Abstract

The scope of this study was to understand the elements involved in the communication of bad news in the context of medical practice in a Brazilian emergency hospital. It consisted of qualitative research, based on medical anthropology. Data collection was gathered over nine months of participant observation and interviews with 43 physicians. The emic analysis was based on the model of signs, meanings and actions. Two categories emerged from the analysis of the data: bottlenecks in communicating bad news relating to interaction one’s own emotions and those of the family member; insufficient academic preparation in addressing death and the impossibility of a cure, with repercussions on professional practice. The difficulties in communicating bad news in the emergency hospital persist and the omission in training has repercussions on professional practice, and the professionals continue to feel ill-prepared. The difficulties are not only technical, didactic or theoretical. Communicating bad news is also permeated by tacit, experiential, relational, emotional, socio-cultural, human, ethical and reflective knowledge.

Key words:
Communication; Emergency hospital service; Medical anthropology

Introduction

Over the course of the twentieth century, the profile of medical practice became increasingly biomedical, specialized, technical, and fragmented, focusing on the disease to the detriment of the doctor-patient relationship and the uniqueness of each patient from social, psychological, and communicational perspectives. However, the perception that medical training requires a model of biopsychosocial, ethical, sensitive, and reflective action¹1 Alves ANO, Moreira SNT, Azevedo GD, Rocha VM, Vilar MJ. A humanização e a formação médica na perspectiva dos estudantes de medicina da UFRN - Natal - RN - Brasil. Rev Bras Educ Med 2009; 33(4):555-561. that considers the determinants and conditions of the health-disease process proposed in the field of public health, which includes communication skills, is recurrent. Communication is assumed to be a dynamic, open, and interactive process²2 Vogel KP, Silva JHG, Ferreira LC, Machado LC. Comunicação de más notícias: ferramenta essencial na graduação médica. Rev Bras Educ Med 2019; 45(Supl. 1):314-321., intrinsic to the human being³3 Isquierdo APR, Miranda GFF, Quint FC, Pereira AL, Guirro UBP. Comunicação de más notícias com pacientes padronizados: uma estratégia de ensino para estudantes de medicina. Rev Bras Educ Med 2021; 45(2):e091.^,55 Diniz SS, Queiroz AAF, Rollemerg CV, Pimentel D. Communicação de más notícias: percepção de médicos e pacientes. Rev Soc Bras Clin Med 2018; 16(3):146-151.. This crucial skill in medical practice³3 Isquierdo APR, Miranda GFF, Quint FC, Pereira AL, Guirro UBP. Comunicação de más notícias com pacientes padronizados: uma estratégia de ensino para estudantes de medicina. Rev Bras Educ Med 2021; 45(2):e091.^,44 Calsavara VJ, Scorsolini-Comum F, Corsi CAC. A comunicação de más notícias em saúde: aproximações com a abordagem centrada na pessoa. Rev Abordagem Gestalt 2019; 25(1):92-102. integrates treatment⁴4 Calsavara VJ, Scorsolini-Comum F, Corsi CAC. A comunicação de más notícias em saúde: aproximações com a abordagem centrada na pessoa. Rev Abordagem Gestalt 2019; 25(1):92-102. since it is inseparable from the experiences, meanings, and meaningful productions⁶6 Souza GA, Giacomin KC, Aredes JS, Firmo JOA. Comunicação da morte: modos de pensar e agir de médicos em um hospital de emergência. Physis 2018; 28(3):e280324.. Therefore, it can generate unpleasant sensations and be a challenging fact for those who receive and for those who communicate bad news²2 Vogel KP, Silva JHG, Ferreira LC, Machado LC. Comunicação de más notícias: ferramenta essencial na graduação médica. Rev Bras Educ Med 2019; 45(Supl. 1):314-321.

3 Isquierdo APR, Miranda GFF, Quint FC, Pereira AL, Guirro UBP. Comunicação de más notícias com pacientes padronizados: uma estratégia de ensino para estudantes de medicina. Rev Bras Educ Med 2021; 45(2):e091.

4 Calsavara VJ, Scorsolini-Comum F, Corsi CAC. A comunicação de más notícias em saúde: aproximações com a abordagem centrada na pessoa. Rev Abordagem Gestalt 2019; 25(1):92-102.^-55 Diniz SS, Queiroz AAF, Rollemerg CV, Pimentel D. Communicação de más notícias: percepção de médicos e pacientes. Rev Soc Bras Clin Med 2018; 16(3):146-151., as it involves psychosocial, emotional, and spiritual aspects of all subjects involved⁴4 Calsavara VJ, Scorsolini-Comum F, Corsi CAC. A comunicação de más notícias em saúde: aproximações com a abordagem centrada na pessoa. Rev Abordagem Gestalt 2019; 25(1):92-102.^,77 Ribeiro KG, Batista MH, Souza DFO, Florêncio CMGD, Jorge WH, Raquel CP. Comunicação de más notícias na educação médica e confluência com o contexto da pandemia de covid-19. Saude Soc 2021; 30(4):e201058..

Bad news is understood as information that negatively influences the patient’s future³3 Isquierdo APR, Miranda GFF, Quint FC, Pereira AL, Guirro UBP. Comunicação de más notícias com pacientes padronizados: uma estratégia de ensino para estudantes de medicina. Rev Bras Educ Med 2021; 45(2):e091.^,55 Diniz SS, Queiroz AAF, Rollemerg CV, Pimentel D. Communicação de más notícias: percepção de médicos e pacientes. Rev Soc Bras Clin Med 2018; 16(3):146-151., related to the diagnosis of serious diseases, interference with quality of life, poor prognosis, or death²2 Vogel KP, Silva JHG, Ferreira LC, Machado LC. Comunicação de más notícias: ferramenta essencial na graduação médica. Rev Bras Educ Med 2019; 45(Supl. 1):314-321.

