Effective Communication with Families of Patients with Heart Problems

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Effective Communication with Families of Patients
with Heart Problems

• Shiva Sharma, M.D
• Pediatric Cardiology Services

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Extensive data has linked effective
physician-patient communication to biological,
psychological, social, and legal outcomes of
care. It has been tied to better adherence,
shorter hospital stays, better efficiency and
cost effectiveness, less malpractice, and not
surprisingly, increased physician and patient
satisfaction
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Outline

• Case presentations followed by discussion of
  effective communication skills
• Work up to more complex scenarios bad
  news/difficult situations and conversations
• Prenatal Counseling
• Medical error disclosure
• Enhancement of quality of care
• Increasing satisfaction Patient/Caregivers
• Promoting excellence in physicians

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Consider a case.

• RH, 10 yr WM
• F Hx of hyperchol. Dad MI at 35 yrs
• Sedentary, obese, male, Mod.? LDL, ?HDL
• TLC program initiated.
• 2nd visit 10 ? in LDL,TG with TLC ?Wt.
• Extended meeting with Dad and RH to understand
  their perspective, rationalize care, and elicit
  their partnership

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The 4 Habits Model - Richard M. Frankel, PhD

• Habit 1 Invest in the Beginning
• Habit 2 Elicit the Patient's Perspective
• Habit 3 Demonstrate Empathy
• "... to know and understand, obviously is a
  dimension of being scientific ... to feel known
  and understood, is a dimension of caring and
  being cared for.
• Habit 4 Invest in the End

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Goals of 4 habits

• Establish rapport build trust rapidly
• Facilitate effective info. exchange
• Demonstrate caring concern
• Increase adherence to plan
• Improve health outcomes
• 120-160,000 interviews in a lifetime. Modest
  improvement in delivery of care can improve
  outcomes , satisfaction and cost.

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The 5 types of empathic responses

• Reflection--"I can see that you are ... "
• Legitimation--"I can understand why you feel ...
  "
• Support--"I want to help."
• Partnership--"Let's work together ... "
• Respect--"You're doing great."

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Bad news
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Conveying bad news and engaging in difficult
conversations with patients and their families
are pivotally important, although
anxiety-provoking components of clinical
practice Clinicians may fear they will not be
able to find the right words They will say too
much, too little, or the wrong thing altogether.
Further, clinicians worry that imparting
difficult news may diminish hope, compound a
familys suffering, or unleash emotional
responses
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Consider a case

• WT, 15yr, AA male
• Exertional chest Pain
• Abnomal EKG with T wave inversion
• Echo Confirmed IHSS
• Family conference

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Review

• What do patients want to know?
• How do patients experience bad news?
• How competent are physicians in giving bad news?
• How should physicians give bad news?
• Does how bad news is given make a difference?
• Do cultural differences matter?

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What do patients want to know?

• 2,331 patients at UK cancer centers
• 98 wanted to know if the illness was cancer
• 87 patients preferred as much information as
  possible
• Need to individualize delivery to patient needs

Jenkins, Br J Cancer 20018448-51
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How do patients experience bad news?

• Bad news results in a cognitive, behavioral, or
  emotional deficit in the person receiving the
  news that persists
• Clinicians cant change the news
• Clinicians can make the news worse, or they can
  help give realistic hopes

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A variety of responses to bad news

• 100 patients diagnosed with cancer
• Shock 54
• Fright 46
• Accept 40
• Sadness 24
• Not worried 15

Lobb, Med J Aust 1999 290-4
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People receiving bad news may not remember much

• Three months after parents received bad news
• 12 of 23 sets took in little or none of the
  information given
• 4 of 23 sets denied that a separate information
  session had occurred
• 10 of 19 sets remembered the information session,
  but didnt understand the content

Eden, Pall Med 1994 105-114
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Medical jargon can make bad news worse

• Technical language frequently unclear
• 100 women with breast cancer
• 73 misunderstood median survival
• No agreement on what a good chance of survival
  meant numerically

Ford, Soc Sci Med 1996 1511-9
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Physicians are inaccurate in detecting distress

• 5 oncologists studied intensively
• None predicted patient distress better than
  chance
• One had negative predictive behavior
• All very satisfied with their performance
• Little probing about patient emotional state

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Patient and clinician stress related to bad news
Clinician
Patient
Stress
Time
Encounter
Ptacek, JAMA 1996 496-502
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The communication challenge

• Physicians may feel discomfort with the intense
  emotions displayed by parents in response to the
  news, such as sadness, anger, and blame.
• Physicians may feel guilty or inadequate
  regarding their inability to cure the child.
• When the childs illness is sudden, little
  opportunity may exist to establish relationships
  with parents before communicating bad news, thus
  making it hard to anticipate parents
  informational and emotional needs.

