Communication

1
Communication

• Almost invariably the act of communication is an
  important part of therapy occasionally it is the
  only constituent. It usually requires greater
  thought and planning than drug treatment and
  unfortunately it is often administered in
  subtherapeutic doses.
• Buckman, R. 1992

2
Communication

• In your groups discuss
• What do you want to get out of today?
• What communication skills training have you
  participated in/delivered.
• Any concerns you might have about the day.

3
Communication the evidence base

• Survey of 2000 people in an out-patients clinic
  in the UK found that 87 preferred as much
  information about their illness as possible (both
  good and bad).
• Jenkins V, Fallowfield L, Saul J. (2001)
  Information needs of patients with cancer
  results from a large study from in UK cancer
  centres. BMJ 84 48-51.

4
Communication with patients its not easy!

• In a study of 476 consultants just under half
  said they had not received sufficient training in
  communication skills.
• Ramirez, Aj. Et al (1995) Burnout and
  psychiatric disorder among cancer clinicians.
  British Journal Cancer 71 1263-1269.

5

• Inadequate communication may be the source of
  much distress for patients and their families and
  mitigate against adjustment to cancer and other
  life threatening illnesses.
• Kruijver I, Kerkastra, A., Van der Weil H (2000)
  Nurse/patient communication in cancer care a
  review of the literature. Cancer Nursing 23, (1)
  20-31.

6
Ways of Working Together

• Confidentiality.
• Respecting each others contribution.
• One person speaks at a time.
• Challenge the issue not the problem.
• Time out.

7

• Many studies have shown that patients want much
  more information than their doctors believe they
  do. We also know that the ability of doctors to
  predict which patients want an active, shared, or
  passive role in decision making is very poor in
  palliative care and when active, potentially
  curative treatment is discussed. Too many
  patients are being seen by too few doctors in
  over burdened clinics with inadequate support.
  Desire for information is not the same as a
  desire to participate in decision making.
• Fallowfield L (2001) Participation of patients
  in decisions about treatment for cancer BMJ 323
  1144 (17TH November)

8

• All patients described their doctors as experts,
  despite different qualities. Six subcategories
  were identified
• The inexperienced messenger.
• The emotionally burdened.
• The rough and ready expert.
• The benevolent but tactless expert.
• The distanced doctor.
• The empathetic professional.
• The relationship was described as very important
  to the patients capacity to handle the
  information and was felt to have built up during
  earlier meetings.
• Friedrichsen MJ, Strang PM, Carlsson ME, (2000)
  Breaking bad news in the transition from curative
  to palliative cancer care-patients view of the
  doctor giving the information Support Care
  Cancer. 2000 Nov 8 (6) 437-8.

9
Patients perceptions of a good communicator (n27)

• Good verbal non verbal skills.
• Approachable personal attributes.
• Knowledge of their subject.
• Bailey, K. Wilkinson, S. (1998) Patients views
  on nurses communication skills a pilot study.
  IPJN 4, (6) 300-305.

10
What patients say (1996)

• They were all very nice, very wonderful, but I
  realized afterwards that nobody told me anything
• He said Its not looking good, we will have to
  have your right breast removed tomorrow and that
  was it, he walked out and that was the only thing
  I knew. It took about 20 seconds .

11
Breaking Bad News The Options

• Lie.
• Deceive.
• Mystify.
• Look on the bright side.
• Break bad news.

12
Communication with family and friends

• The patient has primacy
• A mentally competent patient has the right
  (ethical and legal) to determine who shall be
  informed about his or her medical condition. All
  rights of friends or family are subsidiary to
  this. If a patient decides not to share
  information, although that may be an aggressive
  or vengeful action it cannot be countermanded by
  the professional at the familys request.
  Similarly, however well intentioned, a relative
  stating that the patient is not to be told does
  not have primacy over the patients wishes if the
  patient wishes full disclosure.

13
Communication with family and friends

• The familys feelings have validity
• The feelings of family and friends, although
  secondary to those of the patient, have validity
  and must be acknowledged even if their wishes or
  instructions cannot be followed.

14
To tell or not to tell?

• You dont often need to tell people, they
  usually tell you if you let them.
• The truth must dazzle gradually or every man may
  be blind.

15
To tell or not to tell?

• Realistic worry is better than false
  reassurance.
• Reassurance that turns out to be false leaves
  the patient with further to fall in psychological
  terms.
• (Wilkinson, 1995)

16
Breaking bad news making a difference

• When bad news is broken sensitively it increases
  patients satisfaction.
• (Fallowfield 1990)

17
Guidelines for giving diagnoses

• Communication
• Make formal introductions.
• Find out the patients view of the problem.
• Avoid euphemisms.
• Check the patients understanding.
• Given written information about support and
  information services.
• Give a contact number for further questions.
• Source Kings Fund (1996)

18

• Primary/secondary interface
• GP should
• Prepare patient
• Given written information about what to expect at
  the hospital.
• Inform the consultant about the patients social
  background and relevant family history.
• Consultant should
• Inform GP of diagnosis as soon as possible.
• Inform GP of what has been said and the patients
  reaction.
• Source Kings Fund (1996)

19

• Organisation
• A senior member of the team should give the
  diagnosis. He/she should
• Read the results in advance of the consultation.
• Maximise privacy-patient is on the ward, use
  separate room if possible, or ask neighbouring
  patients to move.
• Minimise interruptions-divert phone, leave
  bleep/pager with a colleague.
• Arrange support, preferably a specialist nurse.
• Document what has been said and how, and any
  unexpected reactions.
• Source Kings Fund (1996)

20
Breaking bad news

• Patients are not protected by their ignorance,
  only isolated.
• Litcher (1978)

21

• There is a recognition that the truth will
  almost be inevitably painful and nothing can make
  it painless, but we must be careful not to
  underestimate anyones inner resources
• Shea/Kendrick (1995)

22
Breaking Bad News

• If breaking bad news is done well our patients
  and their relatives will never forget us. If done
  badly they may never forgive us.
• Buckman (1996)