3 Isquierdo APR, Miranda GFF, Quint FC, Pereira AL, Guirro UBP. Comunicação de más notícias com pacientes padronizados: uma estratégia de ensino para estudantes de medicina. Rev Bras Educ Med 2021; 45(2):e091.^-44 Calsavara VJ, Scorsolini-Comum F, Corsi CAC. A comunicação de más notícias em saúde: aproximações com a abordagem centrada na pessoa. Rev Abordagem Gestalt 2019; 25(1):92-102.^,77 Ribeiro KG, Batista MH, Souza DFO, Florêncio CMGD, Jorge WH, Raquel CP. Comunicação de más notícias na educação médica e confluência com o contexto da pandemia de covid-19. Saude Soc 2021; 30(4):e201058.. Usually, it is up to the physicians to communicate them to patients³3 Isquierdo APR, Miranda GFF, Quint FC, Pereira AL, Guirro UBP. Comunicação de más notícias com pacientes padronizados: uma estratégia de ensino para estudantes de medicina. Rev Bras Educ Med 2021; 45(2):e091.. Since 1980, practical and didactic protocols have been established to train professionals to communicate bad news, with SPIKES, CLASS, and PACIENTE³3 Isquierdo APR, Miranda GFF, Quint FC, Pereira AL, Guirro UBP. Comunicação de más notícias com pacientes padronizados: uma estratégia de ensino para estudantes de medicina. Rev Bras Educ Med 2021; 45(2):e091.^,44 Calsavara VJ, Scorsolini-Comum F, Corsi CAC. A comunicação de más notícias em saúde: aproximações com a abordagem centrada na pessoa. Rev Abordagem Gestalt 2019; 25(1):92-102.^,77 Ribeiro KG, Batista MH, Souza DFO, Florêncio CMGD, Jorge WH, Raquel CP. Comunicação de más notícias na educação médica e confluência com o contexto da pandemia de covid-19. Saude Soc 2021; 30(4):e201058. being the most frequent in the literature in this regard. However, this topic continues to be recognized as complex, triggering suffering, stress, and anxiety in medical professionals³3 Isquierdo APR, Miranda GFF, Quint FC, Pereira AL, Guirro UBP. Comunicação de más notícias com pacientes padronizados: uma estratégia de ensino para estudantes de medicina. Rev Bras Educ Med 2021; 45(2):e091.^,66 Souza GA, Giacomin KC, Aredes JS, Firmo JOA. Comunicação da morte: modos de pensar e agir de médicos em um hospital de emergência. Physis 2018; 28(3):e280324.^,77 Ribeiro KG, Batista MH, Souza DFO, Florêncio CMGD, Jorge WH, Raquel CP. Comunicação de más notícias na educação médica e confluência com o contexto da pandemia de covid-19. Saude Soc 2021; 30(4):e201058.. Moreover, addressing the communication of bad news is still precarious in the medical curriculum²2 Vogel KP, Silva JHG, Ferreira LC, Machado LC. Comunicação de más notícias: ferramenta essencial na graduação médica. Rev Bras Educ Med 2019; 45(Supl. 1):314-321.^,33 Isquierdo APR, Miranda GFF, Quint FC, Pereira AL, Guirro UBP. Comunicação de más notícias com pacientes padronizados: uma estratégia de ensino para estudantes de medicina. Rev Bras Educ Med 2021; 45(2):e091..

Studies have shown that communicating bad news is not limited to the technique³3 Isquierdo APR, Miranda GFF, Quint FC, Pereira AL, Guirro UBP. Comunicação de más notícias com pacientes padronizados: uma estratégia de ensino para estudantes de medicina. Rev Bras Educ Med 2021; 45(2):e091.^,44 Calsavara VJ, Scorsolini-Comum F, Corsi CAC. A comunicação de más notícias em saúde: aproximações com a abordagem centrada na pessoa. Rev Abordagem Gestalt 2019; 25(1):92-102.^,77 Ribeiro KG, Batista MH, Souza DFO, Florêncio CMGD, Jorge WH, Raquel CP. Comunicação de más notícias na educação médica e confluência com o contexto da pandemia de covid-19. Saude Soc 2021; 30(4):e201058., as it involves welcoming and empathy³3 Isquierdo APR, Miranda GFF, Quint FC, Pereira AL, Guirro UBP. Comunicação de más notícias com pacientes padronizados: uma estratégia de ensino para estudantes de medicina. Rev Bras Educ Med 2021; 45(2):e091. and demands an interpersonal relationship⁴4 Calsavara VJ, Scorsolini-Comum F, Corsi CAC. A comunicação de más notícias em saúde: aproximações com a abordagem centrada na pessoa. Rev Abordagem Gestalt 2019; 25(1):92-102.. Thus, many physicians do not feel prepared to perform this task³3 Isquierdo APR, Miranda GFF, Quint FC, Pereira AL, Guirro UBP. Comunicação de más notícias com pacientes padronizados: uma estratégia de ensino para estudantes de medicina. Rev Bras Educ Med 2021; 45(2):e091.^,55 Diniz SS, Queiroz AAF, Rollemerg CV, Pimentel D. Communicação de más notícias: percepção de médicos e pacientes. Rev Soc Bras Clin Med 2018; 16(3):146-151., either because they fear not being safe when transmitting information and expressing emotions or because they feel guilty for causing pain or needing to deal with the discomfort of the patients and their families⁴4 Calsavara VJ, Scorsolini-Comum F, Corsi CAC. A comunicação de más notícias em saúde: aproximações com a abordagem centrada na pessoa. Rev Abordagem Gestalt 2019; 25(1):92-102.. Research shows that 51% of professionals feel affected by communicating bad news²2 Vogel KP, Silva JHG, Ferreira LC, Machado LC. Comunicação de más notícias: ferramenta essencial na graduação médica. Rev Bras Educ Med 2019; 45(Supl. 1):314-321..

Therefore, communication is defined as a relational, dynamic, complex, and multidimensional social process whose practice is contextualized in the historical, political, economic, geographical, institutional, and intersubjective spheres⁸8 Araújo IS, Cardoso JM. Comunicação e saúde. Rio de Janeiro: Fiocruz; 2007.. However, publications on the ways this communication occurs have focused on how physicians should act-in terms of procedures, models, protocols, guidelines, and recommendations⁹9 Olsen JC, Buenefe ML, Falco WD. Death in Emergency Departament. Ann Emerg Med 1998; 31(6):758-765.

