Desenvolvimento de um novo instrumento para avaliar a qualidade da comunicação de más notícias pelos médicos.

Burg, Luciana Bonnassis; Oliveira Filho, Getúlio Rodrigues de; Castanhel, Flávia Del; Schuler, Lara De Luca Maciel; Grosseman, Suely

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Revista Brasileira de Educação Médica

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ORIGINAL ARTICLE • Rev. bras. educ. med. 46 (2) • 2022 • https://doi.org/10.1590/1981-5271v46.2-20210461.ING copiar

Desenvolvimento de um novo instrumento para avaliar a qualidade da comunicação de más notícias pelos médicos.

Autoria SCIMAGO INSTITUTIONS RANKINGS

Resumo:

Introdução:

A maioria dos instrumentos para avaliar a comunicação de más notícias pelos médicos foi desenvolvida para pacientes com câncer e adaptada a outros contextos. Na prática clínica, muitas notícias podem não ser consideradas tão ruins pelos médicos, mas possuem um impacto importante negativo na vida dos pacientes. Assim, ainda há a necessidade de instrumentos para avaliar essa comunicação nos diversos cenários clínicos.

Objetivo:

desenvolver, a partir da perspectiva dos pacientes, um instrumento para avaliar como os médicos comunicam más notícias na prática clínica.

Método:

o estudo foi realizado usando uma abordagem qualitativa exploratória, através de entrevistas semiestruturadas em profundidade com 109 pacientes em dois hospitais de referência no Brasil. A análise de conteúdo foi utilizada para gerar categorias, a partir das quais os itens iniciais do instrumento foram desenvolvidos. A clareza e a relevância dos itens foram avaliadas por um comitê de 11 profissionais médicos e 10 pacientes.

Resultados:

O instrumento incluiu itens sobre as atitudes dos médicos como atenção, respeito e sinceridade e sobre o compartilhamento de informações compreensíveis na linguagem do paciente. O instrumento inicial foi composto por 19 itens, respondidos em uma escala-Likert de 5 pontos. Após avaliação do comitê de juízes, 2 itens foram modificados e 3 foram excluídos; ficando o instrumento final com 16 itens.

Conclusão:

um novo instrumento com 16 itens foi desenvolvido a partir da perspectiva dos pacientes para avaliar a comunicação de más notícias pelos médicos. Após validação adicional, este instrumento poderá ser útil em cenários reais e diversos de más notícias da prática clínica.

Palavras-chave:
Comunicação em saúde; Relação médico-paciente; Instrumento; Qualidade; Médico

