Transcript Clinical Communication Topics Section

Textbook of
Palliative Care Communication
Section V: Clinical Communication
Topics
Chapter 29
PATIENT-CENTERED
COMMUNICATION
Patient-Centered Communication
• Patient-centeredness
– Based on the biopsychosocial model of medicine
that accounts for biological, behavioral,
psychological, and social dimensions of care
– Involves communication that recognizes
expression of symptoms as well as emotion,
concern, feelings
Patient-Centered Communication
• Based on six main functions:
1) fostering the patient-provider relationship
2) providing and receiving information
3) responding to emotions
4) managing uncertainty
5) making decisions
6) enabling patient self-management
Skills for Patient-Centered
Communication
• Name the problem or issue
– Articulate each person’s perspective and come to
agreement on the main issue
• Clarify the facts
– Check understanding by asking verbal questions
• Address negative emotions
– Identify, acknowledge, validate emotions
Skills for Patient-Centered
Communication
• Frame an uncertain prognosis
– Determine the source of uncertainty and frame
information based on what is known and unknown
• Encourage participation
– Provide opportunities and prompt each person’s
preferences
• Teach self-activation
– Represent and advocate for one’s interests and desires
Chapter Thirty
CARE COORDINATION AND
TRANSITIONS IN CARE
Care Coordination and
Provider Communication
• Care coordination involves deliberate
organization of patient care activities AND
sharing information among participants,
ensuring patient preferences are known
• Care coordination relies on shared decisionmaking between provider, patient, family
– Improves engagement, reducing uncertainty
Goals of Care
• Common goals of care:
– Be cured, live longer, improve function, be
comfortable, achieve life goals, support for family
Chapter Thirty-One
TRUST, HOPE, AND MIRACLES
Trust as a “Pre-Existing Condition”
• Trust is a “pre-existing condition,” and hope is
much more than a coping strategy
• Issues of trust are due to psychosocial and/or
cultural predispositions
– Prior healthcare experiences
– The patient’s ability to trust providers
• Issues of power inherent in the patienthealthcare provider relationship
– Status-based power
Context of Hope and Denial
• Insistence on a miraculous cure also may be a
“necessary rest-stop” on the road to
acceptance
• Provider fear of giving “false hope” to patient,
family
– the patient believes in the power of faith to
intervene, not the miracle
– Provider needs to recognize that hope is real,
hope is energizing, and hope is at the center of
healing
The African-American Community
• African-Americans’ experiences with this
country’s healthcare system
– segregated hospitals
– breaches in trust
– a legacy of poor access
• The African-American community is also
largely religious-oriented
AMEN PROTOCOL
• A conversational tool to facilitate discussions
focused on hope for a miracle.
• The palliative care provider steps out of the
provider role for a moment and responds as a
human being, whether he or she is a religious
person or not.
AMEN Protocol
• Affirm the patient’s belief. Validate his or her position: “Ms
X, I am hopeful, too.”
• Meet the patient or family member where they are: “I join
you in hoping (or praying) for a miracle.”
• Educate from your role as a healthcare provider: “And I
want to speak to you about some medical issues.”
• No matter what; assure the patient and family you are
committed to them: “No matter what happens, I will be
with you every step of the way.”
