Communication Challenges

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Communication Challenges

• Peter Martin
• Director of Palliative Care, Barwon Health
• Clinical Associate Professor, Melbourne Uni
• Senior Lecturer, Flinders Uni

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Scope

• Prevalence impact of sub-optimal communication
• Communication principles that underpin good
  practice
• Goals of care
• Clinical Handover
• The role of the family meeting

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Impact of Poor Communication

• Diminishment of patient autonomy
• Less accurate diagnosis
• More complex psychological adjustment
• ? anxiety, distress, depression
• More stress at work for health professionals
• Higher risk of burnout
• Less job satisfaction for health professionals
• Less compliance to treatment more doctor
  shopping
• Less than 50 of issues may be elicited
• Less than half of psychological morbidity is
  recognised
• Decreased patient satisfaction
• More litigation

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Communication Myths

• Training does not help
• You must have training when young
• No evidence about importance of communication
  skills
• Technical and knowledge skills are more important
  for patient satisfaction
• It wastes clinician time
• Talking is not seen as work important to look
  busy with tasks this is mostly from nursing
  literature
• I will open up a can of worms that I cannot fix
• An issue for medicine and nursing particularly
• Discussing difficult issues will increase
  distress of patient and family

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Basics of Good Practice

• Tailoring information to pts style
• Eliciting the emotional, social spiritual
  impact to pt family of the problem (s)
• Determining how much pt wants to participate in
  decision making
• Internal summary periodically summarise
• Checking their understanding
• Allows patient to correct and misunderstandings
• Open ended versus closed questions
• One study the ration was 15.8
• Safety netting
• Explain what will happen if plan not working of
  if things do not improve

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Basics of Good Practice-2

• Being overt about implications of treatment
  decisions
• Using verbal non-verbal skills show empathy
• Active listening and eye contact
• Feedback your intuitions about how they are
  feeling
• I am sensing that you are angry, can you tell me
  about that?
• Multiple modalities of information
• Written as well as verbal, web sites, tapes

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You little PEARLER

• All in the context of how to respond to emotion
  instead of redirecting or pursuing clinical
  detail
• PEARLS
• Partnership
• Empathy
• Apology
• Respect
• Legitimisation
• Support

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Common Mistakes

• Using Terms such as do everything or do
  nothing
• Contrast as one seen as positive and the other
  negative
• Could be reframed as benefits vs...... risks for
  different approaches
• do nothing implies what will be taken away in
  contrast to what will be gained.
• Using euphemisms for death or dying
• Inferring poor prognosis through unnecessary
  complex physiological parameters / detail
• Interrupting the patient as they are about to ask
  something
• Shown that interrupting means consultation takes
  longer

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What is the average time before a Doctor
interrupts a pt / family?

• A)10-20 secs
• B)20-60secs
• 1-3 mins
• gt3 mins

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Other common errors

• Not listening to families concerns / opinions
• Underestimate prevalence of limited literacy
• Tolerate silences pauses
• Make recommendations
• Families may feel they have pulled the plug
• Guilt, bereavement issues

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Blocking Behaviours by HP

• Offering advice and reassurance before issues
  identified
• Not addressing distress as it is normal
• Families may feel that H Profs dont care they
  are upset
• Changing the topic

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Goals of Care

• May not be explicit in an acute medical setting
• Usually a diagnostic or problem orientated
  approach
• Aged care, Rehabilitation Pall Care often goal
  orientated
• Patients families may not have considered what
  the goal is / or should be
• Discussions around goal of care may be pivotal
  and symbolic for pt / family
• Worth investing time to get right first time
• If handled badly may escalate tensions between
  family and treating team

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Methods to assist resolution

• Family meeting / case conference later!
• Spending sufficient time
• Using other professional disciplines
• Help families reflect on what would the patient
  want

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Reflect on what would the patient want

• Some helpful questions may include
• Asking each member of family
• Tell me what sort or person is X?
• What are their interests, hobbies or passions?
• Did they ever state their views on being in this
  situation possibly after a news item or TV
  program?
• Maybe they had friend or relative in this
  situation
• How much did they value they value their
  independence?
• If they could speak now and knew there was little
  hope of independent living and recovery what
  would they want us to do regarding their
  treatment?
• What spiritual beliefs were important to them
  how would that influence their decisions?

