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J. N. Premi

Communicating Bad News to PatientsSUMMARYThis article reviews the literature ondoctor/patient communication,emphasizing the communication of badnews. Available information supports theview that patients want more informaiionthan they generally receive and that,contrary to popular belief, patients who arebetter informed benefit from theinformation they receive. Physicians areseen as taking a less professional approachto communication activities than to clinicalproblem solving. Some strategies forapproaching the problems identified areoutlined. (Can Fam Physician 1981;27:837-841).

SOMMAIRECet article passe en revue la litt6rature sur la relationm6decin-patient et la transmission de mauvaisesnouvelles. Les rapports disponibles nousdemontrent que les patients desirent plusd'informations qu'ils n'en reVoivent g6nkralement etque, contrairement a la croyance populaire, lespatients qui sont les-mieux informes, profitentdavantage de l'information revue. On constate queles medecins ont moins d'aisance dans leur relation-'-"medecin-patient que dans la solution de probIbmescliniques. Quelques strategies d'approche de laquestion sont soulignees.

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Dr. Premi is an associateprofessor of family medicine atMcMaster University. Reprintrequests to: Chariton FamilyCentre, Ste. 601, 25 Charlton Ave.E., Hamilton, ON. L8N 1Y2.

NJ0 PHYSICIAN likes to detect thel1presence of potentially lethal dis-ease. Such a discovery brings with itthe unpleasant reminder of human vul-nerability and the equally unpleasantquestion as to what to do with thenewly found information. The ques-tion extends far beyond simply "tell-ing" or "not telling" to how much totell, when, and to whom. 'How willthe patient react?' 'Can he handle thisinformation?' 'Who is the best personto tell first-the patient or a relative?''Am I certain enough of my findingsand my interpretation to tell now?' arejust a few of the questions and uncer-tainties that arise under such circum-stances. Notwithstanding the unpleas-antness or difficulties of thesesituations, the discovery of serious dis-ease is a fact of clinical life, a fact withwhich every practicing clinician willbe repeatedly confronted.Given that the communication of

bad news is an integral part of medicalpractice, how does the student or prac-ticing physician acquire the requisiteknowledge to manage these situations?A search of the literature in the area isdiscouraging; little seems to be knownabout the actual process of giving badnews. There is, however, much moreinformation concerning the needs andwants of patients and the effect that re-ceiving bad news has on them. Littleof this information seems to have beenincorporated into the clinical practiceof medicine: the debates that rage arenot over how to give bad news butwhether it is appropriate to do so atall.

Three PositionsThere are at least three distinct posi-

tions on what information to convey topatients who have a serious illness.The first position is that patientsshould always be given full informa-tion regardless of their individual per-ceptions or needs.' Another viewstates exactly the opposite: that underno circumstances should patients. beinformed that they have acquired alethal disease, and that falsehood anddeception should be used if necessary,

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on the basis that the patient needs pro-tection from the tenible reality of ter- *minal illness.2 A third view suggests amore flexible approach, with a varietyof psychological and sociological fac-tors to be taken into consideration, butwithout guidelines as to how thismight be done.3 As Waitzkin andStoeckle4 point out, however, all three-i'positions share one thing in common:they all lack any supporting objectiveevidence, seeming to be based on theauthors' ethical positions and evalua--tive judgments.

Surveys of practicing physicians re-veal that this debate is not carried outat a solely academic level, but is re-flected in clinical practice as well.Two surveys,2 similar in nature butcarried out at different times and indifferent venues, reveal some very in-teresting material. Whereas in 1961the majority of surveyed physicians in-dicated a preference for not telling pa-tients they had cancer, in 1977 a pre-ponderance of those surveyedindicated a preference for exactly theopposite. What is most interesting andrevealing is that the basis on whichthese judgments were made was thesame in both situations, and relatedmore to the physicians' personal pref

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erences and beliefs than to objectivescientific evidence. The data base usedin communication skills is apparentlynot subjected to the same academicscrutiny as other clinical skills.Why the difference? Why would cli-

nicians who pride themselves on theirmeticulous scientific approach to clini-cal problem-solving abandon theseprinciples when dealing with the com-munication of bad news? If there areno firm data to explain this phenome-non, there is certainly no lack of spec-ulation on the matter. It has been sug-gested that physicians avoid discussingserious illness with their patients be-cause they have a subconscious fear ofillness and death. It is further specu-lated that it is this characteristic whichpredetermines their entry into medicalschool, ostensibly to provide them-selves with additional control overthese factors.6 It has also been sug-gested that another major reason forwithholding information from patientsis to maintain additional control overtheir behavior, since patients are muchmore dependent on their physicianswhen they do not have sufficient infor-

