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PAPERS: Jacqueline Barnes, Leanda Kroll, Olive Burke, Joanna Lee, Alison Jones, and Alan Stein Qualitative interview study of communication between parents and children about maternal breast cancer BMJ 2000; 321: 479-482 [Abstract] [Full text]

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Cancer and the P-P-F Triad

Tom Oommen   (1 September 2000)

Telling children about a parent's cancer

Jan Smith   (11 September 2000)

Cancer and the P-P-F Triad 1 September 2000
Tom Oommen, Associate Professor of Pharmacology Fr. Fuller's Medical College, Mangalore, India Send response to journal: Re: Cancer and the P-P-F Triad	Whether we like it or not we are constantly communicating. As a matter of fact we cannot NOT communicate. And communication is the oldest of our skills. It is often taken for granted and rarely included in the medical curriculum. And yet communication - whether verbal or non-verbal, remains the single most important tool in the medical profession. Barnes et al do raise vital issues in their study (1) among them one crucial aspect being the time and the extent of the communication between the patient and the family. Patients may verbalise their symptoms, signs, apprehensions and queries either prior to a biopsy, prior to the surgery after the surgery or perhaps never. But it is equally important to accept that in most cases communication occurs between patients and children, members of the health care team or even visitors in other ways. The child is able to observe a grimace on the patient's face, a slowing down of her pace, a stoop in her gait, a decrease in her appetite, a change in the tone of her voice, a drop in her assertiveness, a sobriety in her thinking, a religious outlook in her perspectives, a generosity in her appreciation, a gratitude in her smile, a quickness in her forgiveness, a determination in her poise, a vacant expression in her eyes, a weakness in her grasp, and many more such non-verbal cues which give away much more than a verbal or written diagnosis or an expert medical comment. The children learn to listen with their eyes more than with their ears. Such behavioral or attitudinal changes may be observed even before the patient goes to consult with the oncologist or te family physician. The awareness of cancer is so high that once a patient crosses a certain age she keeps the feare of malignancy foremost in her mind. And, as Shakespeare says, "in the night, imagining some fear, how easy is a bush supposed a bear"! She then feels that any symptom is as suggestive of cancer. Another aspect of this patient-child communication is that a lot of background noise exists between the intended content of the patient and the perceived content in the child. Truth often hurts, but deceit hurts much more. The patient knows and feels the agony of the situation. The tries to use gentle and pleasant phrases to break the news to her children. But the children might have been able to cope much better with the situation and the agonies and apprehensions that followed if they had known the whole truth. This paradigm cannot be quantified statistically unless a study similar to what Barnes et al (1) have done is extended to attitudes and perceptions. It must be accepted that as the disease progresses and the disease becomes more advanced it becomes all the more difficult to hide the truth from the children. This brings us to the concept of the communication triad in the medical profession, the Patient - Physician - Family (PPF) triad. Every member in this triad has an equal responsibility to ensure that the communication is as accurate, as complete and as constructive as possible. Truth-telling may involve a risk and a hope (2) and yet the duty may involve several dangers (3). This triad has withstood the onslaught of cultural diversity. Its effectiveness depends entirely on how the physician can encourage the patient to tell the family (and not, as is commonly practiced, how the physician encourages the family to tell the patient) the details of the diagnosis. The onus of this responsibility should lie with the physician, since he is considered to be the expert who confirms and knows the diagnosis and its prognosis. This shift in paradigm could alter the outcome measures in cancer therapy. References: 1. Jacqueline Barnes, Leanda Kroll, Olive Burke, Joanna Lee, Alison Jones, and Alan Stein. Qualitative interview study of communication between parents and children about maternal breast cancer. BMJ 2000; 321: 479-482 2. Surbone A. Truth-telling: risk and hope. Ann. New York Acad. Sci. 1997; 809: 72-79 3. Verres R. Straight talkin about cancer: duty or danger? Ann. New York Acad. Sci. 1997; 809: 367-381
Telling children about a parent's cancer 11 September 2000
Jan Smith Send response to journal: Re: Telling children about a parent's cancer	Editor - The recent paper by Barnes et al (1) highlights the need for a more focussed approach to the education of health care professionals about how to speak to patients with a serious and potentially life- threatening disease. We endorse the need for more specific training in family dynamics and family responses to illness. We would also emphasise its particular relevance for specialist nurses and oncologists who are usually in the front line of explaining the implications of a cancer diagnosis to the patient. The paper (1) found that some parents were not confident at addressing the informational and support needs of their children, perhaps as a result of their own distress and lack of knowledge. Some parents said, retrospectively, that they would have welcomed some guidance on how to speak to their children, but it is debatable as to when this guidance should be given. The skill of the health care professional lies not only in imparting the appropriate information but also choosing the correct time to do this. Patients may feel the need to come to terms with their own diagnosis before explaining to their children, who may ask difficult and direct questions. Written information such as that published by BACUP can give the patient the confidence to explain to their child, when they are ready, and can reinforce what has been said by the health care professionals. Further support of the patient and their children can be extended into the community through the GP, other community health care professionals and the children's school. Focussed support by school staff, for example, has been shown to improve the child's coping mechanisms if a parent has cancer (2). The health care professional who has already broken bad news to the patient may feel the need to avoid the additional issue of how the patient might inform their children. In order for information-giving to be appropriate, timely and effective, health care professionals require sufficient time to spend with the patient. This represents yet another burden on the already stretched resources of the NHS. We are pleased that this paper has identified another aspect of the complex needs of the patient with a diagnosis of cancer. Jan Smith Lecturer Practitioner in Palliative Care Karen Burnet Deputy Services Manager Ruth Skinner Clinical Nurse Specialist, Breast Care Dr. N.G. Burnet University Lecturer and Honorary Consultant Oncologist Oncology Centre, Addenbrooke's NHS Trust, Hills Road, Cambridge, CB2 2QQ. 1. Barnes J, Kroll L, Burke O, Lee J, Jones A, Stein A. Qualitative interview study of communication between parents and children about maternal breast cancer. BMJ 2000; 321: 479 - 482 2. Birenbaum LK, Yancey DZ, Phillips DS, Chand N, Huster G. School- age children's and adolescents' adjustment when a parent has cancer. Oncol Nurs Forum 1999; 26 (10): 1639-45