Training Bad News Communication by

SHARE Model in Taiwan

Chun-Kai Fang, MD, MSc, PhD(c)

方俊凱
President, Taiwan Psycho-Oncology Society
Chief, Department of Psychiatry, Mackay Memorial Hospital, Taiwan
Taiwan Psycho-Oncology Society
(TPOS)
TPOS since Oct 25, 2009.
TPOS is an academic group about
multidisciplinary subspecialty of
oncology.
TPOS is the membership candidate
of IPOS Federation.
 Ongoing
New diagnosis Death caused by
aggressive
of cancer cancer
treatment

In Taiwan 79,818 466,887 39,917 2008

per year
Department of Health, Taiwan, 2008; Bereau of Health Promotion, Taiwan, 2009
Fallowfield & Jenkins, 2004
 Hospice and Palliative care Psycho-Oncology
1959 Hospice movement, UK
1967 St. Christopher’s Hospice, UK
1969 Book: On Death and Dying, USA
1977 Psychiatric service, MSKCC, USA
1984 Hospice movement in Taiwan IPOS
1986 JPOS
1990 1st Hospice ward, MMH, Taiwan
1992 1st congress of IPOS
1995 2nd congress of IPOS in Kobe
2000 Nature Death Act in Taiwan
2007 1st symposium of PO in Taiwan
2008 EAPOS
2009 TPOS
 The first symposium of psycho-oncology

Yosuke Uchitomi, MD, PhD.

Past president, Japan Psycho-Oncology
Society
Past Chief, Division of Psycho-Oncology, N
ational Cancer. Center Research In
stitute East, Kashiwa, Japan
Professor, Department of Neuropsychiatry,
Okayama University, Okayama, Jap
an
Nov 1, 2007 Mackay Memorial Hospital
Lectures ：
Development of Psycho-Oncology
Truth-telling Practice in Japan
Assessment of Depression in Cancer Patients
Management of Depression in Cancer Patients

6
• The 1st annual conference of
TPOS
• Cancer and Emotion:
• New Era of Cancer Care
2009/10/25
Mackay Memorial Hospital

Dr. Chochinov and Dr. Uchitomi

400 people joined the 1st annual conference in 2009
Members of TPOS: 70 in 2009; 97 in 2010; 109 in 2011
• Post-conference workshop- the 1st workshop of CST
– Dr. Uchitomi on Mackay Memorial Hospital
 Truth telling in Taiwan
• According to some survey in Taiwan, most
cancer patients preferred being told truth
about their diagnosis (92.3%), but most
medical staff felt difficult to tell truth in
cancer care. (Wang, et al, 2004)

11
• “If your relative were diagnosed with cancer,
would you prefer your relative be told the
truth?”
– less than two-thirds of participants (62.6%)
thought the victim should be informed of the
cancer diagnosis, and 37.4% preferred not telling
the truth. (Wang, et al, 2004)
• The reasons given for not telling the truth to a
relative with cancer were that the relative would:
– (1) be unable to stand the diagnosis (63.0%),
– (2) worry excessively (46.6%),
– (3) not cope well with the situation (27.4%), and
– (4) commit suicide (8.2%). (Wang, et al, 2004)
 Nature Death Act
安寧緩和醫療條例
• 中華民國八十九年五月二十三日 (May23, 2000) 立法院三
讀通過法案
• 第八條：
醫師 [doctors] 為末期病人 [terminal patients] 實施
安寧緩和醫療 [hospice care] 時，應將治療方針告知
病人或其家屬。但病人有明確意思表示欲知病情時，
應予告知。 [truth telling to patients or family]
 醫師法 Doctors Act
• 中華民國 九十一 年 一 月 一十六 日 (Jan 16, 2002) 修正
• 第十二條之一 ( 告知之義務 )
醫師 [doctors] 診治病人 [all patients] 時，應向病人或其
家屬告知其病情、治療方針、處置、用藥、預後情形及可能之不
良反應。 [truth telling to patients or family]
 醫療法 Medical Act
• 中華民國九十四年二月五日 (Feb 5, 2005) 修正
• 第八十一條
醫療機構 [all medical staff ] 診治病人 [all
patients] 時，應向病人或其法定代理人、 配偶、親
屬或關係人告知其病情、治療方針、處置、用藥、預
後情形及可能之不良反應。 [truth telling to
patients, family, and the others]
 The condition about CST for truth telling
in Taiwan before AD 2008
• Only teaching for palliative care teams.
• Very few facilitators, but very many
participants. (2:30, always)
• No solid materials or programs to teach.
• Concept: SPIKES model
• Maximal training time under 4 hours.
• Nurses had high motivation to attend training,
but doctors had low motivation.
 Suicide rate of cancer patients or standard mortality rate (SMR)

