Qualitative interview study of communication between parents and children about maternal breast cancerBMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7259.479 (Published 19 August 2000) Cite this as: BMJ 2000;321:479
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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
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.
Lecturer Practitioner in Palliative Care
Deputy Services Manager
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
Competing interests: No competing interests
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
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
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
Competing interests: No competing interests