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COMMUNICATION AND DEALING WITH DIFFICULT QUESTIONS

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Title: COMMUNICATION AND DEALING WITH DIFFICULT QUESTIONS


1
COMMUNICATION AND DEALING WITH DIFFICULT
QUESTIONS
  • JO LENTON COMMUNITY PALLIATIVE CARE CNS
  • ALISON HUMPHREY
  • CNS PALLIATIVE CARE, STHFT

2
  • Communication is in itself a complex and involved
    interaction. When dying patients and grieving
    relatives are involved communication can become
    fraught with barriers, emotions and difficulties.

3
INTRODUCTION
  • The importance of effective communication in
    health care is well documented. This is
    particularly important for patients with advanced
    life-threatening disease and surveys show that
    patients with cancer place good communication
    with health care professionals high on their list
    of priorities.
  • (DOH 2000, NICE 2004)

4
WHAT IS BAD NEWS ?
  • Bad news is defined as information which worsens
    the individuals point of view on their future
    and may cause long-lasting mental and behavioural
    problems.
  • Two levels
  • 1. Temporal interruption in carrying on with life
    e.g. hip replacement.
  • 2. Threat to continuation of life e.g. diagnosis
    of malignant disease.
  • (Rassan, et al (2006) Caregivers Role in
    Breaking Bad News Patients, Doctors and Nurses
    Points Cancer Nursing 29 (4) July/August 302-308

5
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6
HEALTH CARE PROFESSIONAL LED BARRIERS
  • Four factors are recognised to limit HCP
    communication.
  • Fear - unleashing strong emotions
  • Beliefs - emotional problems are inevitable.
  • Support conflict within the team.
  • Inadequate skills not knowing how to assess.

7
PATIENT - LED BARRIERS
  • Three factors are recognised to limit patient
    communication.
  • Fear losing control, previous experience of
    death.
  • Beliefs previous experience of poor
    communication.
  • Difficulties unable to find the right words.

8
NON-VERBAL BEHAVIOUR
  • Personal space.
  • Touch.
  • Eye contact.
  • Facial expression.
  • Gestures.
  • Postures.

9
VERBAL BEHAVIOURS
  • Listening.
  • Silence.
  • Acknowledging.
  • Encouragement.
  • Picking up cues.
  • Reflecting cues.
  • Clarification.
  • Empathy.
  • Challenge.
  • Information giving.

10
VERBAL SKILLS
  • The use of the voice.
  • Type of questions.
  • The way the question is asked.

11
TYPES OF QUESTION
  • Broad open questions.
  • Open directive/ open focused questions.
  • Closed questions
  • Directive questions.
  • Leading questions.
  • Multiple questions.

12
  • Information should be given at a rate at which
    the patient can absorb it, in a language he
    understands and in a form that is meaningful
    within his own social context.

  • Faulkner 1992.

13
ANSWERING QUESTIONS
  • Environment.
  • Check understanding.
  • Information giving.
  • Warning shot.
  • Chunk and check.

14
10 steps to breaking bad news
  • Preparation
  • What does the patient know?
  • Is more information wanted?
  • Give a warning shot
  • Allow denial

15
10 steps to breaking bad news
  • Listen to concerns
  • Encourage ventilation of feelings
  • Summary plan
  • Offer availability for further questions
  • Explain (if requested)
  • Kaye P (1996) Breaking Bad News (Pocket Book).
    Northampton EPL Publications

16
SPIKES model
  • Setting
  • Perception
  • Invitation
  • Knowledge
  • Empathy emotion
  • Strategy summary
  • Baile et al. (2000) SPIKES a six step protocol
    for delivering bad news. Oncologist 5 302-311

17
ABCDE
  • ADVANCE PREPARATION
  • BUILD A THERAPEUTIC
    ENVIRONMENT/RELATIONSHIP
  • COMMUNICATE WELL
  • DEAL WITH PATIENT AND FAMILY REACTIONS
  • ENCOURAGE AND VALIDATE EMOTIONS
  • (Rabow, MW, McPhee, SJ (2000) Beyond
    breaking bad news helping patients who suffer
    Student BMJ 8 45-48

18
TALKING TO PATIENTS INCLUDING GIVING SIGNIFICANT
NEWS
  • STARTING THE CONSULTATION
  • DURING THE CONSULTATION
  • AFTER THE CONSULTATION
  • (Sheffield Teaching Hospitals NHS Foundation
    (2008) Trust Talking to patients including giving
    significant news PD2861)

19
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20
POSSIBLE RESPONSES
  • Denial.
  • Silence
  • Anger.
  • Emotional distress.
  • Compromise/ bargaining.
  • Acceptance.

  • Adapted from Kubler-Ross

21
COPING WITH THE RESPONSES
  • Allow time, recognising need for adjustment and
    give encouragement.
  • Actively listen to their concerns.
  • Help to prioritise concerns.
  • Empathise not sympathise.
  • Be gently realistic.
  • Do not give false hope.

