Breaking bad news: Awareness and practice among Sudanese doctors

Background Breaking bad news is an important task for doctors in different specialties. The aim of the study was to assess adherence of Sudanese doctors to the SPIKES protocol in breaking bad news. Methods A descriptive cross-sectional study recruited 192 doctors, at Wad Medani teaching hospital, Sudan. A questionnaire-based on SPIKES protocol was distributed among 10 departments in our hospital. Data were analyzed using SPSS and Microsoft excel. Results There were (n = 101, 52.6%) females and (n = 91, 47.4%) males among the participants. 95.3% have been involved in breaking bad news, but only 56.3 received education and training about this issue. 43% admitted bad experience in breaking bad news, while 65.6% mentioned that bad news should be delivered directly to patients. The majority (>90%) agreed training is needed in the area of breaking bad news. Usual adherence to the SPIKES protocol was reported in a range of 35–79%, sometimes adherence was reported in a range of 20–44% while never adherence was reported in a range of zero–13.5%. Consultants, registrars, obstetrician and gynecologists and surgeons achieved high scores in breaking bad news. Training is an important factor in achieving high score in SPIKES protocol. The unadjusted effect of background factors on SPIKES score, showed that only training has significant impact on protocol adherence (P = 0.034, unadjusted; and P = 0.038 adjusted). Conclusion Large number of Sudanese doctors will try to adhere to SPIKES protocol. Training is an important factor in the success of breaking bad news.


Introduction
One of the common and most important tasks for practicing clinician is breaking bad news to his patients. Buckman defined bad news as "any news that drastically and negatively alters the patient's view of her or his future" [1]. It is possible to include in the definition of bad news other conditions in which there is "a feeling of no hope" or "a message is given which conveys to an individual fewer choice" [2]. Therefore, even experienced doctor may find certain occasions of breaking bad news required considerable preparations [3]. This can be due in part that some doctors may worry about being blamed, the reactions associated with breaking bad news, and fear of not knowing what will happen especially among young doctors [4]. Importantly, breaking bad news if not well delivered may have an impact on the clinician and patients and relatives. For instance, physicians may become emotionally disengaged from their patients, and its possible this may have an impact on patients or relatives relationship with their doctors [5,6]. Breaking badnews is widely practiced in hospital especially with debilitating illnesses, such as stroke, myocardial infarction, dementia, multiple sclerosis and Parkinson's disease [7,8]. Several protocols have been proposed to communicating bad news and tested in the literature. However, there are a few established recommendations for the delivery of bad news in the United States [9], Germany [10] and the United Kingdom [11]. These protocols are primarily based more on expert opinion, but less on empirical evidence.
The most popular guideline, the SPIKES protocol [12], recommends six-steps for breaking bad news, with a special application for cancer patients [13]. It was evaluated for structuring the delivery of bad news in the United States [14], Germany and other countries [10]. It is used as a guide for this sensitive practice and for communication skills training in this context [15]. The first step is S or setting up phase that points to the preparation of the medical environment, which should preferably be a private, reserved, and pleasant site. The second step is P or perception; it is an opportunity to find what the patient knows about his or her illness through open questions. The third stage is I or invitation is an opportunity to analyze the patient's willingness rate to resolve his doubts about his disease. The fourth stage is the K or knowledge that everything in relation to the diagnosis must be revealed. The fifth stage is the E or emotion, which is the time to express empathy, recognize the patient's emotions, and provide support. The last step is the S or phase of strategy and summary that is the moment to propose treatment and prognosis of the disease, as well as sum up everything that has been said [16,17].
Other protocols are also available like patient-and family-centered approach [18] and an emotion-centered approach [19]. For example, Rabow and McPhee also proposed a model for breaking bad news called ABCDE: A, advance preparation; B, build a therapeutic environment/relationship; C, communicate well; D, deal with patient and family reactions; and E, encourage and validate emotions [6]. There is limited data endorsing the use of the SPIKES protocol in Sudan. However. within the last decade, Sudanese doctors become familiar with SPIKES protocol as most of the international postgraduate medical examinations (mainly from UK) were held in the capital Khartoum. These examinations will include one station at least about breaking bad news.However, in the daily practice of medical doctors, it's very likely to see wide variation in adherence to SPIKES protocol and this can be due to cultural, religious and customs in different parts of Sudan. In this study, we assessed the use of SPIKES protocol in breaking bad news among Sudanese doctors working at Wad Medani teaching hospitals, Sudan.

