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Chapter 2

Communication

M. Racsa, Florida Hospital Memorial Medical Center, Daytona, FL, United States

Abstract

One of the core competencies of providing palliative care is the ability to communicate with patients and their families. While many of us think that we are excellent communicators, there is always room for improvement. Communication is a skill and no matter what level you are starting at, there is always room for growth and refinement. Some basic tools are provided in this chapter to help guide you on your journey toward mastery. Your journey will involve trial and error, taking risks (going outside your comfort zone), taking the time to debrief on what went well or not so well, and what improvements you can make.

Keywords

Palliative care; communication; prognosis

Introduction

• One of the core competencies of providing palliative care is the ability to communicate with patients and their families [1].

• While many of us think that we are excellent communicators, there is always room for improvement.

• Communication is a skill and no matter what level you are starting at, there is always room for growth and refinement.

• Some basic tools are provided in this chapter to help guide you on your journey toward mastery.

• Your journey will involve trial and error, taking risks (going outside your comfort zone), taking the time to debrief on what went well or not so well, and what improvements you can make.

ASK-TELL-ASK

• One of the simplest but most effective approaches to communicating with a patient is the “ASK-TELL-ASK” method [2].

• It demonstrates willingness to listen to and negotiate the patient’s agenda and builds on the patient’s present knowledge and understanding of his/her illness.

Ask	• Ask the patient to describe his/her present concerns and understanding of their illness “What brings you here today?” “To make sure we are on the same page, can you tell me what your understanding of your disease is?”
Tell	• Communicate with the patient using straightforward language • Provide information in small chunks
Ask	• Ask the patient his/her understanding of the information provided “To make sure I did a good job of explaining to you, can you tell me what your understanding is of your treatment plan?” • Clarify the patient’s understanding if needed

Delivering Bad News: SPIKES

• One of the most challenging aspects of being an oncologist is delivering “bad news.”

• SPIKES is a six-step strategy that provides a useful framework for clinicians [2–4].

• We encourage focusing on improving one step at a time.

• Modify and tailor this approach to what feels most authentic to you and what meets your patient’s specific needs.

Setting	S—Setting • Arrange for a private location • Involve significant others • Sit down • Make a connection through eye contact • Manage time constraints and interruptions
Perception	P—Perception of condition and seriousness • Determine the patient’s understanding of his/her illness including the seriousness of their illness • Correct misinformation • Tailor information to the individual’s level of understanding
Invitation	I—Invitation to the patient to give information • Ask the patient if he/she wishes to know the details of the illness • Accept the patient’s right not to know • Offer to answer questions at a later time
Knowledge	K—Knowledge: giving medical facts • Assess the patient’s level of comprehension (including level of education) • Provide information in small chunks • Check periodically for patient understanding • Respond to the patient’s reactions as they occur • Provide facts accurately about treatment prognosis, treatment options, etc.
Empathize	E—Explore emotions and sympathize • Listen for and observe the patient’s emotion • Identify the patient’s emotion • Identify the reason for the emotion • Show the patient that their emotion is recognized • Be quiet • Refer to next section on “Responding With Empathy”
Summarize and Strategize	S—Strategize and summarize • Ask whether the patient needs any clarification • Establish a clear plan for the future

Responding With Empathy: NURSE

• NURSE is a useful guide to respond to patient emotions with empathy [2].

• While it can be tempting to ignore strong emotions, it is important to openly acknowledge and demonstrate empathy when patients are in distress [5].

Naming	• Identify the patient’s emotion • Name the patient’s emotion out loud “Some patients in this situation would be angry…”
Understanding	• Confirm that you understand the patient’s concerns in the context of this emotion • Resist the temptation to provide reassurance before understanding the patient’s primary concern(s) “This must be very difficult for you.” “If I am understanding you correctly, you are concerned about the effect of chemotherapy on your children.”
Respecting	• Respond verbally and nonverbally to the patient’s emotion through appropriate facial expression, touch, or change in posture • Match the level of your response to the patient’s level of emotion • Praise coping skills “I am very impressed with how well you have cared for your wife throughout her treatment …”
Supporting	• Provide support by expressing your concern, confirming your understanding of the patient’s situation (above), or acknowledging the patient’s efforts to cope • Many terminal patients fear abandonment—provide reassurance about your continued commitment to support the patient “I will be here to support you no matter what happens.”
Exploring	• Explore the patient’s concerns and emotions “Tell me more about what you are feeling …”

Discussing Prognosis: ADAPT

• Approaching the topic of prognosis with a patient and their family can be challenging.

