Abstract

This integrative literature review investigates the delivery of bad news in pediatrics. Scientific database search included studies published between 2015 and 2022, which indicate that bad news should be disclosed in an empathetic, objective and frank manner, involving both the child and their caregiver, but partial and adapted to the child’s understanding or maturity. Finally, this study brings suggestions and scientific evidence about delivering bad news in pediatrics, contributing to further enrich knowledge on the subject, especially for the healthcare professionals who deal directly with this context.

Health communication; Child health; Pediatrics

Resumo

Este estudo investiga a transmissão de más notícias em contexto infantil por meio de revisão integrativa da literatura. As buscam nas bases de dados científicas compreenderam trabalhos publicados de 2015 a 2022 e os resultados indicaram que a transmissão de más notícias deve ocorrer de forma empática, objetiva e franca, envolvendo tanto a criança como os acompanhantes, mas, no caso de crianças, a comunicação deve ser parcial, com adequação do conteúdo ao entendimento ou maturidade. Por fim, este estudo visou trazer sugestões e evidências científicas sobre a transmissão das más notícias na infância, contribuindo ainda para enriquecer o conhecimento sobre o assunto, principalmente para os profissionais de saúde que lidam diretamente com esse tipo de situação.

Comunicação em saúde; Saúde da criança; Pediatria

Resumen

Este estudio evalúa la transmisión de malas noticias en el contexto infantil mediante una revisión integradora de la literatura. La búsqueda en bases de datos científicas incluyó artículos publicados entre 2015 y 2022, y los resultados revelan que la transmisión de malas noticias debe realizarse de forma empática, objetiva y franca, implicando tanto al niño como a los cuidadores, pero en el caso de los niños, la comunicación debe ser parcial, adaptando el contenido a su comprensión o madurez. Por último, este estudio pretende aportar sugerencias y evidencias científicas sobre la transmisión de malas noticias en la infancia, a la vez busca contribuir con más conocimiento sobre el tema, especialmente para los profesionales de la salud que tratan directamente con este tipo de situaciones.

Comunicación en salud; Salud infantil; Pediatría

When talking about bad news, the human body naturally reacts with a rush of adrenaline and noradrenaline, neurotransmitters that prepare it for emotions such as fear, anxiety, and stress. This is a defense mechanism since the organism presents the same type of response to dangers found in the environment ¹1. Margis R, Picon P, Cosner AF, Silveira RO. Relação entre estressores, estresse e ansiedade. Rev Psiquiatr Rio Gd Sul [Internet]. 2003 [acesso 15 mar 2023];25(1):65-74. DOI: 10.1590/S0101-81082003000400008
https://doi.org/10.1590/S0101-8108200300... .

An example of a stressful situation is receiving bad news in healthcare institutions, identified since the diagnosis, as there are situations that can drastically and negatively change the patient’s expectations for the future ²2. Sancho MG. Cómo dar las malas notícias em medicina. 3ª ed. Madrid: ARAN; 2006.. As part of the subjective scope, reactions to bad news are perceived by different people with different levels and intensities, being influenced by a series of factors such as personality, family and social support, religion, culture, and experiences of each person ³3. Lopes CR, Graveto JMG. Comunicação de notícias: receios em quem transmite mudanças no que recebem. REME Rev Min Enferm [Internet]. 2010 [acesso 15 mar 2023];14(2):257-63. Disponível: https://bit.ly/46tRRJK
https://bit.ly/46tRRJK... .

Furthermore, communication is a process of assimilation and interpretation of information, concurrently to a sharing of emotions between transmitter and receiver. In this sense, communicating is a fundamental skill, but the process of communicating bad news is a difficult task. It is necessary to identify one’s own emotions and those of the other person for an efficient interaction, not affecting either party critically ⁴4. Pereira MAG. Comunicação de más notícias e gestão do luto [dissertação] [Internet]. Porto: Universidade do Porto; 2008 [acesso 15 mar 2023]. Disponível: https://tinyurl.com/cpfvwv9y
https://tinyurl.com/cpfvwv9y... .