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Resolution - 2

• Though an attempt to achieve complete consensus
  is desirable it is not always achievable
• Often agreement between treating team and next of
  kin
• May not be agreement between next of kin and
  siblings, children
• Increasingly seen with spouse of 2nd marriage and
  children to 1st marriage
• Estranged children
• Social work may help resolve this and many have
  interest / additional training in family therapy
• Notion of the minority / disenfranchised being
  heard by team is important even if outcome
  remains the same

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Resolution - 3

• Being open to review patient progress over time
• This can be difficult when occupying an acute bed
• Encouraging another treating unit to review the
  patient if helps family move towards goal
• Important that the family sees the other team as
  being neutral rarely this may mean from another
  agency
• If there is no progress towards resolution being
  open to involving the public advocate in
  non-confrontational way not as threat
• The knowledge that you offer neutral process may
  resolve issue

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Family issues

• Sensitive to clinician anger / frustration
• Being defensive will add to families concerns
• Either about current team or previous treating
  unit
• Being heard is vital
• Good level of evidence
• Many family members may have only got medical
  information 2nd hand or in piecemeal fashion,
  worth going over from start and emphasising
  pivotal points while family present
• Acknowledgement of emotional, social and
  financial impact on them

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Patient Family Perceptions

• That in a setting such as ICU where end-of-life
  decisions are common
• Families rate communication skills as one of the
  most important skills
• most rate it as more important than clinical
  skills

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Hope versus Reality Getting the balance right.

• Time to adjust to Diagnosis Prognosis however
  sometimes the pace is set by other circumstances
• Be aware if short time frame this may add to
  complexity
• Acknowledging this will add to feeling of empathy
• Need to give hope without colluding to avoid
  discussing difficult issues
• Redirecting hope to comfort, dignity meaning if
  required
• Demoralisation as a concept
• Broaden the diversity of things to hope for.

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Family Conferences

• Many treatment decisions are made with families
• Awareness of explicit hierarchy of decision
  making
• Although legal next of kin retains responsibility
  consensus among family should be initial goal
• Communication occurs in many settings but the
  family meeting is often a focus for decisions
• Evidence that in over half family still did not
  understand diagnosis, prognosis or treatment
• In 75 drs missed cues from family about concerns
• That in same cohort drs thought they had done a
  good job

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Family Conferences-2

• Role of nurses
• Majority of communication concerns raised by
  family could / should (?) be addressed by nurses
• Data is that nurses are no better at end-of-life
  (EOL) discussions than doctors
• Nurses rank these discussions as both some of the
  most rewarding and frustrating parts of their
  jobs
• Large variation in role nurses have in family
  meetings
• Some qualitative data to suggest nurses help
  prompt patient questions at family meeting
• Nurses also initiate / identify need for family
  meeting
• Also facilitate organising and coordinating it
• Afterwards may consolidate, clarify and
  reinforce information

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Family Conferences-3-Preperation

• Clinicians should approach the family meeting
  with the same care planning that they give to
  other (ICU)procedures
• Encourage families to list key questions before
  meeting
• Private venue free of pages phones (family as
  well!)
• Review the medical information
• Ensure that treatment consensus is reached within
  the treating team(s) prior to meeting
• May need separate case conference
• Brief each other about known dynamics within
  family
• Determine which disciplines should be present
• Clarify who has what role, some may be there to
  support family members specifically
• Identify who will chair the meeting
• Reflect on your own emotions to pt family

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An outlined agenda

• Introductions in context
• Normalise the meeting
• Set goals of meeting up front
• Ascertain what family knows
• Review progress of pt to date
• Avoid too much medical detail
• Use checking at key points to confirm
  understanding
• Repeat your understanding of their concerns
• Ask them to summarise what you have told them
• Be open about prognosis
• Avoid emotive language

• Acknowledge uncertainty
• Use the principle of substituted judgement
• What would your X want?
• Facilitate discussion from family members
• Include hope
• Consider redirecting hope to concepts such as
  dignity comfort
• Highlight alternative such as symptom relief
• Acknowledge their emotions
• Summarise agreed treatment plan at conclusion
• Ask if they have any questions at the end

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Individual Initiatives by H Prof

• Insight
• Commitment to on-going development
• Programs
• Literature
• Feedback reflective practice
• Clinical Supervision
• Well established in Psychiatry / Psychology
• Why not in ICU, Pall Care etc?

