Communication Skills in Palliative Medicine

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Communication Skills in Palliative Medicine

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Communication

• A New Conceptual Framework
• B. Breaking Bad News
• C. Therapeutic (or Supportive) Dialogue

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The Goal of Communication

• A. a new conceptual framework
• A better approximation of common clinical
  experience can be obtained with a different
  staging system. The system is based on two
  central principles.

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A new conceptual framework

• Patients facing death exhibit a mixture of
  reactions and response which are characteristic
  of the patient, not of the diagnosis or the stage
  of the process.

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A new conceptual framework

• Progress through the dying process is marked, not
  by a change in the type or nature of emotion, but
  by resolution of the resolvable elements of those
  emotions.

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Basic listening skills for palliative care

• Physical context
• Facilitation techniques
• The empathic response

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Physical context

• Introduction
• Sit down
• Your body language
• Touching the patient

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Facilitation techniques

• Let the patient speak
• Encourage the patient to talk
• Tolerate short silences
• Repetition and reiteration
• Reflection

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The empathic response

• (a) Identifying the emotion that the patient is
  experiencing
• (b) Identifying the origin and root cause of that
  emotion
• (c) Responding in a way that tells the patient
  that you have made the connection between (a) and
  (b).

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The Goal of Communication

• B. Breaking Bad News
• Bad news is confined not only to issues around
  terminal or incurable illness, death and dying.

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The Goal of Communication

• B. Breaking Bad News
• There are many factors which may influence the
  individuals perception of the news, making it
  bad for that particular person at that
  particular time.
• The news may be bad for the giver as well as
  for the receiver.

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Breaking Bad News

• For the receiver (patient or relative), the news
  may be bad because of what has gone before, who
  else will be affected, previous expectations or
  hopes, anxiety about the future, financial
  implications, what others (family, friends and
  society) may think and so on.

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Breaking Bad News

• As healthcare professionals, our main goal is to
  make things better and certainly to do no
  harm. In giving bad news there is a risk of
  causing great upset, hurt and distress to
  recipients, which, in turn, can be distress for
  us.

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Doctors cannot totally abrogate the
responsibility of breaking bad news

• because
• Patients and relatives generally expect to see
  them for medical information and an indication of
  prognosis.

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Doctors cannot totally abrogate the
responsibility of breaking bad news

• because
• They can give specific diagnostic or therapeutic
  information that others may not have available.

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Doctors cannot totally abrogate the
responsibility of breaking bad news

• because
• They are legally responsible for meeting
  patients healthcare needs, and this includes
  giving them (good or bad) information.

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• Ground Rule If you cant answer a question,
  dont try.
• Instead, it is always possible to act as the
  patients advocate listen to the question and
  take it elsewhere for further information.

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Perceptions of Patients Approach

• STEP 1. GETTING STARTED
• STEP 2. FINDING OUT HOW MUCH THE PATIENT KNOWS
• STEP 3. FINDING OUT HOW MUCH THE PATIENT WANTS TO
  KNOW

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Perceptions of Patients Approach

• STEP 4. SHARING THE INFORMATION (ALIGNING AND
  EDUCATION)
• STEP 5. RESPONDING TO THE PATIENTS FEELINGS
• STEP 6. PLANNING AND FOLLOW - THROUGH

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STEP 1. GETTING STARTED

• Get the physical context right
• Where?
• Who should be there?

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STEP 1. GETTING STARTED

• Starting off
• How are you feeling at the moment?
• How are things today?
• Do you feel well enough to talk for a bit?
• I know youre not feeling well, but perhaps we
  could talk for a few minutes now, then I could
  come back tomorrow.

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STEP 2. FINDING OUT HOW MUCH THE PATIENT KNOWS

• The patients understanding of the medical
  situation
• The style of the patients statements
• The emotional content of the patients statement

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STEP 3. FINDING OUT HOW MUCH THE PATIENT WANTS TO
KNOW

• In any conversation about bad news, the real
  issue is not Do you want to know? but At what
  level do you want to know whats going on?

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STEP 3. FINDING OUT HOW MUCH THE PATIENT WANTS TO
KNOW

• If the patient expresses a preference not to
  discuss the information, you should leave the
  door open for later.