7mation to make their own decisions.The temptations to scoff at such ex-

planations, and to disregard the wholearea as being unimportant and un-worthy of further scrutiny is great. Butthe fact remains that poor communica-tion is the most frequent source of pa-tients' dissatisfaction with physicians,and therefore cannot be too lightly dis-missed.4' 8

Acquiring CommunicationSkills

Perhaps the question has not beenposed appropriately. Rather than askwhy they do not perform well, might itnot be better to ask why it would beexpected that physicians should per-form well under such difficult circum-stances? It seems to be assumed thatphysicians will automatically be ableto cope with the unpleasant situationsthey will meet. Fantasies of medicalstudents are more likely to centrearound doing great deeds with theknowledge they have acquired, thanuncovering problems that cannot bepleasantly or amicably resolved. Fur-thermore, topics such as the communi-cation of bad news do not usually ap-pear in the formal curriculum of theundergraduate or postgraduate stu-dent.

In the absence of formal training itis likely that whatever communication

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skills physicians have acquired by thetime they enter practice have eitherbeen self taught or patterned on thoseof their clinical teachers. Opportuni-ties to observe instructors communi-cating bad news are rare. Furthermore,it is likely that these teachers learnedtheir skills in the same way one gener-ation earlier. Considering the issues inthis perspective it may not seem quiteso unreasonable that patients do notsee their physicians as possessing ade-quate communication skills.

Without formal training or anawareness of the scientific informationthat exists in the area, there is littleelse left to do than improvise and de-velop strategies based on personal so-cial experiences acquired before be-coming a professional. Comoroff'makes some important observations onthe manner in which physicians ap-proach communication with patientsand how it differs from their approachto clinical problem solving. The latteris much more likely to be managedthrough the use of rational strategiesthat depend on the conscious mobiliza-tion of scientific knowledge than theformer. Professional communicationsare often managed in the same way associal communications, using rules ofthumb that were developed prior toprofessional training and without ref-erence to scientific information.A physician's behavior is likely to

reflect his training. If there has beenno training, the individual must impro-vise and use his own ingenuity or fallback on skills already developed.Without formal training in the com-munication of bad news many physi-cians apparently adopt their previouslydeveloped ritualized social re-sponses.10

Doing 'The Right Thing'Physicians want to do the right thing

for their patients. The problem is thatthe right thing is not always easy to de-termine and there is always the fright-ening possibility of doing harm. Theseissues are basic in the communicationof bad news and the uncertainty gen-erated by them is often the major de-terminant in the development of clini-cal strategies. While uncertaintycannot be totally eliminated from anyclinical situation, a review of the liter-ature on the needs, wants and re-sponses of patients being told theyhave serious disease is reassuring. Itstrongly suggests that there is room for

a considerable margin of error and thatit is difficult to cause any lasting dam-age. Given sufficient time, almostanyone, it seems, can mobilize theircoping mechanisms to deal with evenblunt or sudden disclosure of painfulinformation.'1' 12

Furthermore, patients do want toknow what is wrong with them and aredissatisfied with the level of informa-tion they generally receive.7' 8, 13However, they have difficulty ininitiating requests for information(those in the lower socioeconomicgroups have greater difficulty thanothers).14 Considering this informa-tion, a patient's failure to ask-ofteninterpreted as an unwillingness toknow-may instead indicate a reluc-tance to initiate the process. Differen-tiation between these two states mayonly be made by providing an opportu-nity and a milieu for the patient toask.

Cassileth15 et al found that not onlydid patients want to know their diag-nosis, but most of them wanted to con-tinue to be informed, and further, toparticipate in the decision-makingabout their ongoing care. Contrary towhat many would expect, this group ofinvestigators found that those whowere best informed and most involvedwere more hopeful than those whowere not. While it is not possible tosay from this that disclosure of infor-mation always promotes hopefulness,it is reassuring to know that it does notexclude or diminish it.

In actuality, the question for physi-cians is not whether to tell the patient,but rather how to have the patient findout. It seems that when patients are notinformed directly about their disease,they are able to acquire the informa-tion in other ways. Often the observa-tion and interpretation of non-verbalbehavior by the health professionalscaring for them, gives many cancer pa-tients the cues from which they willdeduce their problem.16 But it is obvi-ous that patients have many other waysof acquiring information and can bevery proficient in this activity. In aninteresting comparative study betweencardiac and cancer patients Hackettand Weissman17 found that cancer pa-tients knew more about their diseasethan the cardiac patients, even thoughthey had been told less.