• ADAPT is a “talking map” to help clinicians navigate through conversations about prognosis [6].

Ask	• Ask what patient knows “What have other doctors told you about your prognosis or what to expect for the future?” • Ask what he/she wants to know [7,8] “How much do you want to know?”
Discover	• Discover what type of prognostic information would be most useful for the patient For some patients, numbers or statistics about how long they will live are helpful For others, information about living to a particular date or event (e.g., graduation, the birth of a grandchild) may be most helpful
Anticipate	• Anticipate ambivalence Explore patient’s concerns about discussing prognosis
Provide	• Provide information in the format the patient prefers
Track	• Track or respond to patient’s emotion Acknowledge or respond to patient’s emotion

Conducting a Family Meeting/Goals of Care Discussion

• You have probably conducted several family meetings already whether formally or informally.

• The following approach provides a useful guide to conducting a family meeting [4,9–11].

• Note that an effective meeting includes adequate preparation and debriefing afterward.

Premeeting planning	• Clarify the goals of the meeting in your own mind • Review relevant medical history, treatment options, and prognostic information • Review advance care planning information including code status • Coordinate medical opinions between consultants and primary team prior to the meeting • Obtain relevant information related to patients psychosocial, spiritual, and family dynamics
Establish an appropriate setting	• Choose a quiet and private environment • Minimize distractions such as cell phones or pagers
Introductions/establish rapport	• Introduce yourself • Have participants identify themselves and their relationship to the patient • Establish the goals of the meeting Include the patient’s/family’s primary goals and concerns
Assess patient/family understanding	• Determine what the patient or family already knows “What is your understanding of your current medical condition?”
Review medical status	• Present the big picture • Review current status, plan, and prognosis • Provide patient/family members with the opportunity to ask questions
Silence/respond to emotions	• Allow silence • Give patient/family time to react • Acknowledge and respond to their reactions and emotions before moving forward
Present options	• Discuss treatment options including symptom management, palliative care and/or hospice (if appropriate) • Make a recommendation
Manage conflict	• Recognize conflict and name the problem out loud • Listen For example, if the person is angry, he/she may have the need to be heard and understood • Listen to yourself • Identify the cause Conflict may emerge due to conflict between patient and his/her family and/or patient/family and the health care team • Reconcile Find common ground Determine a mutually agreeable solution to the conflict (e.g., establish a time trial for a specific intervention)
Translate goals into care plan	• Consider addressing the following (as appropriate to your patient) Assignment of a health care proxy DNR status Palliative care/Hospice support Other considerations (e.g., diagnostic tests, therapeutic interventions, artificial hydration/nutrition, antibiotics or blood products, and future hospitalization/ICU)
Summarize and document	• Summarize consensus, disagreements, decisions, and the care plan • Clarify next steps including a plan for follow-up • Document in the medical record (who was present, what decisions were made, follow-up plan) • Debrief with the health care team members involved with the patient’s care

FICA Spiritual History Tool

• An important component of palliative care is addressing a patient’s spiritual needs and concerns in the context of his/her health care.

• FICA is a useful means of framing the discussion about spirituality with patients and their families [11].

• Even if you do not feel comfortable discussing a patient’s spirituality, take the first step to acknowledge its importance in a patient’s illness and make a referral to social work or clergy.

Faith and belief	• Inquire about patients faith and beliefs “Do you consider yourself spiritual or religious?” “Is spirituality something important to you?” “Do you have spiritual beliefs that help you cope with stress or difficult times?” • If the patient responds “No,” consider asking “What gives your life meaning?”
Importance	• Explore the importance of their faith and beliefs “What importance does your spirituality have in your life?” “Has your spirituality influenced how you take care of yourself, your health?”
Community	• Inquire whether it is a source of social support “Are you part of a spiritual community?” “Is there a group of people who have been supportive to you during this time?”
Address	• Clarify the meaning of their faith and beliefs in the context of their health care “How would you like me, your health care provider, to address these issues in your health care?” “Does your spirituality influence you in your health care decision-making?” (e.g., advance directives, treatment)

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Table of Contents for Chapter 2. Communication

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