>Statistics on the causes of death and mortality rates across age groups are relevant to understand the contours of bad news interactions in India. An average life expectancy of 64 years, and 9.8 million deaths occuring annually indicate that India has the largest population of any country with life-threatening diseases.[<xref ref-type="bibr" rid="ref13">13</xref>] In 2008, about 524,000 people died due to noncommunicable diseases such as cancer, diabetes, cardiovascular disease, and chronic respiratory diseases, and among communicable diseases tuberculosis caused 280,000 deaths.[<xref ref-type="bibr" rid="ref13">13</xref>] The infant death rate of 49 per 1000 infants of one year of age or below places India among some of the most impoverished countries of sub-Saharan Africa.[<xref ref-type="bibr" rid="ref13">13</xref>] The death rate of 61.3 per 1000 children below the age of five accounts for 20% of the 8.8 million children dying annually around the globe.[<xref ref-type="bibr" rid="ref19">19</xref>] The stillbirth rate of 22 per 1000 births suggests that inadequate prenatal care[<xref ref-type="bibr" rid="ref13">13</xref>] turns the good news about a child's birth into bad news. In spite of the high rate of life-limiting diseases, morbidity, and death, less than 3% of the patients with serious diseases can access palliative care.[<xref ref-type="bibr" rid="ref20">20</xref>] This creates very challenging situations for health care professionals who must speak to and about dying to patients but have nothing to offer in terms of palliative-hospice or home care.</p><p>In India, the access to prompt and efficient health care is dwarfed by the demand for such services. About 0.8 million new cancer patients are added annually, of whom 80% are diagnosed with advanced cancer.[<xref ref-type="bibr" rid="ref16">16</xref>] Similarly, Varghese and colleagues[<xref ref-type="bibr" rid="ref21">21</xref>] found that about 50% of 561 patients presenting with kidney problems had advanced kidney disease at the initial visit. These data show that lack of timely access to health care not only produces more bad news, but makes it very hard to communicate it because it was avoidable. In order to bridge the gap between demand and provision of health care services, the World Health Organiation (WHO) recommended that the Indian government spend at least 5% of its gross domestic product on public health care, compared to the current 4.1% which is $132 per person.[<xref ref-type="bibr" rid="ref22">22</xref>] As a result, government expenditure on health as a percentage of total expenditure on health is only 29.2% and the remaining 70.8% of the health care spending comes from private health care organizations.[<xref ref-type="bibr" rid="ref13">13</xref>] There is only one bed in a major hospital for every 1100 people, 6 physicians, and 13 nurses for every 1000 people in India.[<xref ref-type="bibr" rid="ref22">22</xref>] The failure to match the increasing demand for health care services with adequate financial allocations to public health care encourages the growth of exclusionary private health care in India.[<xref ref-type="bibr" rid="ref23">23</xref>] In short, socioeconomic disparities and inequitable access to health care give rise to large numbers of eventually fatal health conditions, which in turn generate a lot of bad news in India, but only a handful of studies have been done in India on this subject.</p></sec><sec id="sec1-5"><title>POTENTIAL FOR RESEARCHING TRUTH TELLING IN INDIA</title><p>Although the sparseness of empirical studies on the most challenging aspects of clinical communication in India is quite disconcerting, an analysis of the literature produced elsewhere suggests that there is no dearth of researchable issues related to breaking bad news. Below we have provided a synthesis of the extant literature on truth telling under four themes: (a) deciding the amount of bad news to deliver; (b) attending to cultural and ethical issues; (c) managing psychological distress; and (d) producing competent messengers of bad news. We summarize past research efforts in India and elsewhere and suggest directions for future research in India. The studies on breaking bad news in India are presented along with the international research to emphasize that the gaps and richness of the research done in one country or cultural context may have relevance for all.</p><sec id="sec2-1"><title>Deciding the amount of bad news to deliver</title><p>Truth telling requires “greater thought and planning than a drug prescription”[<xref ref-type="bibr" rid="ref24">24</xref>] because there is no simple answer to questions such as whether or how much information patients want, in what phase of the disease trajectory, and how much bad news health care professionals should give them. Studies done in various parts of the world indicate that a majority of patients want truth about their health condition. Although the samples were not representative in most cases, the proportion of patients or the general public wanting to know the truth about their health could be at least 86% in Japan,[<xref ref-type="bibr" rid="ref25">25</xref>] 80% in Argentina,[<xref ref-type="bibr" rid="ref26">26</xref>] 80% in Nepal,[<xref ref-type="bibr" rid="ref27">27</xref>] 92% in Taiwan,[<xref ref-type="bibr" rid="ref28">28</xref>] 58% in Spain,[<xref ref-type="bibr" rid="ref29">29</xref>] 82% in Poland,[<xref ref-type="bibr" rid="ref30">30</xref>] and 87% of African–Americans, 89% of European Americans, 47% of Asian–Americans, and 65% of Mexican Americans in the United States.