difficult communication in oncology nursing. objectives describe the purpose and process of...

Difficult Communication in Oncology Nursing

Objectives

• Describe the purpose and process of communication in oncology nursing.

• Describe strategies for responding to at least three difficult communication scenarios in oncology nursing.

Why Is Communication Important in Cancer Care?

• 2001 Institute of Medicine (IOM) Crossing the Quality Chasm report

• 2011 Patient-Centered Cancer Treatment Planning: Improving the Quality of Oncology Care: Workshop Summary

• 2013 IOM Delivering Affordable Cancer Care in 21st Century Report

Nurse Communication and Quality

• Nurse-patient communication strongly influences patient satisfaction, outcomes and costs of care.

(Press Ganey Associates, 2013)

Communication in Palliative Care

• National Consensus Project for Quality Palliative Care (2013) emphasizes importance of communication in all aspects of care:o Structure and processes of careo Aspects of care:

Physical Psychological and psychiatric Social Spiritual, religious, and existential Cultural

o Care of patient at end of lifeo Ethical and legal aspects of care

Communication in Nursing

• Multiple components• Communication is the foundation of the nurse-

patient relationship.o Knowing the patient as persono Assessment of symptoms, understanding of illness,

goals, values, beliefso Patient and Family Educationo Offering psycho-social-spiritual supporto Assisting with decision making

• Advocating for patient.• Collaborating with the interdisciplinary team.

(Wittenberg-Lyles, Goldsmith, Ferrell & Ragan, 2013; Dahlin, 2010)

Learning Activity

What is Communication?

• Communication: process of mutual influence that is ongoing and dynamic.

• Purpose is to impart:o Informationo Affect

• All communication occurs in relationship to other person(s).

• Communication occurs verbally and non verbally.

(Wittenberg-Lyles, Goldsmith, Ferrell & Ragan, 2013; Grover, 2005)

Levels of Communication

• Tasko The content of the message. o Often verbal (includes written).o Examples: assessing, teaching, supporting

• Relationalo Interpretation of message.o How the message and its delivery influenced

/impressed by the other.o Often construed from nonverbal message.

(Wittenberg-Lyles, Goldsmith, Ferrell & Ragan, 2013)

Nonverbal Communication

• Consider role of culture and context.• Body movement, gestures, eye contact,

position.• Use of touch.• Space and distance “personal space.”• Appearance: grooming, clothing, accessories.• Tone of voice, volume, pitch, rate of speech, use

of pauses and silence.• Time perception.• Attentiveness to verbal and non verbal

message.

Communication Axioms

• One cannot “not communicate.”

• Communication occurs on two levels.

• Nonverbal communication is most powerful.

• Congruence between verbal and non-verbal message enhances credibility.

(Wittenberg-Lyles, Goldsmith, Ferrell, & Ragan, 2013; Grover, 2005)

Communication Needs: Patient and Family

Patients• Need for information• Disclose feelings• Maintain / create

o Sense of controlo Meaning / hope o Purpose

Family / significant other• Information• Permission to speak• To be listened to

(Dahlin, 2010)

Influenced by context, culture, past experience, and trust

Communication Barriers: Nurse

• Failure to listen• Failure to address

concern of the other

• Incongruence• Parroting• Being judgmental• False reassurance• Offering advice

• Changing the subject

• Defending• Rote responses• Patronizing• Distancing• Role / scope of

practice• Lack of time

Communication Barriers: Family / Caregivers

• Belief that nothing will help

• Not wanting to burden / distract the nurse / doctor

• Not wanting to be / appear weak

• Not a legitimate concern

• Not wanting the information

• Responding to provider message to not address topic

• Denial of seriousness of diagnosis

• Culture

Therapeutic Communication Techniques• Listening • Silence• Open ended

questions• Acknowledgement• Restating• Reflecting

• Clarifying• Validating• Focusing• Summarizing• Planning

Non-therapeutic Communication Techniques

• Not listening• Failure to probe• Closed Ended

Questions• Parroting• Being judgmental• Ignoring comments or

affect

• Reassuring• Rejecting• Defending• Patronizing• Giving advice• Changing topics

New Communication Concepts in Nursing Practice

• Emotional Intelligenceo The ability to correctly identify emotions in others and

self, use emotions in reasoning, and understand emotions and manage them.

