id 19940



Giving bad news in the context of cancer care: integrative literature review


Lenilce Pereira de Sousa da SilvaI; Iraci dos SantosII; Sara Zambrotti Maggini de CastroIII

I Nurse. PhD student at the Graduate Nursing Program of the State University of Rio de Janeiro. Rio de Janeiro, Brazil. E- mail:
II Nurse. Titular Professor, State University of Rio de Janeiro. Nursing Graduate Program, Brazil. E-mail:
III Nurse. Specialist in Oncologic Nursing by the National Cancer Institute. Niterói, Rio de Janeiro, Brazil. E-mail:





Objective: to discuss the findings of publications addressing the repercussions of difficult news given to clients by nurses working in cancer care. Method: integrative literature review analyzing publications addressing the repercussions of difficult news given to clients by nurses working in cancer care indexed in databases from 2011 to 2015. The search was performed from May to September 2015 in the LILACS, MEDLINE and BDENF databases. Of the 182 articles found, 156 which did not meet the criteria established were excluded. The final sample consisted of 26 articles. Results: analysis and synthesis of the recorded data obtained the categories: Difficulties in giving difficult news; Developing skills in giving difficult news; Professional training; and Nurse-client relations. Conclusion: there is a need for health personnel to develop social skills for giving news of difficult situations in the course of cancer diseases.

Keywords: Truth disclosure; health communication; oncology nursing; nursing care.




This work was initiated from the observation of the dynamics surrounding the service provided to customers and family members by health professionals of a national reference institution for treatment of various cancers. The severity of cancer and the high complexity that hospitalized people require from nursing care makes nursing professionals to deal everyday with the communication of difficult news1,2.

This situation aroused the desire to find answers to the following question: what are the records in scientific publications addressing the impact of communicating difficult news by nurses working in cancer care? In order to clarify this issue, the following objective was formulated: to describe the findings of publications addressing the impacts of communicating difficult news to customers by nurses working in cancer care.

It is believed that this work may reveal alternative ways for nurses to provide qualified care to clients affected by cancer and their families, contributing to the foundation of nursing care and education, and encouraging further studies, especially in area of ​​oncologic nursing, addressing the communication of difficult news.



Professionals working with cancer care are involved in caring for people undergoing great suffering that runs through the various stages of cancer, namely, the diagnostic confirmation, choosing the most appropriate treatment, fearing mutilation and pain, strong side effects inherent to each therapy, the comings and goings because of scheduled admissions or emergencies, lack of response to therapy with the progression or recurrence of the disease, the depletion of options of curative treatment, referral to palliative care, fear of death, family involvement and supportive networks, in short, the complex feelings, conflicts and subjectivities surrounding these people's lives1,3,4.

Dealing with this world full of peculiarities and the high incidence of hard news, which are reported to the person with this illness and to their relatives, is something that leads to reflections on the need to acquire knowledge on technologies and devices required for qualified communication. These is needed because all suffer, with no exception, when involved in the arduous task of receiving or transmiting such news. The communication of oncologic information is one of the most impactful and difficult moments in the process of working of professionals who care for clients undergoing the course of cancer1.

In this context, the contact with the suffering of others is something relevant, including communicating situations that may result in pain, loss and death. This is, in the opinion of certain authors4, a cascade of bad news.

The experience of knowing clients and their families during the course of oncological disease causes reflexions on the complexity faced by professionals before a serious situation of great magnitude and of epidemiological relevance such as cancer2.



An integrative literature review (ILR) in the Virtual Health Library was carried out in the following databases: Latin American and Caribbean Health Sciences (LILACS), United States National Library of Medicine (Medline/PubMed) and Nursing Database (BDENF).

The ILR is a method whose main characteristic is to gather and synthesize the results of researches developed on a topic through the orderly use of scientific articles available in major sources5,6. This type of review gives the researcher an objective and thorough selection of studies published to date on a given issue, thus contributing to the further development and improvement of clinical practice and pointing gaps that need further studies5,6.

