1. Breaking bad news

Principles

• Be honest, compassionate, patient-centred, and culturally sensitive.
• Maintain privacy and confidentiality.
• Assess what the patient already knows and how much information they wish to receive.
• Use simple, non-technical language.
• Give information gradually and allow silence, questions, and emotion.
• Do not give false reassurance or abandon the patient after disclosure.

SPIKES protocol

1. S - Setting up
   • Arrange a quiet private place, without interruptions.
   • Sit at eye level; allow a relative/support person if the patient wishes.
   • Ensure adequate time.
2. P - Perception
   • Ask what the patient understands: “What have you been told about your illness so far?”
3. I - Invitation
   • Ask how much detail the patient wants: “Would you like me to explain the report in detail?”
4. K - Knowledge
   • Give a warning shot: “I am afraid the report shows something serious.”
   • Explain in small portions using clear language.
   • Avoid jargon such as “metastasis” without explanation.
5. E - Empathy and emotions
   • Observe the response.
   • Acknowledge feelings: “I can see this is very upsetting.”
   • Allow crying, anger, denial, and questions without rushing.
6. S - Strategy and summary
   • Summarise the diagnosis and immediate next steps.
   • Discuss available treatment, referral, support, and follow-up.
   • Check understanding and provide contact/support information.

2. Patient autonomy

Components

• Capacity/competence: The patient can understand, reason, decide, and communicate a choice.
• Adequate information: Diagnosis, nature of treatment, benefits, risks, alternatives, and consequences of refusal should be explained.
• Voluntariness: The decision must be free from force, coercion, or undue influence.
• Understanding: The doctor must check that the patient has understood the information.
• Choice: The patient may accept, refuse, or withdraw from treatment.

How doctors respect autonomy

• Obtain valid informed consent before procedures.
• Communicate in a language the patient understands.
• Encourage questions and shared decision-making.
• Respect refusal of treatment by a competent adult, after explaining consequences.
• Maintain confidentiality and privacy.
• Involve family only with the patient's permission, except where law or emergency permits otherwise.
• Document discussion, consent, refusal, and decisions.

Limitations

• The patient lacks decision-making capacity.
• There is a life-threatening emergency and consent cannot be obtained.
• There is a public-health or legal requirement.
• A patient’s decision poses serious harm to others.

3. Communication with relatives of a patient diagnosed with malignancy on pathology report

Initial approach

1. Verify the report and discuss the case with the concerned senior/pathologist/oncology team before communicating.
2. Do not disclose the report casually in a corridor, on the telephone, or in a crowded ward.
3. First assess whether the patient knows the diagnosis and whether the patient has permitted disclosure to relatives.
4. Arrange a private, quiet setting with sufficient time and seating.
5. Identify the key relative(s) and their relationship to the patient.

Communication

• Start with what they understand: “What have you been told about the test so far?”
• Give a warning statement: “The report has shown a serious finding.”
• State the diagnosis clearly but sensitively: “The biopsy is suggestive of cancer/malignancy.”
• Avoid jargon and avoid premature statements about prognosis.
• Explain that further evaluation is usually needed to determine site, stage, extent, and the most appropriate treatment.
• Allow silence and emotional reactions.
• Respond empathetically: “I understand this is difficult news to hear.”
• Clarify misconceptions, including the mistaken belief that cancer is invariably untreatable.
• Discuss next steps: oncology/surgical consultation, staging investigations, treatment possibilities, symptom control, counselling, and follow-up.
• Check their understanding and encourage questions.

Ethical and legal points

• The patient is the primary person entitled to information.
• Relatives should be informed with the patient’s consent, unless the patient lacks capacity or a legal/public-interest exception applies.
• Maintain confidentiality.
• Record what was communicated, to whom, questions raised, and the plan for referral/follow-up.

4, 6 and 7. Importance of respect in professional relationships with patients, colleagues, seniors, and other health-care workers

A. Respect towards patients

• Treat every patient with dignity, irrespective of age, sex, caste, religion, disability, literacy, socioeconomic status, diagnosis, or behaviour.
• Introduce oneself, address the patient appropriately, listen actively, and allow questions.
• Respect autonomy, privacy, confidentiality, informed consent, and the right to refuse treatment.
• Avoid humiliating remarks, discrimination, stigmatizing labels, or judgmental behaviour.
• Ensure privacy during examination and communication.
• Communicate truthfully, sensitively, and in language the patient understands.

B. Respect towards colleagues and team members

• Recognize that safe care is delivered by a team, including nurses, technicians, pharmacists, attendants, administrative staff, and students.
• Communicate courteously and clearly.
• Listen to concerns, acknowledge expertise, and invite suggestions.
• Share relevant information during handover and referrals.
• Give credit fairly and accept responsibility for errors.
• Avoid bullying, harassment, insults, discrimination, and public humiliation.

C. Respect towards seniors and supervisors

• Be punctual, prepared, honest, and receptive to feedback.
• Follow legitimate instructions and institutional protocols.
• Seek help early when unsure rather than compromising patient safety.
• Disagree professionally and respectfully when needed.
• Do not conceal mistakes or falsify records.

D. Respect towards juniors and students

• Teach patiently and supervise appropriately.
• Correct errors privately and constructively.
• Encourage questions and a safe learning environment.
• Never misuse authority, intimidate, exploit, or harass juniors.

Conclusion

5. Role of doctors in the community

Major roles

1. Care provider
   • Diagnose, treat, refer, rehabilitate, and provide palliative care.
   • Deliver competent, compassionate, equitable, and evidence-based care.
2. Promoter of health
   • Educate people regarding nutrition, hygiene, exercise, mental health, sanitation, tobacco/alcohol avoidance, and healthy lifestyle.
   • Encourage health-seeking behaviour and early consultation.
3. Disease preventer
   • Promote immunisation, antenatal care, screening, and preventive services.
   • Identify risk factors and counsel high-risk individuals.
4. Community health assessor
   • Understand local disease patterns and social determinants of health.
   • Participate in community diagnosis, identification of priority health problems, and health planning.
5. Public-health worker
   • Assist in surveillance, notification of diseases, outbreak investigation, and epidemic/disaster response.
   • Support national health programmes and rational use of resources.
6. Health educator and communicator
   • Correct myths and misinformation.
   • Communicate health messages in understandable, culturally appropriate language.
7. Advocate for vulnerable people
   • Promote access to care for poor, rural, elderly, disabled, marginalized, and stigmatized groups.
   • Address inequity, discrimination, violence, and barriers to care.
8. Professional and ethical role model
   • Maintain confidentiality, honesty, competence, accountability, and respect.
   • Avoid conflicts of interest and uphold public trust.
9. Lifelong learner and teacher
   • Keep medical knowledge updated, use evidence appropriately, teach students and patients, and improve quality of care.