Transcript Why communication skills?

Medical Communication
Grace Varas, DO
UT Health
Division of Geriatric & Palliative Medicine,
Department of Internal Medicine
Why communication skills?
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Important for all medical professionals
Skills are lacking
 Undertrained
 Overconfident
CAN be learned (Procedure, Mnemonics)
Patient/family satisfaction
Quality Care
Risk for BURN Out
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Clinicians report dissatisfaction with family communication.
>70% of clinicians report perceived conflicts with other
staff or family, typically surrounding decision-making for
patients at high risk of dying.
Conflicts were often severe and were significantly
associated with job strain.
Part of the reason that one third of physicians and one half
of nurses report being “burned out.”
IPAL-ICU
Where to Begin?
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Medical communication literature is relatively novel.
First, we looked to the business (!) communication literature.
Getting to YES
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Separate the people from the problem.
Focus on interests, not positions.
Invent options for mutual gain.
Insist on using objective criteria.
Roger Fisher et al. Getting to YES: Negotiating Agreement Without Giving In 1981
New York: Penguin Books.
Five Fundamental Skills
1. A Central Skill: "Ask-Tell-Ask.“
2. When You Are Stuck, Ask for More Information: “Tell Me
More.”
3. Use reflections rather than questions to learn more
4. Skills for Responding to Emotion.
5. Assess the Other Person's Informational, Decision-making
and Coping Style.
Skill 1
"Ask-Tell-Ask."
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Ask the family to describe their current understanding of the issue.
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Tell the family what you need to communicate
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Ask the family WHAT (not IF) they understood of what you just said.
Skill 2:
When You Are Stuck, Ask for More Info: “Tell Me More.”
Remember that every conversation really has at least three levels:
1. "What is happening?"
2. "How do I feel about this?"
3. "What does this mean to me?“
Ways to Ask for More
Some examples of useful invitations to "tell me more” include
the following:
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"Could you tell me more about what information you need at
this point?”
"Could you say something about how you are feeling about
what we’ve discussed?”
"Could you tell me what this means for you and your life?”
Skill 3:
Use reflections rather than questions to learn more
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Simple reflections paraphrase what the person said and do not add
meaning or interpretation.
Complex reflections, on the other hand, go beyond what person
says and includes the clinicians’ thoughts about speaker’s
underlying emotions, values, or beliefs.
These reflections are riskier because clinicians can be incorrect.
Pollak K, Childers JW, Arnold RM. Applying motivational interviewing techniques to palliative care communication
Reflective Statements
Serve three functions:
1. Convey empathy
2. Empower the patient/family
3. Allows silence and time to explore the complexity
of decision-making
Pollak K, Childers JW, Arnold RM. Applying motivational interviewing techniques to palliative care communication
Skill 4:
Responding to Emotion
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Strong emotions – disbelief, sadness, anger, frustration and
hopelessness – are normal when there is potential for death,
loss of physical function, social function or quality of life
When people are experiencing strong emotions they are less
able to hear cognitive information or make decisions.
Skill 4:
Responding to Emotion
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Being empathic is associated with family satisfaction and trust.
 What most people want when expressing strong emotions
is to feel that their situation and emotions are heard and
appreciated.
Acting empathically can enable patients to connect their
emotional reactions to their own important values.
Skill 5:
Assess the Other Person's Informational,
Decision-making and Coping Style
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A recent study found that some family members want to
hear the doctor’s recommendations about what to do,
others specifically said that they did not feel it was the
doctor’s role to give recommendations.
What is a clinician to do?
 Find out who you’re talking to!
Monitors & Blunters
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People who use problem-focused coping have been termed
“monitors.”
As their loved one’s condition worsens beyond the
possibility of recovery, they hit a wall in seeking
information.
May be helpful to gently shift them towards acknowledging
their emotions (NURSE).
Miller, S. M. (1987). Monitoring and blunting: validation of a questionnaire to assess styles of information
seeking under threat. Journal of Personality and Social Psychology, 52, 345–353
Monitors & Blunters
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People who use emotion-focused coping are termed
"blunters."
May not be ready to go beyond denial with you until they
have developed a very high level of trust.
It may be necessary to contain their emotions and shift
them towards information and practical planning using
"ask-tell-ask."
Miller, S. M. (1987). Monitoring and blunting: validation of a questionnaire to assess styles of information
seeking under threat. Journal of Personality and Social Psychology, 52, 345–353
Giving “BAD NEWS”
Families complain that doctors:
 give bad news bluntly/detached manner
 create false hopes through excessive optimism
 focus on detailed medical or statistical information
without offering an interpretation of what the
information means in lay terms and for this patient.
Giving “BAD NEWS”
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“Bad news” can be anything that impacts the patient’s life and
well-being, not just a terminal disease
However, when bad news is communicated well, it can impact
outcomes such as
 Improved family satisfaction
 Decreased anxiety
 Decreased depression
SPIKES
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STEP 1: S— SETTING UP the interview
STEP 2: P— assessing the patient’s PERCEPTION
STEP 3: I— obtaining the patient’s INVITATION
STEP 4: K— giving KNOWLEDGE and information to the
patient
STEP 5: E— addressing the patient’s EMOTIONS with
EMPATHIC responses
STEP 6: S— STRATEGY and SUMMARY
Bailes, et al.
