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Flashcards in management of selected non pain Deck (21):

Steps in communicating serious news

- Prepare
- establish the patients understanding
- determine how much the patient wants to know (ASK)
- deliver the information (TELL)
- respond to the patients feeling
- ascertain the patients understanding (ASK)
- Organize a plan and follow-up process


How to prepare

- deliver the news in person, privately
- minimize interruptions
- Allow time for discussion


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 to learn unwanted information
--> patient may not want to know full details
--> a patient may wish to have a family member informed instead


Delivering serious news

- use phrasing that sends a warning shot to prepare the patients
--> i feel bad to have to tell you that the growth turns out to be cancer
- avoid technical language or euphemisms


After delviering serious news

- Respond to feelings
--> use active listening
--> encourage expression of emotions
--> acknowledge the patients emotions
- organize a plan and follow-up process
--> address the patienst concerns in immediate plan
--> set an appointment for a follow-up visit
--> sicuss additional tests, referrals sources of support


patient-physician communication

- demanding, challenging
- classic methods
-- leave patients feeling unheard and unsupported
--> leave physicians frustrated demoralized
- research suggests that most physician aren't as good at communication as they think
- effective communication is NOT innate; skills can be learned and can be improved with practice


does better communication really make a differences?

- improves patients adjustment to illness
- lessens pain and physical symptoms
- increases adherence to treatment plan
- increases patient satisfaction with care received
- increases enjoyment in practice
- decreases stress and burnout
- decreases malpractice claims


Premium on communication skills

- depth and breadth of internet usage (make patinets avid consumers of information
-advances in biomedical technology (make medical decision making more complicated
- Patients and families need physicians to help INTERPRET the info and ADD medical knowledge, clinical judgment, and experience (WISDOM) that is not available on a website


Talking about serious news

- how the brain processes threats to life
--> flight or fight takes precedence over cognitive processes
--> autonomic response to threat takes precedence over cognitive processing (out of conscious control)


What are key skills about talking about serious news

--> Commit to observe and use emotional data in your communication
--> notice the patients emotion and NAME it for yourself
--> refrain from trying to fix or quiet the patients emotion
--> acknowledge the emotion explicitly
- MOST POWERFUL non-verbal communication is a combination of technical expertise, commitment and integrity - NOT A PRACTICED GESTURE now and then


discussing prognosis

- pitfall = assuming you know what the patient wants
- solution = ask patients how they want to talk about prognosis


patient preference trends

- education correlates with desire for more information
- more advanced illness correlates with wanting less info.


take home message about Prognosis

- before talking about prognosis spend a minute finding out what the patient wants to know


describe the roadmap discussing transition

- prepare yourself
- ensure the patient or family understands the medical situation
- assess the patients readiness to talk about whats next
- use big picture questions to elicit patients values and goals
- outline worries that are barriers to decision making
- offer to make a recommendation
- propose a new treatment plan that meets the patients goals
- request feedback about your proposal


patients response to transition conversation

- ACCEPT that a transition is occurring = ready for specific end of life planning
- Want to negotiate = perceive that they are close to a transition but want to see more evidence
- Decline the clinicians assessment = usually reflects the prospect is too sad, too frightening, or too threatening


take home message about the transition to end of life care

- it 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


Talking about dying

- Pitful = opening the discussion with CPR/DNR and asking separately about every part of resuscitation
- Solution = guide the patient by developing big picture, talking about he care plan, making recommendation


discussing resuscitation preferences roadmap

- decide why you need to discuss a DNA order
- elicit the patients perception of illness and patients values for care
- discuss the big picture of whats happening medically
- make a recommendation about DNR as part of the care plan
- respond to emotion
- tell the patient that you will document the conversation and write an order


Never ever say....

- There is nothing more i can do for you
ALTERNATIVE: "there is nothing more i can do to halt your disease, but there is much more i can do for you during the next weeks and months. we will go through this together."


saying goodbye to patients you do NOT expect to see again

- choose an appropriate time and place
- acknowledge the end of your routine contact
- invite the patient to respond and use the response as a piece of data about the patients state of mind
- frame the goodbye as an appreciation
- give space for the patient to reciprocate
- articulate an ongoing commitment to the patients care
- later, reflex on your work with this particular patient


take home message about conducting discussion about resuscitation

- conducting discussions about resuscitation preferences is a survival skill for doctors who deal with life-threatening illness
- saying goodbye is an advanced skill for talking to patients to whom you feel particularly connected
- these conversations can be tremendously rewarding