[<xref ref-type="bibr" rid="ref31">31</xref>]</p><p>Notwithstanding the above findings, approximately 25-50% of patients with a terminal disease in Australia,[<xref ref-type="bibr" rid="ref32">32</xref>] Argentina, Brazil, France, Belgium, Switzerland,[<xref ref-type="bibr" rid="ref33">33</xref>] Japan,[<xref ref-type="bibr" rid="ref26">26</xref>] Egypt,[<xref ref-type="bibr" rid="ref34">34</xref>] the United States,[<xref ref-type="bibr" rid="ref35">35</xref>] North America,[<xref ref-type="bibr" rid="ref36">36</xref>] Norway, and Denmark[<xref ref-type="bibr" rid="ref37">37</xref>] are kept in the dark about their health status by physicians. The proportion of such patients could be between 50% and 75% in Spain,[<xref ref-type="bibr" rid="ref30">30</xref><xref ref-type="bibr" rid="ref38">38</xref>] Italy,[<xref ref-type="bibr" rid="ref39">39</xref>] Nepal,[<xref ref-type="bibr" rid="ref28">28</xref>] China,[<xref ref-type="bibr" rid="ref40">40</xref>] and many of the Asian countries.[<xref ref-type="bibr" rid="ref36">36</xref>] Withholding bad news from patients diagnosed with terminal diseases is very common across the globe, including in countries with higher rates of bad news disclosure.[<xref ref-type="bibr" rid="ref34">34</xref><xref ref-type="bibr" rid="ref37">37</xref><xref ref-type="bibr" rid="ref38">38</xref><xref ref-type="bibr" rid="ref39">39</xref><xref ref-type="bibr" rid="ref40">40</xref>]</p><p>We found no studies that tell us the proportion of patients in India who want to know bad news and those who expect their family to receive such information and make appropriate decisions for them. There is reason to believe that in general patients want truth about their health because a majority of the patients and family members interviewed by Raja[<xref ref-type="bibr" rid="ref41">41</xref>] for a qualitative study complained that they received insufficient information on diagnosis and prognosis. They also expressed dissatisfaction about physicians who communicated hurriedly and in a harsh manner. We found only one study done by Purrakkal and colleagues[<xref ref-type="bibr" rid="ref42">42</xref>] who reported that 62 out of 100 patients undergoing radiotherapy for various types of cancer at Calicut Medical College (CMC) in India were aware of their diagnosis. Forty four of them informed the researchers that they received the bad news from their physician, nine from their family, seven had guessed it on their own, and two by some other means. These results may not be extrapolated to other places in India because CMC is located in Kerala, which is the first among the 28 states and seven union territories of India to achieve a 94% literacy rate,[<xref ref-type="bibr" rid="ref14">14</xref>] to enact a palliative care policy, and to roll out a community-based program – Neighborhood Network in Palliative Care.[<xref ref-type="bibr" rid="ref43">43</xref>] Purrakkal and colleagues[<xref ref-type="bibr" rid="ref42">42</xref>] have observed that the emphasis given to clinical communication training at CMC must have influenced physicians to discuss bad news with nearly 50% of the participants. Muckaden's[<xref ref-type="bibr" rid="ref44">44</xref>] view that bad news is hidden from about two thirds of patients in India and approximately 15% of patients die without knowing anything about the disease may be a more accurate assessment of this clinical practice.</p><p>Future studies in India should examine the expectations of patients from diverse backgrounds about receiving bad news, and whether they believe that the quality and quantity of health information given to them is sufficient to participate in clinical decisions and prepare for life-transitions. It would be useful to establish a baseline about how many patients diagnosed with eventually fatal diseases actually know the bad news, when they learn the bad news, and whether practices related to delivering bad news differ based on the type or severity of the disease. Such a baseline could be used to assess change in this area of health care practice in the years ahead. Other questions to explore include what health care practices patients find helpful in being able to receive and understand bad news, and what makes it more difficult.</p></sec><sec id="sec2-2"><title>Attending to cultural and ethical issues</title><p>Variation in the demand for and provision of bad news is also attributed to cultural differences. For example, in some cultures, discussions about terminal disease are avoided because uttering the word “death” amounts to inviting or hastening it.