Many professionals have difficulty informing the actual health conditions of the patient or their family members. These situations are complex, and some physicians find it difficult to express their feelings, as they confuse empathy and involvement in the demands of professional limits, making assertive communication with patients and family members complex ⁵5. Diaz FG. Comunicando malas noticias en medicina: Recomendaciones para hacer de la necesidad virtud. Med Intensiva [Internet]. 2006 [acesso 15 mar 2023];30(9):452-9. Disponível: https://bit.ly/456Ulg1
https://bit.ly/456Ulg1... .

The complexity of transmitting bad news extends to the children’s context, where there are debates about the specificities of communication, as transmitting this type of information to a child or adolescent can involve ethical, social, and legal aspects. In this sense, communicating bad news to pediatric patients causes dilemmas for healthcare professionals. Physicians often find themselves with their hands tied due to the impossibility of transmitting information when considering factors such as the child’s age, maturity, and understanding, or even the parents’ annoyance ⁶6. Massignani LRM. Más notícias: o processo de comunicação do médico a crianças e adolescentes hospitalizados [dissertação] [Internet]. Florianópolis: Universidade Federal de Santa Catarina; 2007 [acesso 15 mar 2023]. Disponível: https://tinyurl.com/3rka8359
https://tinyurl.com/3rka8359... .

It should also be noted that, in addition to the aforementioned obstacles, capable of interfering in the communication process, it is necessary to assess the understanding of the news transmitted to the guardian/family member, thus analyzing their decision-making capacity. Furthermore, it is required to consider that communicating bad news becomes an arduous responsibility for healthcare professionals. This process demands sensitivity and ethics to decide the best way and time to inform the child or adolescent of bad news, primarily if it is related to a diagnosis or prognosis ⁶6. Massignani LRM. Más notícias: o processo de comunicação do médico a crianças e adolescentes hospitalizados [dissertação] [Internet]. Florianópolis: Universidade Federal de Santa Catarina; 2007 [acesso 15 mar 2023]. Disponível: https://tinyurl.com/3rka8359
https://tinyurl.com/3rka8359... .

The way the disease is seen culturally and the justification of protecting the patient from their diagnosis or prognosis as attempting to prevent suffering are also essential factors. These factors can interfere with the transmission of information and the patient’s participation in decision-making. However, a study shows that telling the truth has proven to be an essential therapeutic resource, reducing the feeling of isolation and contributing to cooperation between patient and professional ⁷7. Gulinelli A, Aisawa RK, Konno SN, Morinaga CV, Costardi WL, Antonio RO et al. Desejo de informação e participação nas decisões terapêuticas em caso de doenças graves em pacientes atendidos em um hospital universitário. Rev Assoc Med Bras [Internet]. 2004 [acesso 15 mar 2023];50(1):41-7. DOI: 10.1590/S0104-42302004000100033
https://doi.org/10.1590/S0104-4230200400... .

The transmission of bad news is a subject widely identified in healthcare facilities. However, it is little addressed in scientific studies or even during academic training, highlighting the importance of further investigations. Therefore, this work aims to identify and analyze scientific evidence on how bad news is communicated in children’s context. Furthermore, when relating to the theme and the universe of children, the study brings ethical debates and suggestions based on scientific evidence on how bad news should be transmitted in the pediatric setting.

Method

This research is composed of an integrative review of the literature, that is, it aims to synthesize results obtained in research on the topic systematically, orderly, and comprehensively ⁸8. Ercole FF, Melo LS, Alcoforado CLGC. Revisão integrativa versus revisão sistemática. REME Rev Min Enferm. 2014 [acesso 15 mar 2023];18(1):20e936. DOI: 10.5935/1415-2762.20140001
https://doi.org/10.5935/1415-2762.201400... . For the operationalization of this study, six steps were considered: 1) identification of the topic and selection of the guiding question; 2) establishment of inclusion and exclusion criteria; 3) selection of articles; 4) categorization of articles; 5) analysis of studies; and 6) synthesis of knowledge ⁹9. Cardoso RB, Caldas CP, Souza PA. Uso da teoria do conforto de Kolcaba na implementação do processo de enfermagem: revisão integrativa. Rev Enferm Atenção Saúde [Internet]. 2019 [acesso 15 mar 2023];8(1):118-28. DOI: 10.18554/reas.v8i1.2758
https://doi.org/10.18554/reas.v8i1.2758... .