Chapter Thirty-Two
PHYSICAL PAIN AND SYMPTOMS
Communication about Pain
• Cultural background strongly influences:
– Pain perception and reporting about pain
– Pain expression (e.g., stoicism)
– Descriptions of pain
– Language translations can be problematic
– Acceptability of treatment plans
Communication about Symptom
Management
• The patient’s and family’s religious beliefs need to
be explored
• Do not assume you know or understand
patient’s/family’s beliefs because they identify
with a certain cultural/religious background
• Review the advantages and side effects of
medication with patient/family
– Use plain language and translate medical terminology
– The Plain Language Planner for Palliative Care ©
Complications of Pain Management
• Risk of chronic pain management addiction
– Overwhelming prevalence of addiction disorders
across the United States
• Patients who are at high risk of opioid abuse
should be screened
• Providers should discuss mental health
disorders, social factors, personal or family
history of abuse, employment and legal issues
related to substance use or distribution
Communication about Pain
Management at End of Life
• Pain histories may be difficult or impossible to
obtain
– Rely on patient observation, bedside staff, prior
providers, and family members
– Nonverbal scales are available
• Maintain frequent communication with family
to educate on pain from disease progression
and pain management side effects
Chapter Thirty-Three
COMPLEMENTARY AND
ALTERNATIVE MEDICINE
Complementary and Alternative
Medicine (CAM)
• Defined as non-mainstream approaches that go
together with, or in place of, conventional
medicine
• CAM includes
– natural products such as herbal medicines
– mind-body practices such as yoga, guided imagery,
and tai chi
– manipulative body-based practices that include
chiropractic and message therapy.
CAM and Palliative Care
• Talking about CAM modalities requires
building a relationship, establising a
“therapeutic alliance”
– Help patient explore unknown environment of
own death and dying
– Understand the patient's psychological challenges
(anger, resignation), physical symptoms (pain),
and their needs or concerns
Communication about CAM
• When talking about CAM
– Be mindful of cultural setting (cultural belief
behind CAM intention)
– Use metaphors to explain, adjectives to comfort
– Provide reliable evidence of effectiveness
– Address strengths and limits of CAM therapies
The goal of communication about CAM is to
build a therapeutic alliance with the patient
Building a Therapeutic Alliance
• Convey compassion, empathy, and
acknowledge the patient’s dignity and
autonomy
• Recognize the patient’s biopsychosocialspiritual (holistic) needs and wishes
• Ensure sensitivity to, and respect for, the
patient’s concerns and values
• Adopt humanistic and ethical principles of
care
Chapter Thirty-Four
COMMUNICATING ABOUT LIFE
SUPPORT, ARTIFICIAL HYDRATION, AND
NUTRITION
Discussing Artificial Nutrition and
Hydration (ANH)
A very common fear is that the patient will suffer from
thirst and hunger, if ANH is removed.
• Communication should focus on educating family
about the following:
– Remind them that loss of appetite and thirst is normal
– Explain that continuing ANH can cause patient discomfort
and create more complex symptoms
– Describe how the body no longer needs large amounts of
energy and the patient’s digestive system is progressively
slowing down
• Teach the family to keep the patient’s lips moist, using
a swab.
Use Simple Language
To Discuss Life Support
Previous Experiences Frame Your
Ability to Make Decisions
• Take the opportunity to step back before
having difficult conversations with patients.
• Reflect on what is making it hard for you to
begin the conversation.
– Is there an unresolved experience preventing you?
– Did you suffer emotional harm?
– Ask yourself, how is holding onto that experience
going to help you in the present moment or keep
you from being honest with your patient?
Chapter Thirty-Five
ADVANCED CARE PLANNING
ACP Conversation
• Goal is to answer two key questions:
– What do we need to think about when making
decisions about your care?
– If you are unable to participate in healthcare
decision-making, to whom should we speak?
ACP Discussion Points
• ACP should be part of the routine practice of
palliative care admission
• Assessment of patient competence
– Patient must be able to understand and reflect on
illness and values
• Confirmation or appointment of substitute
decision-maker
– Known as proxy, this person should participate in
team discussions
• Preferred place of care
Barriers and Enablers
to ACP Discussions
• Public’s lack of knowledge of ACP
• Who is responsible for ACP?
– Unclear role among multiple providers
• Patient/family not ready to talk about ACP
• High symptom burden impedes patient
involvement
• Interpersonal and family relationships
• Cultural barriers
• Time
Conversation Starters for ACP
• Upon admission to palliative care
– Discuss and confirm treatment preferences at first
meeting (e.g., talk about planned or refused
treatments)
– Verify ACP status (e.g., is there already ACP in
place?)
