Have You ever heard : ..... Have You ever heard : ..... ??

‘‘There is NOTHING to Do with this There is NOTHING to Do with this patient ’patient ’

‘ ‘ Everybody dies ‘ Everybody dies ‘

‘ ‘ You are young. You can have You are young. You can have another child ’another child ’

MISTAKE !MISTAKE !

CommunicatiCommunicationin onin

palliative palliative carecare

Prof. Jacek Łuczak AM w Poznaniu

Quality of LifeQuality of Life

PsychologicalPsychological PhysicalPhysical SpiritualSpiritual

Reactions for information about cancer Reactions for information about cancer disease (E. Kubler-Ross)disease (E. Kubler-Ross)

denial, shock, numbness (trance)denial, shock, numbness (trance) anger, soreness, irritation, aggresionanger, soreness, irritation, aggresion chaffer with destiny - why me ?chaffer with destiny - why me ? depressiondepression acceptationacceptation

Emotions during cancer Emotions during cancer disease:disease:

AnxietyAnxietyAngerAngerFeeling quiltyFeeling quiltyDepressionDepressionHopeHope

EmotionsEmotions

How are you ?How are you ?

I could not sleep…I could not sleep…

Something worries meSomething worries me

I feel abandoned…I feel abandoned…

I’m dying… I’m dying…

Defensive mechanisms Defensive mechanisms ( adaptation in disease): ( adaptation in disease):

Represive mechanismsRepresive mechanismsSensitive mechanisms ( subconscious)Sensitive mechanisms ( subconscious)Conscious mechanismsConscious mechanisms

Is it a cancer , doctor Is it a cancer , doctor ? ?

DON`T PASS OVER IT IN SILENCE !!!DON`T PASS OVER IT IN SILENCE !!!

No, but your disease is...No, but your disease is...

I don`t know, because...I don`t know, because...

Yes, but ...Yes, but ...

Know-how listenings:Know-how listenings:

ActiveActiveReflectiveReflectiveEmpatic Empatic

Partnership with the patientPartnership with the patient

Courtesy in behaviour Courtesy in behaviour Politeness in speechPoliteness in speechNot patronizing , Being honestNot patronizing , Being honest Listening , ExplainingListening , ExplainingAgreeing priorities and goalsAgreeing priorities and goalsDiscussing treatment optionsDiscussing treatment optionsAccepting treatment refusalAccepting treatment refusal

Hope and truthHope and truth

big small falsebig small false

General strategyGeneral strategy

What do you see ?What do you see ?What do you feel?What do you feel?What can you do ?What can you do ?

Detailed strategy:Detailed strategy:

What does your patient need ?What does your patient need ?What does his family need ?What does his family need ?Some important issues from patient`s Some important issues from patient`s

life..life..Let the patient give something...Let the patient give something...

Distancing TacticsDistancing Tactics

Premature reassurancePremature reassurance False eassuranceFalse eassurance NormalisingNormalising Selective attentionSelective attention Jollying alongJollying along Passing the buckPassing the buck ““Turning a deaf ear”Turning a deaf ear” Concentrating on a physical taskConcentrating on a physical task Inappropriately introducing humourInappropriately introducing humour Dissappearing from the stressful situationDissappearing from the stressful situation

Breaking Bad NewsBreaking Bad News How to do it How to do it

guidelinesguidelines( adapted from Mc Master techniq( adapted from Mc Master technique )ue )

Consider where to do it !Consider where to do it ! Do NOT begin with an open questionDo NOT begin with an open question Check patient’s current insight into his/her illnessCheck patient’s current insight into his/her illness Fire a warning shot Fire a warning shot

( eg. I’m afraid it looks more serious than we first thought’)( eg. I’m afraid it looks more serious than we first thought’) Pause Pause

Take your ‘moving on’ cue from the patient. This may often be nonverbal. Take your ‘moving on’ cue from the patient. This may often be nonverbal. Some patients will not want to know more at this stage)Some patients will not want to know more at this stage)

Perhaps use hierarchy of euphemisms Perhaps use hierarchy of euphemisms (again this may depend on the insight of the patient)(again this may depend on the insight of the patient)

Break the News. Do it clearly and without jargon, (so that the patient is Break the News. Do it clearly and without jargon, (so that the patient is not left with more uncertainties)not left with more uncertainties)

PausePause Resist ReassuranceResist Reassurance Acknowledge any obvious feelings you witness in the patient ( eg. This is Acknowledge any obvious feelings you witness in the patient ( eg. This is

very upsetting for you)very upsetting for you) Find out how the patient is feeling. It often helps to prefix what may seem Find out how the patient is feeling. It often helps to prefix what may seem

an obvious statement with something like:an obvious statement with something like:’ this may seem a silly question but I’m wondering how this has left you ’ this may seem a silly question but I’m wondering how this has left you feeling right now?’feeling right now?’

Draw out any immediate concernsDraw out any immediate concerns Be realisticBe realistic Maintain Hope eg. ‘There are things that we can do’ Maintain Hope eg. ‘There are things that we can do’

SOME ADVICESSOME ADVICES one musn’t respond to all the problems during the first visitone musn’t respond to all the problems during the first visit use open questionsuse open questions be understandablebe understandable respond to needs of the patientrespond to needs of the patient predetermine time of talkpredetermine time of talk be onest (synchronization of the words and body language)be onest (synchronization of the words and body language) use silenceuse silence repeat last words of the patientrepeat last words of the patient use paralingvistic sounds …hmm… eh..use paralingvistic sounds …hmm… eh.. don’t speak about yourselfdon’t speak about yourself avoid mentor’s positionavoid mentor’s position be careful if you feel helpless . It is easy to make a mistakebe careful if you feel helpless . It is easy to make a mistake first talk to the patient, secondary -to the familyfirst talk to the patient, secondary -to the family talk to the family over open doortalk to the family over open door Never say:Never say:

Everybody diesEverybody dies You may have another child, (when the one died)You may have another child, (when the one died)

Communication with childrenCommunication with children::

The evidence does suggest that those families who can express The evidence does suggest that those families who can express themselves openly benefit both during the child`s illness and after themselves openly benefit both during the child`s illness and after the death. the death. / Spinetta et al. 1981 // Spinetta et al. 1981 /

The consensus opinion in the literature has moved over the last 20 years from a The consensus opinion in the literature has moved over the last 20 years from a protective approach to children towards honesty and openness / Chesler 1986 / protective approach to children towards honesty and openness / Chesler 1986 /

Many acquire considerable information about their disease , Many acquire considerable information about their disease , including the possibility of death, without being told specifically. including the possibility of death, without being told specifically. This happened even to children who were cared for by staff and This happened even to children who were cared for by staff and parents who were cared for by staff and parents who believed that parents who were cared for by staff and parents who believed that the children would remain naive and protected if their disease was the children would remain naive and protected if their disease was not discussed with them. / Bluebond-Langer 1978, Kendrick et al. not discussed with them. / Bluebond-Langer 1978, Kendrick et al. 1987/ 1987/

Even experienced staff who overtly expressed the wish to be open, have been Even experienced staff who overtly expressed the wish to be open, have been observed to use distancing tactics regularly. / Maguire 1985/observed to use distancing tactics regularly. / Maguire 1985/