Categories/ Subcategories / sub subcategories ^* * Categories appear in bold style, subcategories in italic and sub subcategories in normal style.	Illustrative quotations
What to do before the encounter
Summon other people	“summon family members;” “prepare individual before delivering news together with a team”
Choose a suitable setting/location	“have patient come to the doctor´s office;” “invite patient/family member to a reserved space
Assess whether the moment is appropriate	“do not deliver the news when the person feels ill”
Be certain of the diagnosis	“be certain of the diagnosis before delivering the news;” “wait for confirmation […] and, if uncertain, don´t say it”
Different perspectives on who to tell
Family member/companion	“Summon family members first. Deliver the news explaining things well. Reassure them and inform them well […] so they can tell the patient;” “inform companion if it is serious”
Most stable person	“deliver the news to the right person, the most “stable” person, the person who seems to have it “together”
Patient	“the first person to know must be the patient, and not the person sitting next to them […] don´t tell others”
Who should deliver the news
The physician	“hear it from the doctor´s mouth, and not from others;” “the patient´s doctor should be the one to deliver the news”
How to address the patient
Address the patient by name
Invite the patient to sit down
Look the patient in the eyes	“look person in the eye;” “look at the patient”
Listen to the patient	“be open to listen”
What to consider before delivering the news
Spirituality	“we are Christians, and this really helps us to cope with situations like these […] only He can give us strength”
Conversation with the family members	“clarify things so that the family doesn´t feel guilty;” “the companion should know more than the patient”
Different perspectives on when to deliver the news
After learning whether patient wishes to hear the news	“if I don´t want to know, don´t tell me,” “[…] unless the person doesn´t want to know”
After assessing patient´s health condition	“check everything first, such as blood pressure;”
After observing patient's psychological condition	“carefully observe the person before deciding how to say it […] or how much should be said”
After preparing the patient	“together with a (medical) team”
“in a conversation […] don´t show up out of the blue so as not to scare” / “so as not to shock
	the person”; “don´t jump right into it, but be subtle”
Without preparing the patient	“you should be direct;” “not beat around the bush;” “go straight to the point;” “don´t be evasive… speaking in circles only makes a person more anxious;” “just spit it out”
Depends on the:
- person and culture	“learn what the person is like […] get to know the person […] anxious or nervous…”; “it depends on the culture”
- news	“it depends on the illness;” “it depends on the news, for example, a cancer”
How to prepare the patient
Include other persons such as family members in the conversation
Sit down and talk	“sit down, put the person at ease… let´s talk”
Keep a conversation going	“prepare the patient psychologically;” “have a conversation first, and finally, when the time is right, deliver the news;” ‘[...] the diagnosis should be put together through words that guide the listener to the delivery of a critical piece of news;” “at first, take your time discussing and going over the diagnosis, little by little… have a conversation to help the person understand what is happening […] ‘it´s necessary to contextualize things;” “… if it´s cancer, report everything that has been discovered before delivering the diagnosis;” “explain what the patient had… which resulted in the current condition… explain sequentially, ask about the patient´s life”
Have a structured conversation	“1) have a conversation and appease the shock, 2) the exam results indicate that you have a health condition 3) this is not definitive, your condition is treatable 4) you need to be strong now”
Give clues	“say words to prepare the patient;” “begin by giving clues so the person slowly gets what is happening to them;” “hint at the fact that the person may have something serious”
Different perspectives on how much should be said
Everything	“I want to know everything… you can say it;” “explain details […] whether there´s a solution or not”
Only parts	“never deliver the full news”
Characteristics of communication
Verbal language:
- clear	“as natural and clear as possible”
- using appropriate words/ being gentle with the words	“use appropriate words;” “be careful with the choice of words”
- without using scientific language/technical jargon	“without using scientific language;” not using technical jargon”
- that the patient can understand	“ease into your speech;” “explain things correctly […] not leaving the person clueless”
- with little information at a time
- in a succinct/objective manner
Provide written material	“furnish a written report of the problem”
Non-verbal language:
- speak calmly, slowly, paying attention to the tone of voice	“things must be said gently;” “pay attention to your voice” / “your tone of voice;” “speak calmly […], slowly;” “explain things slowly”
- look the person in the eye
Attitudes during delivery
Presence/ attention	“the news should be delivered as if that patient were special;” “do not leave someone ‘hanging’ saying you´ll be back later to talk”
Active Listening	“listen, be considerate […]”
Caring	“put the person at ease;” “don´t scare the person;” “calm the patient, when the patient cries, embrace them”
Compassion	“their compassionate gaze said everything […] their expression helped me to realize it was serious […] the look in their eyes said it all…”
What the physician should say
That they do their best to try to solve the disease	“tell them: we are going to try to solve this in the best way possible”; “say that things are difficult, but that we are going to try”
That they understand the patient’s perspective	“say that they understand the patient´s point of view”
That there is treatment	“say that treatment exists;”
That there are resources	“point out the positive side, that there are available resources”
Positive things	say positive things, because one´s self-esteems drops to the floor;” “not discourage;” “just keep going so you don´t get depressed”
What to address in the conversation
Explain the disease/illness	“explain the illness… what we´ve got… what is happening”
Explain what is going to happen	“explain what is going to happen;” “show what is coming ahead… all this will bring about;” “explain things so the patient may rebuild their life”
Present treatment options and the pros and cons	“present treatment options”; “present possible treatments;” “explain the pros and cons”
Explain prognosis	“present clear expectations;” “present the chances”
Present a plan	“explain what the patient should do next;” “say what the next steps are;” “present a plan”
Provide referrals, including psychological support	“provide necessary referrals;” “refer (patient/family) to a psychologist”
Attitudes during encounter
Respect	“take the patient seriously;” “no jokes at this time;” “treat (the patient) like a human being, with respect”
Be calm, patient	“be cool […] and calm;” “don´t get annoyed or worked up if the person cries;” “to be patient and impart serenity”
Categories / Subcategories / sub subcategories*	Illustrative quotations
Be considerate	“be considerate;” “engage with the patient”
Be loving	“Treat (patients) with love and care;” “treat (them) in a special way […] being loving”
Sincerity, honesty	“be sincere and truthful;” “do not hide anything;” “be frank;” “place all the cards on the table and say what the patient needs to hear;” […] it´s preferable to deal with the truth than lies;” “be realistic […] sometimes we cry, but then we get up again;” “don´t raise false expectations”
Humbleness, transparence	“being humble is the most important;” “be transparent;” “be a human being, not imposing oneself as a doctor”
Compassion, have concern for patient	“showing compassion”; “show concern for the patient; ”show willingness to help”
Sensitivity	“treat (others) like human beings, be sensitive”
Empathy	“be empathetic, remember that they are human beings;” “you have to believe what the patient is feeling”
Be committed to the patient	“don´t abandon/discontinue patient treatment”
Be supportive, available	“be accessible;” “be supportive, help (patient) to move forward”
Be understanding
Be non-judgmental
Be hopeful	“be hopeful […] you can´t be apathetic when it comes to hope”
Courage	“Have the courage to speak”
Categories / Subcategories / sub subcategories*	Illustrative quotations
Professionalism	“be professional about it, you must love what you do;” “someone who really embodies the role”
Demonstrate confidence

Items¹ 1 developed based on content analysis from 109 interviews. of the instrument following the statement: “When delivering the news, the doctor ....”	N² 2 N = sum of the number of coins applied to the item by the 10 patients from the committee of judges.
1. … talked to me in a suitable setting.	12
2. … asked if I would like someone to be with me.³ 3 modified item (initial version: …asked if I would like a family member to be present).	10
3. … asked what I already knew about my health problem.⁴ 4 item added by researchers.	9
4. … was well informed about my health problem.	12
5. … talked before about the possibility of bad news.⁵ 5 item initially excluded by the experts; it was not assessed by the patients from the committee of judges.	-
6. … gradually explained my health problem.	9
7. … went straight to the point.⁶ 6 item initially excluded by the researchers; it was not assessed by the patients from the committee of judges.
8. … told the truth about my health problem.	18
9. … took away my hope.⁷ 7 modified item (initial version: …gave me no hope).	1
10. … was careful with the words.	14
11. … used words that I could understand.	19
12. … showed that they cared for what I was feeling.	12
13. … talked about treatment options.	19
14. … explained what the next steps would be.	-
15. … demonstrated that they would not abandon me.	18
16. … looked into my eyes.	7
17. … was respectful to me.	11
18. … was kind to me.	9
19. … treated me as a human being.⁵ 5 item initially excluded by the experts; it was not assessed by the patients from the committee of judges.	-

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[1] luciana.burg@yahoo.com.br oliveirafilho.gr@gmail.com flaviadelcastanhel@gmail.com laradlm@gmail.com sgrosseman@gmail.com