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Metoda dialektyczna jako sposób dostarczania złych wiadomości The dialectical method as a way of delivering bad news

Delivering bad news (DBN) to a patient is an enormous challenge and a great mental burden for a doctor. Medical staff members often do not have sufficient skills in this field, or they develop their own techniques. At the same time, proper delivery of information minimises fear in patients and increases their therapeutic engagement and affects treatment results. Although they include protocols that are considered standard in difficult situations, their applicability is usually limited to the particular cultural model in which they were created. Is there any chance to find a relatively culturally stable method of DBN? It seems to be a particularly significant question if we realise the growing rate of social migrations that take place as a part of the globalisation processes. For this reason, we would like to perform and to emphasise the role of the dialectical model of delivering bad news. This method is based on both narrative psychology and the maieutic method, which gradually directs the patient’s awareness of the physical condition he or she is in. For a person who arrives at the truth this way, it is less overwhelming and less hurtful. Through this, our as-sumptions on the dialectical model of DBN may contribute to improving the quality of medical services and patient satisfaction.


INTRODUCTION
Many studies have shown that delivering bad news is a great mental burden for a doctor [1][2][3][4]. Most medical staff members do not have sufficient skills in this field, or they develop their own techni-ques of delivering bad news [5][6][7]. Education at the university or professional level seems to be a relatively effective way of preventing the effects of wrong communication [8,9]. A systemic approach to the problem has positive effects, such as the development of communication skills as well as reduction of stress and occupational burnout [3,10,11]. A proper delivery of information minimises fear in patients, increases their therapeutic engagement, and affects treatment results [12,13].
However, research of this aspect of communication rarely notices that the way bad news is delivered and received is rooted in the sociocultural context. Depending on a culture's axiology, the notification models assume a form that is appropriate for them.
On the grounds of Anglo-Saxon bioethics, where a patient has a right to full knowledge of the diagnosis, prognosis, and possible treatment options, the open communication model is usually used [14].
European deontology requires that the patient's situation is taken into account, and it gives the doctor the right not to give bad information in strictly defined circumstances, unless the patient persistently demands such information [4]. This process needs far-reaching individualisation [15] and, as a consequence, the doctor's advanced competences when it comes to communicating bad news, which, as we know, is problematic [4]. Interestingly, some studies show that notification protocols that have not been adjusted culturally and have just been implemented structurally show little effectiveness. When the SPIKS protocol was used for giving bad news to European patients from Germany, it turned out that such conduct had no good results, which, conversely, can be observed in Anglo-Saxon countries [16].
In Asian models [17] as well as the ones used in Middle Eastern countries the doctor-patient relation has a much more paternalistic character [18]. Yet another take on the asymmetry of the roles may be seen in some Muslim culture references where it is not the patient him or herself but the entire family who collectively takes further decisions concerning treatment [19].
In the face of this data, the question if there is a relatively culturally stable method of delivering bad news seems important. It is particularly significant if we realise the growing rate of social migrations that take place as part of the globalisation processes. This obviously pertains to migrations of not only patients but also doctors. Being shaped and functioning in one socio-cultural system and using health services or practising one's profession in another Kulturkreis can constitute a serious communication barrier.

DIALECTICAL MODEL OF DELIVERING BAD NEWS
It seems to us that a relatively universal way of delivering bad news can be proposed (Table 1). What is more, our proposal refers to the concept suggested by de Walden-Gałuszko based on the explanatory model [20].
Two dialectical traditions form the theoretical foundations for this method. Maieutics is the first one. It is one of the stages of Socratic dialectical method and it constitutes the formal framework of the method. The second one is narrative psychology, which provides the content component for the discussed way of delivering bad news.
In this context, the essence of the maieutic method is that the doctor helps his or her patient discover the truth about their condition on their own. A patient who discovers the truth about his or her condition in the first person not only avoids its dogmatic exposure by his or her doctor but, above all, may assimilate the difficult facts in an easier way [21]. It is assumed in this method that the acceptance of bad news is a process that takes time and has its particular emotional dynamics. De Walden-Gałuszko (2011) emphasises the fact that the difficult truth about the disease is like a medication that has to be administered in appropriate dosages and adjusted to a patient's personal needs and sensitivity [20].
In the dialectical model of giving bad news, just as in the other notification models (SPIKES, BREAKS, PEWTER, COMFORT, etc.), three basic spheres may be indicated: preparation (when), delivering (what), and arrangement (how) [22]. What makes it different from the other model ways of delivering bad news is the individuated way of making conversation. The principles of narrative therapy are its foundation [23]. This communication method is, above all, about creating semantic space for a patient who, with use of the category of his or her own language, names and, at the same time, interprets the condition he or she is in. The job of the doctor is to direct the patient towards the necessary situation of discovering the truth concerning his or her condition but also, and above all, to adopt the patient's categories which, from this moment on, will be used in further communication. The doctor does not impose ultimate and objective truth, which often happens and is manifested in the use of medical language's technical categories. If we construct the world with language [24], then the doctor's job is to help find a way into the world of the patient's disease and then to explore it together with the use of the patient's language's categories. The relationship based on partnership that is rooted in empathic and individuated narrative assumes a gentler assimilation of bad news as well as tension and stress reduction for both doctor and patient. Rita Charon, the author of the term narrative medicine (or illness narrative), emphasises the significance of patients' accounts or stories for the entire therapeutic process. She points out that medicine even requires narrative skills, which are the basis of effective medical practice [25]. The patients' narratives are the elements that allow us to sympathise with them in their illnesses and to immerse our- A warning that the news he or she will be given is not good.
I am sorry, but your results are worse than I have expected. I was really worried by your results.
After the "warning shot" and moving on to the next stage it is worthwhile to remain silent for a moment so that the difficult information is acknowledged by the patient.
Describing the disease.
The tests have shown some atypical cells in your pancreas. I have noticed that new focuses of the disease have appeared.
We provide the description of the disease using simple sentences, without medical terminology. We speak slowly and we are prepared for the patient's interference. At this point, we need to watch the patient's reactions. If there are excess emotional responses, we need to consider offering another appointment. It is important not to label the disease, not to name it but to describe it.
The dialectical process is completed by the patient's specific questions.