Descriptors in Health Sciences (DECS) selected for inclusion of studies were: oncologic nursing, health communication, nursing care. To investigate the communication of difficult news, we used the descriptor disclosure of truth, because "communication of difficult news" does not exist as a descriptor. In order to perform the research in the English language, the following terms were used: oncology nursing, health comunication, nursing care e truth disclosure . To the Spanish language, the terms used were: enfermería oncologica, comunicación en salud, atención de enfermería e revelación de la verdad . The boolean operators and and or were used in different combinations in each database. The survey was conducted in the period from May to September 2015.

The search strategy used in the abovementioned databases was: truth disclosure or revelación de la verdad or revelação da verdade and oncology nursing or enfermería oncológica or enfermagem oncológica and health communication or comunicação em saúde orcomunicación en salud and nursing care or atención de enfermería or cuidados de enfermagem, what resulted in 182 potential articles. The review was drawn from the systematic fulfillment of six distinct steps5, summarized as follows:

The first step consisted in the choice of the theme for this study, which is the communication of difficult news in oncology. The following inquiry was proposed as guiding question: which scientific publications address the effects of communicating hard news to the life of nurses working in oncology?

To comply with the second step, the following inclusion criteria were applied: articles published between 2011 and 2015 in Portuguese, English and Spanish; only full-length articles from journals dealing with nursing and/or neoplasms, indexed and available in the aforementioned databases. Exclusion criteria were: articles with limited access, articles with pediatric and/or adolescents customers, addressing only the communication of difficult news from the perspective of clients and/or family members and articles that did not link the communication of difficult news to illness due to cancer.

In the third step, articles were read in full-length and organized in a form containing the following information: author, title, journal and summary of the main results.

In the fourth and fifth steps, the three researchers carried out the review of these studies. We opted for Bardin content analysis 7 because this uses systematic and objective procedures of description of the content of messages leading to the interpretation of the results.

Among the 182 articles obtained in the initial stage of selection, 156 were excluded because they did not meet the following inclusion criteria: articles with pediatric and/or adolescents customers (6); communication of difficult news from the perspective of clients and/or family members (11); articles that did not link the communication of these news to cancer (65); inadequacy to the object of study (74).

Articles excluded for being inadequate to the object of study refer exclusively to cancer descriptions, treatments and communication in general, with no correlation with the problem of difficult news in oncology. Thus, 26 works were selected 8-33.

In the sixth step, after analysis and synthesis of articles, these were distributed into five themes: Challenges in communicating difficult news; Development of skills in communicating difficult news; Professional qualification; Nurse-client relationship; Impacts of the communication of difficult news.


Twenty six articles8-33 were selected for this ILR, considering the author, title, journal and synthesis of results in free translation into Portuguese, as described in Figures 1 and 2.

FIGURE 1: Main features and findings of the investigated articles. Rio de Janeiro, October 2015.

FIGURE 2: Main features and findings of the investigated articles. Rio de Janeiro, October 2015.

We show the description of the 26 studies8-33 considering the categories identified, authors, level of evidence and results. The analysis showed predominance of the category - Challenges in communicating difficult news (12); followed by the others: Development of skills in communicating difficult news (9); Professional qualification (3); Nurse-client relationship (1); Repercussions of the communication of difficult news (1).

FIGURE 3: Categories, authors and level of evidence of the investigated articles. Rio de Janeiro, October 2015.

Challenges in communicating difficult news

Data point predominantly 12 articles in which the challenges in communicating difficult news are perceived by health professionals as a factor that causes intense suffering in their daily practice. Dealing with the emotions of customers and family members before an adverse situation means that these professionals have the difficult task of confronting their own emotions.

Many doctors mention difficulties when it comes to communicating adverse prognostics to customers. These difficulties, according to them, are directly related to the characteristics of those suffering with cancer and the support systems available17, 21.

According to some authors, the families of seriously sick people are always trying to postpone the emotional confrontation that a difficult new may cause. The family's desire of spearing the client from the adverse prognosis has been a disincentive for doctors to adopt a more direct communication with customers8, 17, 25.

In contrast, a study published in 2011 in England, showed that there is disagreement between 80% of people with cancer about their wish of learning as much information on their disease as possible, and only 43% of doctors are willing to provide information for users with cancer with poor prognosis16.