Yr Authors Period Suicide Rate Suicide Rate

in cancer pt in General SMR*
(/100,000) (/100,000)
Europe 2003 Levi et al. 1995-1998 14.4 (M) ─ ─
4.6 (F)
USA 2008 Misono et 1973-2002 31.4 16.7 ─
al.
UK 2009 Robinson et 1996-2005 ─ ─ 1.45 (M)
al. 1.19(F)
Australia 2009 MacFarlane 1983-2002 ─ ─ 1.78
et al.
Korea 2010 Ahn et al. 1993-2005 ─ ─ 2.00(all)
3.45(1st Y)
Taiwan 2010 Chung et al. 2002-2004 288.9 13.59 (2002) ─
(3 years) 14.16 (2003)
15.31(2004)
 Very big change because of JPOS,
particularly from Dr. Uchitomi

SHARE (Fujimori, 2005) London ,2007

1. Supportive: Breaking bad news only to you or your family.

environment Breaking bad news after it is definite.
2. How to deliver: Telling honestly. But not using the word “cancer” repeatedly.
the bad news Explaining until you are satisfied.
3. Additional: Telling about your life expectancy.
information Discussing your everyday life and work in the future.

4. Reassurance and: Telling with concern for your feelings.

Emotional support Showing the same concern for your family as for you.
Fujimori et al.: Psycho-Oncology, 2005; 2007

本課程講義為國科會研究計畫 非經授
權請勿使用
Subjects ： 571 cancer patients, 7 oncologists Fujimori et al. 2005; 2007
Methods ： In-depth interview, Survey
Every Taiwanese understand the process
Analysis: Content analysis, Factor analysis
because they learn writing by the
Results ： 619 opinions→70 items→4 domains
model.
S upportive
起 S RE Environment

承 H RE H ow to deliver A dditional
the bad news information
轉 A RE
合 R eassurance and
H RE
E motional support
 Informed consent & Mind
Very Eastern
Informed ConsentCulture

Knowledge 知→ Emotion 情→ Will 意

Information→Emotion→Consent
 TPOS promoted SHARE in Taiwan

• 2007-Oct: Dr. Uchitomi came to Taiwan. (lecture)