• Motivational Interviewingo Helpful in settings of ambivalence and resistance.o The focus on understanding the patient’s motivation of

a behavior/decision and supporting self efficacy.

(Codier, Muneno, & Freitas, 2011; Pollak, Childers, & Arnold, 2011)

Motivational Interviewing

• Basic tenetso Resist the righting reflexo Be curious about the patient’s motivations and

experiences. o Listen.o Empower the patient.o Use open ended questions, affirmations, reflections

and summary. o Allow patients to talk as much as the clinician.o Use reflective statements. o Provide advice or guidance only after asking

permission.(Pollak, Childers, & Arnold, 2011)

COMFORT Initiative

• Nurse communication curriculum for early palliative care integration in oncologyo Based in narrative nursing practiceo Patient and family centered o Adaptive communication among health care team

including patient and family

(Wittenberg-Lyles, Goldsmith, Ferrell, & Ragan, 2013)

Axioms of COMFORT

(ClinicalCC, 2013)

What Makes some Conversations Difficult

• Disagreement about “facts”o Uncertaintyo Lack of clear

informationo Inconsistent

informationo Failure to have a plan

• Timing• Our own emotions

o Feeling awkward and vulnerable

o Lack of preparationo Feelings of guilt or

failureo Fear of consequences

(Sheldon, Barrett, & Ellington, 2006; Davis, Krisjanson, & Blight, 2003; Stone, Patton, & Heen, 1999)

Nurses’ Role in Difficult Conversations

• American Nursing Association (ANA) Position Statementso Nursing Care and Do Not Resuscitate and

Allow a Natural Death Decisions (2012)o Registered Nurses’ Roles and Responsibilities

in Providing Expert Care and Counseling at the End of Life (2010)

Common Difficult Nurse:Patient Conversations in Oncology

• Information regarding cancer diagnosis and cancer therapies.

• Supporting patients who received bad news.

• Advance Care Planning and clarifying goals of care.

More Common Difficult Nurse: Patient Conversations

• Answering difficult questions:o “Will this treatment work?”o “Will this cure me?”o “Am I dying?”

• Coping with intense emotions

• Offering psychological and spiritual support

• Conflict

Patient and Family Expectations

• You will be honest and truthful.• You will not abandon them.• You will elicit and request their values/goals and

will help as much as is possible to achieve these.• You will assist them to explore their realistic

options• You will work with the entire interdisciplinary team

to assure consistency in plan of care • You will LISTEN!

(Dahlin, 2010)

Listening and Presence• Listening and being present are key elements to

effective communication.

• Both require focus and energy.

• Listening requires hearing, understanding, analyzing, reflecting and summarizing to affirm that you have heard correctly.

• Presence requires being available physically, emotionally and intellectually.

Listening Exercise

General Approach to Difficult Conversations

• Listen

• Establish trust

• Ask – Tell – Ask

• Plan for follow up discussion or action

(Baer & Weinstein, 2013; Back, Arnold, Baile, Tulsky, & Fyer-Edwards, 2005)

Information Sharing and Breaking Bad News

Setting

• Nurse – patient communication may be a formal interview but is more often is informal as other care is provided.

• When possible, assure:o Time to offer attention to patient and familyo Privacy o Invite other members of IDT to participate

Assessment of Information Needs

• How much information is needed / wanted?

• Who or who else should have the information?

• Establish what is known or suspected.

Sharing Information

• Align with patient.• Avoid jargon, abbreviations.• Give information in small amounts with frequent

pauses to allow for questions/ clarifications.• If delivering or reaffirming bad news, give a

warning.• Allow time for patient and family to process the

news/ information.• Elicit and answer additional questions.

