Oct 10, 2016
By Shira Klapper, Senior Writer/Editor
Long-accepted practice in Sri Lanka is for doctors to share a patient’s cancer diagnosis, treatment options, and prognosis only with family, and to hide the information from the patient. This practice comes from a deep-rooted cultural belief that family should protect the patient from distressing news, safeguarding him or her from carrying the emotional burden of disease. Wishing to honor the family’s wishes, doctors in Sri Lanka have followed the practice of withholding information from the patient, except in cases when the patient insists on knowing the details of the illness.
However, in the past few decades, many doctors from Sri Lanka have been trained in the West, where they have assimilated the value of being transparent about a patient’s health care status. Many of these doctors began to wonder if there was a way forward for Sri Lanka that would honor families’ wishes and expectations while also being straightforward with patients. This question led Chrishanthi Rajasooriyar, MD, MBBS, along with colleagues from Sri Lanka and Australia, to carry out a study that used qualitative interviews to ask: What are patients’ and families’ expectations in regards to receiving information about diagnosis?
The study, “Breaking Bad News in Ethnic Settings: Perspectives of Patients and Families in Northern Sri Lanka,” published in the Journal of Global Oncology (JGO), August 10, 2016, carried out interviews with 20 patients and 20 family members from the Tamil ethnic group in northern Sri Lanka. The study found that an overwhelming 95% of patients professed a desire to personally hear their cancer diagnosis from medical staff, whereas only 45% of family members believed that the diagnosis should be disclosed to the patient rather than to the family. The most common reason family members cited for wanting the diagnosis to be told to them, rather than the patient, was fear that the patient would become upset.
Commenting on these findings, Dr. Rajasooriyar said, “I never expected that 95% of the patients would say they want the treatment diagnosis, options, and outcomes to be discussed with them. Going into this study, I felt that given the culture, the traditions, and religious background of Sri Lanka, we couldn’t just translate Western practice onto local culture, but in the meantime I also felt that it wasn’t right not to tell anything to the patient. This study might show a way forward in that we can now educate families about the patient’s wish to know the diagnosis.”
When Doctors Don’t Share Diagnoses, Patients Turn to Google
In interpreting the results from the study, Dr. Rajasooriyar cited a technology that often comes up in discussions of cultural disruption: the internet.
“In the old days, people rarely had access to information, and since most medical information was in English, and most people in Northern Sri Lanka don’t speak English, patients had no way of finding out what was wrong. But the internet changed everything. Now, everyone has access to information, and in their native language. So even if we don’t tell patients the diagnosis, they’re going to enter in symptoms and find out on their own.”
Changing Practice in a Culturally-Appropriate Way
As far as next steps, Dr. Rajasooriyar said that medical schools and other schools that train health care providers in Sri Lanka need to emphasize skills on delivering bad news in a way that is culturally appropriate for the cultural context. This will mean including family in all discussions of diagnoses—while also making sure to honor patients’ wishes to know information about their illness.
To change the culture, doctors are not the only ones who will need education on this topic—Dr. Rajasooriyar is working with medical students, as part of their community service projects, to create five- to ten-minute videos geared towards families about the importance of sharing diagnoses with patients; the videos will be played in clinic waiting rooms.
For now, Dr. Rajasooriyar is hopeful that cultural practice will change.
“It will take education and some time, since it’s not very easy to suddenly shift someone’s mindset, but eventually, one day, things will change.”
Chrishanthi Rajasooriyar, MD, MBBS, is an oncologist at Jaffna Teaching Hospital, in Jaffna, Sri Lanka.
Abstract of the original JOP article.
PDF of the original JOP article.
Rajasooriyar C, Kelly J, Sivakumar T, et al. Breaking bad news in ethnic settings: perspectives of patients and families in northern Sri Lanka. J Glob Oncol. Epub August 10, 2016.
The Exclusive Coverage series on ASCOconnection.org highlights selected research from JCO, JGO, and JOP, with additional perspective provided by the lead or corresponding author.
@ 2016 American Society of Clinical Oncology