The literature search was carried out in the SciELO, LILACS, PubMed, and MEDLINE databases in the first quarter of 2023 and comprised articles published from 2015 to 2022. The following descriptors and their combinations in Portuguese and English were used to search for articles: “health communication and child health or pediatrics”; and “transmission of bad news and child health or pediatrics,” controlled and arranged in the Health Sciences Descriptors of the Virtual Health Library (DeCS/BVS) and the Medical Subject Headings, of the National Library of Medicine (MeSH/NLM).

National and international articles whose content was available in full and free of charge were included within the established timeframe. Duplicates, case studies, those that did not directly relate to the topic, and those with insufficient information were discarded.

Initially, a survey of all the materials found was carried out, and then the abstracts were read to determine which met the established criteria. The articles chosen were critically and cautiously read to understand how literature presents itself concerning the topic studied. Once these steps were completed, the material was analyzed to address the main contributions of this research.

Results

Ten articles were selected that met the review criteria. A few national and international articles cover the communication of bad news in a pediatric context, given the scope and difficulty of dealing with the topic in the hospital context. PRISMA ¹⁰10. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD et al. A declaração Prisma 2020: diretriz atualizada para relatar revisões sistemáticas. Epidemiol Serv Saúde [Internet]. 2022 [acesso 15 mar 2023];31(2):e2022107. DOI: 10.1590/s1679-49742022000200033
https://doi.org/10.1590/s1679-4974202200... flowchart was used to present the processes of study selection and identification (Figure 1).

Most of the excluded publications were related to health communication in general, focused on the diagnosis itself, and without specific thematic involvement with bad news or children’s health. Research, especially articles that involve questions about bad news, is constantly related to pedagogical perspectives during undergraduate studies and/or residency, generally for physicians. Therefore, it is essential to highlight that the specific topic of news transmission in pediatrics requires further studies.

Most of the studies selected are qualitative (50%) and integrative reviews (20%), while cross-sectional (10%), bibliographic (10%), and methodological (10%) studies reached the same proportion. Studies in medicine prevail, although one of them is in nursing. To facilitate understanding, Chart 1 briefly presents the selected articles with the following information: authorship, year, objective, method, and main results.

The results showed that the transmission of bad news must occur in a scenario that involves empathy, objectivity, and frankness and that both the child and companions must be involved. For children, communication must be partial, with the content of the diagnosis or prognosis being adapted to the understanding or maturity of the child. Thus, the child is treated as a subject of rights, with autonomy in their health-disease process ¹¹11. Afonso SBC, Minayo MCS. Relações entre oncohematopediatras, mães e crianças na comunicação de notícias difíceis. Ciênc Saúde Colet [Internet]. 2017 [acesso em 15 de mar 2023];22(1):53-62. DOI: 10.1590/1413-81232017221.14592016
https://doi.org/10.1590/1413-81232017221...

12. Gonçalves SP, Forte IG, Setino JA, Cury PM, Salomão JB Jr, Miyazaki MCOS. Comunicação de más notícias em pediatria: a perspectiva do profissional. Arq Ciênc Saúde [Internet]. 2015 [acesso 15 mar 2023];22(3):74-8. Disponível: https://bityli.com/HVoWn6
https://bityli.com/HVoWn6...

13. Zanon BP, Cremonese L, Ribeiro AC, Padoin SMM, De Paula CC. Comunicação de más notícias em pediatria: revisão integrativa. Rev Bras Enferm [Internet]. 2020 [acesso 15 mar 2023];73(4):e20190059. DOI: 10.1590/0034-7167-2019-0059
https://doi.org/10.1590/0034-7167-2019-0...