[<xref ref-type="bibr" rid="ref45">45</xref>] A case study by Kaufert and Lavallee[<xref ref-type="bibr" rid="ref46">46</xref>] revealed that aboriginal Canadians consider that even parting with a toe amounts to violation of the wholeness of the body and therefore these researchers highlighted the need for cultural sensitivity when disclosing news about amputation. Among some cultures, people believe that adult sons and daughters are responsible for ensuring the peaceful death of their parents and burdening the dying parents with bad news may be perceived by the patient and relatives as dereliction of filial duty.[<xref ref-type="bibr" rid="ref47">47</xref><xref ref-type="bibr" rid="ref48">48</xref><xref ref-type="bibr" rid="ref49">49</xref><xref ref-type="bibr" rid="ref50">50</xref><xref ref-type="bibr" rid="ref51">51</xref>]</p><p>Often the question whether it is ethical to disclose bad news directly to patients or not is grounded in cultural values. Some physicians believe that they are duty-bound to protect their patients from emotional distress and hopelessness, even at the cost of denying the patients the truth about their health.[<xref ref-type="bibr" rid="ref25">25</xref><xref ref-type="bibr" rid="ref38">38</xref><xref ref-type="bibr" rid="ref40">40</xref><xref ref-type="bibr" rid="ref52">52</xref>] Concealment of bad news is more common in the case of a terminal disease and often justified on the grounds that truth telling condemns a patient to social death, by which is meant treating a living person as if they are already dead.[<xref ref-type="bibr" rid="ref53">53</xref>] Often physicians discuss bad news and care plans with family caregivers rather than with the patient.[<xref ref-type="bibr" rid="ref34">34</xref><xref ref-type="bibr" rid="ref52">52</xref><xref ref-type="bibr" rid="ref54">54</xref>] About 90% of the 224 physicians who answered a questionnaire given by Chan and Goh[<xref ref-type="bibr" rid="ref55">55</xref>] in Singapore felt that it is more appropriate to discuss bad news with the patient's immediate family first, as a way of making decisions about disclosing the news to the patient or not. In contrast, some health care professionals believe that “truth” belongs to the patient.[<xref ref-type="bibr" rid="ref25">25</xref><xref ref-type="bibr" rid="ref33">33</xref><xref ref-type="bibr" rid="ref36">36</xref><xref ref-type="bibr" rid="ref40">40</xref><xref ref-type="bibr" rid="ref52">52</xref><xref ref-type="bibr" rid="ref54">54</xref><xref ref-type="bibr" rid="ref56">56</xref>] Literature also identifies situations where the patient's or family's views on truth telling differ from that of the standard procedures or perspectives of health care providers.[<xref ref-type="bibr" rid="ref46">46</xref><xref ref-type="bibr" rid="ref57">57</xref><xref ref-type="bibr" rid="ref58">58</xref><xref ref-type="bibr" rid="ref59">59</xref><xref ref-type="bibr" rid="ref60">60</xref>]</p><p>Most importantly, research has demonstrated the dynamic nature of culture and therefore the changes occurring in people's beliefs and behaviors related to bad news. Particularly, a shift from a paternalistic perspective on truth telling toward valuing patient autonomy is evident across all societies in recent years but the pace of such change is dissimilar. As early as 1672, French physician Samuel de Sorbiere declared that truth telling is a good idea indeed, but he predicted it would not catch on and it would jeopardize the medical profession.[<xref ref-type="bibr" rid="ref4">4</xref>] The classical study by Oken[<xref ref-type="bibr" rid="ref61">61</xref>] in 1961 is witness to the staunchly paternalistic medical culture in the United States a few decades ago, finding that about 90% of the 219 physicians who participated in that study reported that they were withholding news about cancer from their patients. Novack and colleagues[<xref ref-type="bibr" rid="ref62">62</xref>] replicated the study and found a reverse trend within two decades; this time 98% of the 258 participants stated that they disclosed a cancer diagnosis to patients. Both studies reported a shift in physicians’ attitudes on providing bad news to cancer patients rather than actual practices on truth telling. Recently, Chan and Goh[<xref ref-type="bibr" rid="ref55">55</xref>] queried 221 medical specialists in Singapore about whether they had noticed a change in the number of patients who demanded information about a bad diagnosis compared to 10 years previously. Approximately 88% of the participants gave an affirmative answer, and moreover, 94% of them said that patients have become more knowledgeable about medicine than the patients a decade before, attributing the change brought about to internet technology. These studies indicate that both health care and societal culture, which is the system of beliefs and values and behaviors, is changing due to a wide variety of systemic and structural changes.