– Frame as part of routine provision of palliative
care-intake process
– Identify primary caregiver, family relationships
– Assess patient understanding of illness
Chapter Thirty-Six
SEXUALITY
Sexuality and Touch
• Human need for physical closeness through
touch can communicate comfort, caring
• Physical expression of connection and
closeness involves communication about
sexuality and the power of touch
Communicating Through Touch
• Touch is the “physical” language of love,
affection, support, validation
• Procedural Touch
– Touch because of tests, procedures, examinations
– Typically unpleasant and distressing
• Expressive Touch
– Communicates concern and affection while
respecting and recognizing patient’s humanity
T.O.U.C.H.
• An assessment and intervention tool for
communicating about sexuality
• Take a history of touch and its place within the
caregiver relationships
• Organize touch responses using body mapping
to help the patient identify where she/he likes
and does not like to be touched
T.O.U.C.H.
• Unify physical touch with emotional feelings
and the resulting feelings of connection
• Co-create opportunities for the patient being
touched by the partner or loved one
• Honor the effort and risk-taking required by
the patient, partner, or loved one to reinvest
in and make gains with touch
Chapter Thirty-Seven
SPIRITUALITY
Defining Spirituality
• Form and content of a patient’s spirituality
may vary significantly from patient to patient.
• For the purposes of this chapter, spirituality is
defined as an individual’s beliefs, values,
behaviors, and experiences related to ultimate
meaning.
Spiritual Needs in Palliative Care
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Overcoming fears
Finding hope
Discovering meaning in life
Desire to talk about peace, death, and dying
Spiritual support from the healthcare team
can augment support from faith communities
or serve as primary spiritual support.
SACR-D
• A clinical guide to promote healing by
acknowledging, listening to, and providing a
compassionate presence to deeply spiritual
questions
SACR-D
• Self-awareness
– Provider attunement, degree of openness
regarding spirituality
• Assessment
– Spiritual assessment to determine role and
importance of spirituality in person’s life
• Compassionate Presence
– Tone of care conveyed through body language and
attitude
SACR-D
• Refer to Additional Spiritual Supports
– The act of referring to a spiritual care provider
– Spiritual care providers have specialized
knowledge in assessment and spiritual care
interventions
• Dialogue
– Need to understand a person’s spirituality in
language that is accessible to them.
Chapter Thirty-Eight
GRIEF REACTIONS
Grief and Bereavement
• Psychological and Psychiatric domain of care
under National Quality Project Guidelines
• Begins at initial contact with care team
• Patients, Caregivers, and Providers all
experience loss, and therefore, grief
• Skillful communication is important to enable
discussions about grief and provide
bereavement care
Understanding the Terms
• Grief – normal reaction to loss
– Physical loss and symbolic or psychosocial losses
• Anticipatory Grief/Preparatory Grief
– The grieving process occurring prior to the
patient’s death
• Complicated Grief, Prolonged Grief Disorder,
Complex Persistent Bereavement Disorder
– Bereavement process marked by severe morbidity
representing a clinical disorder
Team Communication for
Bereavement Care
• Monitor patient and caregiver for current condition and risk
factors for anticipatory grief
– Discuss team support needed for patients and caregivers with
high risk factors
• Make a team decision on what terms will be used to discuss
grief
– Complicated grief, Prolonged grief disorder, or Persistent
complex bereavement disorder
• Provide education so that team members are able to
recognize signs of risk for disenfranchised grief
• Encourage team members to reflect on their own grief in
order to recognize patient’s/family member’s grieving
process and their needs.
Communication Skills for
Grief and Bereavement
• Elicit descriptions of patient and caregiver’s personal
experience of loss
– “What has it been like for you since you received the
diagnosis?”
• Explain that the grieving process affects every thought and
emotion in a person’s life
• Provide information and facilitate access to professional
and community resources
• Normalize through education by explaining normal range of
experiences
– Emphasize that others experience similar symptoms
– Acknowledge that although it does not feel normal, grief is
normal