Communication Flashcards
Benefits of effective communication
- Reduces patient distress
- Improves treatment adherence
- Improves satisfaction with care
- Improves informed decision-making and increases likelihood that patient choices remain consistent with stated goals, values, and preferences
- May increase delivery of high value care, guiding patients away from ineffective treatments
Barriers to effective communication
Patient
- Discomfort with asking questions
- Pre existing misinformation
- Lack of trust of healthcare system
- Language barriers
- Cultural differences contributing to discrepancies in expectations
Physician
- Physician fears of the impact of the diagnosis on their own reputation
- Difficulties in coping with patient emotion/reaction
- Uneasiness in their own ability to answer questions
Effective communication despite barriers
FIFE method:
Feelings - related to illness, esp. fears
- “What are you most concerned about?”
Ideas
- “What do you think might be going on?”
- “What do you think X means?”
Function
- “How has your illness affected your life?”
- “What have you had to give up because of X?”
Expectations
- “What do you expect or hope I can do for you today?”
- “Do you have expectations about how doctors can help?”
When faced with abnormal test results/findings how do you discuss and how much do you discuss?
- If results are not yet definitive, set up a clear plan for follow up and further investigation. Reassure the patient that you will obtain a conclusive result as quickly as possible.
- Inquire about fear and directly address it - e.g. “I hear you’re concerned about cancer. What made you immediately go there?” - the patient may share more information that could be relevant.
- Avoid giving false reassurance or leaping to a definite diagnosis without further investigation
- Present the info available
Ask the patient directly - would you like to discuss this further now, or would you prefer to wait until we have more information?
- If the patient wants, explore the possible outcomes (e.g. cyst, benign lesion, tumour, etc.)
Physicians and truth telling
In the past, physicians commonly withheld a cancer diagnosis, now open disclosure is the norm.
Almost all patients want full info (particularly Anglo-Saxon origins)
The majority of patients want to participate actively in decision making (particularly those with higher education, younger patients, and female patients). Physicians often underestimate the degree to which patients want to be involved in decision making.
In some cultures, it is customary for family members rather than patients be told the diagnosis.
ALL patients should be asked at the outset how much information they want and with whom this information should be shared. Assumptions based on culture and demographics should never be made.
SPIKES method for breaking bad news
Setting up
- Review the chart and test results
- Arrange for appropriate family members and HCPs to be present if possible
- Private setting with enough space
- Turn off phones/pagers
- Introduce all individuals
- Sit down, chairs for everyone
- Avoid breaking bad news over the phone
Perception
- Ask the patient what they understand about their medical situation
- Explore what has been done, but also the meaning of tests and interventions.
- May ask specifically about why a test was done, etc.
- Allows an established baseline of understanding, correction of misinformation, reframing of unrealistic expectations, and filling in of knowledge gaps
- “It would be helpful for me to know what you understand about your health at this point”
Invitation
- Verify whether or not the patient is open to receiving the information you have to share
- “Would you like me to talk about the test results now?”
- Can also check in with the patient that if they want more or less information, they should ask.
- Allows HCP to be reassured the patient wants the news, provides the patient with some control over the content of the meeting, and can guide the HCP with regard to how much detail to provide.
Knowledge
- Let the patient know the news is not food before giving further details (“E.g. the test results unfortunately . . .”
- Use non-technical language
- Use a slow pace with opportunities for the patient to ask questions and check in regarding understanding
- Use clear words without euphemisms, but avoid excessive bluntness
- Give news, but also plan for the future - including options for symptom control, treatment
Emotions
- Validate the patient’s emotion and give empathic results.
- “I know this isn’t what you’d hoped for.”
- “This is obviously upsetting. It would be for anyone.”