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SPIKES model for delivering bad news

• S - setting up the interview. This portion of
  the protocol recommends a mental rehearsal for
  physicians before delivering the news
• P assessing the patients perception. This
  portion of the protocol encourages the physician
  to use open-ended question to assess how much the
  patient/parent knows before breaking the news.
• I obtaining the patients invitation. This
  step involves asking the patient/parent at the
  time of testing how they would like the results
  to be explained.
• K giving knowledge and information to the
  patient.
• E - addressing the patients emotions with
  empathetic responses.
• S- strategy and summary.

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Prenatal counseling
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As prospective parents, when you learn your baby
has a congenital heart defect, the news can be
devastating. Feelings of helplessness, confusion,
fear and mourning over the loss of a healthy baby
occur. In addition, extremely difficult and life
changing discussions and decisions need to take
place in a relatively short period of time.
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Case history (Fetal)

• MJ is a 25 yr WF. 18 wks gestation fetus found to
  have CHD and told about it.
• Fetal echo HLHS confirmed with MA and AA
• Extended Family conference with Mom and Dad.

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Parental stress following prenatal diagnosis
ofCongenital Heart Disease

• Earlier studies have reported
• Increased maternal anxiety with prenatal
  diagnosis of any fetal anomaly (Detraux et
  al,1998)
• Considerable psychological distress in
  mothers(as compared to fathers) which may be
  markedly underestimated by healthcare providers
  (Leithner et al, 2004). This may require
  professional help in the perinatal period. (Skari
  et al, 2006)

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Fetal counseling

• Help families cope with the news of CHD
• Help families understand prognosis/diagnosis.
• Make transition to post natal life as seamless as
  possible

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Fetal counseling (cont.)

• Try not to overwhelm the parents
• Challenge to provide the information in a way
• that is easily understood
• Only a small fraction of what is said is likely
• to be retained
• Typically go through normal anatomy and
• physiology and then go through the defect
  
• Benefit of multi-disciplinary approach

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Medical error
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Respect for patient autonomy is a cornerstone
of the Codes of Medical Ethics of the American
Medical Association (AMA) and encompasses the
rights of patients to receive all information
necessary to make informed and educated decisions
about their care. Disclosure of adverse
events is implicit in this principle, because
without it patients are not fully informed.
Failure to disclose threatens the trust inherent
in a doctorpatient relationship. Research on
patients, family members, and attorneys suggests
that patients are less likely to sue if
disclosure has taken place
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• What do patients actually expect after an
  injurious medical error has occurred?
• Numerous studies in adults have examined this
  question, and five key messages have emerged.
  Patients want
• An explicit statement that an error occurred
• To be told what the error was
• To be told why the error occurred
• To know what will be done to prevent recurrences
• An apology

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The 7 Ws of disclosure

• Why disclose?
• To preserve patient autonomy and
  patient-physician trust
• Because ethically it is the right thing to do
• Who should disclose?
• Health care worker with whom the patient has a
  trusting relationship, usually the responsible
  physician
• Others involved in the incident (eg, nurse,
  pharmacist may be included)
• If the physician cannot disclose, another health
  care worker with an established relationship with
  the patient or a member of the hospital
  leadership or quality and safety program should
  do the disclosure.
• A senior hospital administrator may need to be
  involved in serious cases.
• The patients primary nurse should be included in
  the discussions to be able to support the patient
  after the disclosure has occurred.

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The 7 Ws of disclosure (cont.)

• To whom should the communication be made?
• To the patient
• If this is not possible, to family members or
  substitute decision makers
• What types of events should be communicated?
• Any incident that has resulted in harm to the
  patient
• Other incidents at the discretion of the
  responsible physician
• What information should be communicated?
• Acknowledge that the event occurred and give the
  facts.
• Take responsibility and apologize.
• Commit to finding out why.
• Explain what impact the event will have on the
  patient now and in the future.
• Describe steps being taken to mitigate the
  effects of the injury.
• Describe steps being taken to prevent a
  recurrence.

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The 7 Ws of disclosure (cont.)

