textbook of palliative care communication section i: communication principles
DESCRIPTION
Approaches to Communication Relationship-driven – Patient and family do not receive information; they co-create messages and construct meaning with providers – Information is not the main outcome of clinical communication Outcome is the relationship built between provider and patient/family. Information-driven or sender-based – Outcome is based on delivery and receipt of medical knowledge – Receipt of information is considered effective communication Outcome derives from the sender’s performanceTRANSCRIPT
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Textbook of Palliative Care Communication
Section I: Communication Principles
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OVERVIEW OF COMMUNICATIONChapter One
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Approaches to Communication• Relationship-driven
– Patient and family do not receive information; they co-create messages and construct meaning with providers
– Information is not the main outcome of clinical communication
• Outcome is the relationship built between provider and patient/family.
• Information-driven or sender-based – Outcome is based on
delivery and receipt of medical knowledge
– Receipt of information is considered effective communication
• Outcome derives from the sender’s performance
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Our Concept of Communication
• Transactional– The parties contribute to and negotiate the meaning of
messages, both verbally and nonverbally• Relational– All messages have at least two levels of meaning: the
task or informational level and the relationship level, which cues interactants how to interpret and process the message itself
• Mutual – Communicators influence one another
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COMFORT Communication Model
The seven basic principles of palliative care communication, from a relational communication perspective:– Communication (clinical narrative practice) – Orientation and opportunity– Mindful communication– Family– Openings– Relating– Team
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A HISTORICAL PERSPECTIVE IN PALLIATIVE CARE COMMUNICATION
Chapter Two
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Communication: The Cornerstone of Quality Care
Early Focus of Communication in Healthcare– Avoided the subject of death and dying– Discussing death and dying was perceived as
stressful to patient
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Hospice and the Role of Communication
Hospice Movement: Strides forward in Communication
Hospice providers encouraged open and honest communication– Introduction of team-based care and team
communication
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Communication Comes to the ForefrontNational Consensus Project
• In 2004, clinical practice guidelines were developed by a consortium of the leading palliative care organizations, representing a major advance in palliative care
• Quality communication is at the core of all the palliative care guidelines:– Domain 1-Structure and Process of Care– Domain 2 – Physical– Domain 3 – Psychological and Psychiatric– Domain 4 – Social– Domain 5 – Spiritual– Domain 6 – Cultural– Domain 7 – End of Life– Domain 8 – Ethical and Legal
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Current Communication Trends in Palliative Care Literature
• Patients’ and families’ desire for honest and open communication
• The importance of communicating hope in palliative settings
• Barriers to communication• Communication needs among pediatric
populations• Use of technology to improve communication
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Current Limitations of Palliative Care Communication
• Research has focused on physician-patient interactions
• Communication education restricted to “breaking bad news” discussions
• Protocols or “step” approaches have excluded relational approach
• Training has been limited to lecture format
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TRANSACTIONAL COMMUNICATIONChapter Three
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Transmission Model of Communication
• Also called the sender-oriented approach– Sender transmits message to receiver
• Shortfalls:– Uneven balance of power between sender and
receiver (ex: healthcare provider and patient)– Depicts communication as product of independent
parties without a guarantee that important information will be heard and understood by receiver
– Little concern for medium and medium’s effectiveness (face-to-face, telephone, email)
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Transactional Model of Communication
• People are simultaneously senders and receivers in an ongoing process– Each person is influenced by the other– Emphasizes shared meaning and what happens
“between people”, between the sender and receiver• Benefits:– Encourages people to share power– Reminds people to be attentive to cues about how
others interpret information – Recognizes social, environmental, personal factors
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BATHE
• A five-part guide for responding to emotions– Background information (Briefly, what has been
going on?)– Affect (How has this affected you?)– Trouble (What troubles you most?)– Handling things (How have you been handling this
situation?)– Empathy (It sounds like this is very stressful)
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Relationship-Centered Care Model
• Focus on how relationships are enacted across all healthcare providers who are serving the patient– Mindful Communication (awareness of self, others,
relationships, and being open to new ideas)– Diversity of Mental Models (how to manage diversity
within the context of care)– Mutual Respect (team members are honest,
respectful of each other)– Mix of Social and Task-Related Interactions (have fun,
but be productive)
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CONSUMER COMMUNICATION AND PUBLIC MESSAGING
Chapter Four
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Knowledge of Palliative Care
• In 2011, a national poll revealed that 7 in 10 Americans are not knowledgeable about palliative care
• Providers are also unfamiliar with the scope of palliative care, equating palliative care to hospice
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Definition of Palliative Care• Palliative care is specialized medical care for people with
serious illnesses. Its goal is to provide relief from the symptoms, pain, and stress of a serious illness – whatever the diagnosis – to improve the quality of life for both the patient and the patient’s family.
• Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient’s other doctors to provide an extra layer of support. Palliative care is appropriate for all patients suffering from serious illness - at any age and at any stage - and can accompany curative treatment.
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Key Messages to Convey about Palliative Care
Palliative Care:• Helps provide the best possible quality of life• Helps manage pain, symptoms, and stress of illness• Is a partnership between patient, family, and
healthcare providers• Provides the patient and family an extra layer of
support• Is appropriate at any age and at any stage of a
serious illness, alongside curative treatment
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Resources for Palliative Care Communication
• Vitaltalk (vitaltalk.org)– Advanced communication skills resources and courses
for professionals focused on balancing honesty with empathy, when discussing serious illness.
• Palliative Care Communication Institute (pccinstitute.com)– Free teaching materials to advance a patient-centered
training program called COMFORT– designed to teach communication strategies for patient-centered palliative care.
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COMMUNICATION ETHICSChapter Five
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Communication Ethics
• Ethical communication is a form of care, subject to ethical norms:– Respect for personhood– Minimize harm– Maximize benefit
• Cecily Saunders summarizes an approach to sensitive communication: “The real question is not ‘what do you tell your patients?’ but rather ‘what do you let your patients tell you?’”
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Palliative care as a moral practice
• Goals of practice need to be well-defined and resonant with larger social values
• Palliative care must have shared internal values that promote the goals of practice
• Palliative care provides “agency” to patients, allowing care to be patient-centered, enabling the patient to develop and exercise a sense of self by engaging with the world in a manner that sets and achieves goals by doing things for oneself.
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Communication as an Ethical Obligation
• Communication should seek to:– discern and incorporate the values and preferences
of patients and family members, thereby respecting their autonomy
– minimize the risk of avoidable harm, thereby respecting nonmaleficence
– maximize benefit to patients and families by engaging processes and producing outcomes that are consistent with how they would define “good,” thereby honoring beneficence.
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Communication within the Team
• Moral agency of team members is a significant part of the ethical equation
• Be attentive, self-aware, and reflective to the emotional responses of oneself and other healthcare providers
• Consider professional hierarchy in healthcare
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COMMUNICATION IN PALLIATIVE SOCIAL WORK
Chapter Six
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Social Work Communication
• Diagnosis– Tailor information to individual and family needs– Address Psychosocial concerns
• Plan of Care– Organize and interpret patient and family data
• Advance Care Planning– Support patient autonomy, self-determination– Include caregivers
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Social Work Communication
• Pain and Symptom Management– Educate patient and family about medication, side
effects– Teach complimentary and alternative techniques
• Practical support– Discuss home care needs, insurance, financial needs
• Assess patient distress– Provide supportive counseling– Reinforce strengths and coping mechanisms
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Social Work Communication
• Religious, spiritual, existential issues– Discuss degree of religiosity, use of spirituality as
coping mechanism– Discuss guilt, regret, need for forgiveness
• Evaluate role of culture in understanding of illness, role of language, decision-making style
• Integrate cultural values into decision-making
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Social Work Communication
• End of life communication– Discuss practical aspects of patient’s death– Discuss hopes and fears for patient and family– Educate about expected course
• Talking about hospice– Participate in intake assessment– Identify psychosocial concerns– Target caregivers with high bereavement distress
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COMMUNICATION IN PALLIATIVE MEDICINE
Chapter Seven
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Why Communication in Palliative Medicine Matters
• Findings across research studies illustrate a need for communication:– Only half of all patients discussed hospice with any
doctor two months before death– More than half of lung and colorectal cancer patients
thought their chemotherapy was curative– Only a third of lung cancer patients understood that
radiation would not cure them– Less than 20% of patients had accurate awareness of
their prognosis
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Key Barriers to Communication
• Patient factors– Emotional overwhelm, language barriers, cultural barriers
may create mistrust of physicians; patients may have limited health literacy, over-estimate cure
• Physician factors– Lack of proper communication skills or training in managing
emotions; fear of causing pain or taking away hope • Healthcare factors– No incentives for patient-centered communication, multiple
transitions of care, multiple subspecialists
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SPIKES: A strategy for sharing poor prognosis/serious diagnosis
•Arrange for some privacy•Involve significant others•Sit down•Make connection and establish rapport with the patient•Manage time constraints and interruptions
S: Setting
•Determine what the patient knows about the medical condition or what is suspected.“Before you tell, ask.”