The language used by health professionals is typically based on overly technical and complex terms. This was a difficulty pointed out in some results of the research23, 29 and shows how important is that communication, especially with clients and family members who are receiving difficult news, be decoded into a simpler language to be understood.

Finally, professionals seek a fair measure, that is, the difficult balance between avoid to completely eliminate the hopes or strengthen expectations that are not realistic. Palliative chemotherapy is an example of a valid therapeutic resource in some specific situations, but that sometimes ends up being used as a way to keep clients and family believing that something can still be done, and that, consequently, there may still be a chance of cure19.

Development of skills in communicating difficult news

It was identified in nine articles that there is great concern among health professionals regarding the development of skills to communicate difficult news. Note that training courses aimed at communication with clients and family members suffering serious and life threatening diseases have been increasingly valued. Professionals who participate in these trainings have been able to handle more skillfully the care for these people9, 18.

The increasingly constant need for training health professionals' communication skills has caused an improvement in empathy and has decreased the burden of those who often need to communicate bad news9, 18.

Professional qualification

Less frequently (three articles), it is clear that there is a concern with training the communication of difficult news during the qualification of health professionals. The lack of preparation in this training phase can become a potential problem when these professionals have to face difficult problems in their daily practice.

A study conducted on the effectiveness of qualification programs for medical residents showed that the current trend is justified by the best results in the consultations of future professionals who have this content in their curriculum10.

Another research on the quality of communication conducted among medical students, people with cancer and their family members, concluded that the professional training of doctors before starting their practice it is indispensable30.

Nurse-client relationship

Questions related to the need to establish a strong link between clients and family members and health professionals were raised. In the case of client, this is needed because they go through life changes caused by the serious illness and confronting the issues of finitude and death; and in the case of professionals, because they need to act empathetically, supporting and minimizing the suffering of those who are cared for, but also their own suffering, because they need to feel well in order to provide care.

A survey with Japanese oncologists found that younger professionals have more empathy with their clients than the more experienced professionals. Empathy should be a widely used tool for oncologists, because they often have bad news that must be reported to their cancer patients and family members32.

Health institutions, however, need to be aware of this fact and need to stimulate training programs for their health professionals, mainly for those acting in the area for longer times, among which lower degree of empathy is observed 32.

Impacts of the communication of difficult news

Stress has been identified as one of the impacts on the lives of those who need to communicate bad news in their daily practice.

The guiding question of this research - "which scientific publications address the impact of communication difficult news among nurses working in cancer care?" - is recalled here. It is noteworthy that despite the fact that this category was mentioned by only one article15 this was privileged to be the heart of this work.

The fact of being found in only one study, addressing one of the impacts of communicating difficult15 ended up increasing the desire of researchers to find new answers to this question that is little explored.



The objective proposed by this work was achieved by demonstrating that scientific production focusing on the communication of difficult news to clients and their families due to difficulties of relationship, social skills and communication of health professionals, mainly nurses, is limited, including at the international level.

This review resulted in the themes: Difficulties in communicating difficult news; Development of skills in communicating difficult news; Professional qualification; Nurse-client relationship; Impacts of the communication of difficult news. It is noteworthy that, among the levels of evidence found in the articles that composed the ILR, the predominant level was 2 in 22 publications.

It is imperative to open new spaces for nursing professionals to reflect on this complex theme that permeates the practice of care and human dignity of clients, family members and other health professionals.



1.Instituto Nacional de Câncer (Br). Coordenação geral de gestão assistencial. Coordenação de educação. Comunicação de notícias difíceis: compartilhando desafios na atenção à saúde. Rio de Janeiro: INCA; 2010.

2.Instituto Nacional de Câncer José Alencar Gomes da Silva (Br). Coordenação de prevenção e vigilância. Estimativa 2014: incidência de câncer no Brasil. Rio de Janeiro: INCA; 2014.

3.Instituto Nacional de Câncer (Br). Ações de enfermagem para o controle do câncer: uma proposta de integração ensino-serviço. 3a ed. atual. amp. Rio de Janeiro: INCA; 2008.

4.Lugarinho LP, Rosário SE. Atenção ao vínculo e saúde do trabalhador: um bom encontro. In: Instituto Nacional de Câncer (Br). Coordenação geral de gestão assistencial. Coordenação de educação. Comunicação de notícias difíceis: compartilhando desafios na atenção à saúde. Rio de Janeiro(RJ): INCA; 2010.