14. Soeiro ACV, Teixeira RS, Celidônio TG, Lustosa, MM, Fonseca DC. Bioética e comunicação de más notícias em oncologia pediátrica: experiência em um hospital público. Artigos.Com [Internet]. 2020 [acesso 15 mar 2023];16:e3298. Disponível: https://tinyurl.com/544e3edn
https://tinyurl.com/544e3edn...

15. Santos LF, Oliveira LMAC, Munari DB, Barbosa MA, Peixoto MKAV, Nogueira ALG. Quando a comunicação é nociva no encontro entre profissional e família da criança hospitalizada. Enferm Glob [Internet]. 2015 [acesso 15 mar 2023];(37):204-15. Disponível: https://bityli.com/45354L
https://bityli.com/45354L...

16. Fontes CMB, Menezes DV, Borgato MH, Luiz MR. Comunicação de más notícias: revisão integrativa de literatura na enfermagem. Rev Bras Enferm [Internet]. 2017 [acesso 15 mar 2023];70(5):1089-95. DOI: 10.1590/0034-7167-2016-0143
https://doi.org/10.1590/0034-7167-2016-0...

17. Setubal MSV, Goncalves AV, Rocha SR, Amaral EM. Programa de treinamento para comunicação de más notícias baseado em revisão de vídeos e na estratégia Spikes: o que pensam os residentes de perinatologia? Rev Bras Ginecol Obstet [Internet]. 2017 [acesso 15 mar 2023];39(10):552-9. DOI: 10.1055/s-0037-1604490
https://doi.org/10.1055/s-0037-1604490...

18. Zampoli ACM. Comunicação com familiares de pacientes em cuidados paliativos perinatais. Pleiade [Internet]. 2018 [acesso 15 mar 2023];12(26):125-31. Disponível: https://tinyurl.com/5sfkur7c
https://tinyurl.com/5sfkur7c...

19. Soeiro ACV, Vasconcelos VCS, Silva JAC. Desafios na comunicação de más notícias em unidade de terapia intensiva pediátrica. Rev. bioét. (Impr.) [Internet]. 2022 [acesso 15 mar 2023];30(1):45-53. DOI: 10.1590/1983-80422022301505PT
https://doi.org/10.1590/1983-80422022301... -²⁰20. Zanon BP, Paula CC, Ribeiro AC, Pandoin SMM. Validação de conteúdo para subsidiar o acompanhamento da revelação do diagnóstico de HIV na infância. Rev Bras Enferm [Internet]. 2022 [acesso 15 mar 2023];75(supl 2):e20210027. DOI: 10.1590/0034-7167-2021-0027
https://doi.org/10.1590/0034-7167-2021-0... .

Discussion

Communicating bad news is one of the most challenging tasks in clinical practice among healthcare professionals ²¹21. Pereira ATG, Fortes IFL, Mendes JMG. Comunicação de más notícias: revisão sistemática da literatura. Rev Enferm UFPE On Line [Internet]. 2013 [acesso 15 mar 2023];7(1):227-35. DOI: 10.5205/1981-8963- v7i1a10226p227-235-2013
https://doi.org/10.5205/1981-8963-v7i1a1... . In this regard, some studies are conducted to discover the best way to carry it out. Based on the findings of this review, it is highlighted that many of the works focus on recommendations on aspects seen as fundamental in communication.