•Listen to the patient’s level of comprehension•Accept denial but do not confront at this stage
P: Perception of condition/
seriousness
•Ask patient if s/he wishes to know the details of the medical condition and/or treatment
•Accept patient’s right not to know•Offer to answer questions later if s/he wishesI: Invitation from
patient to give information
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SPIKES continued
•Use language the patient would understand.•Consider educational level, socio-cultural background, current emotional state
•Give information in small chunks, warn the patient you are about to give bad news
•Check whether the patient understood what you said•Respond to the patient’s reactions as they occur•Give any positive aspects first
K- Knowlege:giving
medical facts
•Prepare to give an empathetic response:•1. Identify emotion expressed by the patient (sadness, silence, shock etc.)• 2. Identify cause/source of emotion•3. Give the patient time express his or her feelings, then respond in a way that demonstrates you have recognized connection between 1 and 2.E - Explore
emotions and sympathize
•Patients who have a clear plan for the future are less likely to feel anxious and uncertain-so clarify their understanding
•Close the interviewS – Strategy and summary
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COMMUNICATION IN PALLIATIVE NURSING
Chapter Eight
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Nurse Communication
• Participates in patient assessment and in collaborative care planning with team– Nurses rated by public as most trusted healthcare
team member• Uses symptom assessment instruments to
evaluate pain, take pain history• Uses verbal or symbolic means appropriate to
patient to assess coping
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Nurse Communication
• Facilitates communication within circle of care– Patient, family, healthcare team, other providers
• Assessment and attention to spiritual issues and concerns for patient and family
• Elicits cultural identification, strengths, concerns, needs– Determines cultural background as source of
resilience and strength for patient and family
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Nurse Communication
• Communicates signs and symptoms of dying process to patient, family, others
• Explains what to expect in the dying process and provides support post-death
• Contributes to ongoing discussion about goals of care, promoting understanding of patient’s preferences
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Barriers to Nurse Communication
• Personal– Cultural norms, shyness, fears, fear of mortality,
unresolved personal losses• Educational– Few nursing schools offer instruction in palliative care– Lack of experience with death, dying, and communication– Younger generation of nurses have had little exposure or
practice with face-to-face verbal communication• Professional– Inadequate nursing education and role ambiguity
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COMMUNICATION IN PALLIATIVE CARE CHAPLAINCY
Chapter Nine
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Basics of Chaplain Communication
• Assist in Meaning-Making– Global meanings are a person’s most basic values
and beliefs about the way the world works– Situation meaning is the meaning given to a
particular event such as illness or death• Emphasis on active listening rather than
information-giving• Do not proselytize or impose one’s beliefs on
others
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Barriers
• Defining chaplaincy– “Being present” is too vague– Any two chaplains do not describe their work in
the same way– Need to translate spiritual work into medical
language and processes• Healthcare team members do not know how
to conduct spiritual assessment; refer to chaplain
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Chaplain as Team Member
• Expert on spiritual subject matter• Offer guidance on spiritual communication• Provide understanding about family culture and
spiritual traditions/rituals• A chaplain is often viewed as a neutral, trusted
person as compared to other healthcare providers
• Assist with families who are awaiting miracle cure
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Future Work
• More research is needed to document outcomes and accountability of chaplain services– Document the benefit of chaplain services– Document patients’ spiritual needs ents– Document interventions to reduce spiritual
distress
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COMMUNICATION IN CLINICAL PSYCHOLOGY
Chapter Ten
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Clinical Psychologist in Palliative Care
• Four key roles:– Assess and target treatment services for patients– Provide education and supportive services to
families and caregivers– Participate in educational and support activities
that assist the palliative care team
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Provision of patient assessment services
• Assessment Aims– Symptoms, duration, and situational factors
associated with psychosocial health• Assessment Approaches– Interview and self-report questionnaires– Neurocognitive functioning
• Assessment Domains– Pre-morbid functioning, health literacy, perception
of illness
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Provision of treatment services
• Goal-setting and Problem-solving– Establishing goals grounded in patient values
• Psychotherapy– Cognitive Behavioral Therapy• Tools to modify dysfunctional thinking and behavior
– Existential Psychotherapy• Helping patient confront the struggle of being human
– Psychotherapy at the End of Life• Assist patient to achieve a respectful death, dignity
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Psychologists’ involvement with patients’ family systems
• Supporting family communication• Cultural health beliefs• ‘law of double death’ in families– Awareness of likelihood of death, but do not
discuss their fears or concerns with one another• ‘third person’ in families– Families cannot discuss anxieties related to death
with patient, but can with other parties
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The Psychologist as a member of the interdisciplinary palliative care team
• Contribute patient information to team• Educate staff• Provide staff support and facilitation of self-
care as a team member– Assistance with compassion fatigue, trauma