Strategy and Summary
- Pace the meeting so that it is not too long
- Ensure there is a plan for the future, whether it involves treatment, testing, or an appointment
- Patients vary in how detailed the plan will be (some will want to defer further decisions, others want to develop a preliminary plan)
Evidence for SPIKES
- Shown to increase physicians’ set of competency
- Guideline allows it to be tailored to patients’ needs
How to navigate family members’ requesting information regarding a patient
- Responsibility is to the patient, who has the right to choose who her health information is disclosed and from who it is withheld
- Remember that even disclosure that a patient is under your care can be a breach
Tell family members:
- It is not ethically permissible for you to disclose information about the family member without their explicit consent (this avoids family members thinking the HCP is being evasive)
- Suggest they ask their family member directly, and that if the family member wants they can always accompany her to an appointment
- Listen attentively to any concerns
How to share info regarding prognosis
- Misunderstanding about prognosis and treatment aim (e.g. palliate vs cure) is common
- Lack of communication can influence treatment decisions - patients who overestimate their prognosis or do not discuss options with physicians are more likely to receive aggressive care
- Why is the patient asking about prognosis? Is there a specific goal?
- Clarify that it is impossible to know exactly how long any individual patient will live
- Clarify that it is not curable
- Give an approximate time frame as a range, if known to you - e.g. “Patients with your condition typically live for several months, though it’s impossible to know exactly how many . . . patients with serious illnesses, like yours, are also more likely to get unexpected complications, like a blot clot or infections, which is why it is important to plan ahead.”
- Reassure that you will continue to provide close care as their condition changes, including with community resources.
Does discussion of prognosis cause patients to lose hope
- Hope is important for patients and families to maintain
- Hope can take different forms and can be reframed by exploring realistic goals
- Prognostic information can still be shared in a way that respects a patient’s need for ambiguity, but also allowso them to plan to reach their goals. E.g. “I also hope that you will be able to go to the wedding in July, but it would be more certain that you could attend if the date was moved to January. Do you think that would be possible?”
- Wish statements can be useful to convey empathy and support, while gently acknowledging that their realization is unlikely. “I wish there was a treatment that could cure your cancer.”
Indications for a family meeting
- Essential to ensure all family members are on the same page.
- Change in the status of the patient
- Change in the treatment plan
- Discord amongst family members
- Plan for discharging a patient home
‘Family’ refers to all those important to the patient, which may be relatives and friends alike. Key members of the healthcare team should also attend.
Effective family meetings
Prep:
- Prepare by familiarizing yourself with the chart, with attention to goals of care and objectives of the meeting
- Consider a pre-meeting with healthcare providers to discuss goals, who will lead, potential sources of conflict and how to manage
- Consider contacting other consultants in advance so that their opinion is available prior to the meeting (e.g. med onc)
Meeting:
- Private setting, with those in a circle
- If patient is unconscious, decide with the help of the SDM where to meet (e.g. with the patient present or not)
1. Introductions
2. Summary of goals of the meeting
3. Clarify the family’s understanding of the patient’s condition and treatment plan (ensure that all family members are on the same page, especially if only one speaks)
4. Summarize the current situation from the point of view of the treating team and clarify any misunderstandings. Listen and validate reactions, differing points of view, identify family concerns
5. Direct the meeting toward a treatment plan and clarify family view of the future
6. Clarify family coping, emphasise family strengths and commitment to one another
7. End the meeting with a summary and clear goals for care. Also consider a family ‘spokesperson’ to be the main point of contact if the family member is large.
Dealing with family members or patients with strong negative emotions (anger, denial, etc.)
NURSE acronym:
Name, Understand, Respect, Support, Explore.
- Name the emotion you hear expressed.
“It sounds like you are very distressed/upset/sad . . .” - Understand - normalise the emotion
“ . . . which is understandable given how quickly/difficult/”
- Convey understanding of the specific emotion, not the overall situation
- Simply saying “I understand” can sound perfunctory and dismissive. - Respect - state appreciation of their efforts
“You’ve provided a lot of care and support for your mother . . .” - Support - focus on the patient and their needs and offer help.
“I’ll do my best to get more support at home/nursing care/work to find meds . . .” - Explore - open up discussion to the emotion or distress expressed
“You mentioned . . . can you tell me more about that?”