10 Shoenberger JM, Yeghiazarian S, Rios C, Henderson SO. Death notification in the emergency departament: survivors and physicians. West J Emerg Med 2013; 14(2):181-185.^-1111 Lamba S, Nagurka R, Offin M, Scott SR. Structured communication: teaching delivery of difficult news with simulated resuscitations in an Emergency Medicine Clerkship. West J Emerg Med 2015; 16(2):344-352.-but do not include the emergency care scenario. There is a lack of studies on physicians’ perception of communicating bad news in emergency hospitals⁹9 Olsen JC, Buenefe ML, Falco WD. Death in Emergency Departament. Ann Emerg Med 1998; 31(6):758-765.^,1212 Aredes JS, Giacomin. KC, Firmo JOA. O médico diante da morte no pronto socorro. Rev Saude Publica 2018; 52:42. and the experience of these professionals in communicating it. Moreover, research⁶6 Souza GA, Giacomin KC, Aredes JS, Firmo JOA. Comunicação da morte: modos de pensar e agir de médicos em um hospital de emergência. Physis 2018; 28(3):e280324. shows that the aspects involved in this communication have been poorly documented. Therefore, the present study aimed to understand the elements that cross the communication of bad news in medical practice in a Brazilian emergency hospital.

Methodology

This is a qualitative research, anchored in the methodological, theoretical framework of hermeneutic anthropology¹³13 Geertz C. A interpretação das culturas. Rio de Janeiro: LTC; 2008. within medical anthropology¹⁴14 Kleinman A, Clifford R. Stigma: a social, cultural and moral process. J Epidemiol Community Health 2009; 63(6):418-419.^,1515 Uchôa E, Vidal JM. Antropologia médica: elementos conceituais e metodológicos para uma abordagem da saúde e da doença. Cad Saude Publica 1994; 10(4):497504. - an approach that considers the social dimensions and the intersubjective experience in the health-disease phenomenon and distinguishes two inseparable aspects: disease - biological process and medical diagnosis - and illness - the psychosocial human experience of the disease¹⁵15 Uchôa E, Vidal JM. Antropologia médica: elementos conceituais e metodológicos para uma abordagem da saúde e da doença. Cad Saude Publica 1994; 10(4):497504..

This article is part of a larger the ethnographic study entitled: ‘Vidas em risco: uma abordagem antropológica sobre as representações da morte entre médicos que trabalham em setores de urgência’ (Lives at Risk: An Anthropological Approach to Representations of Death Among Doctors Working in Emergency Departments - free translation for Brazilian Portguese). It is in accordance with Resolutions No. 466/2012 and No. 510/2016 of the National Health Council (Conselho Nacional de Saúde) and was approved by the Ethics Committees of the Federal University of Minas Gerais (Universidade Federal de Minas Gerais) and the Hospital Foundation of Minas Gerais (Fundação Hospitalar de Minas Gerais).

Data were collected from a large public emergency hospital in Belo Horizonte, Minas Gerais, Brazil. The diversity of medical specialties and the heterogeneity of profiles for critical patients in varied circumstances (acute cases, trauma, accidents, and others) outlined the choice of the institution. The collection of ethnography data lasted nine months, from December 2012 to August 2013, totaling 864 hours of fieldwork for immersion in the sociocultural universe of the institution’s physicians in 12-hour day and 12-hour night shifts, including weekends, holidays, and on specific occasions such as popular demonstrations, the end of a football championship, among others. Participant observation was performed for 24 hours to investigate different contexts.

Data collection was mediated by participant observation and semi-structured guided interviews with volunteer physicians, guests on their shifts and workplace. The main axes included in the interview script were: a) the choice of profession and workplace; b) the dynamics of the unit and challenges in the work process; c) definition of death, preparation, representations, feelings, interests, and relationships in the face of death; d) if it is challenging to give news about sick patients; e) how the profession prepares them to face death; f) if it is challenging to deal with patients who are not curative; g) how they deal with death in the unit they work. Snowball sampling¹⁶16 Patton MQ. Qualitative research and evaluation methods. London: Sage Publications; 2002. was used to selecting participants, with one interviewee indicating another. Observations were registered in a field diary, and interviews were recorded and transcribed. Data collection was terminated when the quality, quantity, and intensity of the data collected allowed us to evidence the extent of the investigated phenomenon¹⁷17 Minayo MCS. Amostragem e saturação em pesquisa qualitativa: consensos e controvérsias. Rev Pesq Qual 2017; 5(7):1-12..

Data analysis was emic - aimed at understanding the communication of death from the physician’s point of view - and guided by the ‘signs, meanings, and actions’ model¹⁴14 Kleinman A, Clifford R. Stigma: a social, cultural and moral process. J Epidemiol Community Health 2009; 63(6):418-419.^,1818 Corin E, Uchôa E, Bibeau G, Kouma-Re B. Articulation et variations des systèmes de signes, de sens et d'actions. Psychopathol Afr 1992; 24:183-204.^,1919 Corin E, Uchôa E, Bibeau G, Harnois G. Les Attitudes dans le Champ de la Santé Mentale. Repères Théoriques et Méthodologiques pour une Étude Ethographique et Comparative. Montréal: Centre de Recherche de I'Hopital Douglas/Centre Collaborateur OMS; 1989.. In this model, practice is the object of study to trace back to the semantic level; it provides a privileged access route to cultural systems. The levels of analysis between each of the signs, meanings, and actions are identified, as well as the relationship between them and their nodal and connection points¹⁸18 Corin E, Uchôa E, Bibeau G, Kouma-Re B. Articulation et variations des systèmes de signes, de sens et d'actions. Psychopathol Afr 1992; 24:183-204.^,1919 Corin E, Uchôa E, Bibeau G, Harnois G. Les Attitudes dans le Champ de la Santé Mentale. Repères Théoriques et Méthodologiques pour une Étude Ethographique et Comparative. Montréal: Centre de Recherche de I'Hopital Douglas/Centre Collaborateur OMS; 1989..

To ensure anonymity, the interviewees were labeled as F for female and M for male physicians, followed by the interview order, medical specialty, and age.