5.Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto contexto - enferm. [Internet]. 2008 [citado em 17 maio 2016]. 17(4):758-64. Disponível em:

6.Polit DF, Beck CT, HunglerBP. Fundamentos de pesquisa em enfermagem: métodos, avaliação e utilização. 5a ed. Porto Alegre(RS): Artmed; 2004.

7.Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2011.

8.C herny NI (org.) Factors influencing the attitudes and behaviors of oncologists regarding the truthful disclosure of information to patients with advanced and incurable cancer. Psychooncology. [Internet]. 2011 [cited 2015 Sep 14]; 20(12):1269-84. Available from:

9.Cohen Castel O, Alperin M, Ungar L, Kravtsov I, Amiel GE, Karkabi K. Urologists' attitudes regarding information sharing with prostate cancer patients--is there a common ground forcollaboration with family physicians? J Cancer Educ. [Internet]. 2011 [cited 2015 Sep 14]; 26(2):315-21. Available from:

10.Fagerlin A, Zikmund-Fisher BJ, Ubel PA. Helping patients decide: ten steps to better risk communication. J Natl Cancer Inst. [Internet]. 2011 [cited 2015 Sep 14]; 5; 103(19):1436-43. Available from:

11. Gadgeel SM. Hope and realism: the perfect balance? J Clin Oncol. [Internet]. 2011 [cited 2015 Sep 14]; 1; 29(16):2291-2. Available from:

12.Kiely BE, Stockler MR, Tattersall MH. Thinking and talking about life expectancy in incurable cancer. SeminOncol. SeminOncol. [Internet]. 2011 [cited 2015 Sep 14]; 38(3):380-5. Available from:

13. Lenzi R, Baile WF, Costantini A, Grassi L, Parker PA. Communication training in oncology: results of intensive communication workshops for Italian oncologists. Eur J Cancer Care (Engl). [Internet]. 2011 [cited 2015 Sep 14]; 20(2):196-203. Available from:

14. Nabhan C, Bitran JD, Moore C. Disclosing the cancer diagnosis:the myth and the truth. J Clin Oncol. [Internet]. 2011 [cited 2015 Sep 14]; 20;29(6):e145-6; author reply e147. Available from:

15. Otani H, Morita T, Esaki T, Ariyama H, Tsukasa K, Oshima A, et al. Burden on oncologists when communicating the discontinuation of anticancer treatment. Jpn J Clin Oncol. [Internet]. 2011 [cited 2015 Sep 14]; 41(8):999-1006. Available from:

16.Wittmann E, Beaton C, Lewis WG, Hopper AN, Zamawi F, Jackson C, et al. Comparison of patients' needs and doctors' perceptions of information requirements related to a diagnosis of oesophageal or gastric cancer. Eur J Cancer Care (Engl). [Internet]. 2011 [cited 2015 Sep 14]; 20(2):187-95.Available from:

17. Yamamoto F, Hashimoto N, Kagawa N, Okita Y, Chiba Y, Kijima N, et al. A survey of disclosure of diagnosis to patients with glioma in Japan. Int J Clin Oncol. [Internet]. 2011 [cited 2015 Sep 14]; 16(3):230-7. Available from:

18. Atasoy BM, Sarikaya O, Kuscu MK, Yondem M, Buyukkara E, Eken EG, et al. Students meeting with caregivers of cancer patient: results of an experience-based learning project. J Cancer Educ. [Internet]. 2012 [cited 2015 Sep 14]; 27(4):656-63. Available from:

19.Kadakia KC, Moynihan TJ, Smith TJ, Loprinzi CL. Palliative communications: addressing chemotherapy in patients with advanced cancer. Ann Oncol. [Internet]. 2012 [cited 2015 Sep 14]; 23 Suppl 3:29-32. Available from:

20. McHenry M, Parker PA, Baile WF, Lenzi R. Voice analysis during bad news discussion in oncology: reduced pitch, decreased speaking rate, and nonverbal communication of empathy. Support Care Cancer. [Internet]. 2012 [cited 2015 Sep 14]; 20(5):1073-8. Available from:

