Beyond words and science: contributions to a debate
Além das palavras e da ciência: contribuições para um debate
Elisabeth Meloni Vieira
Departamento de Medicina Social, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo. firstname.lastname@example.org
The paper entitled "Breaking bad news during prenatal care: a growing challenge" brings to the fore the discussion on the issue of communication among physicians and patients, or more broadly between the healthcare team and patients. The disclosure of information is an important step for the patient, their family, parents and other kin to participate in difficult decisions about procedures and cares for terminating life or situations of very severe diagnosis and prognosis, such as when a fetal problem is detected.
The need for the individualized disclosure of bad news has been described as crucial and a standard for good communication between physicians and patients. It takes into account that the disclosures should be tailored to the expectations and needs of the patient, since individuals differ with respect to the amount of information they want and in their methods for coping. In addition, it also takes into consideration that for most people time is needed to absorb and adjust to bad news, and therefore disclosure should be a gradual process over time. Moreover it recognizes that mutual confidence, trust and respect are the basis for the relationship1. Individualized disclosure was sanctioned by the Division of Mental Health of the World Health Organization in 1993.
Although the subject has been extensively studied over the last few decades, there is still a pressing need for research2. This need can be identified as knowledge pertaining to the field of "soft" technology as opposed to "hard" technology, as defined by Merhy3.
In fact, the paper approaches the core of communicative interaction during a critical moment when the physicians find it difficult to speak and the patients find it difficult to listen. Although science and medicine are becoming more and more capable of detecting health problems at early stages of pregnancy, physicians do not appear to be prepared to deal with the communication of bad news. For some authors, medicine has lost sight of its original purpose, as it has been transformed into an efficient instrument for achieving technical goals, with little regard for their human or social implications4.
Reading the paper, it becomes clear that the introduction of a new hard technology should also bring into discussion the appropriate "soft" technology to cope with it. This combination should be regarded as part of the microethics defined as "the ethics that happens in every interaction between every physician and every patient"4.
Understanding patients' expectations and needs for those critical moments has been the focus of some studies, especially in the obstetric, pediatric and geriatric areas. In many cases, decision-making about the fetus and the pregnancy, such as interruption or continuation, resuscitation or compassionate measures for life support will be needed5. Discussion can help parents and relatives to grasp and accept the circumstances, especially when they participate in the decision-making process. Hope, spirituality and emotion are important values, which must be respected and talked over during these critical moments.
Studies have shown that when physicians pay close heed to emotions, there is an improvement of communication with patients. Therefore, it has been recommended that training programs should include this subject2. However, because spiritual and emotional values are culture-specific for each society, more studies should be developed in order to increase the understanding of patients' needs during the communication of bad news.
1. World Health Organization (WHO). Communicating bad news: behavioural science learning modules. Geneva: WHO, Division of Mental Health; 1993.
2. Boss RD, Hutton N, Sulpar LJ, West AM, Donohue PK. Values parents apply to decision-making regarding delivery room resuscitation for high-risk newborns. Pediatrics 2008; 122(3):583-589.
3. Merhy EE. Um ensaio sobre o médico e suas valises tecnológicas: contribuições para compreender as reestruturações produtivas do setor saúde. Interface Com, Saúde, Educ 2000; 4(6):109-116.
4. Komesaroff PA. From bioethics to microethics: ethical debate and clinical medicine. In: Komesaroff PA, editor. Troubled bodies: critical perspectives on postmodernism, medical ethics, and the body. Durham, London: Duke University Press; 1995. p. 62-86.
5. American Academy of Pediatrics. No initiation or withdrawal of intensive care for high-risk newborns: Committee on Fetus and Newborn. Pediatrics 2007; 119:401-403.