Results

The study population consisted of 43subjects - 25 male and 18 female physicians, aged between 28 and 69 years - who work in specific units of the emergency hospital for severe patients at risk of death in different contexts, including 23 physicians from the entrance door - operating room, recovery rooms, multiple traumas, and clinical emergencies; 16 physicians from intensive care units - for adults, children, severe burns and extension care services; and four physicians from the progressive care unit, aimed at patients with chronic sequelae. Table 1 shows the characterization of the interviewees.

Two categories emerged from the data analysis: ‘Insertion in medical practice: the challenges of the professional in the communication process’ and ‘Main reasons given for the challenges of medical practice: interface with professional education and training.’

‘Insertion in medical practice: the challenges of the professional in the communication process’

This category presents the main bottlenecks presented by the interlocutors related to intersubjective interaction in the professional practice of communicating bad news:

I felt challenged in almost everything, but more in practice. The theory is something we study, but the practice is totally different. When you are in practice, it involves your emotions, the emotions of those you are dealing with, all together with the patient’s emotions, and this is something we don’t learn. It is life, the day-to-day, that teaches this, such as dealing with your suffering, your sadness, in relation to events, your anxiety (I18, neurosurgery, M, 34 years old).

I missed the approach with the families, the contact with the emergency and urgent care patients. Although we have clinical practice follow-ups in our undergraduate studies, by delivering information to the family and contacting the patient, we are not prepared for these aspects. This is something we learn in our own practice after graduating. Because it’s one thing to be present when your preceptor or professor is delivering the news; in those cases, you don’t feel responsible for the information. Many times, we learn by observing, but real learning happens when you apply it [communicating bad news] and when you are directly facing the problem. So, everything that we lack practice in, we end up feeling unprepared for (I21, internal medicine, M, 34 years old).

The relationship with family members is sometimes tricky, as the family member tends to deny [the patient’s situation]: they rationalize and deny it simultaneously. Sometimes, during the visit, for example, there is a patient in the SAV [intensive care bed for brain death protocol], and you explain that the patient will not walk, will not talk, that only a miracle will allow them to recover. You spend about 20 minutes talking about the severity of the patient’s condition. I just don’t take away their hope. Some people say, ‘Look, my condolences, the patient is dead, we are just completing the tests.’ Not me; I like to talk, and at the end of the conversation, after explaining a thousand things, the person asks, ‘So, doctor, in a few days, will the patient be going home?’ It seems like the relative didn’t hear anything you said; they completely deny the patient’s condition’ (I26, internal medicine, M, 32 years old).

In the reports, it is possible to identify the communication challenges faced by the interlocutors, which are transversal to professional practice, especially when dealing with the emotions of the actors inserted in the dynamics of care (patient, companion, and the professional themselves), the direct relationship with the family member, particularly concerning the transmission of news, including the communication of clinical conditions with a very poor prognosis and cases resulting in death. Communicating someone’s death means that the professional ‘lost the battle’ with it (Field Diary), and it is considered the most difficult activity of their professional practice, leading to a feeling of impotence and an inclination to avoid this moment. The challenges arise from cultural, institutional, and personal issues, such as having to deal with the family’s reaction and feeling like failures. After doing so, ‘most withdraw, disappear from the area where they work for a while, and only return later’ (Field Diary).

A very common phrase used when delivering news, whether about the clinical condition or death, is: ‘We did everything possible.’ This phrase is used especially when there is no favorable prognosis and the patient is either in critical condition or has died. Physicians use it as a way to justify to the family that they utilized all available resources - both technical and human - to try to reverse the situation, but it was not enough to prevent the death.

Sometimes, we face difficulties because we have patients who are not candidates for resuscitation. A patient with such a large (intracerebral) hematoma that draining it is pointless. Cases where the patient ‘if they stop [living], they stop,’ that’s difficult for me to accept. I have resuscitated severely burned patients who were not indicated for it, because you resuscitate them, and the patient stops again later and doesn’t come back. It’s hard for me to see a patient in cardiac arrest and not be able to resuscitate them because they have no prognosis (I5, anesthesiology, F, 32 years old).

In fact, the phrase ‘We did everything possible’ could be extended to ‘We did everything possible and impossible’ because, in many cases, doctors, even knowing the irreversibility of the condition, insist on the procedures. Some arguments for this instance were presented as follows:

Often, the family puts a lot of pressure on us as the ‘savior,’ as if we had that power (I4, anesthesiology, F, 33 years old).

They still hold this romanticized view and think it’s a beautiful thing... for example, when the doctor resuscitates a person, they think the doctor can interrupt this course. As if it were something too gratifying, too sublime, too unique, and it is not [...] Because we work with both situations, there are patients with whom I can intervene concretely, and you determine their favorable prognosis. But it is also common to have patients where you determine the end... that they are going to die, they pass away. If I want the bonus, the credit for having made a positive intervention, I should also accept the burden of a fatal intervention, right? Actually, there is no difference between the two for me, because if I don’t allow myself to see it this way, with a certain level of impersonality... (I6, anesthesiology, M, 33 years old).

The patient that we know is going to die is a little more challenging for us because our training is to save them [...]. It is much more frustrating to deal with a person who has a poor prognosis than a patient who is able to survive (I10, general surgery, M, 39 years old).

It’s very difficult for me when I am forced to do things with a patient that I would not like to do because sometimes the family does not demonstrate an understanding and ends up forcing the medical team to take certain actions. Sometimes, in dealing with the family, I realize that a colleague did not know how to approach an aspect, and this leads to the decision of an invasive procedure that I do not consider beneficial for the patient. Then I get upset having to carry it out (I27, internal medicine, M, 34 years old).

All these factors mentioned have repercussions on the challenge of communicating bad news:

The patient’s family is at the mercy of the doctor. They place supreme power in us (I12, general surgery, M, 64 years old).

