In-patient suicide after telephone delivery of bad news to a suspected COVID-19 patient: What could be done to improve communication quality?

Breaking bad news is a critical communication competency for healthcare professionals. Any disclosure of a life-threatening event, such as a malignancy diagnosis, often causes significant stress to patients. While some patients may respond with acceptance and a determination to fight their illness, research has consistently shown that cancer patients often respond to the disclosure of their diagnosis with a range of negative emotions, such as anxiety, distress, and depression [1, 2]. These reactions are often accompanied by feelings of fear, uncertainty, and a sense of loss of control over their lives. Patients may also experience denial, manifesting as reluctance to accept or discuss the diagnosis [3]. Avoidance is another common reaction, where patients may choose to avoid certain situations or people that remind them of their illness [4]. These reactions are not uncommon and are a natural response to the stress and uncertainty of cancer diagnosis.

A common ethical dilemma in breaking a cancer diagnosis is that patients have different preferences and coping mechanisms when dealing with difficult news, and it is important to explore their wish to know about their health condition. Some patients may want to be fully informed about their diagnosis, prognosis, and treatment options, as they believe it empowers them to make decisions and take control of their healthcare. They may also value the opportunity to prepare emotionally and practically for the challenges that lie ahead. However, other patients may prefer to shield themselves from the potentially distressing information [5]. They may prioritize maintaining hope, protecting their mental well-being, or focusing on the present moment rather than dwelling on the future. Previous students showed that different cultures or religions influence how patients perceive the disease, their desire to know about the health condition, or their willingness to accept a diagnosis. For example, in some cultures, cancer is seen as a death sentence, leading to denial or avoidance of diagnosis and treatment [6]. There is a social stigma and gender label attached to cancer, which can lead to shame and embarrassment about the diagnosis [7-9]. Patients may be reluctant to seek medical attention, disclose their diagnosis, or follow through with treatment due to fear of being ostracized or discriminated against.

Remote communication methods like video and phone calls are being used more frequently to prevent the spread of the virus during disease outbreaks, such as the COVID-19 pandemic. It has become more difficult for healthcare professionals to inform patients about their cancer diagnosis. However, giving a cancer diagnosis over the phone can be a challenge since it does not allow for in-person support, and can come across as impersonal and insensitive. Unfortunately, in some cases, delivering bad news can have tragic consequences. One such example occurred during the COVID-19 pandemic in Hong Kong, where an elderly patient, who had been hospitalized in an isolation ward, was informed of his malignancy diagnosis over the phone and subsequently suffocated to death using a plastic bag. This article will examine a real-life suicide case in a hospital after a patient was informed of their cancer diagnosis via telephone and discuss the implications of telecommunication on breaking bad news [10].

The case covers several topics, including healthcare, patient care, cancer diagnosis, COVID-19, isolation protocols, communication with patients and their families, and the importance of addressing pain and sleep issues in healthcare settings. There is no way to know, retrospectively, whether the doctor's choice to disclose the cancer diagnosis via ward telephone contributed to the patient's suicide. Nevertheless, it is worth discussing the appropriacy of breaking bad news via telephone in a hospital setting. This tragic incident highlights the importance of proper patient care and communication during hospital stays.

The COVID-19 pandemic has demonstrated that telecommunication may be necessary when infection control concerns render traditional in-person consultations less preferable. How, then, might we adapt such that bad news can be broken remotely empathetically and skilfully? Various authors have contributed to the discussion on adjustments that can be made to improve remote communication of bad news during the COVID-19 era. Landa-Ramirez et al. proposed a systematic tool to help healthcare providers deliver bad news virtually [27], while Vitto et al. and Gonçalves Júnior, Jucier et al. offered ways in which the SPIKES protocol can be modified to better meet patients' needs during virtual delivery of bad news [15, 28]. Mr. A's cancer diagnosis was delivered via ward telephone. If possible, a communication device with video and audio, such as a smartphone or tablet, is preferred over audio-only communication [29].

Research conducted across different clinical settings has demonstrated that telecommunication with both video and audio is considered superior to audio-only teleconsultations in building rapport, providing visual cues and reassurance, and enhancing communication [30-32]. This sentiment is also shared by clinicians and patients' family members, who believe phone calls are helpful for brief updates. In contrast, video calls are preferable for aligning clinician and family perspectives [24]. Furthermore, it is essential to consider many nonclinical factors that may affect information delivery, such as patient health literacy, religion, social-cultural practice, and language barriers. Relational autonomy is a dominant culture and value in Hong Kong, and family involvement in consultations is highly valued [33]. Allowing the patient to include their loved ones in remote conversations is crucial, especially if the patient is undergoing isolation and has limited opportunities to connect with others. Given the emotionally challenging nature of receiving a cancer diagnosis virtually while being in isolation, mental health professionals or palliative care specialists should also be involved, if necessary, to assist the patient in navigating through the process [1].

Bad news should be delivered in person whenever possible in a clinical setting. When circumstances prohibit information from being delivered promptly and face-to-face, the benefits of breaking bad news in person must be balanced against the disadvantages of delaying information disclosure, which requires a holistic understanding of patients' needs. The tragic incident prompted reflection on the proper use of digitalized technology in the burgeoning telehealth system as a means of health communication. Telemedicine complicates communication in healthcare settings, especially when breaking bad news. Before incorporating teleconsultation as a regular clinical service, individual characteristics (e.g., empathetic listening and observation skills among healthcare providers) and organizational readiness (operational barriers, patient safety, and privacy settings) to adopt videoconferencing should be reviewed and assessed in the local context. This is important in view of global trends to increase the use of telecommunication in healthcare settings and anticipation of future events, such as pandemics, which may necessitate widespread application of telehealth.

The authors contributed equally to the drafting and revision of the manuscript.

The authors declare no conflict of interest.

This study is a theoretical discussion and does not require ethics clearance.

This study does not involve human research participants, and therefore no informed consent was obtained.