22
COLLUSION
  • The patient has the right to know what is wrong
    with them.
  • Knowledge can be the antidote to fear.
  • Reassurance that information sharing will be at
    the patients own pace.
  • Facilitate communication between patient and
    carer.

23
Handling difficult questions
  • Check the reason for the question
  • Ask for their view of the situation
  • Show interest in the patients ideas
  • Be prepared to admit that you dont know
  • Dont be afraid to describe your difficulties in
    answering
  • Acknowledge the uncertainty the distress it may
    cause them
  • Speak from experience, not certainty

24
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25
SUMMARISING
  • Provide leadership and support.
  • Maintain open and honest communication.
  • Re- enforce individuality and allow appropriate
    adjustment.
  • Avoid unrealistic expectations and inappropriate
    hope.
  • Maintain patient autonomy.

26
CONCLUSION
  • Communicating with a patient who has a life-
    limiting disease is difficult for us all. It
    reminds us of our own mortality.
  • However to share and be entrusted with the
    patients feelings brings great reward.

27
REFERENCES
  • Abel, J, DennisonS, Senior-Smith,G, DolleyT,
    Lovett,J, Cassidy, S (2001) BREAKING BAD NEWS
    DEVELOPMENT OF A HOSPITAL BASED TRAINING WORKSHOP
    The Lancet Oncology 2 (6) 380-384
  • Buckman, R (1992) HOW TO BREAK BAD NEWS A GUIDE
    FOR HEALTH CARE PROFESSIONALS The John Hopkins
    Unversity Press, Baltimore MD.
  • Faulkner, A, Maguire, P (1994) TALKING TO CANCER
    PATIENTS AND THEIR RELATIVES. Oxford University
    Press, Oxford
  • Faulkner, A (1998) EFFECTIVE INTERACTION WITH
    PATIENTS CHURCHILL LIVINGSTONE, EDINBURGH
  • Kaye P (1996) BREAKING BAD NEWS (Pocket Book).
    Northampton EPL Publications
  • Rabow, MW, McPhee, SJ (2000) Beyond breaking bad
    news helping patients who suffer Student BMJ 8
    45-48
  • Rassan, M, Levy, O, Schwartz,T, Silner, D (2006)
    Caregivers Role in Breaking Bad News Patients,
    Doctors and Nurses Points Cancer Nursing 29 (4)
    July/August 302-308
  • Sheffield Teaching Hospitals NHS Foundation Trust
    (2008) TALKING TO PATIENTS INCLUDING GIVING
    SIGNIFICANT NEWS PD2861
  • Twycross, RG, Lack, S (1984) THERAPEUTICS IN
    TERMINAL CANCER London, Pitman

28
REFERENCES
  • WWW.BREAKINGBADNEWS.CO.UK/INDEX.ASP
  • WWW.PCPS.UCL.AC.UK/COMMSKILLS/STUDENT_HANDBOOK/BAD
    _NEWS.HTM
  • WWW.SKILLSCASCADE.COM/BADNEWS.HTM
  • WWW.NEWGRANGE-PROCESS.NET

29
SCENARIOS
  • 80 YEAR OLD LADY ADMITTED FOLLOWING COLLAPSE AND
    MALAENA. CT SCAN SHOWS LIVER METASTASES, OMENTAL
    CAKE, ASCITES, BILATERAL LOWER LOBE PES AND
    PLEURAL EFFUSIONS. SHE IS VERY ANXIOUS AND DOES
    NOT LIKE HOSPITALS. FAMILY AWARE OF HER
    DIAGNOSIS, BUT PATIENT NOT. FAMILY DO NOT WANT
    THE PATIENT TO KNOW. HOW WOULD YOU DEAL WITH THIS
    SITUATION ?

30
SCENARIOS
  • 40 YEAR OLD LADY WHO IS MARRIED AND HAS TWO
    CHILDREN, ONE AGED 9 AND ONE AGED 6. SHE HAS
    BREAST CANCER WITH LIVER METASTASES. SHE IS GOING
    TO HAVE SOME PALLIATIVE CHEMOTHERAPY AND ASKS YOU
    IF SHE SHOULD TELL HER CHILDREN ABOUT HOW POORLY
    SHE IS AND IF SO WHAT ARE THE BEST WAYS TO SAY IT
    TO THEM? HOW DO YOU DEAL WITH THIS SITUATION?

31
SCENARIOS
  • 51 year old man initially told he had
    hepatocellular carcinoma. Attended clinic and
    given result of MRI scan, which does not show
    cancer, but cirrhosis of the liver. Wife also
    present. Patient very shellshocked and wife very
    angry. How would you deal with this situation ?

32
SCENARIOS
  • 65 year old lady with learning difficulties and a
    diagnosis of breast cancer. Admitted with general
    deterioration and hypercalcaemia. Treated for
    hypercalcaemia and chest infection, but no
    improvement. Liver metastases diagnosed on this
    admission. Unable to communicate well, but in
    distress. Her sister is her next of kin and fully
    involved with her care.

33
  • Thank you
  • for
  • Listening
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