Http:// Module #3 END-OF-LIFE CARE: Module 3 Communicating with Patients and Families

Module #3http://www.growthhouse.org/stanford

END-OF-LIFE CARE:Module 3

Communicating with Patients and Families

Module #3http://www.growthhouse.org/stanford

• Talk too much• Rarely explore patients’ values & attitudes• Discuss uncertainty using vague language

Tulsky, et al., 1998

• Avoid patients’ affective concernsParle, et al., 1997

• Overemphasize cognitive communication• Fail to assess patient understanding

Braddock, et al., 1999

Identified Deficits in Physician Communication Skills

Module #3http://www.growthhouse.org/stanford

Recognize the importance of effective end-of-life (EOL) communication

Increase your EOL communication skills in:– Listening– Sharing bad news– Pronouncing death

Improve your ability to incorporate this content into your clinical teaching

Learning Objectives

Module #3http://www.growthhouse.org/stanford

Outline of Module

Background

Three techniques critical to EOL communication

Skills training– Listening– Sharing bad news– Death pronouncement– Diversity

Physician self-care strategies

Module #3http://www.growthhouse.org/stanford

General Challenges to Patient-Physician Communication

• Time constraints• Language differences• Mismatch of agendas• Lack of teamwork• Discomfort with strong emotions• Quality of physician training• Resistance to change habits

Buckman (1984), Ford et al (1994), Buss (1998)

Module #3http://www.growthhouse.org/stanford

Unique Challenges in Communication at the end of life:

• Emotionally laden material

– For patient, for family, for providers

• Issues of uncertainty are common

– Prognosis

– What is it like to die?

– The meaning of death

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Three Techniques Critical to End-of-Life Communication

• Distinguish between cognitive and affective elements of communication, and respond appropriately

• Clarify ambiguity

• Listen in balance with speaking

Suchman,1997

Module #3http://www.growthhouse.org/stanford

Two Elements to Keep in Mind:

• Cognition = intellectual component

• Affect = emotional component

Module #3http://www.growthhouse.org/stanford

Cognitive Response

• How might you respond to the cognitive component of the patient or family member’s communication?

Module #3http://www.growthhouse.org/stanford

Affective Response

• Identify and explore the affect:– “You seem angry (worried, upset) about this. Can

you help me understand what’s going on for you?”

• Acknowledge the probable source of affect and connect it with its source

– “You’ve been through a lot. No wonder you’re feeling like this.”

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Clarify Ambiguity

• Ambiguous statements:– “I want you to take care of me when the time comes”– “I want everything done for my father”

• What do you hear?– “I want compassionate care”– “I want assisted suicide”

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Listen in Balance with Speaking

• Convey listening nonverbally• Delay your response for a few moments• Reflect the affective component

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Delay Exercise

A’s: Talk about a memorable experience with dying, that you have had as a practitioner

B’s: • Distinguish between cognitive and affective

components • Listen for ambiguity• Listen in balance with speaking

– Convey listening nonverbally– Delay response for a few moments– Reflect the affective component

Module #3http://www.growthhouse.org/stanford

Debrief

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Sharing Bad News

• Step 1: Prepare

• Step 2: Convey Information

• Step 3: Follow Up

Module #3http://www.growthhouse.org/stanford

Step 1: Prepare

• Prepare yourself

• Prepare the recipients

• Prepare the environment

Module #3http://www.growthhouse.org/stanford

Step 2: Convey Information

• Establish empathic connection

• Give an advance alert

• Convey realistic information in a clear manner

• Observe and respond to cognitive and affective reactions

• Clarify ambiguity

• Restore and catalyze hope

Module #3http://www.growthhouse.org/stanford

Step 3: Follow Up

• Set concrete goals

• Connect patient/family with support systems

• Arrange follow-up meetings

• Convey commitment and non-abandonment

• Communicate with treatment team

Module #3http://www.growthhouse.org/stanford

Training Tape

Sharing Bad News in Two Different Ways

• Two scenarios from the End-of-Life Physician Education Resource Center

http://www.eperc.mcw.edu

Module #3http://www.growthhouse.org/stanford

Discussion

First scenario

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Discussion

Second scenario

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Skills

Sharing Bad News:

• Step 1: Prepare

• Step 2: Convey Information

• Step 3: Follow Up

Skills Practice

Module #3http://www.growthhouse.org/stanford

Debrief

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Action Plan

Summarizing the Bad News Role Play

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Death Pronouncement

• Not just a medical event• Very important to family• Most physicians have not been trained to do this• A skill that requires practice

Death Pronouncement

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• Find out about the situation• Pronounce/say goodbye• Console the family• Silence• Follow-up paperwork and other business

Steps in Pronouncing Death

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Role Play #1

• A patient died on the wards• The nurse has just called you to “pronounce the

patient”• The patient is alone in the room• Model saying goodbye• There is no ‘right’ or ‘wrong’ way to do this

Module #3http://www.growthhouse.org/stanford

Role Play #2

• A patient has died on the wards• The nurse has just called you to “pronounce the

patient”• Family member(s) present in the room• Model the communication aspects of

pronouncing a person dead• There is no ‘right’ or ‘wrong’ way to do this

Module #3http://www.growthhouse.org/stanford

Debrief

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Summary

• Most of us have not been taught how to pronounce death

• We may never have seen it done• We are there as a guest in the room• How does a doctor say goodbye to a human

being?

Module #3http://www.growthhouse.org/stanford

• Anticipate death where possible, and keep family up-to-date beforehand

• Use skills of sharing bad news• Allow time for immediate reaction• Suggest they take their time coming in• Provide contact person and explicit instructions• Arrange follow-up

Death Notification by Telephone

Module #3http://www.growthhouse.org/stanford

Learning Objectives

Recognize the importance of effective end-of-life communication

Increase your EOL communication skills in:– Listening– Sharing bad news– Pronouncing death

Improve your ability to incorporate this content into your clinical practice

Learning Objectives