The dialectical method as a way of delivering bad news

INTRODUCTION

Many studies have shown that delivering bad news is a great mental burden for a doctor [1–4]. Most medical staff members do not have sufficient skills in this field, or they develop their own techniques of delivering bad news [5–7]. Education at the university or professional level seems to be a relatively effective way of preventing the effects of wrong communication [8, 9]. A systemic approach to the problem has positive effects, such as the development of communication skills as well as reduction of stress and occupational burnout [3, 10, 11]. A proper delivery of information minimises fear in patients, increases their therapeutic engagement, and affects treatment results [12, 13]. However, research of this aspect of communication rarely notices that the way bad news is delivered and received is rooted in the sociocultural context. Depending on a culture’s axiology, the notification models assume a form that is appropriate for them. On the grounds of Anglo-Saxon bioethics, where a patient has a right to full knowledge of the diagnosis, prognosis, and possible treatment options, the open communication model is usually used [14]. European deontology requires that the patient’s situation is taken into account, and it gives the doctor the right not to give bad information in strictly defined circumstances, unless the patient persistently demands such information [4]. This process needs far-reaching individualisation [15] and, as a consequence, the doctor’s advanced competences when it comes to communicating bad news, which, as we know, is problematic [4]. Interestingly, some studies show that notification protocols that have not been adjusted culturally and have just been implemented structurally show little effectiveness. When the SPIKS protocol was used for giving bad news to European patients from Germany, it turned out that such conduct had no good results, which, conversely, can be observed in Anglo-Saxon countries [16].
In Asian models [17] as well as the ones used in Middle Eastern countries the doctor-patient relation has a much more paternalistic character [18]. Yet another take on the asymmetry of the roles may be seen in some Muslim culture references where it is not the patient him or herself but the entire family who collectively takes further decisions concerning treatment [19].
In the face of this data, the question if there is a relatively culturally stable method of delivering bad news seems important. It is particularly significant if we realise the growing rate of social migrations that take place as part of the globalisation processes. This obviously pertains to migrations of not only patients but also doctors. Being shaped and functioning in one socio-cultural system and using health services or practising one’s profession in another Kulturkreis can constitute a serious communication barrier.

DIALECTICAL MODEL OF DELIVERING BAD NEWS

It seems to us that a relatively universal way of delivering bad news can be proposed (Table 1). What is more, our proposal refers to the concept suggested by de Walden-Gałuszko based on the explanatory model [20]. Two dialectical traditions form the theoretical foundations for this method. Maieutics is the first one. It is one of the stages of Socratic dialectical method and it constitutes the formal framework of the method. The second one is narrative psychology, which provides the content component for the discussed way of delivering bad news. In this context, the essence of the maieutic method is that the doctor helps his or her patient discover the truth about their condition on their own. A patient who discovers the truth about his or her condition in the first person not only avoids its dogmatic exposure by his or her doctor but, above all, may assimilate the difficult facts in an easier way [21]. It is assumed in this method that the acceptance of bad news is a process that takes time and has its particular emotional dynamics. De Walden-Gałuszko (2011) emphasises the fact that the difficult truth about the disease is like a medication that has to be administered in appropriate dosages and adjusted to a patient’s personal needs and sensitivity [20].
In the dialectical model of giving bad news, just as in the other notification models (SPIKES, BREAKS, PEWTER, COMFORT, etc.), three basic spheres may be indicated: preparation (when), delivering (what), and arrangement (how) [22]. What makes it different from the other model ways of delivering bad news is the individuated way of making conversation. The principles of narrative therapy are its foundation [23]. This communication method is, above all, about creating semantic space for a patient who, with use of the category of his or her own language, names and, at the same time, interprets the condition he or she is in. The job of the doctor is to direct the patient towards the necessary situation of discovering the truth concerning his or her condition but also, and above all, to adopt the patient’s categories which, from this moment on, will be used in further communication. The doctor does not impose ultimate and objective truth, which often happens and is manifested in the use of medical language’s technical categories. If we construct the world with language [24], then the doctor’s job is to help find a way into the world of the patient’s disease and then to explore it together with the use of the patient’s language’s categories. The relationship based on partnership that is rooted in empathic and individuated narrative assumes a gentler assimilation of bad news as well as tension and stress reduction for both doctor and patient. Rita Charon, the author of the term narrative medicine (or illness narrative), emphasises the significance of patients’ accounts or stories for the entire therapeutic process. She points out that medicine even requires narrative skills, which are the basis of effective medical practice [25]. The patients’ narratives are the elements that allow us to sympathise with them in their illnesses and to immerse ourselves in their experiences, which seems particularly important in the present Evidence-Based Medicine era. Here, Charon even offered the term Narrative Evidence-Based Medicine, which showed how the two fields complemented each other [26].
It needs to be emphasised that the discussed method has some formal limitations. We must assume that communication skills on a rather advanced level are the condition for its proper use. They include using the paraphrasing technique, a well-developed active listening skill, the competence of attention to words, gestures, or emotions, or the use of solution-focused therapeutic narrative (TSF) elements [27], thanks to which the patient’s consciousness may be taken up by positive contents even in the face of the most difficult news. Although we propose the dialectical method as the resolution that can meet the requirements of globalisation and intercultural migration, we are aware that it still demands a doctor to have high cultural competences. Doctors and health workers intend to provide adequate care and proper attention for ethnic minorities; however, they confront many difficulties, among others fear and uncertainty, as well as linguistic barriers and presumptions about cultural issues [28, 29]. The presented method also requires particular moral sensitivity, which gains a special meaning in a difficult moment like the one when a doctor is delivering bad news and when the patient’s good should constitute the highest value to the doctor [30]. It is worth mentioning that still there is a risk of a refusal to engage with such a process. The implications of such a possibility may be the aforementioned challenges, but also the professionals’ lack of self-confidence in terms of communication skills. Hence, it is so important to work on the progress in this area and improve his or her competences.

CONCLUSIONS

The maieutic method consists of gradually directing the patient’s awareness to the physical condition he or she is in. Its assumption is that the patient reaching a relatively mature awareness of his or her condition is a time-consuming process and its dynamics is individual. This method of delivering bad news consists of the truth being gradually released in the patient’s awareness by the doctor. For a patient who arrives at the truth this way, it is less surprising and less hurtful. The doctor, on the other hand, can approach the patient in a personalised way and show him or her some real support [31]. What is more, this technique combines the two doctor-patient relation models that are most frequently favoured by patients in the situation of bad news being delivered: the model based on partnership and the one based on dialogue and empathy [32, 33].

The authors declare no conflict of interest.