Acknowledging the Feelings

• Information about disease, symptoms and treatment may elicit both positive and negative emotions.o Watch body language, facial expressionso Ask about feelings

• Acknowledge and validate feelings.o Numbness, sadness, anxiety, anger, fear are common

reactionso Name the obvious

Make a Plan

• Having a specific plan helps alleviate uncertainty.

• Provide any written information that may be needed.

• Provide interim contact information.

Advanced Care Planning (ACP)

Advanced Care Planning (ACP)

• ACP discussion benefits for patients with a terminal illness and life expectancy of ≤ 1 year:o Does not shorten survival rather improves

survivalo Lower rates of ICU admissiono Improved quality of life with earlier enrollment

and longer stay in Hospiceo Lower health care costs in last week of life

(IOM, 2011; Chung et al., 2009; Wright et al., 2008; Ganti et al., 2007; Weeks et al., 1998)

Advanced Care Planning (ACP)

• Discussions with patients to elicit their values, preferences, concerns that form decision making for health care and end of life care.o Process, not an evento Decisions may change over timeo Ambiguity and inconsistency common

• Increases patient–family satisfaction; decreases family distress; improves patient-family –provider communication.

(Waldrop & Meeker, 2012; Dahlin, 2010)

What is Important about ACP• Allows the patient to state their wishes.

• Empowers patients with some control in disease management and end of life planning.

• Promotes trust.

• Normalizes the discussion of end of life planning and allows ACP to be seen as ordinary like any other treatment discussion.

• Relieves the surrogate decision maker of the burden of making difficult decisions.

ACP Discussions in Oncology

• Only 30-40 % of oncology patients have had ACP discussion with providers.

• Many patients admitted to hospital have never had ACP discussions.

(Cohen & Nirenberg, 2011)

ACP Documentation

• Includes the following:o Living willso Medical Orders for Life Sustaining Treatment

(MOLST) o Orders for Do Not Resuscitate (DNR), Do Not Attempt

Resuscitation (DNAR) or No Code for both the hospital and out of hospital settings

o Do Not Intubate (DNI)o Health Care Power of Attorney / Surrogate health care

decision makers / Proxy

Why is ACP so hard?

• Sensitive topic o Hard to ask the questions and raise issue

• Finding appropriate language• Concern that patient will misinterpret intention of

the discussiono New diagnosiso Prognosis

• Fear of frightening patients• Time• Timing

(Smith et al,, 2010; Temel et al., 2010; Panagopoulou, 2008; Wright et al., 2008; Connor, 2007; Matsuymam, Reddy, & Smith, 2006; )

Challenges for Providers• Little education and training in End of Life Care • Concerns that ACP could lead to futile treatments

or encourage use life sustaining therapies whether appropriate or not

• Fear of litigation• Lack of time to get to know patients and families• No knowledge about previous discussions of

wishes, preferences, and goals of care• Lack of documentation of important

conversations• Expectation of outcomes of the conversation

Challenges for Patients

• Often patient wishes are unknown or not honored.

• May feel pressured to receive therapies they don’t want.

• Fear of abandonment.• Don’t know they can decline treatment in any

setting.• Don’t know about options such as home

services.• Have poor insurance coverage for palliative /

end of life care. (Cohen & Nirenberg, 2011)

Ethical Considerations for ACP

• Respect for persons

• Advocacy

• Veracity

• Decision Making o Capacity o Substituted judgmento Best Interest

Nursing’s Ethical Obligations for ACP

• Code of Ethics

• Professional Organizationso American Nurses Associationo Hospice and Palliative Care Nursing o Oncology Nursing Society

Values

• What does the person hold dear in life?

• What is their definition of quality of life?

• What gives them strength?

Beliefs

• What is person’s meaning of life?

• What is person’s religion?

• Is the person spiritual?

• What are the person’s thoughts on the afterlife?

