Communication is a skill that changes the perception of a situation for the better (the good news, which removes a worrying diagnosis) or for the worse (the bad news, which raises awareness about the cruelty of a disease and the consequent transitory or definitive changes in the quality of life of life, including ideas of acceleration towards the end of life).
Knowledge, skill and attitude – the three attributes of competence – are essential so that the issuance and reception of information, data and facts in a dialogic manner are in line with morality, ethics and legality. The triad in the field of communication strengthens the term doctor-patient connection, fundamentally due to the sense of mutual respect, namely, respect for oneself and for the other, which admits delivery and reception capabilities.
Communication in the bedside ecosystem benefits from the maximum inclusion of the biotics involved and who represent health professionals, patients/family members, system managers and health institutions. There are numerous difficulties of understanding due to the different angles of vision articulated with the interests. A common thread of harmony is sincerity, the habitual essentiality of doctor-patient-doctor communication. Occasionally, non-verbal-body language communication speaks louder and becomes the message that best reveals realities.
The bedside has its own alphabet, which composes infinite forms of communication. On the professional side, the compositions must have as a common denominator what is exposed in Art. 34 and 35 of the current Code of Medical Ethics:
Physicians are prohibited from not informing the patient of the diagnosis, prognosis, risks and treatment goals, except when direct communication may cause harm, in which case, they must notify their legal representative; as well as exaggerating the severity of the diagnosis or prognosis.
On the patient’s side, contemporary communication content should privilege the classic anamnesis and the expression of the right to autonomy in the figure of free and informed consent. The qualification of a news item can be different between interlocutors. Reaching a diagnosis can represent, at the same time, a feeling of adversity for the patient and professional satisfaction for the therapeutic orientation. What seems to be two distinct circumstances tends to unify during the clinical trajectory of care, due to an awareness, by the patient, of the technoscientific aspects, and, by the doctor, of the individual human aspects of the patient.
The clinical course that is under real bilateral involvement tends to catalyze communication at the bedside. The doctor soon learns that words calculated to suit any situation fail in the absence of structured case-by-case adjustments. The biggest enemy is quantitative time, reason to invest in qualitative time, by mastering the alphabet at the bedside. Appropriate setting and timing and a willingness to hear oneself speak (avoid turning the dialogue into a monologue) and to hear oneself listen (avoid getting out of tune when the patient speaks) contribute to the good relationship between communicative efficiency and waste of time.
It is very important for the health professional to know the teaching of the communication coach Anett Grant, cited by Jung and Kyrillos, about the following succession: aligning with the patient’s concerns, building a bridge towards the techno-scientific view and classifying goals and potential for achievement point-to-point cooperates to clarify in its greatest sense of clarity, that is, the conviction (the quantum allowed by ethics) that causes credibility.
When the doctor leaves the scene and the patient and family members pass on the news, it is desirable that there is a feeling of objectivity in the messages, hierarchy of information and answering to doubts. A challenge!
Bad news, with its power to frustrate expectations that usually negatively and seriously affect the vision of the future, becomes the worst news if poorly communicated. Vocalized on the physician’s initiative, always a duty; never evil, bad news requires communication strategies in the health area that aim to avoid both lack and exaggeration in emission/reception.
A structured sequence aims to consider the information gathered from the patient, the transmission of medical data, patient support and the establishment of the patient’s commitment to the planning of conducts. In oncology, the SPIKES protocol exemplifies the notion of usefulness of sequential steps based on preparation (time is of the essence), perception (of what is already known by the patient), information (if desired by the patient), knowledge (producing clarification), attention to emotion (value of empathy) and cooperation (walking together in the face of needs).
The oncological disease, as a biological system that involves primary tumor, remissions, metastases, genetic traits and life habits, expresses the high dimension of the power of the word of science on the patient’s routine. Its psychosocial aspects are influenced by the ingrained concept of a disease with no return, despite the auspicious panorama provided by the successive advances of the specialty/discipline in knowledge and training.
Doctors and patients share words of uncertainty in oncology. It is necessary that they contribute to decisions that make sense in a situation full of dilemmas that, at the same time, signal the technical-scientific limitations of medicine – which bring together benefits that are not always sufficient and harm that is often excessive – and alert to the resulting possibility of redirection of therapeutic to palliative treatments.