21.Rodriguez Del Pozo P, Fins JJ, Helmy I, El Chaki R, El Shazly T, Wafaradi D, et al. Truth-telling and cancer diagnoses: physician attitudes and practices in Qatar. Oncologist. [Internet]. 2012 [cited 2015 Sep 14]; 17(11):1469-74. Available from:

22. Tobin GA . Breaking bad news: a phenomenological exploration of Irish nurses' experiences of caring for patients when a cancer diagnosis is given in an acute care facility (part 1). Cancer Nurs. [Internet]. 2012 [cited 2015 Sep 14]; 35(6):E21-9. Available from:

23. Al-Amri AM. Future Saudi doctors and cancer patients agree cancer patients should be informed about their cancer. Asia Pac J ClinOncol. [Internet]. 2013 [cited 2015 Sep 14]; 9(4):342-8. Available from:

24.Kondo K, Fujimori M, Shirai Y, Yamada Y, Ogawa A, Hizawa N, et al. Characteristics associated with empathic behavior in Japanese oncologists. Patient EducCouns. [Internet]. 2013 [cited 2015 Sep 14]; 93(2):350-3. Available from:

25.Locatelli C, Piselli P, Cicerchia M, Repetto L. Physicians' age and sex influence breaking bad news to elderly cancer patients. Beliefs and practices of 50italian oncologists: the G.I.O.Ger study. Psychooncology. [Internet]. 2013 [cited 2015 Sep 14]; 22(5):1112-9. Available from:

26. Merckaert I, Liénard A, Libert Y, Bragard I, Delvaux N, Etienne AM, et al. Is It Possible to Improve the Breaking Bad News Skills of Residents When a Relative Is Present? A Randomised Study. Br J Cancer. [Internet]. 2013 [cited 2015 Sep 14]; 12;109(10):2507-14. Available from:

27. Wuensch A, Tang L, Goelz T, Zhang Y, Stubenrauch S, Song L, et al. Breaking bad news in China--the dilemma of patients' autonomy and traditional norms. A first communication skills training for Chinese oncologists and caretakers. Psychooncology. [Internet]. 2013 [cited 2015 Sep 14]; 22(5):1192-5. Available from:

28.Zamanzadeh V, Rahmani A, Valizadeh L, Ferguson C, Hassankhani H, Nikanfar AR, et al. The taboo of cancer: the experiences of cancer disclosure by Iranian patients, their family members andphysicians. Psychooncology. [Internet]. 2013 [cited 2015 Sep 14]; 22(2):396-402. Available from:

29.Engelhardt EG, Garvelink MM, de Haes JH, van der Hoeven JJ, Smets EM, Pieterse AH, et al. Predicting and communicating the risk of recurrence and death in women with early-stage breast cancer: asystematic review of risk prediction models. J ClinOncol. [Internet]. 2014 [cited 2015 Sep 14]; 20;32(3):238-50. Available from:

30. Fujimori M, Shirai Y, Asai M, Kubota K, Katsumata N, Uchitomi Y. Effect of communication skills training program for oncologists based on patient preferences for communication when receiving bad news: a randomized controlled trial. J Clin Oncol. [Internet]. 2014 [cited 2015 Sep 14]; 10; 32(20):2166-72. Available from:

31.Sep MS, van Osch M, van Vliet LM, Smets EM, Bensing JM. The power of clinicians' affective communication: how reassurance about non-abandonment can reducepatients' physiological arousal and increase information recall in bad news consultations. An experimental studyusing analogue patients. Patient EducCouns. [Internet]. 2014 [cited 2015 Sep 14]; 95(1):45-52. Available from:

32. Fujimori M, Uchitomi Y. Reply to B. Gyawali B. et al. J Clin Oncol. [Internet]. 2015 [cited 2015 Sep 14]; 10;33(2):223-4. Available from:

33. Gyawali B, Tsukuura H, Honda K, Shimokata T, Ando Y. Some questions on the randomized controlled trial of communication skills training for oncologists. J Clin Oncol. [Internet]. 2015 [cited 2015 Sep 14]; 10; 33(2):222. Available from: