Evaluating guidelines for improving clinician-patient communication in cancer care

¶ … Rating: 3. Although the paragraph is succinct and clear as to the value of communication with cancer patients saying that optimal communication builds, trust, respect, and reciprocity, the authors only mention in passing that excellent communication significantly affects clinical outcomes. There is a huge literature on the critical need for communication with cancer patients -- as, indeed, with all patients who are critically ill - and elaborating somewhat on the ways that deficient communication can aggravate outcome may be helpful for readers of this article as well as for prompting them to improve their communication. Furthermore, the authors could have defined effective communication as well as conceptualized their definition of 'sub optimal' communication. This is particularly important in a treatise that seeks to improve communication.

The clinical question covered by the guidelines in specifically described.

Rating 2. See above. A more expanded literary review of studies that point to ineffective clinician-patient cancer-related communication as well as possible shortfalls or discrepancies in any of these studies would have lent more credence and body to the guideline.

3. The patients to whom the guideline is meant to apply are specially described

Rating 4. The generic term 'cancer patient' is used. Although the term 'cancer' could be differentiated, the generic term provides us with sufficient detail.

Scope and Objective

1. The overall objective is to improve communication of clinicians towards cancer patients. Results would transmit information more clearly and without distortion from clinician to patient. Improved communication would also build trust; cement a supportive relationship, and positively effect clinical outcomes. Lastly, empathetic and effective communication will also go far in reducing patient's distress.

2. A detailed description of the clinical question would address precisely how and in which manner would the most effective communication occur. What are the most important elements to consider when communicating with patients? Also included are questions on how to tell people that they have cancer; how to discuss the prognosis; how to prepare patients for a medical procedure; how to discuss treatment options; and how to discuss disease progression

3. The population that is covered by the guideline is cancer patients as a whole (all ages, all cancer types, both sexes, all ethnicities; no distinction is made) from the time that their disease has been discovered to all aspects of their condition and treatment.

Stakeholder Involvement

4. The guideline development group includes individuals from all the relevant professional groups

Rating 3. The generic term 'clinician' is used. I am not sure whether this refers to nurses, social workers, palliative care physicians, psychiatrists, psychologists, oncologists, surgeons, and family physicians as detailed in the description of the 110 participants. There are aspects of the article that make me think this term to be conducive to physician or nurse alone. I may be incorrect.

More so, it seems to me that communication with cancer patient is just as important a subject in reference to patient educators and in reference to all who come into contact with patient as consistent and abundant literature on the subject shows.

5. The patient's views and preferences have been sought

Rating 1 & 4. It is difficult to grade this question since it is irrelevant. On the one hand, it was the cancer practitioners' feedback that was obtained, rather than the patient's views and preferences. On the other hand, the objective was, and is, superb communication with cancer patients so that their views and preferences can be concretely understood and fulfilled. In this way, their views and preferences have been sought.

6. The target users of the guidelines are clearly defined

Rating 2. As explained before, the generic term 'clinician' is used. I am not sure whether this refers to nurses, social workers, palliative care physicians, psychiatrists, psychologists, oncologists, surgeons, and family physicians as detailed in the description of the 110 participants. There are aspects of the article that make me think this term conducive to physician or nurse alone.

8. Systematic methods were used to search for evidence

Rating 4: The literature had been thoroughly plumbed by teams of clinical, content, and methodology experts who had then drawn up and distributed a draft do their findings to Ontario cancer practitioners for review. The respondents were nurses, social workers, palliative care physicians, psychiatrists, psychologists, oncologists, patient educators, surgeons, and family physicians. They also included members of the Provincial Palliative Care Committee and the Provincial Psychosocial Oncology Committee

9. The criteria for selecting the evidence are clearly described

Rating 3: The method is clearly described. The evidence-based recommendation of the draft and examples of the EB recommendations are lacking.

10. Rating 3. The methods used for formulating recommendation are, on the whole, clearly described. There are times when the authors direct one to former research.

11. The health benefits. have been considered in formulating recommendations

Rating1. Irrelevant question

Rigor of Development

12. There is an explicit link between the recommendation and the supporting evidence

Rating 4. Authors proceed from describing their methodology of draft and feedback to delineating the most effective methods for achieving clinician-patient communication in all stages.

13. The guidelines have been externally reviewed by experts

Rating 4. Responses were received from 33 individuals. These included nurses, social workers, palliative care physicians, psychiatrists, psychologists, oncologists, patient educators, surgeons, and family physicians, as well as members of the Provincial Palliative Care Committee and the Provincial Psychosocial Oncology Committee

14. A procedure for updating the guideline is provided.

Rating 3: Indirectly. Implications that this is so may be derived from the same methodology that prompted it in the first place and that seems to have been conducted on previous occasions. Namely, by a comprehensive review of the relevant literature and soliciting feedback from specialists.

Clarity and presentation

15. The recommendations are specific

Rating 4. Extremely so and categorized according to every conceivable situation.

16. The different options for management of the condition are clearly presented

Rating 4. Communication in the different situations is described at length and detailed, with specifics, examples, and in a clear and understandable manner.

17. Key recommendations are easily identifiable

Rating 4 The whole is clear, and recommendations in each category are italicized and accentuated.