Among such recommendations are offering emotional support ¹²12. Gonçalves SP, Forte IG, Setino JA, Cury PM, Salomão JB Jr, Miyazaki MCOS. Comunicação de más notícias em pediatria: a perspectiva do profissional. Arq Ciênc Saúde [Internet]. 2015 [acesso 15 mar 2023];22(3):74-8. Disponível: https://bityli.com/HVoWn6
https://bityli.com/HVoWn6... , transmitting the news in an empathetic, honest, and objective way ¹³13. Zanon BP, Cremonese L, Ribeiro AC, Padoin SMM, De Paula CC. Comunicação de más notícias em pediatria: revisão integrativa. Rev Bras Enferm [Internet]. 2020 [acesso 15 mar 2023];73(4):e20190059. DOI: 10.1590/0034-7167-2019-0059
https://doi.org/10.1590/0034-7167-2019-0... , and maintaining the hope of the patient and family in the treatment ¹⁶16. Fontes CMB, Menezes DV, Borgato MH, Luiz MR. Comunicação de más notícias: revisão integrativa de literatura na enfermagem. Rev Bras Enferm [Internet]. 2017 [acesso 15 mar 2023];70(5):1089-95. DOI: 10.1590/0034-7167-2016-0143
https://doi.org/10.1590/0034-7167-2016-0... . From this perspective, the authors emphasize that the healthcare team must transmit the information to children and adolescents, except that, in cases of very young children who cannot fully understand the situation, the transmission must be directed to their family ¹¹11. Afonso SBC, Minayo MCS. Relações entre oncohematopediatras, mães e crianças na comunicação de notícias difíceis. Ciênc Saúde Colet [Internet]. 2017 [acesso em 15 de mar 2023];22(1):53-62. DOI: 10.1590/1413-81232017221.14592016
https://doi.org/10.1590/1413-81232017221... .

Children usually are partially informed about bad news, considering their age and level of understanding, which supports this result ¹²12. Gonçalves SP, Forte IG, Setino JA, Cury PM, Salomão JB Jr, Miyazaki MCOS. Comunicação de más notícias em pediatria: a perspectiva do profissional. Arq Ciênc Saúde [Internet]. 2015 [acesso 15 mar 2023];22(3):74-8. Disponível: https://bityli.com/HVoWn6
https://bityli.com/HVoWn6...

13. Zanon BP, Cremonese L, Ribeiro AC, Padoin SMM, De Paula CC. Comunicação de más notícias em pediatria: revisão integrativa. Rev Bras Enferm [Internet]. 2020 [acesso 15 mar 2023];73(4):e20190059. DOI: 10.1590/0034-7167-2019-0059
https://doi.org/10.1590/0034-7167-2019-0... -¹⁴14. Soeiro ACV, Teixeira RS, Celidônio TG, Lustosa, MM, Fonseca DC. Bioética e comunicação de más notícias em oncologia pediátrica: experiência em um hospital público. Artigos.Com [Internet]. 2020 [acesso 15 mar 2023];16:e3298. Disponível: https://tinyurl.com/544e3edn
https://tinyurl.com/544e3edn... . It is also necessary to highlight the importance of talking to parents or guardians to make a joint decision about the amount of information and how to provide it ¹²12. Gonçalves SP, Forte IG, Setino JA, Cury PM, Salomão JB Jr, Miyazaki MCOS. Comunicação de más notícias em pediatria: a perspectiva do profissional. Arq Ciênc Saúde [Internet]. 2015 [acesso 15 mar 2023];22(3):74-8. Disponível: https://bityli.com/HVoWn6
https://bityli.com/HVoWn6... .

In contrast, there are cases in which the healthcare professional faces an ethical impasse, such as when family members request not informing the patient’s health status to the children themselves ²²22. Lino CA, Augusto KL, Oliveira RAS, Feitosa LB, Caprara A. Uso do protocolo Spikes no ensino de habilidades em transmissão de más notícias. Rev Bras Educ Med [Internet]. 2011 [acesso 15 mar 2023];35(1):52-7. DOI: 10.1590/S0100-55022011000100008
https://doi.org/10.1590/S0100-5502201100... , often to “protect them” ⁶6. Massignani LRM. Más notícias: o processo de comunicação do médico a crianças e adolescentes hospitalizados [dissertação] [Internet]. Florianópolis: Universidade Federal de Santa Catarina; 2007 [acesso 15 mar 2023]. Disponível: https://tinyurl.com/3rka8359
https://tinyurl.com/3rka8359... . There are also circumstances in which the family pretends that nothing bad is happening and feigns ignorance, a simulation often reciprocated by the patient attempting to avoid worrying the family. Such situations increase isolation and prevent patients from talking openly about their condition, a process that, for them, can be fundamental ²³23. Leal F. Transmissão de más notícias. Rev Port Med Geral Fam [Internet]. 2013 [acesso 15 mar 2023];19(1):40-3. DOI: 10.32385/rpmgf.v19i1.9903
https://doi.org/10.32385/rpmgf.v19i1.990... .