How to approach conflict between family members regarding goals of care
- Hierarchy of SDMs is in most cases:
1. partner
2. adult children
3. parents
4. Siblings
Families with higher levels of pre-existing conflict often tend to have stronger preferences for life-prolonging care
Advance care planning has been shown to decrease family conflict and allow open discussion of the patient’s wishes
Use the SPIKES framework to approach discussions with family members when patients lack decision making capacity. Consider:
- Ensure there is time for all viewpoints
- Emphasise that being an SDM is about not what they would want if they were the patient, but what they feel the patient would want if she could decide for herself
- Ask if there is a written advance directive (can provide clarity)
- Explore what the patient has expressed to her children or to the provider in the past about opinions/preferences
- Recap the patient’s condition and treatment to date, including the severity
- Discuss risks/benefits of each intervention, including impact on quality and quantity of life
- Discuss the concept of ‘burden without benefit’ if you feel a procedure/intervention is clearly without benefit to either quality or quantity
- Providence guidance on the basis of existing information, clinical experience, the balance of burdens and benefits for improving QOL and minimizing suffering
If no consensus emerges, three options:
- Postpone decision making and recommend participants take time to think
- Time limited trial of a given therapy, with a specific outcome that will determine whether it is continued or not
- Call in a third party (palliative care, ethics, or spiritual care consult)
Should families be told when death is imminent?
- Recognizing impending death is a clinical skill based on signs and symptoms of the dying process
- This is often not discussed with patients or their families.
Barriers
- Hope the patient will get better
- Lack of a definitive dx or event causing death
- Poor communication skills
- Concerns about what interventions/tx/meds may be requested
- Fear of shortening life
- Cultural and spiritual barriers
Consequences of not discussing
- Loss of trust
- Dissatisfaction
- Uncontrolled symptoms
- Family members not being present at or around the time of death
- Unmet cultural/spiritual needs
- Inappropriate interventions
Explicitly disclosing imminent death should involve discussing what the process looks like may help family cope and facilitate treatment planning
How to interact with families after a death
- Ensure families have time for spiritual or religious rites
- Have answers or resources to questions around practical matters (e.g. what happens to the body, how to obtain a copy of the death cert, how to find a funeral director)
- ‘Close the cycle’ - members of the healthcare team or staff members very involved in the care make contact with the family at or after the time of death (in person, by telephone, or by mail)
- Consider bereavement supports after the death, and connecting with families at the time of the death and a week or two afterwards is helpful for this
Strategies to avoid burnout
- Maintaining physical health
- Effective professional relationships
- Transcendental perspective
- Talking with others
- Engaging in hobbies
- Ensuring clinical variety
- Maintaining personal relationships
- Setting boundaries
- Interprofessional team environment with close working relationships
- Debriefing amongst team members about stressful discussions and deaths
Criteria for ‘patient centeredness’
Institute of Medicine Committee on Quality of Health Care in America:
- Eliciting and understanding the patient’s perspective
- Understanding the patient’s psychosocial context
- Achieving a shared understanding of the problem and its appropriate treatment in the context of the patient’s preferences and values
- Empowerment, by involved patients actively in decision making
Impact of affect on decision making
Affect - emotions associated with the content of the conversation
Strong negative affect, not improved by caregivers, can result in impaired processing of communication and understanding
Physician affect can also negatively impact patient understanding and result in higher anxiety
Domains of effective communication between patients and doctors
- Adequate information - straightforward, understandable
- Receptive when patients are ready to talk
- Balance between honesty and empathy
- Doctors elicit and respond to patient concerns
- Doctors to attend to emotion
Patients want an open-ended, empathic approach with maximal quality of interactions, rather than quantity.
Tips for good communication
- Ask patients and families around their communication preferences (discussion versus recommendation)
“Some patients like to consider all their options before making a decision, where others prefer their doctor makes a specific recommendation. Which of these styles appeals to you?”
“Some patients prefer their doctor acknowledges and discusses emotional issues that go along with having an illness, while others prefer not to discuss these kinds of things with their physician. What’s your preference about this?”
- Ensure open ended questions
- Respond to affect and prompt patients around emotional concerns as needed
- Ask before telling (ask about understanding before telling)