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STEP 4. SHARING THE INFORMATION (ALIGNING AND
EDUCATION)

• Decide on your agenda (diagnosis / treatment plan
  / prognosis / support)
• Start from the patients starting point (Aligning)

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STEP 4. SHARING THE INFORMATION (ALIGNING AND
EDUCATION)

• Educating
• Give information in small chunks
• Check reception frequently
• Reinforce and clarify the information frequently

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STEP 4. SHARING THE INFORMATION (ALIGNING AND
EDUCATION)

• Educating
• Check your communication level (adult adult,
  etc.)
• Listen for the patient agenda with the
  patients

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STEP 5. RESPONDING TO THE PATIENTS FEELINGS

• Identify and acknowledge the patients reaction

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STEP 6. PLANNING AND FOLLOW - THROUGH

• Planning for the future
• 1.Demonstrate an understanding of patients
  problem list
• 2.Indicate you can distinguish the fixable from
  the unfixable
• 3.Make a plan or strategy and explain it

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STEP 6. PLANNING AND FOLLOW - THROUGH

• Planning for the future
• 4.Identify patients coping strategies and
  reinforce them
• 5.Identify and incorporate other sources of
  support

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STEP 6. PLANNING AND FOLLOW - THROUGH

• Supporting the patient
• Making a contract / Follow - through

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Perceptions of Relatives (Family) Approach

• The patient has primacy.
• The familys feeling have validity.

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Perceptions of Relatives (Family) Approach

• Social support and stress reduction
• Managing conflict and letting go
• Loss of dignity and privacy
• Caregiver deceptive communicative strategies
• External communication sources

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Perceptions of Relatives (Family) Approach

• Family meetings
• It is important to prepare properly for such
  meeting, and to decide, often with the patient,
  who should be there and which members of staff
  will be the most appropriate facilitators.

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Family meetings

• It is helpful for the team to work in pairs for
  example a doctor and a social worker. The doctor
  might begin with an overview of the illness and
  its history, to be followed by the social worker
  exploring the familys reaction to it.

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Family meetings

• The family should do most of the talking the aim
  is to help them solve the problem, not to solve
  it for them. The family may need to experience
  new ways of relating to one another.

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The Goal of Communication

• C. Therapeutic (or supportive) dialogue
• Many physician under-rate the value of
  therapeutic dialogue because it is not included
  in the curricula of most medical school, and they
  are thus unfamiliar with its use.

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The Goal of Communication

• C. Therapeutic (or supportive) dialogue
• Supportive communication is obviously central to
  psychiatric and psychotherapeutic practice, but
  is generally not taught to medical or nursing
  students outside those disciplines.

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The Goal of Communication

• C. Therapeutic (or supportive) dialogue
• Hence, it often seems an alien idea that a doctor
  or nurse can achieve anything by simply listening
  to the patient and acknowledging the existence of
  that individuals emotions.

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Therapeutic (or supportive) dialogue

• Nevertheless, supportive dialogue, during any
  stage of palliative care, is an exceptionally
  valuable resource and may be the most important
  (and sometimes the only) ingredient in a
  patients care.

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Therapeutic (or supportive) dialogue

• The central principle of effective therapeutic
  dialogue is that the patient should perceive that
  his or her emotions have been heard by the
  professional and acknowledged.

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Therapeutic (or supportive) dialogue

• It may then become apparent that there are
  problems that can be met, but even if there are
  no solutions, the simple act of supportive
  dialogue can reduce distress.

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Therapeutic (or supportive) dialogue

• For the acknowledging the patients emotion, the
  empathic response is of prime importance,
  although it cannot be the only component of the
  professionals side of the dialogue.

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Therapeutic (or supportive) dialogue

• Obviously a single technique cannot create an
  entire relationship nevertheless, many
  professionals are unfairly perceived as being
  insensitive or unsupportive, simply because they
  do not know how to demonstrate their abilities as
  listeners.

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Therapeutic (or supportive) dialogue

• The empathic response is one of the most reliable
  methods of demonstrating effective listening.

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Therapeutic (or supportive) dialogue

• In addition to responding in this way, the
  professional should also attempt to assess the
  nature and value of the patients responses in
  coping with the situation, to disentangle the
  emotions that have been raised by the discussion,
  and try to resolve any conflicts that may have
  arisen.

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How can we ensure it is done well?
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DNR

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