</p><p>In terms of attitudes about delivering bad news to patients in India, a survey administered by Purakkal, Pulasseri, and Ravindran[<xref ref-type="bibr" rid="ref63">63</xref>] revealed that more than 78% of 850 medical students, interns, and faculty members indicated that bad news should be disclosed to patients; however, this study does not provide information about how many of those who participated in the study actually discuss bad news directly with their patients. There is reason to believe that nondisclosure is common practice in India due to various sociocultural pressures. For example, Dighe, Jadhav, Muckden, and Sovani[<xref ref-type="bibr" rid="ref64">64</xref>] reported that among 31 parents of children diagnosed with a terminal disease, 12 refused to disclose the bad news to the children because they thought that the children were unable to bear the shock or were too young to understand the implications of the disease. A cross-sectional comparative study examined attitudes toward informed consent among physicians in the Indian State of Kashmir and Malaysia.[<xref ref-type="bibr" rid="ref65">65</xref>] Among 48 physicians in Kashmir, 42% reported that they disclose bad news directly to patients, and 35% said that they would ignore the family's request to withhold such information. This study points out that the fear of causing distress, depression, and suicidal thoughts in patients are the main reasons for withholding bad news about serious illness. Chattopadhyay and Simon[<xref ref-type="bibr" rid="ref66">66</xref>] provided a case example to suggest that attitudes about non-disclosure are disease-specific; Indian society perceives cancer as a “disease without hope,” for instance. Recently, Kumar and colleagues[<xref ref-type="bibr" rid="ref67">67</xref>] reported that all the 35 radiation oncologists surveyed by them dismissed the view that the condition of patients deteriorates when they know the truth. Again, all participants preferred truth telling to patients, but only 11 of them said that they would not comply with family's request to withhold bad news from patients. Research evidence also suggests that bad news disclosure in India is influenced by the gender of the patient. For example, Purrakkal and colleagues[<xref ref-type="bibr" rid="ref42">42</xref>] reported that among the 44 cancer patients who received bad news from their physicians, the ratio between men and women patients was 2-1.</p><p>In short, these studies provide some insight into physicians’ attitudes about truth telling in India and the external pressure to withhold such information from patients, but shed litle light on the spectrum of psychosocial, cultural, institutional, and existential factors influencing the processes of communicating bad news. There is a great deal of diversity within and across ethno-cultural communities, and various geographical regions in India, but no studies were found that explored the differences among various religious, linguistic, and socioeconomic classes in India. Researchers should examine the diverse cultural values and ethical considerations that impact truth telling preferences in India by conducting studies in different parts of the country and population groups belonging to different religious, cultural ethnic, linguistic, and socioeconomic backgrounds. Studies examining the influence of religious beliefs, for example, cross-sectional studies comparing Hindus with minority faith groups might yield important insights for practice, as might differences among socioeconomic groups. So also more research is necessary to know what creates or perpetuates a culture that either supports or obstructs truth telling with various cultural subgroups. Recently, the need for integrating a gender lens in health research is emphasized across the globe. Hence, more Indian studies to explore the preferences of male and female patients about health information and to explain whether the gender of health care professionals changes truth telling practices in India are timely.</p></sec><sec id="sec2-3"><title>Managing psychological distress</title><p>Bad news generates a variety of emotions in patients, family caregivers, and health care professionals alike. Butow and colleagues[<xref ref-type="bibr" rid="ref68">68</xref>] found that shock (54%), fright (46%), and sadness (24%) are the most frequent emotions in cancer patients upon learning the truth about their illness. Another study explains that diseases such as cancer not only cause physical pain but also generate fear about the loss of functional abilities, diminished sense of control, loss of hope, and anxiety about loss of life.