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Communication

Key points

  • Being able to openly discuss changes in care and talk comfortably about end-of-life issues is important. Patients respect and value this part of a GP’s role.
  • Useful Tip

Most patients expect their doctor will raise palliative care issues when needed. Find an opening statement you are comfortable using.

  • Plan ahead for discussions about palliative care when possible. Several strategies can help:
    • Clinical practice guidelines on communicating prognosis and discussing end-of-life issues are available. They provide examples of opening questions and useful phrases for these conversations
    • Find questions or phrases you are comfortable using to initiate and continue conversations about palliative care
    • When organising an appointment where prognostic information many be communicated, check if the patient wants someone to be there with them.

Palliative Care and the Human Connection: Ten Steps for What to Say and Do

From Dr Diane E Meier, Director of the Center to Advance Palliative Care (CAPC) (US)


Clinical practice guidelines - Communicating prognosis and end-of-life issues (Summary)

National Health and Medical Research Council (NHMRC)

The clinical practice guidelines are summarised using the acronym PREPARED
 
Prepare for the discussion, where possible:
  • Confirm pathological diagnosis and investigation results before initiating discussion
  • Try to ensure privacy and uninterrupted time for discussion
  • Negotiate who should be present during the discussion
Relate to the person:
  • Develop rapport
  • Show empathy, care and compassion during the entire consultation
Elicit patient and caregiver preferences:
  • Identify the reason for this consultation and elicit the patient’s expectations
  • Clarify the patient’s or caregiver’s understanding of their situation, and establish how much detail and what they want to know
  • Consider cultural and contextual factors influencing information preferences
Provide information, tailored to the individual needs of both patients and their families:
  • Offer to discuss what to expect, in a sensitive manner, giving the patient the option not to discuss it
  • Pace information to the patient’s information preferences, understanding and circumstances
  • Use clear, jargon-free, understandable language
  • Explain the uncertainty, limitations and unreliability of prognostic and end-of-life information
  • Avoid being too exact with timeframes unless in the last few days
  • Consider the caregiver’s distinct information needs, which may require a separate meeting with the caregiver (provided the patient, if mentally competent, gives consent)
  • Try to ensure consistency of information and approach provided to different family members and the patient and from different clinical team members
Acknowledge emotions and concerns:
  • Explore and acknowledge the patient’s and caregiver’s fears and concerns and their emotional reaction to the discussion
  • Respond to the patient’s or caregiver’s distress regarding the discussion, where applicable
(Foster) Realistic hope:
  • Be honest without being blunt or giving more detailed information than desired by the patient
  • Do not give misleading or false information to try to positively influence a patient’s hope
  • Reassure that support, treatments and resources are available to control pain and other symptoms, but avoid premature reassurance
  • Explore and facilitate realistic goals and wishes, and ways of coping on a day-to-day basis, where appropriate
Encourage questions and further discussions:
  • Encourage questions and information clarification; be prepared to repeat explanations
  • Check understanding of what has been discussed and if the information provided meets the patient’s and caregiver’s needs
  • Leave the door open for topics to be discussed again in the future
Document:
  • Write a summary of what has been discussed in the medical record
  • Speak or write to other key health care providers involved in the patient’s care. As a minimum, this should include the patient’s general practitioner
Ref: Clayton JM, Hancock KM, Butlow PN, Tattersall MHN, Currow DC. Clinical practice guidelines for communicating prognosis and end-of-life issues with adults in the advanced stages of a life-limiting illness, and their caregivers. Med J Aust. 2007;186(12):77.
 

Fast Facts - On communication skills for specific situations

# 011 Delivering Bad News-Part 2, 2nd ed
Very practical steps to help in breaking bad news, and ways to support trainees as they learn this skill.
 
# 162 Advance Care Planning in Chronic Illness
This Fast Fact reviews key concepts of the Advance Care Planning (ACP) process.
 
# 163 Decision Making in Chronic Kidney Disease (CKD)
This Fast Fact reviews key concepts of the ACP process for CKD patients.
 
# 065 Establishing End-of-Life Goals: The Living Will Interview, 2nd ed
Doctor-patient discussions about end-of-life treatment are often framed as a choice between 'medical treatment vs. treatment withdrawal'.

# 038 Discussing Hospice, 2nd ed
Palliative care discussions with seriously ill patients should always take place in the context of the larger goals of care, using a step-wise approach.

# 042 Broaching the Topic of a Palliative Care Consultation with Patients and Families, 2nd ed
This Fast Fact provides tips for beginning a discussion leading to a visit by a palliative care consultation team.
 
Families and Family Meetings
 
# 226 Helping Surrogates Make Decisions
This Fast Fact reviews an approach to help surrogates through the decision process when patients cannot participate in decision making themselves.
 
# 047 What Do I Tell The Children, 2nd ed
A common question asked by dying adults or their family members is What do I tell the children?
 
# 219 Responding to Requests for Non-Disclosure of Medical Information
This Fast Fact will introduce readers to a practical approach to responding to families who request non-disclosure to the patient.
 
# 222 Preparing for the Family Meeting
As with any procedure, preparation is essential to ensure the best outcome. This Fast Fact reviews how to prepare for a Family Meeting.

# 016 Moderating an End-of-Life Family Conference, 2nd ed
Learning the process steps of a Family Conference are an important skill for physicians, nurses and others who are in a position to help patients and families reach consensus on end-of-life planning.
 