From my point of view, it is not ideal, not even close to ideal. Maybe a doctor in an emergency room situation is sometimes very focused on the urgency, on the critical patient, and sometimes gives less importance to delivering news to the family because they know they are trying to save a life. If we stop to think, we see that the person accompanying the patient is very lost, so often, you have to stop, think, and realize that your relationship with the patient’s family has to be better. During visiting hours, you are in a room with critically ill patients; sometimes, you are giving news to one family, and another patient is already drawing your attention away. So, the person who is always in this dynamic, I think, fails a little in this relationship (I15, neurosurgery, M, 40 years old).

It is a very difficult relationship because those who come to the emergency room are not in an expected situation; the phone call comes to the person’s house saying: oh, something happened to so-and-so. So, the family members are more anxious, the patients are younger, and they are healthy patients. So, it is much more challenging to approach a family, talk about the severity of the case, and tell them that the patient has passed away (I4, anesthesiology, F, 33 years old).

What I find very difficult is delivering the news of a death. I never get used to it; every time a patient dies in our service, I feel distressed about having to deliver the news. So, when the patient dies, we call the family, and they tell me: oh, the patient’s family is there waiting for the news. This part is the saddest; it is the worst moment of the medical shift, of medical practice, of our profession. Delivering this news always makes me very upset. When the patient is already very critical, and you have to give the news, the family kind of expects it, but sometimes it happens that the family comes to see the patient, the patient is doing well, the family leaves, and in the middle of the night they get a call to come to the hospital, and when they arrive, you have to tell them that the patient died. This is very difficult, very sad. Death: I introduce myself and say that the patient was very critical, we tried everything, but we couldn’t, or the patient was even improving, but there was a complication, the patient went into shock, etc. I use ‘passed away,’ ‘died,’ ‘did not survive.’ Sometimes, you also deliver the news, and the family member faints, screams; I try to comfort the patient (I35, internal medicine, M, 69 years old).

It is worth mentioning that no gender differences were identified; both male and female doctors demonstrated sensitivity and affection in relation to the theme contemplated in the study. In the same direction, the time in the profession (little or much) and the different activity units in the researched universe did not influence the challenge of communicating bad news.

‘Main reasons given for the challenges of medical practice: interface with professional education and training’

This analytical category presents the main reasons pointed out by the interlocutors regarding the challenges presented in the previous category (Chart 1).

We noted that medical training is transversal to the main reasons pointed out for challenges with professional practice.

Lack of academic preparation in addressing issues related to the impossibility of cure and death - training is more linked and restricted to the biomedical model: death is an outcome to be avoided inordinately, and academic preparation is focused on the maintenance of biological life. The signs’ keep the patient alive,’ ‘prepared to prolong life,’ ‘prepared to diagnose and treat,’ ‘we see death during medical school as a great villain,’ ‘prepared to learn to be the superhero, the savior, the winner of death,’ ‘doctors in training are prepared to diagnose and treat’ illustrate this perspective.

Lack of academic preparation - interpersonal relationship (beyond the patient). In this subcategory, the interviewees point out the lack of preparation during medical school regarding interpersonal contact, especially with family members.

Lack of academic preparation pertinent to contact with professional practice (communication of bad news, among others). Here, the interlocutors indicate the need for practical contact with issues inherent to professional practice. They highlight the lack of preparation for communication, the approach with family members, the doctor-patient relationship, and the application of readings in the fields of anthropology and psychology.

When asked about the death(s) that most marked them throughout their academic and professional trajectory, a specific period of professional training was recalled in most reports:

I was a student, still in clinical internship. There was a patient from the countryside with an undiagnosed disease. He had an enlarged spleen and liver, fever, weight loss, and symptoms we couldn’t identify. We ended up admitting him for investigation, and we couldn’t discover anything. So, this patient... I was in the internship for three months and spent about a month and a half with this patient. Then he had to undergo surgery; he went into surgery [feeling] fine but ended up dying on the operating table. This was my first experience with death, and I was devastated because I start thinking: Should he have gone for surgery? The doctors recommended it; I was just a mere student. But then you start to think: What if he were my patient? If I were the responsible clinician, would I have recommended this? You start to dwell on it, wondering where there was a failure, trying to find some sort of fault within yourself as a doctor (I42, internal medicine, F, 28 years old).

I remember many deaths, but perhaps what shaped me the most... Interestingly, I was in the fourth year of medical school, [...] there was an older woman with heart failure. With my student’s emotions, I felt I knew more than the doctor caring for her. She died due to insanity [...]. This marked me because the doctor who was caring for her didn’t even care. He didn’t take care of the patient; I noticed this patient in the ward precisely because of that, because no one was paying attention; she was neglected, and I felt very much affected. I think that shaped me, and I saw that we shouldn’t let this happen. Seeing a person die who is being cared for is different. This changed me so much that it has been almost 40 years, and I haven’t forgotten (I29, cardiology, M, 63 years old).

I was a student, and I remember an older woman who had heart failure and needed a heart transplant, which is the final treatment for those with this type of disease. And I was very young and saw the difficulty of dealing with our limitations, the impotence of seeing the person getting worse every day and not being able to do anything (I40, internal medicine, M, 29 years old).

Discussion

The interviewed doctors mention the fear of ‘losing’ the patient, the investment in care, the complex hospital context, the social situation of the family members, and the suffering of those left behind, as well as the gaps in academic training regarding the learning of skills as essential factors in addressing the patient’s death and interacting with the family members.

Most recognize flaws in medical training, especially when it comes to the experience of communicating bad news. During medical school, they report having had specific subjects of anthropology and medical psychology at the beginning of the program, when they had not yet started the clinic practice, but at no time is thanatology discussed - which highlights the lack of academic preparation to deal with issues related to patients with severe conditions and with death. Transversal to this is the commitment to two crucial skills for the professional: communication and decision-making. The ability to communicate in the territory of investigation - urgency and emergency hospital - is manifested in several types of news applicable to the professional in this context: announcing the death, informing about the severity of the case and possible chronic sequelae, and communicating to the patient and their family members that there are no longer therapeutic possibilities for a cure. Decision-making, in turn, is intertwined with care outcome in two main points: guilt and, simultaneously, the professional’s demand to maintain the patient’s biological life.