[<xref ref-type="bibr" rid="ref69">69</xref>] A number of studies have shown that patients and family caregivers highly value a professional's capacity for empathic communication in the context of bad news. For example, Hunt, Elston, and Galloway[<xref ref-type="bibr" rid="ref70">70</xref>] found that parents of children with progressive diseases are more satisfied with healthcare professionals who communicate caringly rather than those who demonstrate only pharmacologic expertise. Besides verbal sensitivity, the empathic gestures of professionals have a healing effect for parents both when caring for the dying child and during the bereavement period.[<xref ref-type="bibr" rid="ref71">71</xref>] In short, empathic communication assuages the emotional stress stemming from bad news and humanizes the otherwise pharmacologically and technologically driven healthcare environment.</p><p>Health care professionals’ ability to manage their own stress is as integral an aspect of their communicative competence as addressing the emotional reactions of patients and family caregivers. Often the deteriorating condition of their patients causes intense distress for healthcare professionals,[<xref ref-type="bibr" rid="ref36">36</xref>] which prevents them from disclosing bad news to patients[<xref ref-type="bibr" rid="ref72">72</xref>] and discussing impending death.[<xref ref-type="bibr" rid="ref73">73</xref>] For example, a qualitative study done in Sweden[<xref ref-type="bibr" rid="ref74">74</xref>] described the complex psychosocial stress experienced by 30 oncologists who reported feeling a loss of control in almost all aspects of their life. They found it hard to control their emotions, thoughts about their own mortality, doubts about their professional skills, feelings of helplessness, and loneliness. Such psychosocial stressors are likely to curtail their ability to communicate effectively and with empathy.</p><p>Studies by Mohanti and colleagues[<xref ref-type="bibr" rid="ref75">75</xref>] and another by Supe[<xref ref-type="bibr" rid="ref76">76</xref>] shed some light on the hardships experienced by medical interns in India in the context of breaking bad news. Kumar[<xref ref-type="bibr" rid="ref67">67</xref>] who examined the attitudes among 35 radiation oncologists about truth telling has merely mentioned that 21 participants felt depressed after bad news encounters. These studies were not specifically designed to examine the psychological issues confronting health care professionals in the context of truth telling. In contrast, Muckaden[<xref ref-type="bibr" rid="ref44">44</xref>] focused on the psychological dimension of bad news in women treated for cervical cancer in Mumbai and based on two case-examples, identified anxiety, sadness, suicidal ideation, guilt for seeking treatment late, and anger against physicians for mismanaging the care process. A study by Coenen and colleagues[<xref ref-type="bibr" rid="ref77">77</xref>] has significance for learning how to support the distressed bad news recipients because this study explored the conceptions of “dignified dying” among 560 nurses in the United States, Ethiopia, Kenya, and India. It has thrown some light on the efforts of Indian nurses to preserve hope among terminally ill patients, provide them with spiritual support, and empathize with them through physical touch. Nevertheless, there is still room for studies to document the psychosocial processes in the context of delivering bad news because we do not know how bad news encounters affect physicians, nurses, social workers, and psychologists in India, and how to they cope with it. This issue can be studied from the view point of patients and their families, as well. Spirituality is another important area related to patient care to persons with eventually fatal health conditions and truth telling. India is known for its spiritual heritage and practices such as Yoga and meditation, but we are yet to see research on the usefulness of applying such spiritual exercises to manage the distress caused by bad news.</p></sec><sec id="sec2-4"><title>Producing competent messengers of bad news</title><p>The literature also talks about the need for evidence-based education or training to nurture competence. Until recently, it was customary to speak about a physician's capacity for clinical communication as his or her “bedside manner,” assumed to be largely mirroring his or her personal qualities and not something that could be taught.[<xref ref-type="bibr" rid="ref78">78</xref>] Clinical communication as a formal subject remained a “minor subset of marginal interest to the field” of health care.[<xref ref-type="bibr" rid="ref79">79</xref>] Interestingly enough, health care consumers have always been perceptive about the significance of communication for good patient care. The expectations of patients regarding clinical interactions, an increasing volume of research, and access to training programs and courses on clinical communication may have changed the attitudes of medical students and physicians about the significance of communicative competence for patient care in some countries. However, the opportunities for education in clinical communication vary considerably across the globe, and therefore, clinical communication is yet to be perceived by all students and educators as central to medical education.