No News is Bad NewsProblems do arise, however, when

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patients are left to their own designs toacquire information. The interpreta-tion of such things as non-verbal be-havior and nuances of language isopen to considerable error unless somemeans of validation is available. Manypeople misinterpret unclear informa-tion in such a way as to make it worsethan it really is. In a study aptly titled"No News is Bad News", Reynolds18describes the anxiety and fear gen-erated in patients when they weregiven insufficient information, andmakes a plea for better doctor patientcommunication. She cites a situationin which a patient who was told to ex-pect the worst before her surgerythought the message was that shewould not survive the procedure,rather than the intended message thather lesion was probably malignant.Evidently failure to communicate in-formation clearly under such circum-stances can produce its own set of un-wanted problems.On the other hand, many physicians

express a concern about how patientswill cope with bad news and how theywill cope with the patient if things donot go well. No one wants to cause un-necessary discomfort by revealing toomuch at one time-more than the pa-tient wants to hear or can manage.While the concern is understandable,and in many ways laudable, it does notseem to be founded on fact. Oken2points out in his study that while manystories circulated about the disastrousresults of informing patients abouttheir diagnoses, they were all hearsayand could not be documented by thoserelating them. It also seems that re-ceiving information in a very bluntfashion is not a major problem formost patients, because they are quiteable to cope with it in one way or an-other.1I1The weight of available evidence

then seems to support a position thatdisclosure of bad news is not harmfulto patients, with some evidence sug-gesting that failure to communicateclearly may be. However it does notseem sensible to recommend a courseof action simply because it may notcause harm. Is there any evidenceavailable to suggest that such a policymay be of benefit?

What Happens WhenPatients Are Better Informed?

It has been demonstrated that pa-tients with cancer have difficulty with

relationships and that some of this atleast is caused by the ambivalent feel-ings and behavior to which they aresubjected in their relationships.'0 Ithas also been shown that better in-formed patients cope better with theirdisease, are more compliant to treat-ment, less anxious and generally morefunctional.'5 On the basis of the avail-able evidence, open communicationappears to be of great benefit, givingthe patient an avenue for informationand support.Two studies deal with the effects of

giving preoperative patients informa-tion on their possible postoperativecourse; while the studies do not ad-dress themselves directly to the issueof giving bad news, their findingsseem relevant enough to be taken intoconsideration. Thus Egbert et al19found that when patients were in-structed preoperatively about what toexpect in the postoperative period,they were both more comfortable andrequired less analgesia in this periodthan a comparable group of patientswho were not so instructed. In a moreelaborate study, Janis20 found that pro-viding information preoperatively topatients who had either low or moder-ate anxiety increased their anxietysomewhat in that period but reduced itpostoperatively. Even more important,however, patients with low anxiety inthe preoperative period who were notinstructed had a more stormy post-operative period than would have beenexpected from their preoperative as-sessment. Again the weight of the evi-dence suggests that provision of infor-mation is likely to be bothpsychologically and medically helpfulto the patient.Not a Simple ProblemHow does one differentiate between

those who want to know and thosewho do not? How does one approachthe problem even if the patient has sig-nalled his willingness to know? It ishere that there is the greatest defi-ciency in research and knowledge:only two references in my entire litera-ture review address themselves to theproblems of educating health profes-sionals in this area. Of those, one de-scribed a physician's experience inteaching medical students about thedelivery of bad news;21 the other gavesome common sense advice on how toapproach the problem clinically.22Neither provided any scientific evi-dence for what was offered.

With or without scientific evidence,however, the practicing physicianmust have an approach for managingthose clinical situations in whichserious disease is discovered. Whatcan be distilled from the informationavailable to direct the physician whowished to become more effective inthis area?

It is clear that the circumstances sur-rounding the provision of bad news arenot nearly as volatile as is generallybelieved. Patients cope with bad newsrather well; setbacks are infrequent,and, as a rule, not serious. Placed inthe perspective of the variety and vol-ume of clinical tasks undertaken byphysicians, the communication of badnews has to be seen as a comparativelylow risk activity. Physicians probablytake greater risks, for example, eachtime they write a prescription.