• 2008-Oct: Dr. Fang decided to promote in Taiwan, and
authorized from Dr. Uchitomi.
• 2008-Dec to 2009-Feb: Dr. Fang arranged Ms. Chung (social
worker) learned SHARE-CST in Japan.
• 2009-Sep: Dr. Fang learned CST-TTT in Japan.
• 2009-Oct: Dr. Uchitomi came to Taiwan. (mini-SHARE)
• 2010- May: TPOS began the CST-TTT program.
• 2010-Sep: TPOS was certificated by JPOS
• 2011~: Bureau of Health Promotion authorized TPOS to
promote CST by SHARE.
2009 Makuhari ( 幕張 ), Chiba, Japan
 SHARE in Taiwan
For Cancer Care Team For All Residents
• National policies and CME • Hospital-based medical
• TPOS and Bureau of Health education
Promotion organized the • Objective structured clinical
national project. examination (OSCE) centers
• National facilitators. organized the teaching
project.
• Trainers.
 SHARE in Taiwan
For Cancer Care Team
• National policies and CME
• TPOS (since Oct, 2009) and
Bureau of Health Promotion
(since May, 2010) organized
the national project.
• National facilitators.
For All Residents
• Hospital-based medical
education
• Objective structured clinical
examination (OSCE) centers
organized the teaching
project.
• Trainers.
 Training the1st generation of facilitators in
2010-5-1 Start to share
2010-6-19 Practice
2010-6-26 Modify materials
2010
May 1 (5hrs) Introduction, miniSHARE
June 5-6 (10hrs) CST-TTT (facilitators)
June 19-20 (10hrs) Teaching workshop
June 26 (5hrs) Modify materials
July 17(5hrs) Modify materials
August 7(5hrs) Modify materials
August 14 (5hrs) Teaching workshop
August 15 (6hrs) CST-1D-SHARE
September 4-5 CST-TTT
(12hrs) Certificated by JPOS
September 18 CST-1D-SHARE
(6hrs)
At least 53 hours
SHARE-TPOS 1.X in 2010
 Essential course of CST- 6 hrs(1 day)
supported by National Bureau of Health Promotion
• August 15, 2010
2nd annual conference of TPOS, Sep 4-5,
2010.
Ms. Fujimori and Ms. Ninomiya
certificated TPOS to practice SHARE.
L: Hitomi Ninomiya
R: Maiko Fujimori
Characters of trainers [1] in 2010 (N=74)
N (%)
Age Mean ± SD (range)
36.15±8.02 (23-55)
Gender
Male 18 (25.0)
Female 54 (75.0)
Education
College 8 (11.1)
University 43 (59.7)
MS or PhD 21 (29.2)
Seniority
1-3 years 12 (16.7)

4-6 years 14 (19.4)

7-9 years 9 (12.5)

Over 10 years 37 (51.4)

Characters of trainers [2] in 2010 (N=74)
N (%)
Occupation
Physicians 25 (34.7)
Psychologists 2 (2.8)
Nurses 28 (38.9)
Social workers 11 (15.3)
Others 6 (8.3)
Training time
6 hrs (1D-SHARE) 51 (68.9)
12 hrs (CST-TTT) 23 (31.1)
Satisfy Very
Very bad 4 (5.6) good and
Bad 1 (1.4) good:
93.1%
Good 19 (26.4)

Very Good 48 (66.7)

Attitude and ability of communication Skill (70 items) in 2010. (N=74)

Pre-test Post-test
Mean SD Mean SD T P

Total 265.14 18.89 286.60 16.49 12.716 <0.0005

S 45.34 6.57 47.18 7.25 2.614 0.001

H 78.56 6.70 85.78 5.30 11.603 <0.0005

A 69.55 6.01 75.10 4.84 9.179 <0.0005

RE 71.68 6.22 78.55 4.54 10.744 <0.0005

行政院衛生署國民健康局 100 年度

Since 2011

癌症病情告知溝通技巧
種子人員培訓計畫

執行機構：台灣心理腫瘤醫學學會
計畫主持人：方俊凱
 Communication Meetings in 2011 (2 hrs)
To introduce CST-SHARE to Taiwanese medical staff, TPOS offered 4
communication meetings to promote the national program.
Time Location Hospitals Experts
Jan-18 Taipei 18 22
Jan-20 Kaohsiung 14 22
Jan-21 Taipei 19 28
Jan-27 Taichung 10 12
Total 84
 SP workshops in 2011(3.5 hrs)
Time Location SP (n) Hospitals
April-17 Taipei 36 5
May-14 Kaohsiung 16 3
July-30 Taichung 25 5
Total 77

Teaching workshops in 2011(6 hrs)

Time Location Pre-facilitators
April-24 Taipei 6
Jun-26 Taipei 13
July-2 Kaohsiung 8
Total 27
chairman