18. The guidelines is supported with tools for application

Rating 4 Examples are liberally sprinkled throughout. Communication prescriptions are described in a way that can be understood by all.

Applicability

19. Barriers in applying guideline have been discussed

Rating 1. Not at ll. A clinician may feel discomfort in certain situations, such as in witnessing patient cry or in revealing regression of disease or condition of disease in the first place. None of these instances are mentioned.

20. The potential cost implications .. have been considered

Rating 1. Question is irrelevant.

21. The guideline presents key review criteria for monitoring

Rating 4. Criteria are thorough and specific.

22. The guideline is editorially independent from the funding body

Rating 4 The PEBC notes itself to be editorially independent from Cancer Care Ontario and the Ontario Ministry of Heath and Long-Term care.

23. Conflicts of interest of guideline members have been recorded.

Rating 4 The PEBC remarks that it is sponsored by but otherwise editorially independent from Cancer Care Ontario and the Ontario Ministry of Health and Long-Term care.

Categorize process and outcome measures using outcome evaluation methods.

I would rate the process measures of Rodin et al. (2009) valid based on the fact that they were based on authoritative and scientifically impressive sources. These included guidelines from the Australian National Breast Cancer Center and the Australian National Cancer Control Initiative; an updated systematic review of the research evidence, and a consensus by the Clinician -- Patient Communica-tions Working Panel of the Program in Evidence- Based Care of Cancer Care Ontario.

The reliability of these studies also lends credence to the outcome measures in that the study gains internal validity due to the fact that the process measures matched the objective of the study.

The fact, however, that only 33 participants responded renders the sample small and detracts from its reliability making it difficult to replicate to other instances. This renders the outcome measures unreliable.

On the other hand, similar online and offline research, both quantitative and qualitative, time and again, indicates the importance of communication in terms of hospice patient care. Cancer patients, it is shown, too profit from improved doctor-patient communication (e.g. Jaffe & Ehrlich, 1997). Studies and experience indicate the importance of the hospice nurse possessing excellent interpersonal skills with the patience and ability to listen to their patients and to help them through their challenging time. Elisabeth Kubler-Ross, for instance, time and again reiterated the importance of excellent clinician-patient communication skills in all processes of their dying. The AACN (American Association of Critical-Care Nurses, 2006; Hardin, 2005) model, likewise, which addresses importance of communication between clinician and patient also reinforces the salutatory benefits of clinician-patient communication lending further credence to this study and to outcome measures. The brunt of her job depends more on listening to, being with, and making the patient feel good than actually treating the patient. Consistent research in the nursing field in general and in the cancer domain in particular support the importance of clear, empathetic, patient-centered communication (e.g. McClain & Rosenfeld, 2003; Sandoval-Cros, 1999; Watson et al., 1999). This guideline delineates the descriptors of such communication. Since the sample of respondents is small, the study needs to be conducted on wider and reiterated populations.

Summarize evidence-based guidelines relevant to hospice inpatient care unit.

In short, the practice of clear, supportive, emphatic communication with hospice patients is urged. Recommendations are many, but reduction to key points relevant to hospice inpatient care unit may include the following:

Communication should be patient-centered with needs and preferences of patient considered

Decision-making should accord to patient's needs and preferences

Clinician's verbal and non-verbal behavior should be respectful of patient's ethnicity, age and personal preferences

Significant news should be given carefully, one-to-one, in a quite place

Communication should be honest and optimistic, showing concern for patient and willingness to be there for him or her

Use memory heuristics, such as visual aids, or recording the consultation to help patient remember details.

Allow patients to express feedback and articulate their feelings

Provide time for discussion and response to upsetting news

Communication should be simple and clear devoid of medical jargon

Communicate with both individuals and with their family or support system.

Reference

American Association of Critical-Care Nurses (AACN). (2006). The AACN Synergy Model for Patient Care. Retrieved November 15, 2006, from http://www.certcorp.org/certcorp/certcorp.nsf/vwdoc/SynModel? Opendocument

Hardin, S. (2005). Introduction to the AACN Synergy Model for Patient Care. In S.R. Hardin & R. Kaplow (Eds.), Synergy for clinical excellence: The AACN Synergy Model for Patient Care (pp. 3-10). Sudbury, MA: Jones and Bartlett Publishers.

Jaffe, C. & Ehrlich, C.H. (1997). All kinds of love: Experiencing hospice. New York,

NY: Baywood Publishing Co.

McClain, C.S. & Rosenfeld, B. (2003). Effect of spiritual well-being on end-of-life despair, The Lancet, 36, 1603-1607.

Rodin, G. et al. (2009) Clinician -- patient communication: evidence-based recommendations to guide practice in cancer Current Oncology -- Volume 16, Number 6

Sandoval-Cros CJ. (1999) Common psychological problems in the cancer patient Moffitt Cancer Center

http://www.moffitt.org/moffittapps/ccj/v6n5/dept6.htm

Watson M, Haviland JS, Greer S, Davidson J, & Bliss JM. (1999). Influence of psychological response on survival in breast cancer: a population-based cohort study. Lancet; 354:1331 -- 6