Methodology
This is a cross-sectional study conducted from August to December 2019, at Wad Medani teaching hospitals, Gezira state, central Sudan. A self-administered questionnaire was designed to elicit information on doctor's knowledge and practices about breaking bad news to patients and their relatives. The questionnaire was distributed among 10 departments (medicine, surgery, pediatric, pediatric surgery, urology, nephrology, ENT, orthopedic, oncology, obstetrics and Gynecology departments). Medical officers, residence registrars and consultants working in Wad Madani teaching hospitals and agreed to fill the questionnaire were included in this study. The following were excluded: house officers in those hospitals departments, doctors who did not have direct contact with patients (radiologists and pathologists) and doctors who refuse to participate or not available at the time of the study. Participants received questinnare with covering letter with details of projects, right of responsendents and confidentiality of the data.
The questionnaire consisted of three sections. The first section was personal data including age, gender, clinical position and specialty. The second section was related to their practice about breaking bad news which composed of sex items. Each item was measured on a 3-point Likert scale (usually, sometimes and never). The items were based on the SPIKES model of breaking bad news. The third section asks the doctors about their past experiences, opinions and the need for a training program in breaking bad news which composed of 11 items. Acceptance of hospitals administrations on approval was also taken. The data obtained were secured and kept confidential and were used only for research purposes.

Method of determination sample size
192 doctors were enrolled in this study, stratified by random sampling. As we intend to utilize a mixed linear model, we estimated the sample size assuming a small effect size (Cohen's d = 0.15), with ten different clusters (representing the specialties of participating doctors), and power of 0.8, significance of 5%. The minimum required sample size is (n = 159) doctors. (Cohen J. 1988. Statistical power analysis for the behavioral sciences (2nd ed.).

Statistical analysis
The data were analyzed using SPSS (Statistical Package for Social Sciences) version 23 and Microsoft excel. Descriptive statistics were applied to describe the pattern of the data In terms of following SPIKES protocols, we summed up the score for the six SPIKES responses. This gives a potential total of 12 for perfect adherence to the protocol. Logistic regression analysis was used to determine factors that have an impact on breaking bad news.

Ethical approval
Was obtained from the Research Ethical Committee of the University of Gezira-Faculty of Medicine on September 11th, 2019.

Adherence to SPIKES protocol by specialty, rank and training
Adherence to the SPIKES protocol can be seen in Table 3. Usual adherence to protocol was reported in a range of 35-79%, sometimes adherence was reported in a range of 20-44% while never adherence was reported in a range of zero-13.5% (Table 3). In terms of following SPIKES protocols, we summed up the score for the six SPIKES responses. This gives a potential total of 12 for perfect adherence to the protocol. The mean score was 9.3 (SD = 1.78). The responses ranged between 4 and 12, and the median was 10. The maximum of 12 was achieved by (n = 23, 12%) doctors (Table 4). Figure 1 showed the SPIKES protocol with potential of 12 for perfect adherence to the protocol. Consultants, registrars, obstetrician and gynecologists and surgeons achieved high scores in breaking bad news. Training is an important factor in achieving high score in SPIKES protocol. The unadjusted effect of background factors on SPIKES score, showed that only training has significant impact on protocol adherence (P = 0.0341, unadjusted; and P = 0.038 adjusted) ( Table 5).

