Communicating with patients and families
Communication can be the most effective medical therapy.
General talk tips:
- Talk less, listen more.
- Be aware of non-verbal communication.
- Get a professional interpreter if first language not your own.
- Use plain language.
- Check for patient/family understanding when giving medical information.
Patient Dignity Question
This one question can provide very useful information that will aid in the care of the whole person: “What do I need to know about you as a person to give you the best care possible?”
Breaking Bad News
S=Setting up interview
- Preparation, privacy, involve significant other.
P=assess patient’s Perception
- “Tell me what you understand about your illness?”
I=Invitation to information
- “Some people like all the information, others just want the big picture. How much information is right for you?”
K=sharing Knowledge and information
- Words of warning: “I have some bad news for you…”
- Share information in plain and clear language.
- Check for patient understanding: “Is this making sense to you?”
E=addressing Emotions with Empathetic responses
- Empathize and validate “This must be difficult for you…”
- When not sure what to say – silence is OK.
S=Strategy and Summary
- Identify coping strategies, sources of support.
- Ask if patient/family have any questions.
- Plan for the future “We can meet again in 1 week to see how you are doing.”
Advance care planning conversations
Patient/family need clinician to initiate ongoing conversation.
Introduce early in illness and revisit after change in disease status, hospitalization or if patient asks.
“Have you discussed your thoughts about the future with your family or ever put them down in writing?”
“How do you make decisions. Do you make them on your own or make them as a family?”
“If you were unable to speak for yourself who will make decisions for you?”
“Do you have any fears or worries about the future?”
“Is there anything that would be worse than death for you?”
Aware of all options
“There may come a time when we suggest treatments you don’t feel comfortable with or a time when you wish to stop treatment. We will understand and support you in this decision and will continue to work with you to have you live as well as possible.”
“Some people like to know all the details, others just want the big picture and some prefer not to discuss it at all. What is best for you?”
If information desired, start with:
“Tell me what you understand about your illness.”
If prognosis uncertain:
“We are not very good at predicting how long people live with your disease, but I would estimate years/months/days.”
Other useful phrases:
“We cannot cure your disease, but our goal is to help you live as well as you can for as long as you can.”“Although we don’t have any further treatments to reverse the disease, there’s always something we can do to help you feel better.”
CPR in advanced illness
- Success rate very low in advanced illness.
- Focus on what will be done and not what is no longer offered.
“We will do everything we can to help you live as well as you can for as long as you can but when you die we will help you to have a peaceful and natural death.”
If there is unwillingness to accept this explore concerns and myths:
- DNR does NOT mean no more treatment.
- CPR will not improve the outcome of the illness.
Discussion about withdrawal/withholding of treatment; transitioning to end-of-life careFollow modified SPIKES – see Breaking Bad News
S = Include significant others.
P = “Tell me what you understand about your illness at this time?”
I = “Are you the kind of person who wants to know all the details, just the outline or not talk about this at all?” “Do you make decisions on your own or as a family?”
K = “When you began the treatment the hope was that the disease would remain controlled (or cured) Unfortunately the disease is continuing to progress and we need to consider what is next.”
Give information about disease state, reason for withdrawal/withholding and focus on what can still be done.
“Although we do not have any further treatments to reverse or stop this disease, there is always something we can do to help you feel better.”
Share information, and check for understanding or questions.
If there is a decision to be made: “Would it be helpful to you if the team made a recommendation?”
Decision-making can be a process and may need further meetings.
E = validate feelings with empathy.
S = summarize discussion and decisions if made. Document and share with team so everyone “on the same page”. Or plan to meet to further discuss or decide.
Goals of care
- Assist in developing care plan that best fits patient’s beliefs and values.
- Part of ongoing process and may change over time as patient condition changes.
- Can be part of end-of-life or advance care planning conversations or on its own.
“How is this illness affecting you and your family?”
“What is most important to you now?”
“Does the treatment you are receiving feel right to you?”
“Do you have any worries or concerns about the future?”
- Confirm what you heard from the patient:
“So what I am hearing is that you feel…”
May be useful if patient/family have ongoing distress over direction of care, non-compliance with treatment, requesting futile treatment, have distrust of healthcare team. Kleiman’s questions:
- “What do you think has caused your problem?”
- “Why do you think it started when it did?”
- “What do you think your sickness does to you?”
- “How severe is your sickness? Will it have a short or long course?”
- “What kind of treatment do you think you should receive?”
- “What are the most important results you hope to receive from this treatment?”
- “What are the chief problems your sickness has caused for you?”
- “What do you fear most about your sickness?”
Talk tips for difficult situations.
“Don’t tell them they are dying”
Explore and try to understand basis of request ethical obligation is to ask the patient what information they want about their illness – and to respect this.
If your language is not the language of the patient – get a professional interpreter and ask about preference for information and decision-making.
“Everything must be done”
Aggressive disease therapy not indicated yet patient/family repeatedly request full medical therapy. Explore what patient/family understand about the illness – consider cultural questions, ensure family fully informed.
Explore what “everything must be done” means to patient and family.
Find “common ground” between patient/family and healthcare team and work from this point.
Build trust with patient/family and ensure consistent messaging.
Patient/family anger with life and health situation can be projected on to healthcare team. Do not take personally, but do not ignore.
Identify the emotion.
“You seem angry today.”
If you understand the cause of anger you can validate it. “It must be hard for you to hear this bad news.”
If you do not understand the source of the anger, ask: “Can you help me understand why you are feeling this way?”
Patients with poor (health) literacy
- Health literacy: ability to access, understand, evaluate, and communicate information about own health. More than ability to read.
- Low health literacy →poor health outcome, frequent hospital and emergency use, poor control of chronic disease
- Screening: remember SOS
- Schooling: concerns if below Secondary School
- Opinion of own reading ability: concerns if Only an Okay reader
- Support needed for reading: concerns if Sometimes Seeks help
- When you explain: slow rate of speech, short sentences, no medical jargon, make 3 main points
- Don’t ask if patient understands (everyone says yes), ask what you have explained to them: what is the problem; what is it that I have to do; why is it important to do this?