The data indicate that communicating bad news is frequent and requires a respectful posture of individual and group differences, and it should be directed to each patient and family carefully⁷7 Ribeiro KG, Batista MH, Souza DFO, Florêncio CMGD, Jorge WH, Raquel CP. Comunicação de más notícias na educação médica e confluência com o contexto da pandemia de covid-19. Saude Soc 2021; 30(4):e201058.. In one study, 96% of physicians reported communicating bad news, but 62.2% reported not having training to develop this competence, and only 6.1% rated having good skills for this communication⁵5 Diniz SS, Queiroz AAF, Rollemerg CV, Pimentel D. Communicação de más notícias: percepção de médicos e pacientes. Rev Soc Bras Clin Med 2018; 16(3):146-151.. Diniz et al.⁵5 Diniz SS, Queiroz AAF, Rollemerg CV, Pimentel D. Communicação de más notícias: percepção de médicos e pacientes. Rev Soc Bras Clin Med 2018; 16(3):146-151. showed that 92.5% of physicians face challenges in addressing death with patients and family members, and often, the patient receives bad news without having a companion. Many professionals learn by observing colleagues or by trial and error⁵5 Diniz SS, Queiroz AAF, Rollemerg CV, Pimentel D. Communicação de más notícias: percepção de médicos e pacientes. Rev Soc Bras Clin Med 2018; 16(3):146-151.. Another study indicated that 52.8% of professionals reported challenges in communicating bad news and a lack of academic training on the subject, and 74% were unaware of some method of communication²2 Vogel KP, Silva JHG, Ferreira LC, Machado LC. Comunicação de más notícias: ferramenta essencial na graduação médica. Rev Bras Educ Med 2019; 45(Supl. 1):314-321.. In addition, the authors found variations regarding age, gender, culture, education, family context, and the disease process that require flexibility from those who communicate the news. Moreover, despite the transformations in pedagogical projects, 38% report that talking about the end of treatment is difficult, and 28% report challenges in communicating death to family members⁷7 Ribeiro KG, Batista MH, Souza DFO, Florêncio CMGD, Jorge WH, Raquel CP. Comunicação de más notícias na educação médica e confluência com o contexto da pandemia de covid-19. Saude Soc 2021; 30(4):e201058.. Physicians reflect on their work and need to deal with the complexity of their feelings⁴4 Calsavara VJ, Scorsolini-Comum F, Corsi CAC. A comunicação de más notícias em saúde: aproximações com a abordagem centrada na pessoa. Rev Abordagem Gestalt 2019; 25(1):92-102., including professionals’ anxiety²2 Vogel KP, Silva JHG, Ferreira LC, Machado LC. Comunicação de más notícias: ferramenta essencial na graduação médica. Rev Bras Educ Med 2019; 45(Supl. 1):314-321..

In the present study, the repercussions on the recipients of the bad news also affect the professionals, as there is concern about the emotional and physical reactions and how to manage the situation. In this regard, offering medical training that includes community engagement, where students are integrated into health services, internships, and residency programs to experience comprehensive care, is crucial. Additionally, students should be placed in environments that allow for emotional expression, fostering a humanized education that develops biopsychosocial and spiritual competencies and skills, considering the sociocultural and epidemiological context¹1 Alves ANO, Moreira SNT, Azevedo GD, Rocha VM, Vilar MJ. A humanização e a formação médica na perspectiva dos estudantes de medicina da UFRN - Natal - RN - Brasil. Rev Bras Educ Med 2009; 33(4):555-561..

Medical practice, anchored to the biomedical model, attributes to the professional the function of fighting tirelessly for the maintenance of life, even though the impossibility of cure and death itself are recurrent events, especially in the hospital context of urgency and emergency⁸8 Araújo IS, Cardoso JM. Comunicação e saúde. Rio de Janeiro: Fiocruz; 2007.. Such counterpoints make doctors deal daily with situations they were not - and, consequently, are not - prepared to deal with. In many cases, these professionals are anchored to evasive mechanisms to conceal the expression of their emotions throughout professional practice⁶6 Souza GA, Giacomin KC, Aredes JS, Firmo JOA. Comunicação da morte: modos de pensar e agir de médicos em um hospital de emergência. Physis 2018; 28(3):e280324..

Throughout the medicine program, the students undergo several experiences that will contribute to shaping their professional profile. One of them is a mandatory curricular internship in service, representing a singular medical training period. Students face more challenging situations because clinical activities take center stage at this program stage, accounting for 80% to 90% of their study hours²⁰20 Maia MV, Struchiner M. Meaningful Learning and the Electronic Reflective Portfolio in Medical Education. Rev Bras Educ Med 2016; 40(4):720-730.. Although students lack autonomy in practice and are not directly responsible for care, this stage enhances the development of their responsibilities. There is a greater proximity to challenging experiences inherent to the practice of medicine, especially through daily contact with the patient, their families, and the boundaries of life and death. The students will encounter complex experiences, such as diagnosing incurable or potentially lethal conditions, facing patients deaths, communicating bad news, making decisions about therapeutic approaches, and dealing with pressures from multiple actors involved in the care dynamics (professionals, patients, families), as well as from managers and healthcare systems²⁰20 Maia MV, Struchiner M. Meaningful Learning and the Electronic Reflective Portfolio in Medical Education. Rev Bras Educ Med 2016; 40(4):720-730.. The literature indicates that, throughout the internship, professionals improve in the process of communicating bad news, but still face difficulties in developing relational aspects and dealing with emotions⁷7 Ribeiro KG, Batista MH, Souza DFO, Florêncio CMGD, Jorge WH, Raquel CP. Comunicação de más notícias na educação médica e confluência com o contexto da pandemia de covid-19. Saude Soc 2021; 30(4):e201058.. In this learning scenario, the students can understand that they, as future health professionals, should not - and cannot - suffer either.