Preferences for Care

• What are goals of care?

• Will use of life-sustaining treatments assist in achieving goals?

• Where does patient want care if dying?

When to Initiate Discussion

• Routinelyo When you first meet patiento Discussion regarding diagnosis and treatmento When a poor prognosis is being presentedo Non-urgent treatment decisions

• Urgento When there are difficult decisions to makeo When there is an unexpected change in clinical

condition

• When the patient asks for it

Starting the Conversation

• “Have you thought about:

o if things don’t go well?”

o the extent of treatment you would want?”

o who would make decisions for you in the case you could not make them?”

o how you would guide them in the decisions?”

o what you would want if your disease became more advanced?”

Hope for the Best; Plan for the Worst

• Hope is a multifaceted construct; no universal definition.

• Hope as a belief, desire, expectation, or wish for positive future occurrence or outcome.

• Clarifying hopes for outcomes is part of ACP as is reframing hope.o “What are you hoping will happen?”o “If that is not possible, what else would you hope for?”

(Cooper, 2006; Back, Arnold & Quill, 2003)

Eliciting Goals with Families

• “What do you imagine [the patient] would have done or wanted in this situation?”

• “Given what’s gone on, what are your hopes for [the patient] the future?”

• “Can you please help me to understand what I need to know about [the patient’s] beliefs and practices to take the best care of [the patient]?”

(End of Life Nursing Education Consortium, 2013)

Achieving Common Understanding

• Use summary statements. Consider decisions for “therapeutic trial” or as needing only family assent.

• Check for understanding of the decisions made.

• Seek consensus on the decision or on the need for more information.

(End of Life Nursing Education Consortium, 2013)

Responding to Difficult Questions

• Common difficult questions are: o “Am I dying?” o “Is the cancer worse?”o “Will you help me die?”

• All raise emotional and ethical issues for the nurse.o Best response is often exploration of the question.o Builds nurse-patient relationship through trust and

veracity.

Responding to Difficult Questions

• Acknowledge the question.o “That is not a simple question. I will do my best to

answer.”o “That is not a simple question. I am wondering what

brought it up now?”

• Explore the underlying concern.o Understanding of disease status.o Psychosocial – Spiritual concerns: anxiety,

depression, hopelessness, suicidal Ideation.

Continuing the Response

• Provide information and support.

o Do not be afraid to say, “I do not know but I will try to find out.”

o Do not make promises that you cannot keep.

o Involve the interdisciplinary team.

Responding to Strong Emotions

• Name the emotion

• Explore the emotion

• Validate the emotional response

• Offer support

Conflict Negotiation

• Goal: Arrive at shared perspective or goal.

• In patient care, the wishes and best interests of the patient take precedent.

• A “learning stance” may be helpfulo “Help me understand your position, concerns,

emotions, motivations.” o Clarification often eases the conflict.

Steps in Conflict Negotiation

• Identify the conflict• Weigh the benefit / burden in addressing it

o What is at stake?• Address the conflict• Identify goal of resolving the conflict

o Focus on facts not emotions• Explore the conflict

o Learning stance with each party stating their perspective and understanding

• Problem Solve

(Kendall & Arnold, 2009)

Summary

• Communication is fundamental to nursing practice.o Establishing and continuing the nurse-patient

relationshipo Patient and Family Educationo Assessmento Collaboration

• Effective communication requires listening and presence.

• Use techniques to assist in difficult conversations.

References

• Full list of references included with your handouts

Special Thanks: Authors

Connie Dahlin APRN-BC, ACHPN, FAAN, FPCN

Palliative Care Nurse Practitioner – North Shore Medical CenterBoston, MA

and

Maureen Lynch APN-BC, AOCN®, ACHPN, FPCN

Nurse Practitioner – Dana Farber Cancer CenterBoston, MA

Special Thanks: Expert Reviewer

Debra Heidrich MSN, RN, ACHPN, AOCN®

Nurse ConsultantWest Chester, OH