Do I have metastases? Does this mean that I have cancer?
The essence of the proposed way of communicating is guiding the patient towards the situation in which he or she defines his or her condition on his or her own. The diagnosis appearing in the awareness of the patient and the patient naming and uttering it is key for this method of communicating bad news. The patients who discover "bad news" in their awareness find it easier to assimilate it. This way of disclosing bad news also reduces the amount and intensity of defence mechanisms. This stage is about confirming the diagnosis. It is important to leave space for the manifestation of the patient's emotions (e.g. crying, sadness, confusion, anger). Allowing silence is also this kind of space.
Expressing support and constructing a proposal of an individual solution for the patient.
I can see you are really worried. I will do my best to help you, and that is why I would like to offer a treatment which is about... I care about your recovery, which is why you need to take the medication I have prescribed you regularly. You may feel bad after them.
They eliminate cancerous cells. Your body's healthy cells will rebuild with time and the cancerous ones will die.
The patient's awareness being taken up by positive images builds the patient's motivation for fighting his or her disease. It is advisable to extend the conversation's key moment by undertaking to give an illustrative description of how the medications work and what the specifics of the therapy as well as the possible side effects are. This reduces the patient's stress and anxiety. It is important that during the explanation of these aspects we indicate the goal that we want to achieve. It must not be forgotten that the detail of such information should be adjusted to the needs and capabilities of the patient. The detailed information concerning the effects of the applied treatment may be discussed during another appointment. If it is possible, it is a good solution to illustrate your statement, for example by drawing what we are talking about, describing the procedure on a 3D model or an image.
selves in their experiences, which seems particularly important in the present Evidence-Based Medicine era. Here, Charon even offered the term Narrative Evidence-Based Medicine, which showed how the two fields complemented each other [26]. It needs to be emphasised that the discussed method has some formal limitations. We must assume that communication skills on a rather advanced level are the condition for its proper use. They include using the paraphrasing technique, a well-developed active listening skill, the competence of attention to words, gestures, or emotions, or the use of solution--focused therapeutic narrative (TSF) elements [27], thanks to which the patient's consciousness may be taken up by positive contents even in the face of the most difficult news. Although we propose the dialectical method as the resolution that can meet the requirements of globalisation and intercultural migration, we are aware that it still demands a doctor to have high cultural competences. Doctors and health workers intend to provide adequate care and proper attention for ethnic minorities; however, they confront many difficulties, among others fear and uncertainty, as well as linguistic barriers and presumptions about cultural issues [28,29]. The presented method also requires particular moral sensitivity, which gains a special meaning in a difficult moment like the one when a doctor is delivering bad news and when the patient's good should constitute the highest value to the doctor [30]. It is worth mentioning that still there is a risk of a refusal to engage with such a process. The implications of such a possibility may be the aforementioned challenges, but also the professionals' lack of self-confidence in terms of communication skills. Hence, it is so impor-tant to work on the progress in this area and improve his or her competences.

CONCLUSIONS
The maieutic method consists of gradually directing the patient's awareness to the physical condition he or she is in. Its assumption is that the patient reaching a relatively mature awareness of his or her condition is a time-consuming process and its dynamics is individual. This method of delivering bad news consists of the truth being gradually released in the patient's awareness by the doctor. For a patient who arrives at the truth this way, it is less surprising and less hurtful. The doctor, on the other hand, can approach the patient in a personalised way and show him or her some real support [31]. What is more, this technique combines the two doctor-patient relation models that are most frequently favoured by patients in the situation of bad news being delivered: the model based on partnership and the one based on dialogue and empathy [32,33].
The authors declare no conflict of interest.

Steps and aim Questions or phrases Description and justification of the interaction
Include the patient in taking further decisions concerning the therapy.
If you have any questions, I am happy to answer them. What do you think about my proposal? If any questions or doubts arise after the appointment, you can write them down. I will try to answer them at the next appointment. Think my proposal over, consult it, please. At the next appointment we can make a decision concerning further treatment.
Indicating our readiness to answer the patient's questions or clarify doubts and bringing the patient into the decision-making mode is a necessary element of communication with the patient. This provides us with information about the patient's emotional condition and his or her preferences when it comes to further therapy. From the patient's point of view, being able to impact the situation results in an increased sense of security.
Summary of the meeting. We have agreed that the following appointment will take place in our Oncology Centre on Wednesday, 30 th April at 12.00 in room number 117. I know this is a difficult situation for you. I will do whatever I can to make you feel better.
During the summary it is good to indicate the planned following steps to the patient in a precise way (using nouns and numerals). We must bear in mind that the impact of stress distorts understanding and memory, so it is a good idea to write down key information about the following visit on a piece of paper that the patient receives. When saying goodbye to the patient, we should express our understanding and support. Adequate haptic signals could emphasise the expressed care and stress the engagement.