It is worth mentioning that, in 2014, the National Curriculum Guidelines (Diretrizes Curriculares Nacionais - DCN) for medicine programs were reformulated. Among the main guidelines, the teaching of active methodologies that train critical and reflective professionals stands out. The pedagogical project should center on the students as active subjects throughout the learning process and the teachers as facilitators and mediators. Educational institutions must propose strategies for students to develop skills and attitudes to deal with real-life situations, problems, and complexities²¹21 Brasil. Ministério da Educação (MEC). Conselho Nacional de Educação. Câmara de Educação Superior. Resolução CNE/CES nº 3, de 20 de junho de 2014. Institui diretrizes curriculares nacionais do curso de graduação em Medicina e dá outras providências. Diário Oficial da União 2014; 23 jun.. In this perspective, medical training is based on competencies. According to Epstein and Hundert²²22 Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA 2002; 287(2):226-235., competence refers to a set of elements that involve cognitive, interpersonal, affective, emotional, and moral aspects, capable of improvement and evolution through praxis, action, and reflection.

These proposals for changes in the teaching and training of future professionals reflect the need to develop strategies that meet the new complexities of the medical profession and society as a whole. In addition to acquiring technical skills, professionals need to develop skills related to effective communication, organization, teamwork, and professionalism²³23 Garcia MAA, Nascimento GEA. Aplicação do Portfólio nas Escolas Médicas: Estudo de Revisão. Rev Bras Educ Med 2019; 43(1):163-174.^,2424 Stelet BP, Romano VF, Carrijo APB, Junior JET. Portfólio reflexivo: subsídios filosóficos para uma práxis narrativa no ensino médico. Interface (Botucatu) 2017; 21(60):165-176..

The insufficiency in the training of interpersonal and psychosocial skills²⁵25 Peixoto TC, Passos ICF, Brito MJM. Responsabilidade e sentimento de culpa: uma vivência paradoxal dos profissionais de terapia intensiva pediátrica. Interface (Botucatu) 2018; 22(65):461-472. and in the communication of bad news¹⁰10 Shoenberger JM, Yeghiazarian S, Rios C, Henderson SO. Death notification in the emergency departament: survivors and physicians. West J Emerg Med 2013; 14(2):181-185.^,2525 Peixoto TC, Passos ICF, Brito MJM. Responsabilidade e sentimento de culpa: uma vivência paradoxal dos profissionais de terapia intensiva pediátrica. Interface (Botucatu) 2018; 22(65):461-472.

26 Monteiro DT, Reis CGC, Quintana AM, Mendes JMR. Morte: o difícil desfecho a ser comunicado pelos médicos. Estud Pesqui Psicol 2015; 15(2):547-567.^-2727 Kovács MJ. Instituições de saúde e a morte. Do interdito à comunicação. Psicol Cienc Prof 2011; 31(3):482-503. is revealed in a recurring communication model in healthcare that is predominantly informational and unidirectional⁸8 Araújo IS, Cardoso JM. Comunicação e saúde. Rio de Janeiro: Fiocruz; 2007.. Training in communication skills can be useful; however, few studies demonstrate their effectiveness, as they usually evaluate the change in the behavior of medical students, but not necessarily their reflexes on patients²⁸28 Alewani SM, Ahmed YA. Medical training for communication of bad news: a literature review. Int J Health Promot Educ 2014; 3:51..

The act of communicating is intersubjective, constituted by interlocutors embedded in a given context, and fundamental in the field of healthcare⁸8 Araújo IS, Cardoso JM. Comunicação e saúde. Rio de Janeiro: Fiocruz; 2007.. Although frequent, communication of bad news in the emergency hospitals is complex and embarrassing because the doctor, touched by their human dimension, expresses reactions and emotions that should be hidden in this environment⁶6 Souza GA, Giacomin KC, Aredes JS, Firmo JOA. Comunicação da morte: modos de pensar e agir de médicos em um hospital de emergência. Physis 2018; 28(3):e280324.. Therefore, the intersubjective relationship with patients and families must be improved in the emergency context. In this setting, communication is often superficial, quick, and confusing, challenged by the lack of time and adequate space for communication, especially when confronted by other emergency demands⁶6 Souza GA, Giacomin KC, Aredes JS, Firmo JOA. Comunicação da morte: modos de pensar e agir de médicos em um hospital de emergência. Physis 2018; 28(3):e280324..

Moreover, the institutional context of fighting against death, the working conditions with professional overload, the lack of prior knowledge about the patient and their family, the death circumstances, a biomedical education with gaps in interpersonal and communication skills, and the predominantly technical role contribute to the professional’s discomfort in communicating bad news. This is because they are affected by the emotional reaction of the other person and by their expectations regarding the treatment. Therefore, the challenge is not related to conveying technical information but rather to the interaction and intersubjective encounter with the other person, dealing with psychosocial and cultural aspects⁶6 Souza GA, Giacomin KC, Aredes JS, Firmo JOA. Comunicação da morte: modos de pensar e agir de médicos em um hospital de emergência. Physis 2018; 28(3):e280324..

Communicating bad news is still challenging due to the impact on those who receive it, the feeling of failure of the professional who transmits it due to the impossibility of saving lives, and dealing with their feelings in the face of death. This lack of preparation and the patient’s perception of a lack of skill also highlight the need for strategies to help reduce fear, insecurity, and anguish in communicating bad news, to better handle the boundaries between life and death, and to manage both the other person’s and one’s own subjectivity⁵5 Diniz SS, Queiroz AAF, Rollemerg CV, Pimentel D. Communicação de más notícias: percepção de médicos e pacientes. Rev Soc Bras Clin Med 2018; 16(3):146-151.. Although fundamental, the proper delivery of bad news is still lacking in healthcare services⁵5 Diniz SS, Queiroz AAF, Rollemerg CV, Pimentel D. Communicação de más notícias: percepção de médicos e pacientes. Rev Soc Bras Clin Med 2018; 16(3):146-151., which should ensure an interpersonal relationship between the narrator and the recipient of the news. This appropriate communication is a right and is essential for understanding the content of the information, whether it pertains to the diagnosis, treatment, care strategies, health promotion, or respect for each patient⁴4 Calsavara VJ, Scorsolini-Comum F, Corsi CAC. A comunicação de más notícias em saúde: aproximações com a abordagem centrada na pessoa. Rev Abordagem Gestalt 2019; 25(1):92-102..

