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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
Module #3http://www.growthhouse.org/stanford
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.”
Module #3http://www.growthhouse.org/stanford
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”
Module #3http://www.growthhouse.org/stanford
Listen in Balance with Speaking
• Convey listening nonverbally• Delay your response for a few moments• Reflect the affective component
Module #3http://www.growthhouse.org/stanford
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
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
Skills
Sharing Bad News:
• Step 1: Prepare
• Step 2: Convey Information
• Step 3: Follow Up
Skills Practice
Module #3http://www.growthhouse.org/stanford
Action Plan
Summarizing the Bad News Role Play
Module #3http://www.growthhouse.org/stanford
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
Module #3http://www.growthhouse.org/stanford
• Find out about the situation• Pronounce/say goodbye• Console the family• Silence• Follow-up paperwork and other business
Steps in Pronouncing Death
Module #3http://www.growthhouse.org/stanford
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
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