[<xref ref-type="bibr" rid="ref80">80</xref>]</p><p>Health care professionals who do not recognize the need for communicative competence are less likely to consider the training programs on patient-physician communication as important. For example, von Gunten[<xref ref-type="bibr" rid="ref81">81</xref>] reports a study in which cancer patients and oncologists were asked to suggest an important topic for continuing medical education. About 88% of cancer patients said that the oncologists should be taught to communicate well; about 90% of the oncologists wanted more medical science knowledge. In another study, physicians reported that diagnostic ability is the most crucial skill, whereas patients gave prominence to the listening skills of the physician.[<xref ref-type="bibr" rid="ref82">82</xref>]</p><p>Awareness of the need for communicative competence is but one side of the coin; the other side is access to training programs. The lack of professional development programs to improve the capacity of practicing clinicians,[<xref ref-type="bibr" rid="ref83">83</xref>] and absence of training related to the existential and spiritual concerns of patients induces a sense of inadequacy among health care providers.[<xref ref-type="bibr" rid="ref74">74</xref><xref ref-type="bibr" rid="ref84">84</xref><xref ref-type="bibr" rid="ref85">85</xref>] Research has shown that many physicians do not meet the expectations of patients with eventually fatal diseases and medical students do not feel confident to attend to the psychosocial needs of dying patients.</p><p>Research evidence also suggests that training programs contribute in great measure towards communicative competence, if the quality and comprehensiveness of such trainings is ensured. Watling and Brown[<xref ref-type="bibr" rid="ref86">86</xref>] presented a series of case-based workshops on communication skills to 12 Neurology residents. The cases covered topics such as breaking bad news, dealing with “difficult” patients, carrying out patient directives, disclosing medical errors, and discussing death. Most importantly, the participants kept a reflective journal on the scenarios they encountered in their practice. The researchers concluded that together with structured input sessions, the use of personal portfolios such as reflexive journaling may promote life-long learning about clinical communication. Similarly, ongoing professional development forums such as biweekly palliative care seminars contribute to communicative competence.[<xref ref-type="bibr" rid="ref87">87</xref>] Kersun, Gyi, and Morrison[<xref ref-type="bibr" rid="ref88">88</xref>] surveyed 171 medical fellows who graduated over the course of five years from a medical college in the UK. The purpose of this study was to evaluate the usefulness of a training program consisting of various activities such as observing senior clinicians, being observed while practicing, reading, lectures, role plays, workshops, and videos related to communication of bad news. These researchers concluded that training may help physicians feel better prepared to break bad news, but opportunities to observe senior clinicians communicating bad news and a greater number of years of clinical practice experience are the most influential factors in instilling a sense of adequacy or competence about communicating bad news.</p><p>Mohanti and colleagues[<xref ref-type="bibr" rid="ref75">75</xref>] assessed palliative care knowledge in 100 medical residents of a tertiary hospital in India and found that 25% of participants reported no knowledge about palliative care, 51% rated the palliative care training given during residency as inadequate, and about the same number of participants expressed a lack of confidence in delivering palliative care. Another Indian study reported that among 111 residents, 86% were familiar with palliative care concepts; however, only 13% expressed confidence in providing palliative care and only 15% of that subgroup felt that they had been adequately trained to deliver bad news.[<xref ref-type="bibr" rid="ref89">89</xref>] These authors have expressed concern about the prospects of palliative care in India because medical professionals are entering into health care practice without sufficient conceptual knowledge and skills about pain relief, multidisciplinary practice, and communication. Many of the patients interviewed by Raja[<xref ref-type="bibr" rid="ref41">41</xref>] were confused about their diagnosis and remarked that the nurses knew a lot about their health condition but were unwilling to divulge it. Notably, they informed the researcher that they could not ask the physicians questions or clarifications because the physicians rarely interacted with them as equals.