The expression of the impact of communication on the patient is sensitive as the attitudes employed by the physician – and the multiprofessional team – are composed of good practices to clarify medicine far from perfection to the layman. Because it is professional concern that the continuum of improvement of useful and effective methods is commonly seen as below the desired level of security; the promotion of clarification cannot dispense with the human acclimatization of being a doctor-being a patient, nor the harmonization of ethical-legal conventions determined by society.
The oncologist aligns his own and collective experience in the literature and uses analogous clinical pasts to foreshadow the future that may require challenges of accepting uncomfortable realities, a commitment to survival and the demand for dignity in death.
Strong emotions arise in the midst of the authenticity of the truth, the charity of possible softening and the compassion of silences interspersed with the doctor’s intention not to be indifferent to the disease or the patient: a complex unity of conflicts. Anxiety, anger, guilt, fear of change in relationships, removal from family and work functions, loss of independence and financial worries combine to cause hesitation and accentuate obstacles to the patient’s ability to understand.
The quality of communication, especially with regard to bad news, is associated with the magnitude of the attunement provoked. The bilateral desire for understanding adjustments makes what has been said can be redacted and what was missing can be added. In this way, the continuum of information, which is usual for the oncologist and uncommon for the patient (surprised by the diagnosis and developments) is better reorganized. The bedside teaches how rigid pre-determinations should not be intended about attitudes in communication involving the patient with oncological disease. There are styles in emission and gradations of empathy and repulsion in reception that are not easily predictable.
Experienced doctors collect successes and failures of desired clarifications. They make up an upward in-service learning curve, supported by systematic and periodic analyzes of the real facts of communication and by the understanding of social and cultural peculiarities. I highlight a Brazilian study on oncology, homage and incentive for research: Primo and Garrafa searched for data from the Brazilian reality about a decade ago. They applied nine questions to 120 women, distributed in a wide age group (21 to 78 years old) with a young average (40.3 years old), aiming to assess the quality of communication about diagnosis, treatment and prognosis of genital or breast cancer. Using a cross-sectional descriptive-analytical design, they analyzed patients with malignant disease who were undergoing treatment at a specialized oncology outpatient clinic. The authors merged cases in advanced (66.6%) and early (33.3%) stages of oncologic disease.
The three questions on diagnosis involved the first information, implying the plurality of its attainment in multiple places of referral of the case, the uniformity of the information renewed in a specialized environment and the perspective of clarification contrapositions. The treatment questions quartet sought to know the patient’s desire to be involved with options, his understanding of differences, aptitude and climate for active participation in the selection.
The two questions about prognosis reinforced the aspect of adherence to treatment and deepening of knowledge about evolutionary possibilities. Three questions resulted with an evident overlap of answers, all of them referring to the statement want to know (83.3% and 83.4% said yes, respectively, about treatment options and about everything about the disease) and know (63.4% said they were aware of natural progression). Therefore, the research highlighted that the women involved wanted to feel informed about the development of the disease.
On the other hand, Primo and Garrafa showed a heterogeneity of responses about the behavior of physicians, patient assimilation and the feeling of freedom/competence to actively participate in decision-making. These data reinforce that, however much intuition can be used in health communication, training programs should be developed in order to obtain the greatest degree of lucidity on these variables, applicable to a continental and multi-ethnic country.
Bioethics reinforces the concept that good practices in health matters require efficient communication. Its interdisciplinary involvement provides subsidies so that individualizations in the compositions become more comprehensive about benefits and harms. As more rational understanding occurs, there will be less gap-filling by inapplicable analogy and unwelcome imagination. This facilitates deliberation in the face of the complexity of decisions in oncology.
In this way, bioethics values the improvement of dialogue derivations for the best adaptation to the parties involved and gives strong support to the conduct of the case, according to greater or lesser acceptance of the exercise of autonomy offered to the patient and eventual controversies in the way of seeing the patient. decision making as negligence or recklessness.
Primo and Garrafa, for their analysis of the effect of the word on what has already happened and on what may happen in a group of patients with oncological disease that can have an impact on the female identity, provide useful data for the construction of excellence in communication in the face of disease. oncology. It is a welcome contribution to the harmony of the trinomial Science-Education-Human Being.