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Initiatives by Patient / Family

• RCT of a question prompt sheet, endorsed or not
  by the medical oncologist
• Consultations where patients received a question
  prompt sheet
• and it was endorsed by the doctor
• were significantly shorter!
• (p0.02) (about a 7 minute difference)
• Brown, Butow Tattersall, BJC. 2001

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Prompt Sheet Hyperlinks

• http//www.mja.com.au/public/issues/186_12_180607/
  cla11246_fm.pdf
• http//www.psych.usyd.edu.au/mpru/communication_to
  ols.html

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Institutional Initiatives for Good Communication

• Pro-active instead reactive approach (i.e.
  compliant driven)
• Place of clinical audit and death review with
  greater emphasis on psycho-social endpoints
• Qualitative and quantitative data
• Policies that mandate / stipulate conversations
  with families
• Example of ICU protocol of family meeting
  occurring within set time after ventilation
• More advanced care planning
• More consensus re goals of care
• Less resource utilisation
• Discussions with family through
  multi-disciplinary approach
• Other disciplines bring diversity of approach
• Greater documentation of families pts wishes

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Institutional Initiatives for Good Communication

• Tools have been used to facilitate process
• Goals of Care Assessment Tool GCAT
• This makes clinician document
• Prognosis
• Whether pt or family aware of this
• Presence or absence of advanced care planning
• Family support involvement
• Adequacy of pain symptom relief
• Tool is triggered by change in pts course
• Patient / Family asks for DNR order
• Patient / Family asks for Palliative Care
  involvement
• New terminal diagnosis or other significant
  change / Dx
• Patient generated QOL tools facilitate more
  holistic discussion and lead to better pt Dr.
  satisfaction

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Institutional Initiatives for Good Communication

• Educational Initiatives evidence based mostly
  undergrad
• VCCCP, the importance of actors it makes it
  real
• Controlled and safe to practise
• Although many advanced training programs
  inclusive, little after the hurdle
• MRCP (FRACP?)
• RACP (FAChPM) mandated for advanced trainees
• May be senior clinicians who are most in need
• Professional Development Programs may be method
  of mandating this.
• Respecting Patient Choices ?
• Research
• Informational material for pts families (www
  written)
• Design of the wards where these discussions occur

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Team Dynamics

• Evidence that facilitating interaction between
  junior senior medical staff led to greater
  discussion about goals of care
• Pts families will only get the best care if we
  create a culture of asking open / or difficult
  questions
• Role of internal vs. external debriefing
• Importance of recognising influence of personal
  anger / frustration by health professionals in
  their interaction with families
• Especially with families labelled difficult or
  in denial
• Countertransference in psychiatry terms
• Although nearly always present insight is key

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Summary

• Most decisions can be reached using good
  communication skills without conflict or
  unnecessary distress
• Family meetings appear to facilitate
  understanding, discussion and consensus
• When early conflict present it should be chaired
  by a senior clinician , important that senior
  staff are represented
• Senior nurses have pivotal role
• Allied health should be heavily involved in
  support of family
• Many families want the senior clinicians to take
  a degree of responsibility for decision while
  respecting their views
• Is guilt a huge factor for families?

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Bibliography

• Communication in intensive care settings The
  Challenge of futility disputes. Fins et al Crit
  Care Med 2001 Vol 29 No. 2
• The family conference as a focus to improve
  communication about end-of-life care in the
  intensive care unit Opportunities for
  improvement Curtis et al Crit Care Med 2001 Vol
  29 No 2
• Key communication skills and how to acquire
  them. Peter Maguire, Carolyn Pitceathly BMJ Vol
  325 September 2002
• Patient-physician communication. Maria
  Suarez-Almazor Current Opinion in Rheumatology
  Vol 16, 91-95
• Questions?