SP workshop in
2011
chairman
 Projector and audio

Teaching workshop in 2011

CST-SHARE
Video SHARE-TPOS 2.X since2011
Video 1 of TPOS
Video 2 of TPOS
 2011
Communication Skill Training-Training the Trainers (CST-TTT)

Date Location Trainee

1 5/21-22 Taipei 30
2 5/28-29 Kaohsiung 28
3 7/09-10 Taipei 29
Day1: 27
4 8/13-14 Taichung
Day2: 26
 Characters of trainers [1] in 2011
N= 114, response rate: 100% 。
Gender Male 50.9% Occupation Physician 57.4%
Female 49.1% Nurse 21.8%
Education College 3.6% Psychologist 11.8%
University 56.4% Social 4.5%
MS or PhD 40.0% worker

Seniority 1-3 Y 8.2% others 4.5%

4-6 Y 20.9% hospital Med. Center 38.2%

7-9 Y 14.5% General H. 53.6%

Local H. 5.5%
Over 10 Y 56.4%
Others 2.7%
 Characters of trainers [2] in 2011
department Oncology 37.7% Motivations Need 69.7%
Psychiatry 15.1% Interest 66.1%
Inter. or 10.4% Ordered 40.4%
Surg. Others 1.8%
Others 36.8% Others: ‘want to become a facilitator’,
Others: GP, Gyn, et al. et al.
Efficiency of CST
Attitude and ability of communication Skill (70 items) in
2011. (N=87)
Pre-test Post-test T P
(mean±SD) (mean±SD)

Total 266.41±23.39 279.17±23.92 5.990 <0.001

S 47.97±7.55 48.54±7.14 0.834 0.406

H 77.86±8.06 82.57±8.21 6.409 <0.001

A 69.07±7.81 72.25±8.29 5.215 <0.001

RE 71.52±7.99 75.80±8.44 6.644 <0.001

 CST-SHARE
National Facilitators in Taiwan
5 Grand Facilitators
4 psychiatrists
1 radiation-oncologist

17 Semi-Grand Facilitators
22 Facilitators

Total 44 until Sep, 2011

 CST-SHARE
National Facilitators in Taiwan
Number (N=44) Percentage
Gender M 20 45.5%
F 24 54.5%
TPOS Member 31 70.5%
Specialist Psychiatrists 14 31.8%
Oncologists 9 20.5%
Oncologic nurses 9 20.5%
Psychologists 6 13.6%
Social workers 6 13.6%
Location North Taiwan 33 75.0%
Middle Taiwan 3 6.8%
South Taiwan 6 13.6%
East Taiwan 2 4.6%
• Research project: 100-2511-S-182-004-
• Truth Telling in Cancer: The Difference between
Patient Preference and Physician Practice
• Program Investigator (PI) ： Tang, WR.
• Co-PI ： Fang, CK, et al.
• 2011/8/1-2012/7/31
 Next year

Hospital-based programs
– CST-1D-SHARE [preference]
– 6 hrs/1 day
– CST-mini SHARE
– 4 hrs/0.5 day
Promote lecture (1hr)
– CST-lecture-SHARE
CST-1D-SHARE
Oct-1, 2011

Vice superintendent superintendent

 SHARE in Taiwan
For Cancer Care Team For All Residents
• National policies and CME • Hospital-based medical
• TPOS and Bureau of Health education
Promotion organized the • Objective structured clinical
national project. examination (OSCE) centers
• National facilitators. organized the teaching
project.
• Trainers.
 Mackay Memorial Hospital
• PGY residents (Post Graduate Year)
• 1st year residents
– All new physicians in Mackay Memorial Hospital
have to learn SHARE since Oct, 2009.
• OSCE center
• CST-mini SHARE
 CST in Taiwan
• TPOS and Bereau of Health Promotion began
to promote CST in Taiwan, not only for
doctors but also for all medical staff.
• SHARE model is appropriate for training
communication skills in Taiwan.
• Taiwanese staff have to find the native data
about preference of cancer patients and
family among truth telling.