As evidenced by the interlocutors, researchers acknowledge that these difficulties in communicating bad news can stem from academic training that still places little value on communication skills, humanized care, and establishing a bond with patients and their families⁴4 Calsavara VJ, Scorsolini-Comum F, Corsi CAC. A comunicação de más notícias em saúde: aproximações com a abordagem centrada na pessoa. Rev Abordagem Gestalt 2019; 25(1):92-102.. Protocols have been created precisely to establish a better bond and, above all, efficient, empathetic, and respectful communication with patients and their families⁴4 Calsavara VJ, Scorsolini-Comum F, Corsi CAC. A comunicação de más notícias em saúde: aproximações com a abordagem centrada na pessoa. Rev Abordagem Gestalt 2019; 25(1):92-102.. However, practical training in bad news communication is still rare, and simply delivering the news does not equate to qualified communication³3 Isquierdo APR, Miranda GFF, Quint FC, Pereira AL, Guirro UBP. Comunicação de más notícias com pacientes padronizados: uma estratégia de ensino para estudantes de medicina. Rev Bras Educ Med 2021; 45(2):e091.. Ethical and humanistic principles are required for the reception and integrated care of the patient⁴4 Calsavara VJ, Scorsolini-Comum F, Corsi CAC. A comunicação de más notícias em saúde: aproximações com a abordagem centrada na pessoa. Rev Abordagem Gestalt 2019; 25(1):92-102..

The hegemonic training model is anchored in the biomedical paradigm, focusing on disease from a biological perspective, and is technicist, generalizing, and mechanistic²⁹29 Camargo Jr KR. O paradigma clínico-epidemiológico ou biomédico. Rev Bras Hist Cienc 2013; 6(2):183-195.. Death is still viewed objectively as a technical problem regulated by the physician, underestimating other psychosocial, cultural, and spiritual aspects²⁶26 Monteiro DT, Reis CGC, Quintana AM, Mendes JMR. Morte: o difícil desfecho a ser comunicado pelos médicos. Estud Pesqui Psicol 2015; 15(2):547-567.^,2929 Camargo Jr KR. O paradigma clínico-epidemiológico ou biomédico. Rev Bras Hist Cienc 2013; 6(2):183-195.. It is not a subject of study in medical school²⁸28 Alewani SM, Ahmed YA. Medical training for communication of bad news: a literature review. Int J Health Promot Educ 2014; 3:51.^,3030 Ariès P. O homem diante da morte. São Paulo: Unesp; 2014.. When addressed, it is done so in a reductionist manner, as something to be avoided at all costs, associated with professional incompetence rather than the impossibility of cure²⁵25 Peixoto TC, Passos ICF, Brito MJM. Responsabilidade e sentimento de culpa: uma vivência paradoxal dos profissionais de terapia intensiva pediátrica. Interface (Botucatu) 2018; 22(65):461-472.^,2626 Monteiro DT, Reis CGC, Quintana AM, Mendes JMR. Morte: o difícil desfecho a ser comunicado pelos médicos. Estud Pesqui Psicol 2015; 15(2):547-567..

Thus, despite curricula moving toward implementing training in the communication of bad news and encouraging the inclusion of communication training in the medical curriculum, the focus remains on curative measures, and the space to reflect on the loss of patients is incipient. The predominant approach still emphasizes the triumph of life over disease and views death as a failure. As a result, psychological issues, death, and verbal and non-verbal communication skills are given little consideration throughout academic training²2 Vogel KP, Silva JHG, Ferreira LC, Machado LC. Comunicação de más notícias: ferramenta essencial na graduação médica. Rev Bras Educ Med 2019; 45(Supl. 1):314-321.. Therefore, medical education still requires improvement aimed at quality of service, humanization, and care²2 Vogel KP, Silva JHG, Ferreira LC, Machado LC. Comunicação de más notícias: ferramenta essencial na graduação médica. Rev Bras Educ Med 2019; 45(Supl. 1):314-321.. Figure 1 summarizes the interlocutors’ perspectives.

We observed that the gap in training impacts professional practice. Professionals have reported that the difficulties persist, and they continue to feel emotionally unprepared to communicate bad news⁷7 Ribeiro KG, Batista MH, Souza DFO, Florêncio CMGD, Jorge WH, Raquel CP. Comunicação de más notícias na educação médica e confluência com o contexto da pandemia de covid-19. Saude Soc 2021; 30(4):e201058., aligning with our findings. Therefore, feelings, attitudes, self-awareness, relational skills, connection, empathy, and comprehensive care must be addressed⁷7 Ribeiro KG, Batista MH, Souza DFO, Florêncio CMGD, Jorge WH, Raquel CP. Comunicação de más notícias na educação médica e confluência com o contexto da pandemia de covid-19. Saude Soc 2021; 30(4):e201058.. Medical education has been focused on the maintenance of life, and the communication of bad news has not been presented as a possibility of medical care²2 Vogel KP, Silva JHG, Ferreira LC, Machado LC. Comunicação de más notícias: ferramenta essencial na graduação médica. Rev Bras Educ Med 2019; 45(Supl. 1):314-321.^,66 Souza GA, Giacomin KC, Aredes JS, Firmo JOA. Comunicação da morte: modos de pensar e agir de médicos em um hospital de emergência. Physis 2018; 28(3):e280324.^,77 Ribeiro KG, Batista MH, Souza DFO, Florêncio CMGD, Jorge WH, Raquel CP. Comunicação de más notícias na educação médica e confluência com o contexto da pandemia de covid-19. Saude Soc 2021; 30(4):e201058.. The transformations of the DCN for the medical school are still very recent to impact professional practice. The present research indicates that the majority of professionals believe that the learning of bad news communication remains insufficient, highlighting the existing gap in academic training and the need for these issues to be addressed also in other daily professional actions, with the creation of reflective groups, the review of standard operating procedures, and the provision of continuous education actions parallel to the reformulation of basic education.

In the present study, professionals criticized the teaching methods employed, the Flexnerian curricula that dichotomize health and disease phenomena, and point to the need for the teacher to be a learning agent, guide, and facilitator of students’ protagonism. In this scenario, knowledge is not only didactic and theoretical; it is also tacit, experiential, relational, emotional, sociocultural, ethical, reflective, and human in dealing with one’s own subjectivity and that of others.

References

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