It is also clear that patients will sig-nal their willingness to be informedand involved if given the opportunityto do so. Armed with basic interview-ing skills a physician can use the pa-tient as a regulatory agent who will de-fine the limits about how muchinformation to give and when to giveit. Based on the literature cited, thereis no doubt that patients have opinionsabout what they and others shouldlearn about their condition and willshare this with anyone if given the op-portunity.

Beyond this however, little morehas been documented. Nonetheless, aseries of strategies based on generaltexperience and conventional wisdomcan be used to provide the foundationfor an approach to the communicationof bad news. The fact that many ofthese strategies have not been sub-jected to scientific testing in the classi-cal sense does not make them less use-ful. Many of the thoughts andmaneuvers outlined below haveproven to be a useful way to thinkabout and approach communicationproblems encountered in clinical medi-cine.

Strategies1. Have a plan in mind before start-ing. The communication of bad newsis a difficult activity and cannot beproperly executed by relying on therules of communication utilized in so-cial encounters. Patients will almostcertainly be handicapped to some de-gree during the encounter because offear, and the introduction of uncer-tainty into their lives. The patient will

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likely look to the physician to providesupport and guidance to a greater de-gree than usual. Indeed, a few patientsmay require very directive advice untilthey regain their equilibrium.

Emotions are contagious, and in-tense emotions interfere with clearthinking. In the face of a very upsetpatient the physician who has notthought through his management planbefore introducing the bad newsbegins to feel the pressure of having tosolve problems as well as attend to adistressed patient. Having a set of gen-eral rules about how to manage com-munication of bad news and having atentative management plan for the spe-cific problem before beginning theprocess leaves the physician free todeal with what happens in the here andnow, rather than having to think aboutroutine matters.

For example, if a breast lump is en-countered during examination of awell woman, the patient will verylikely be upset as the specter of cancerwill be raised in her mind.23 24 Whatshould she be told? How certain is thediagnosis? What further informationwill be required? A mammogram? Abiopsy? Or a repeat examination afterthe next period? If this decision ismade before beginning the dialogue,the physician will appear much moreconfident of what is to be done. Themanagement plan can be changed ifthe patient is not satisfied or if new in-formation comes up-but it will likelybe changed less using this approachthan if the problem is thought throughwhile the process of informing is un-derway.

It is, however, probably very impor-tant to provide the patient with a man-agement plan of some kind during anencounter in which bad news isbroken. Recent evidence29 suggeststhat health related problems favoremotion-focused coping, and that situ-ations assessed as unalterable-orwhere no action can be taken-alsofavor this kind of response. On theother hand situations assessed as re-quiring more information or in whichsomething constructive can be donefavor problem-focused responses.Based on this information, a physicianmay be able to direct a patient's copingresponse toward problem-solving ac-tivities and away from emotional reac-tions by identifying and emphasizingthose aspects of the problem that lendthemselves to action or to informationgathering.

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2. Give the patient control over thequantity and timing of the informationhe receives. Even the patient whowants to know everything usually doesnot want to hear it all at once. A strat-egy commonly used by experiencedphysicians is to start the communica-tion with very vague or euphemisticterms and become more specific as thepatient asks for more information.25Such an exchange may go as follows:

"During my examination I found athickening (lump, mass) in your rec-tum that I think requires further atten-tion."

"Oh, is it serious?""I don't know yet, but it could

be.""Well what do you think it is?""I can't be sure yet, but it feels very

much like a tumor.""A tumor! What kind of tumor?""I'll have to arrange some further

tests before I can answer that for cer-tain, but it could be a malignanttumor.""Are you telling me I have

cancer?""No. But I am telling you you

might have cancer."This particular conversation took

place in the space of a few minutes butit could stop anywhere along the wayand be resumed a day or a week later.Some patients don't want to knowuntil the physician is certain of thediagnosis. The essential point is, how-ever, that the patient will respond tothe physician's lead and will give theclues as to how the physician shouldproceed.

Another strategy that can be veryuseful is to ask the patient how muchhe wants to know before the investiga-tion is started. If a man has hemoptysishe may indicate his wish to discuss thefindings of his bronchoscopy fully ormay indicate his willingness to takewhatever suggestions are made fortreatment without hearing about thespecifics of the diagnosis. Knowingthe patient's wishes before the investi-gation starts makes the subsequentcourse of action much easier to de-velop.