• When should communication take place?
• As soon as the event is recognized and the
  patient is physically and emotionally capable
• Ideally within 24 hours after the event is
  recognized
• Where should the communication take place?
• In a private and quiet area

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Simplified Summary
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Parental requirements

• Normality
• Certainty
• Health information
• Partnership

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What parents look for

• Delivery of information
• Levels of support
• Relationship with the caregiver
• Management of events

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Delivery of information

• Verbal , one on one basis
• Nonverbal communication, eye contact
• Simple language at level with parents
• Supplemental visual, written, websites to give.
• Check out www.pted.com

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Relationship with physician/ caregiver

• Establish rapport and trust by LISTENING to
  parents patients
• Partner with parents
• Including older child in conversation
• Treat as individuals.

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Levels of support

• Contact numbers
• Open access
• RN contact
• Web based support groups
• Other families in the area with similar diagnosis
  -
• School staff

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Management of events

• Parents want control over events
• Access to specialized RN, MD, CHOA type hot line.
• Information for school

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Development of professional competence
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Professional competence is defined as the
habitual and judicious use of communication,
knowledge, technical skills, clinical reasoning,
emotions, values, and reflection in daily
practice for the benefit of the individual and
community being served.
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Dimensions of professional competence

• Cognitive
• Core knowledge
• Basic communication skills
• Information management
• Applying knowledge to real-world situations
• Using tacit knowledge and personal experience
• Abstract problem-solving
• Self-directed acquisition of new knowledge
• Recognizing gaps in knowledge
• Generating questions
• Using resources (eg, published evidence,
  colleagues)
• Learning from experience

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Dimensions of professional competence

• Technical
• Physical examination skills
• Surgical/procedural skills
• Integrative
• Incorporating scientific, clinical, and
  humanistic judgment
• Using clinical reasoning strategies appropriately
  (hypothetico-deductive,
• pattern-recognition, elaborated knowledge)
• Linking basic and clinical knowledge across
  disciplines
• Managing uncertainty
• Context
• Clinical setting
• Use of time

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Dimensions of professional competence

• Relationship
• Communication skills
• Handling conflict
• Teamwork
• Teaching others (eg, patients, students, and
  colleagues)
• Affective/Moral
• Tolerance of ambiguity and anxiety
• Emotional intelligence
• Respect for patients
• Responsiveness to patients and society
• Caring

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Dimensions of professional competence

• Habits of Mind.
• Observations of ones own thinking, emotions, and
  techniques
• Attentiveness
• Critical curiosity
• Recognition of and response to cognitive and
  emotional biases
• Willingness to acknowledge and correct errors

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Training physicians team to deliver effective
care

• Heart of medicine is patient-physician encounter
  to heal the whole patient
• PERCS (Program to Enhance Relational and
  Communication Skills)
• MD RN, MSW, Students non-hierarchical
• Promote self awareness, self assessment

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Summary

• Quality of care depends a lot on good
  communication with families
• Good communication depends a lot on listening to
  our patients and showing empathy.
• Good listening means good care.
• Parents are not looking for how much you know
  but how much do you care.

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Relationship Centered Care
Report of the Pew-Fetzer Task Force on Advancing
Psychosocial Health Education
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• Reflection--"I can see that you are ... "
• Legitimation--"I can understand why you feel ...
  "
• Support--"I want to help."
• Partnership--"Let's work together ... "
• Respect--"You're doing great."

Cohen-Cole SA, Bird J. Building rapport and
responding to patient's emotions. In Cohen-Cole
SA. The medical interview the three-function
approach. St Louis, MO Mosby Year Book 1991. p.
21-7.
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Learning objectives

• 1. Best practices for
• a) information delivery
• b) management of parental anxieties
  expectations
• c) communication of rare conditions (
  the unknowns)
• d) communication of bad news
• e) empowering families/patients
• 2. Pre natal Counseling
• 3. Team Approach Coordinating care and
  support

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Giving bad news

• Reviewing the evidence
• Recommendations for clinicians
• Cultural considerations

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The communication challenge (cont.)

• Prognostic uncertainty may lead to reluctance in
  providing information about outcomes.
• While bad news may be best provided in the forum
  of a family conference, such conferences are
  time-consuming and require advanced planning.
• Additionally, societal and family expectations
  that death is avoidable through advanced
  technology work against physicians credibility
  when discussing the inevitability of a childs
  death, especially when trust has not been
  established.

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The communication challenge

• Conveying bad news and engaging in difficult
  conversations with patients and their families
  are pivotally important, although
  anxiety-provoking components of clinical
  practice
• Clinicians may fear they will not be able to find
  the right words
• They will say too much, too little, or the wrong
  thing altogether.
• Further, clinicians worry that imparting
  difficult news may diminish hope, compound a
  familys suffering, or unleash emotional responses