In such situations, healthcare professionals must develop new attitudes to produce the beneficial effects of keeping children informed about their health status. Transmission must respect the uniqueness of each child, according to their stage of development, their demands, their possibilities of understanding, and their “time” ²⁴24. Lecussán P. A criança e o diagnóstico: o pediatra deve contar à criança doente seu diagnóstico? Rev Assoc Med Bras [Internet]. 2001 [acesso 15 mar 2023];47(4):269-95. DOI: 10.1590/S0104-42302001000400017
https://doi.org/10.1590/S0104-4230200100... . Accordingly, scholars ²⁵25. Marcon C. A consulta pediátrica e os aspectos comunicacionais entre o médico residente, a criança e sua família [dissertação]. Florianópolis: Universidade Federal de Santa Catarina; 2003.,²⁶26. Young B, Dixon-Woods M, Windridge KC, Heney D. Managing communication with young people who have a potentially life threatening chronic illness: qualitative study of patients and parents. BMJ [Internet]. 2003 [acesso 15 mar 2023];326:305-10. DOI: 10.1136/bmj.326.7384.305
https://doi.org/10.1136/bmj.326.7384.305... concluded that parents and professionals must give due importance to the patient’s desire to be involved, although the needs of the parents and the patient may differ.

Minimizing factors such as noise and/or communication failures is essential in this scenario ¹³13. Zanon BP, Cremonese L, Ribeiro AC, Padoin SMM, De Paula CC. Comunicação de más notícias em pediatria: revisão integrativa. Rev Bras Enferm [Internet]. 2020 [acesso 15 mar 2023];73(4):e20190059. DOI: 10.1590/0034-7167-2019-0059
https://doi.org/10.1590/0034-7167-2019-0... . Noise is associated to the professional’s inability to deal with emotions, whether their own or the patient’s, and to the use of a language inaccessible to the family. The failures are related to techniques that are not significant during transmission, such as silencing and the transmission of misleading information.

Such deficiencies can affect the patient’s understanding of their health status, increasing anxiety, hindering their psychological adjustment, and causing distrust. In other words, failure to provide information interferes with adequate understanding and leads to several obstacles in adherence to treatment. On the other hand, the correct way of reporting reduces patient uncertainty and contributes to acceptance of the disease ²⁷27. Vogel KP, Silva JHG, Ferreira LC, Machado LC. Comunicação de más notícias: ferramenta essencial na graduação médica. Rev Bras Educ Med [Internet]. 2019 [acesso 15 mar 2023];43(supl 1):314-21. DOI: 10.1590/1981-5271v43suplemento1-20180264
https://doi.org/10.1590/1981-5271v43supl... .

The habit of communicating must be regularly present in the relationship between professionals, family members, and children, providing humanized care in which those involved feel welcomed and guided. Consequently, their anxiety levels regarding the situation are reduced, which also contributes, in turn, to the effectiveness of communication in this triad and, therefore, to the treatment ¹⁵15. Santos LF, Oliveira LMAC, Munari DB, Barbosa MA, Peixoto MKAV, Nogueira ALG. Quando a comunicação é nociva no encontro entre profissional e família da criança hospitalizada. Enferm Glob [Internet]. 2015 [acesso 15 mar 2023];(37):204-15. Disponível: https://bityli.com/45354L
https://bityli.com/45354L... .