It is also important to tailor informa-tion to each patient's concerns, knowl-edge and experience, because this re-duces the risk of causing unnecessaryworry or discomfort. A patient who istold he has a carcinoma of the trans-verse colon may have more concernsabout having a colostomy than havingcancer per se. It is only by asking the

patient about his specific concerns thatthis can be determined.3. Allow the patient time to integrateinformation. Even in situations wherenon-fatal illness is being discussed,there is a limit to the amount of infor-mation that patients can incorporate atany given time.26' 27As the seriousnessof the illness becomes greater, so doesthe potential impact on the patientwhich in turn will diminish the indi-vidual's ability to hear and incorporatenew information.

It is a common experience for physi-cians that having informed a patient ofthe possibility of a malignant lesion,and having then fully explained theimplications of the illness and a rec-ommended course of action, to dis-cover the next day that the patient isasking the same questions, often giv-ing the impression that the matter hasnot been discussed at all.

In the uncomfortable circumstancesof telling bad news, there is a tendencyto tell it all in the first encounter and'get it over with'. Such a strategy isoften not only inefficient because repe-tition will be necessary, but sometimescounter-productive-the patient mayselectively hear the negative aspects ofthe information and retain a gloomierpicture than is warranted by the facts.4. Soften the bad news with goodnews-or at least hope. It seems diffi-cult if not impossible when confrontedwith having to tell someone they havecancer that anything good would beconveyed. It is indeed rare, however,even with the most serious illness thatthere is not something about which tobe hopeful. A malignant lesion in thebreast is never good news, but it is notas bad as a malignant lesion with axil-liary lymph node involvement, or iflymph nodes are involved this is not sobad as secondary disease in distantsites. In her classical descriptivestudy, Kiibler-Ross16 found that pa-tients wanted and were appreciative ofany information that provided hope.

Certainly, the more advanced thedisease the poorer the prognosis, butno one can be sure which patient willdo well in spite of the severity of thedisease. Boyd describes a patient withcarcinoma of the rectum who survivedfor 17 years after the lesion was judgedto be inoperable.28 While the patientmust be allowed the awareness of theseverity of his illness, he is also enti-tled to know that there are exceptionsto the rule.

For each individual, the distance be-

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tween being and not being on this earthis infinite. While everyone knows thatthose who are born must also die, thisremains essentially academic until oneis confronted directly with one's ownmortality. Making the journey fromimmortality to mortality is painful andtakes time. One of the commonly usedmechanisms to buffer this process isdenial.

Denial is an adaptive mechanismsometimes seen by physicians as beinguniversally bad and therefore a maneu-ver that is not permitted under any cir-cumstances. Admittedly, denial can bea pernicious mechanism when it be-comes the major adaptive maneuverfor coping with the everyday world.But as Kiibler-Ross16 has describedand Lazarus12 points out, denial is anessential and normal adaptive mecha-nism under certain circumstances. Itcan buy time and comfort for the pa-tient -while he completes his underly-ing grief work and is thereby betterable to confront the realities of the sit-uation. Supporting a patient's denialwhile he is incorporating bad newsmay be not only humanitarian, but alsoconstructive.5. Never tell the patient a falsehood.At first glance this particular recom-mendation seems to be contradictoryto what has already been said, particu-larly in regard to the comments on de-nial. But further scrutiny will revealthat this is not so.

Not telling a falsehood must not beequated with unsolicited full disclo-sure of all the known facts. A questionof initiative is raised, as well as theconsideration of whose needs are to beserved by the information.

Patients need information to makeintelligent decisions about their owntreatment, but they do not need toknow all the details about the courseand prognosis of their disease to do so.Patients also need more general infor-mation about their illness and how itmight affect them, so that they canplan for the future.

Physicians feel a responsibility toprovide sufficient information so thatthe patient will be able to take the re-sponsibility for these decisions. Physi-cians also frequently express a need toprovide more information so that theywill not be held accountable if thecourse of illness is worse than origi-nally predicted. Unfortunately, theonly way to be absolutely certain thatthis does not occur is to predict theworst possible prognosis for all pa-

tients, a course of action few physi-cians would care to follow.One way to avoid th'is apparent bind

is to differentiate between the prog-nosis for the disease in question an'dfor this patient in particular. It can bemade clear to the patient that one canonly speculate, and not accurately pre-dict, the course of his own illness andthat the information being offered isabout the natural history of his diseaseand not him. Within this framework itis possible to respond to even the mostpointed questions truthfully and stillleave room for hope. If most patientswith carcinoma of the rectum have co-lostomies, not all do. If the prognosisfor carcinoma of the stomach is lessthan five percent survival at five years,there are still some individuals withthe disease who are alive at the end offive years.A more general perspective of this

point is encompassed in the storyabout the difference between optimistsand pessimists. A pessimist sees a halfglass of water as half empty while theoptimist sees it as half full. While halfof a glass of water iN a finite quantity,there are choices in the way in which itcan be described and the choice madeby the physician can have a real impacton the patient's morale.

