Flashcards in Lecture 8- Communication of Serious News Deck (31):
Steps in communicating serious news
- Establish the patient's understanding
- Determine how much the patient wants to know (ASK)
- Deliver the information (TELL)
- Respond to the patient's feelings
- Ascertain the patient's understanding (ASK)
- Organize a plan and follow-up process
Preparing for communicating difficult news
- plan what will be discussed
- Ensure that all medical facts and confirmations are available
- Choose an appropriate, comfortable setting
- Deliver the news in person, privately
- Allow time for discussion
- Minimize interruptions
Establishing the patient's understanding
- What have other doctors told you about your condition or procedures that you have had?
- How sick are you?
- How is your illness impacting your life?
- What can't you do that you wish you could still do?
What and how much does the patient want to know?
- Avoid making assumptions
- Patients have the right to be told the truth AND to decline the learn unwanted information
- Remember... a patient may NOT want to know full details and a patient may wish to have a family member informed instead
Delivering the Serious News
- Use a sensitive, straightforward manner
- Avoid technical language or euphemisms
- Check for understanding and clarify difficult concepts
- Use phrasing that sends a "warning shot" to prepare the patient (ex. - I feel bad to have to tell you that the growth turns out to be cancer"
After delivering serious news
- Respond to feelings- use active listening, encourage expression of emotion, and acknowledge the patient's emotions
- Organize a plan and follow-up process
- address the patient's concerns in immediate plan
- set follow-up appt.
- Discuss additional tests, referrals, sources of support
- Provide information on how you can be reached with additional questions
- Extremely demanding and challenging
- The classic methods have left patients feeling unheard, unsupported, frustrated, demoralized
- Research suggests that most physicians aren't as good at communication as they think
- Effective communication is not innate; skills can be learned and improved with practice.
How good communication makes a difference for patients
- Improves patient's adjustment to illness
- Lessens pain and physical symptoms
- Increases adherence to treatment plan
- Increases patient satisfaction with care received
How good communication makes a difference physicians
- Increases enjoyment in practice (increased thriving)
- Decreases stress and burnout
- Decreases malpractice claims
Why do patients and families need physicians to communicate well?
- to help interpret the information and ADD medical knowledge, clinical judgement, and experience (wisdom) that is not available on a web site
How the brain processes threats to life
- "fight or flight" - takes precedence over cognitive processes
- Autonomic response to thread takes precedence over cognitive processes (its out of the patient's control)
- therefore, when giving serous news, the most important skill is the ability to detect and respond to a patient's emotions
How to recognize and respond to emotion
1. commit to observe and use emotional data in your communication
2. Notice the patient's emotion and name it for yourself
3. Refrain from trying to fix or quiet the patient's emotion
4. acknowledge the emotion explicitly!
- verbally or non-verbally
Verbal Acknowledgement Mneumoic- NURSE
N- Name the emotion
U- understand the emotion
R- Respect (praise) the patient
S- Support the patient
E- Explore the emotion
Non-verbal acknowledgement mneumoic- SOLER
- Face the patient Squarely to indicate interest
- Adopt an Open body posture
- Lean toward the patient
- use Eye contact to show you are paying attention
- maintain a Relaxed body posture
Take home message of communication...
- when giving serious news, track the patient's emotional data; it can be more important than the cognitive data.
Discussing prognosis- the pitfall and solution
Pitfall- assuming you know what the patient wants
Solution- Ask patients how they want to talk about prognosis
Physician strategies in regard to prognosis
- 37% realists
- 40% are optimists
- 23% are avoiders
Patient preference trends
- Education has correlated with a greater desire to know more information
- More advanced illness correlates with wanting LESS information
How much do you want to know about prognosis?
- Some people want lots of details
- Others want to focus on big picture
- Others would rather not discuss what may happen in the future...
- Which would be best for you?
How do patients respond to "which would be best for you?"
- Want explicit discussion with information
- They DON'T want information
- They are ambivalent
How to communicate to those who WANT information
- Provide the information
- Acknowledge the patient's and family's reaction to the news explicitly
- Check for understanding
How to communicate to those who DON'T want information
- Try to elicit and understand why the patient doesn't want to know
- Acknowledge the patient's concerns
- Ask for permission to revisit the topic
- Make a private assessment about whether prognosis might change patient's current decision making
How to communicate to those who are ambivalent
- Name the ambivalence
- Explore pros and cons of knowing and not knowing
- Acknowledge the difficulty of the patient's situation
- consider outlining the options for discussion and consequences
Take home message about communicating prognosis
Before talking about prognosis, spend a minute finding out what the patient wants to know
Common pitfall and the solution to transition to end-of-life care
- Common pitfall- keep cheerleading until you decide it is time for the patient to be "realistic"
- The solution- Work on the big picture and the goals that are still achievable
Patient's responses to transition converstion
- Accept that a transition is occurring and are ready for specific end-of-life planning
- Want to negotiate- they perceive that they are close to a transition but want to see more evidence
- Decline the clinician's assessment- usually states that the prospect is too sad, too frightening, or too threatening
Take home message about transition conversation
- A transition to end-of-life care is a turning point in a life. Patients and families may not remember the exact words that you used, but they will remember your respectfulness, attention, and empathy (or lack of it)
The common pitfall about talking about dying and the solution
-Common pitfall- opening the discussion with CPR/DNR and asking separately about every step of resuscitation
-Solution- Guide patient by developing the big picture, talking about the care plan, and making a recommendation
Roadmap for discussing resuscitation
- Decide why you need to discuss a DNR order
- Elicit the patient's perception of illness and patient's values for care
- Discuss the "big picture" of what's happening medically
- Make a recommendation about DNR as part of the care plan
- respond to emotion
- Tell patient you will document the conversation and write an order
The one thing you should NEVER EVER say
"There is nothing more I can do for you"