Therefore, it is reiterated that family support promotes understanding and fosters the ability to deal with suffering, pain, and problems. In other words, when the professional team realizes the consequences of the hospitalization and values dialogue, it is possible to include the family and the child in transmitting information ²⁸28. Lançoni AC Jr, Azevêdo AVS, Crepaldi MA. Comunicação entre equipe de saúde, família, criança em unidade de queimados. Psicol Estud [Internet]. 2017 [acesso 15 mar 2023];22(4):623-34. DOI: 10.4025/psicolestud.v22i4.35849
https://doi.org/10.4025/psicolestud.v22i... .

Another essential factor that must be considered during transmission is the emotional bond. The news should preferably be given to parents or legal guardians. However, there are cases in which it can also be intended for the person with the most significant emotional bond with the child—possibly their caregiver and/or the companion present during hospitalization ¹⁴14. Soeiro ACV, Teixeira RS, Celidônio TG, Lustosa, MM, Fonseca DC. Bioética e comunicação de más notícias em oncologia pediátrica: experiência em um hospital público. Artigos.Com [Internet]. 2020 [acesso 15 mar 2023];16:e3298. Disponível: https://tinyurl.com/544e3edn
https://tinyurl.com/544e3edn... .

From the bond of affection established, the child builds their emotional structure and capacity for internalization, which is influenced by their experiences and their relationship with the environment in which they are inserted ²⁹29. Lemos SCA, Gechele HHL, Andrade JV. Os vínculos afetivos no contexto de acolhimento institucional: um estudo de campo. Psicol Teor Pesq [Internet]. 2017 [acesso 15 mar 2023];33:e3334. DOI: 10.1590/0102.3772e3334
https://doi.org/10.1590/0102.3772e3334... . Through this bond and emotional intimacy, the transmission may become less conflicting for the child ¹⁴14. Soeiro ACV, Teixeira RS, Celidônio TG, Lustosa, MM, Fonseca DC. Bioética e comunicação de más notícias em oncologia pediátrica: experiência em um hospital público. Artigos.Com [Internet]. 2020 [acesso 15 mar 2023];16:e3298. Disponível: https://tinyurl.com/544e3edn
https://tinyurl.com/544e3edn... .

It is also important to emphasize that the transmission of bad news causes suffering to parents/companions. Empathetic and humanized communication can reduce suffering, helping to understand and accept the disease. Furthermore, the Spikes protocol is considered a helpful tool in this process ¹⁸18. Zampoli ACM. Comunicação com familiares de pacientes em cuidados paliativos perinatais. Pleiade [Internet]. 2018 [acesso 15 mar 2023];12(26):125-31. Disponível: https://tinyurl.com/5sfkur7c
https://tinyurl.com/5sfkur7c... , and its association with empathy can strengthen the bond between physicians, family members, and patients and contribute to the academic training of healthcare professionals ³⁰30. Calsavara VJ, Scorsolini-Comin F, Corsi CAC. A comunicação de más notícias em saúde: aproximações com a abordagem centrada na pessoa. Rev Abordagem Gestál [Internet]. 2019 [acesso 15 mar 2023];25(1):92-102. DOI: 10.18065/RAG.2019v25.9
https://doi.org/10.18065/RAG.2019v25.9... .

The Spikes protocol was created based on reflections and consideration about this complex and fundamental process of communicating bad news. This instrument aims to facilitate communication through six steps to guide professionals from planning to the moment after the bad news is transmitted, seeking to minimize impacts ³¹31. Becze E. Strategies for breaking bad news to patients with cancer. ONS Connect [Internet]. 2010 [acesso em 15 de mar 2023];25(9):14-5. Disponível: https://pubmed.ncbi.nlm.nih.gov/20945670/
https://pubmed.ncbi.nlm.nih.gov/20945670... .