No Golden RulesBernard Shaw is supposed to have

said that "the only golden rule is thatthere are no golden rules". This seemsparticularly relevant to the communi-cation of bad news. Each patient, eachphysician, and each situation is dif-ferent and the flexible use of any strat-egy will be the only appropriate basison which to approach the problem.The communication of bad news willnever be pleasant, but it can berewarding for the physician whoknows that his planning, and his com-munication skills have made the situa-tion a little less unpleasant for the pa-tient.

References1. Eustene AC: Explaining to the patient:A therapeutic tool and a professional obli-gation. JAMA 1957; 165:1110-1113.2. Oken D: What to tell cancer patients.JAMA 1961; 175:1120-1128.3. Blumgart HL: Caring for the patient.N Engl J Med 1964; 270:449456.4. Waitzkin H, Stoeckle JD: Inforrationcontrol and the micropolitics of healthcare: Summary of an ongoing researchproject. Soc Sci Med 1976; 10:263-276.S. Novack DH, et al: Changes in physi-

cians' attitudes toward telling the canctgrpatient. Jh4MA 1979; 241:897-900.6. White LP: The self image of the physi-cian and the care ofdying patients. Ann NYAcad Sci 1969; 164:822-831.7. Waitzkin H, Stoeckle JD: The communi-cation of information about illness. AdvPsychosom Med 1972; 8:180-215.8. Stimson G, Webb B: Going to see thedoctor. London, Routledge and KeganPaul, 1975.9. Comaroff J: Communicating informa-tion about non fatal illness: The strategiesof a group of general practitioners. SociolRev 1976; 24:269-290.10. Wortman CB, Dunkel-Schetter C: In-terpersonal relationships and cancer: Atheoretical analysis. J Soc Issues 1979;35:120-155.11. Aitken-Swan J, Easson EC: Reactionsofcancer patients on being told their diag-nosis. Br Med J 1959; 1:779-783.12. Lazarus RS: Positive denial: The casefor not facing reality. Psychology Today1979; 13:4445.13. McIntosh J: Processes of communica-tion: Information seeking and control asso-ciated with cancer. Soc Sci Med 1974;8:167-187.14. Boreham P, Gibson D: The informa-tive process in private medical consulta-tions: A preliminary investigation. Soc SciMed 1978; 12:409416.15. Cassileth BR, et al: Information and-participation preference among cancer pa-tients. Ann Intern Med 1980; 92:832-836.16. Kubler-Ross E: On Death and Dying.New York, MacMillan Publishing Co.,1969.17. Hackett TP, Weissman AD: Denial asa factor in patients with heart disease andcancer. Ann NY Acad Sci 1969; 164:802-811.18. Reynolds M: No news is bad news: Pa-tients views about communication in hospi-tal. Br Med J 1978; 1:1673-1676.19. Egbert LD, et al: Reduction of post-operative pain by encouragement and in-struction ofpatients. N Engl J Med 1964;270:825-827.20. Janis IL: Psychological Stress. NewYork, Academic Press, 1974.21. Souhami BL: Teaching what to sayabout cancer. Lancet 1978; 2:935-936.22. Baird E: Breaking bad news to elderlypatients. Patient Care 1975; 9:102-117.23. Paterson R, Aitken-Swan J: Publicopinion on cancer. Lancet 1954; 2:857-861.24. Public opinion survey: Public att-tudes toward cancer. Ca: A Cancer Jour- .

nalfor Clinicians 1980; 30:92-98.25. Holland J: Understanding the cancerpatient. Ca: A Cancer Journal for Clini-cians 1980; 30:103-112.26. Ley P, Spelman MS: Communicationin an outpatient setting. Br J Soc ClinPsycho 1965; 4:114-116.27. Kupst MJ, et al: Evaluation ofmethods to improve communication in thephysician-patient relationship. Am J Orth-opsychiatr 1975; 45:420428.28. Boyd W: A Textbook ofPathology, ed5. Philadelphia, Lea and Febiger, 1947.29. Folkman 5, Lazarus RS: An analysis-ofcoping in a middle aged community sam-ple. J Health Soc Behavior 1980; 21:219-239.

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