Discussion
Communication skills and in particular breaking bad news is regarded as one of the important skills for clinician with regular contact with patients [20,21]. The aim of this study was to explore Sudanese doctor's awareness and evaluate practice in the relation of breaking bad news to patients and their relatives. Adherence to SPIKES protocol was found to be 80%, 84.3% in Korea and Brazil respectively [22,23]. We showed that majority of doctor usually or sometimes adhere to the SPIKES protocol, while never adherence was reported in a range of zero-13.5%. Bad experience with breaking bad news is inevitable outcomes in certain occasions. In our study, we showed that 43.8% have such experience, this percentage almost similar to studies in Nigeria and Korea [22,24].
This was attributed to no training or education, which is common problems across the different countries like USA and Nigeria [24,25] It worth mentioning, education per se will not improve communication in breaking bad news unless its combined with training [26]. Training will give opportunity to overcome stress associated with breaking bad news and help clinicians to develop confidence [27,28]. The variability in the adherence to the six steps of the SPIKES in our study, was also shown in different studies [10,11,23,24]. Interestingly, registrars showed equivalent level of consultants in adherence to the SPIKES protocol. This can be attributed, doctors in training are more likely to stick to guidelines in preparation for final local medical postgraduate exam in Sudan or the international medical postgraduate examinations, and at one stage may score better than their consultants [29]. Logistic regression analysis showed that training and education is an important factor in achieving excellent adherence to SPIKES protocol. Training and education is important for all clinician irrespective of their specialists. It worth mentioning, in pediatric its important to be trained in breaking bad news to families [27,28,30]. Culture, beliefs, patient level of education, traditions and religious can have an impact on delivering bad news. For instance, in Brazil and Sudan, families are likely to be heavily involved in the patient choice and decision and this may explain why 34.6% of participants in this study believe that bad news should be shared with family [20,23,31]. While 65.6 of the participants believed that bad news should be delivered directly to the patient and this can be attributed for growing trend of respecting patient right and confidentiality as stated by Sudan medical council. In addition, the era of internet and globalization contributed significantly in patient's education. Sudan, like other countries in the Middle East and the far East, where breaking bad news is delivered to the family rather than directly given to the patients. Muneer et al., showed that about 50% of Sudanese patients do not like to know their diagnosis according to the opinion of their doctors, and 20% of doctors would conceal the diagnosis from a patient upon the request of the relatives. Importantly, under one-quarter of doctors followed a standard protocol. They have also showed most of the doctors agreed that patients have the right to know everything about their diagnosis [32]. Elsiddek et al. showed only 25% of Sudanese patients with gastrointestinal malignancies were told about their correct diagnosis, the rest of patients were told they have mass or lump [33]. Salem and Salem mentioned that the trend in most countries in Middle East in breaking bad news will change with time and will be patient centred approach [34]. They have also developed a model of breaking bad news in Muslim countries based on mnemonic IGAD ( I for interview, G or gather information or background, A for assess family and religion views, A for achieve rapport and D for disclosure of information to the patient or the family based on physician use of IGAD). We recommend a new approach based on patient-family centred approach in breaking news in stages. Sudanese society and family structure is still based on extended family style and majority of families are living in extended and interconnected families and houses. The COVID-19 pandemic brought high level of unity and solidarity among Sudanese families and communities. Importantly, there is change and shift in attitude and acceptance of the terminal illness. Smart phones, technologies and internet contributed in increasing awareness and importantly how to seek medical help. Therefore, the new approach based on patient-family centred approach in stages may have the opportunity to fit within the Sudanese culture. This approach is based in giving the same information to the patient and family gradually and in stages. For instances, during clinical examination, patient and family will be told about the differential diagnosis and in the second interview both family and patient will be told the diagnosis.This may sound as simple approach, but one benefit we as physicians we do not appreciate, is fact that the extended families and interconnected communities during COVID-19 pandemic provided extensive support not only for patients but also for families. In other words, extended families and interconnected communities may provide similar support to the palliative support provided in Western societies. This may also bring degree of satisfaction for patient and family as terminal illness and end of life bring reconciliation and forgiveness among extended families and interconnected communities especially in Sudan. Indeed, further research will be needed to assess if this model of breaking bad news can be useful in Sudan.
This study is not without limitations. The cross-sectional design of the study may not allow for the temporal relationship. The participants were recruited from Wad Madani Teaching Hospital, therefore its not possible to generalize the result for the whole Sudan. Another important limitations, The SPIKES protocol is a mnemonic to remind clinicians of important steps in the delivery of bad news, but each bad news encounter is different, and not every step may be relevant in every clinical situation. Self-reported recall of whether each of these steps is followed never, sometimes, or always in practice is subjective and may be biased (clinicians may perceive that they do this more often or better than they do in reality). Despite these limitations we believe this study is novel, and it showed that training is an import factor in breaking bad news.

Conclusion and recommendation
Breaking bad news is a fundamental doctor's skill. Considerable weight in undergraduate medical curricula should be considered for building communication skills. Moreover, frequent Continuing Professional development (CPD) for doctors is required to develop these skills to be able and confident in breaking bad news for better health care delivery.