</p><p>The incidence of clinical bad news is likely to increase in India because as pointed out by Drummer and Cook,[<xref ref-type="bibr" rid="ref90">90</xref>] in the past decade the forces of globalization are contributing to the higher incidence of “diseases of affluence” or noncommunicable diseases in emerging economies such as India, China, and Brazil. Therefore, the need for health care professionals who are well trained to communicate bad news can hardly be overemphasized. This, in turn, highlights the urgency of more studies to develop evidence-based and effective training programs related to clinical communication. Fortunately, awareness about the singificance of multisdisciplinary approaches to care for persons and families delaling with eventually fatal health conditions is increasing across the globe. In connection with such a philosophy of patient care, health care professionals belonging to various health disciplines and skills are working in teams to deliver bad news and deal with its outcomes. There is a great potential for designing training programs related to clinical communication to medical, social work, nursing, and spirtual support students within the same cohorts and evaluating its usefulness for changing the current hierarchical flow of health information in Indian clinical settings.</p></sec></sec><sec sec-type="conclusion" id="sec1-6"><title>CONCLUSION</title><p>Breaking bad news in a caring way is an aspect of clinical communication and patient care that is highly valued by patients, and a task many health care professional have to do almost daily, but find it as challenging as ever. This review of the literature shows that the topic “breaking bad news” is of interest to many researchers, professional health educators, and care providers in India. Although there are already a number of studies that shed light on attitudes regarding breaking bad news, they do not explain the processes and practices that emanate from such attitudes and perspectives.</p><p>In summary, future research in India should give priority to the experiences and expectations of patients because bad news is about them and they are affected most by eventually fatal diseases. A number of studies can be designed to explore the perspective of patients with various types of eventually fatal diseases and sociocultural backgrounds about the amount and timing of receiving bad news. Their experiences about receiving bad news will help in evaluating and improving communicative competence among health care professionals.</p><p>Generally, all health care professionals love to give good news, and therefore, breaking bad news is very hard for them. Unfortunately, we do not know about the psychosocial implications for health care providers of bearing bad news in India. Most of the extant literature presents the truth telling attitudes of physicians or medical students rather than their actual practices, or impacts. Further, the role of allied health care professionals such as nurses and social workers in communicating such sensitive health information and supporting the recipients of such news has not received the due attention of researchers.</p><p>India has been a home for all major religions and ancient spiritual practices, but very little research has taken place examining the application of spiritual and philosophical resources to difficult clinical interactions. Although there is some research evidence to show that clinical communication is receiving more attention in medical education, we know little about training in communicative competence for health care professionals in multidisciplinary formats. Such collaborative skill development is likely to increase collegiality in all forms of caring processes, including communication of bad news to patients and families. Health researchers have a great responsibility to engage in research that will produce socioculturally relevant training programs, to present alternatives to a hierarchical and physician-centered clinical communication, and to increase multidisciplinary approaches to patient care. We envisage great studies on truth telling in India to change the clinical communication practices everywhere. We look forward to collaboration with health researchers and professional health educators to design research projects and training programs related to various aspects of truth disclosure in India and internationally.</p></sec></body><back><fn-group><fn fn-type="supported-by"><p><bold>Source of Support:</bold> Nil.</p></fn><fn fn-type="conflict"><p><bold>Conflict of Interest:</bold> None declared.</p></fn></fn-group><ref-list><title>REFERENCES</title><ref id="ref1"><label>1</label><element-citation publication-type="book"><article-title>Palliative Care Australia – PCA</article-title><source>Palliative and end of life care glossary of terms</source><year>2008</year><publisher-loc>Australia</publisher-loc><publisher-name>National Quality and Standards Director, Palliative Care Australia</publisher-name></element-citation></ref><ref id="ref2"><label>2</label><element-citation publication-type="book"><person-group 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