The steps are: 1) setting: preparation for the meeting; 2) perception: uncover of what the patient knows about their health status; 3) invitation: an invitation to dialogue; 4) knowledge: transmission of information in plain language; 5) emotions: an approach to patient’s emotions; and 6) summarize: summary of everything that was said, in addition to establishing goals and strategies for facing subsequent challenges ²²22. Lino CA, Augusto KL, Oliveira RAS, Feitosa LB, Caprara A. Uso do protocolo Spikes no ensino de habilidades em transmissão de más notícias. Rev Bras Educ Med [Internet]. 2011 [acesso 15 mar 2023];35(1):52-7. DOI: 10.1590/S0100-55022011000100008
https://doi.org/10.1590/S0100-5502201100... ,³²32. Galvão AM, Valfreixo MCGS, Esteves M. Processo comunicacional na transmissão de más notícias: revisão da literatura. In: Livro de Atas do II seminário internacional em inteligência emocional. Bragança: Instituto Politécnico de Bragança; 2015 [acesso 15 mar 2023]. p. 247-62. Disponível: https://tinyurl.com/yah5x3hp
https://tinyurl.com/yah5x3hp... ,³³33. Cruz CO, Riera R. Comunicando más notícias: o protocolo Spikes. Diagn Tratamento [Internet]. 2016 [acesso 15 mar 2023];21(3):106-8. Disponível: https://bityli.com/8UDBol
https://bityli.com/8UDBol... .

Resident professionals highlighted this protocol as a guiding instrument to organize the delivery of bad news, being capable of helping to understand the emotional needs of patients ¹⁷17. Setubal MSV, Goncalves AV, Rocha SR, Amaral EM. Programa de treinamento para comunicação de más notícias baseado em revisão de vídeos e na estratégia Spikes: o que pensam os residentes de perinatologia? Rev Bras Ginecol Obstet [Internet]. 2017 [acesso 15 mar 2023];39(10):552-9. DOI: 10.1055/s-0037-1604490
https://doi.org/10.1055/s-0037-1604490... . At the same time, it is necessary to include it in similar training in residency programs. Bad news, when poorly or insensitively delivered, can cause emotional disturbances in the family, and communication can be improved through already structured and organized protocols, such as Spikes ³⁴34. Traiber C, Lago PM. Comunicação de más notícias em pediatria. Boletim Científico de Pediatria [Internet]. 2012 [acesso 15 mar 2023];1(1):3-7. Disponível: https://tinyurl.com/3d6buwvb
https://tinyurl.com/3d6buwvb... .

Furthermore, healthcare professionals found a curricular deficit concerning professional training for delivering bad news when approaching academic training. They perceive this lack because they sometimes do not feel prepared to communicate the case adequately, using the personal or professional knowledge acquired through experience. Thus, the importance of implementing professional techniques aimed at this type of communication is evident ³⁵35. Souto DC, Schulze MD. Profissionais de saúde e comunicação de más notícias: experiências de uma unidade neonatal. Rev Psicol Saúde [Internet]. 2019 [acesso 15 mar 2023];11(3):173-84. DOI: 10.20435/pssa.v0i0.690
https://doi.org/10.20435/pssa.v0i0.690... .

Final considerations

Although there are dilemmas regarding delivering bad news, it is concluded that it must occur empathetically and objectively, and that the child and their family members must be involved in this process. However, these findings do not end the debate on the topic, mainly because, as with any research, some limitations must be recognized, among which breadth stands out. This study only covered full articles, searched in the abovementioned databases, and within the time frame, which limited its outcomes.

Despite these limitations, one cannot fail to recognize some of the contributions made by the study to advances in knowledge on the subject. The results regarding the two variables studied (delivering bad news and child health) contribute to the literature, in which there is a lack of recent studies. Another contribution is the importance of studying the topics discussed here: transmitting bad news is seen as an arduous task for most healthcare professionals, who have difficulty informing the patient or family member about the patient’s actual health conditions.

Finally, the possibility of new studies involving a broader and more diverse scope must be considered, guaranteeing greater representativeness and generalization of results. At the same time, other research methods are suggested, such as qualitative analyses that use case studies.

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