# 227 The Family Meeting: End-of-Life Goal Setting and Future Planning
This Fast Fact discusses an approach to goal setting when the expected length of life is short.
 
# 224 Responding to Emotion in Family Meetings
This Fast Fact provides a detailed approach to emotions that arise during family meetings.

# 225 The Family Meeting: Causes of Conflict
This Fast Fact explores understanding the causes of conflict and how to plan an effective strategy to move beyond the conflict to meet the needs of the patient and surrogates.
 
Specific Communication Skills
 
# 021 Hope and Truth Telling, 2nd ed
This Fast Fact discusses the difficult balance between maintaining hope and truth telling, especially as it applies to giving bad news.
 
# 017 Patient-Centered Interviewing, 2nd ed
Patient-Centered Interviewing - You can assess a patient’s illness experience by asking about 4 dimensions - Feelings, Ideas, Function and Expectations. The acronym FIFE can be a helpful reminder.
 
# 216 Asking about Cultural Beliefs in Palliative Care
Patients’ cultural backgrounds profoundly influence their preferences and needs regarding discussing bad news, decision making, and the dying experience. This Fast Fact offers a framework for taking a ‘cultural history’ to better understand a patient’s and family’s needs.

# 019 Taking A Spiritual History, 2nd ed
Taking a spiritual history is one way to support the patient.
 
# 026 The Explanatory Model, 2nd ed
Have you ever had this experience - you are talking with a patient about some care option and you just cannot come to an agreement?

# 029 Responding to Patient Emotion, 2nd ed
Here are eight tasks that guide you in responding to patient emotion.
 
# 059 Dealing With The Angry Dying Patient, 2nd ed
A guide to managing anger in palliative care situations is presented.
 
# 183 Conflict Resolution I: Careful Communication
This Fast Fact provides an alternative approach to conflict resolution based on understanding a patient’s or family’s story, attending to their emotions, and establishing shared goals.

# 184 Conflict Resolution II: Principled Negotiation
Principled negotiation is an approach to resolving conflict that avoids power struggles and unwanted compromises.

# 194 Disclosing Medical Error
This Fast Fact will address how to disclose error with a patient/family.

# 195 Responding to a Colleague's Error
This Fast Fact will discuss responding to a colleague’s error.

# 203 Managing One's Emotions as a Clinician
This Fast Fact focuses on clinicians’ emotional responses to patient care.
 
# 022 Writing a Condolence Letter, 2nd ed
One of the most meaningful acts of kindness you can do for a mourner is to write a letter of condolence.
 
Barriers to Communication

# 154 Use of Interpreters in Palliative Care
This Fast Fact reviews key issues when using interpreters in the palliative care setting.
 
# 078 Cultural Aspects of Pain Management, 2nd ed
The meaning and expression of pain are influenced by people’s cultural background.

# 152 The Military History as a Vehicle for Exploring End-of-Life Care with Veterans
Knowing the components of a military history can be a useful tool in bridging the silence that often surrounds the war experience and can act as a catalyst for discussions about end-of-life preferences.

# 153 Health Literacy in Palliative Medicine
This Fast Fact reviews assessment and management strategies for poor health literacy.

# 241 Improving Communication When Hearing Loss is Present
Hearing loss can lead to misunderstandings, which in the health care setting can literally have life-or-death implications.
 
Ethical Issues
 
# 055 Decision Making Capacity, 2nd ed
Decision making capacity (‘decisionality’) refers to a physician’s determination, based on clinical examination, that a patient is able to make medical decisions for him- or herself.
 
# 056 What to do When a Patient Refuses Treatment, 2nd ed
A core aspect of bioethics is that a competent adult patient has a right to refuse treatment, even when the physician believes that the treatment would be beneficial.
 
# 164 Informed Consent in Palliative Care - Part I
This Fast Fact reviews the legal basis for informed consent. 
*Discussion is based on USA setting, but general principles are relevant for Australia.

# 165 Informed Consent in Palliative Care - Part II
This Fast Fact discusses common myths about informed consent that arise in palliative care.

# 172 Professional Patient Boundries in Palliative Care
This Fast Fact reviews issues in health professional-patient boundaries in palliative care.
 
# 156 Evaluating Requests for Hastened Death
This Fast Fact provides guidance on how to evaluate and initially respond to a patient who raises the topic of a hastened death.

# 159 Responding to a Request for Hastening Death
This Fast Fact focuses on possible ways of responding to patients who continue to want a hastened death despite every effort to find appropriate palliative care alternatives.
 
# 193 Decision Making for Adults with Developmental Disabilities Near the End-of-Life
This Fast Fact will address medical decision making for adults with developmental disabilities (DD) who are facing terminal or life-limiting diseases such as cancer, end-stage organ failure, or progressive debility.
 
# 207 Withdrawal of Dialysis: Decision Making
This Fast Fact reviews key issues pertaining to the decision to stop chronic dialysis.

# 206 Genetic Screening and DNA Banking at the End-of-Life
Once patients die their DNA is no longer readily available for future testing. On the other hand, decisions about genetic testing are complex and can have profound emotional, familial, and financial impacts on those affected and should not be pursued hastily.

From: Palliative Care Network of Wisconsin (US)

Last updated 15 February 2017