Empathic statements
Exploratory questions
Validating responses
“I can see how upsetting this is to
you.”
“How do you mean?”
“I can understand how you felt that
way.”
“I can tell you weren’t expecting
to hear this.”
“Tell me more about it.”
“I guess anyone might have that
same reaction.”
“I know this is not good news for
you.”
“Could you explain what you mean?”
“You were perfectly correct to think
that way.”
“I’m sorry to have to tell you this.”
“You said it frightened you?”
“Yes, your understanding of the tests
is very good.”
“This is very difficult for me also.”
“Could you tell me what you’re
worried about?”
“It appears that you’ve thought
things through very well.”
“I was also hoping for a better
result.”
“Now, you said you were concerned
about your children. Tell me more.”
“Many other patients have had a
similar experience.”
There is nothing like a great NURSE!
Attending to the family's emotions (NURSE):
 Name the emotion. "I know this is not what you wanted to
hear. It must be overwhelming.”
 Understand the emotion. "I can see how difficult this is for
you.”
 Respect the participants. "Given all that has happened, I
respect how hard you're trying to do what your dad would
have wanted.”
 Support the participants. "I will come back tomorrow. I'm
sure you have questions, so please write them down so that
we can go over each one of them.”
 Explore possibilities. "Tell me a little more about what you
are thinking.”
Tulsky et al.
Setting Goals of Care
Palliative docs have more difficult “difficult conversations:”
 Like an intensivist, may not have a pre-existing relationship with
patient & family
 Perceived need to make decisions on accelerated schedule
(hours to days)
 Patient often is incompetent, use of SDMs
 Hard for family members to understand why the current
treatments cannot achieve their goals (“got better the last
time”)
 A decision to shift goals and focus on comfort means that the
patient may die relatively quickly, which raises the stakes of the
loss and makes it harder for the family to think of other things to
hope for, exacerbating their sense of loss and guilt and
increasing the emotional cost of the transition.
Recommended Procedures for GOC Setting:
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Identify the legal surrogate decision maker and how the
family wants to make decisions.
When talking to surrogates assess their knowledge and
then provide information about the current medical
information: The SPIKES technique
Ask key questions to elicit the patient’s values
Ask about how the surrogates are doing
Suggest a course of action
Sometimes given the patient’s goals, try a time-limited
treatment trial
Time-Limited Trials
CLEARLY tell them:
1. what the treatment is
2. the goals that you are looking for the treatment to achieve
3. what you will be looking for to determine whether those goals
are being achieved
4. over what period of time to see if the
treatment “works or not.”
Talking About Prognosis
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Explain how you came up with the prognostic estimation.
Some experts also recommend describing both the probability of
death as well as the probability of survival to improve
understanding.
Talking About Prognosis
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Explain the uncertainty that is inherent in all prognostication.
Let the family know you are watching closely and will meet with
them again to discuss any changes in the patient’s condition.
Talking About Prognosis: Example
“This is the average survival time. Some people do better than
average, some do worse. We will work together to try to beat
the odds, but I will be there with you whatever happens.”
Pearls: Ideas to Facilitate Conversations about Transitions
1. Invite the conversation: Do not force your agenda.
2. Respond to emotion, especially hope
3. Respond to guilt and feelings of responsibility
4. Reaffirm your commitment to the patient/family
5. Give the family some time to think about what you said
6. Praise the patient and family for their work up to this point
Interprofessional Communication
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Lacking in the literature. (boo!)
Has focused on ICU
Physician leadership and “communication openness” have been
cited as necessary for other professionals to feel their ideas
matter and impact goals of care discussions.
Crucial for improving quality and safety of medical care.
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Reader, T., Flin, R., Mearns, K., & Cuthbertson, B. (2007). Interdisciplinary communication in the Intensive Care Unit. British Journal of Anaesthesia, 98,347-352
2. Anon. article reviewed for JPM, publishing pending.
Back to the Business Lit…
What makes a great team?
1. Make time for team members to appreciate each other's skills
2. Surface and manage emotional issues that can help or hinder
the team's progress
3. Celebrate team success
Sound familiar?
Harvard Business Review http://blogs.hbr.org/hmu/2008/02/make-your-good-team-great-1.html,
Accessed November 2011
Family Satisfaction
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Increased proportion of time that family members talk (as
compared to physicians) is associated with higher satisfaction
ratings
Three empathic behaviors are associated with satisfaction:
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Assurances that the patient will not be abandoned before
death
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Assurances that the patient will be comfortable and will not
suffer
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Support for family's decisions about EOL care
RULE OF THUMB: If you’re talking ½ the time, you’re talking TOO
MUCH!
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Allow people time to process information and ask questions.
VALUE Statements
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V = Value and appreciate what the family said
A = Acknowledge the family’s emotions
L = Listen to the family’s description of the patient and
U = Understand the patient as a person
E = Elicit and ask questions of the family
Mularski, et al.
VALUE Statements
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RCT of 126 critically ill patients cared for in 22 ICUs
95% of family members in the VALUE group reported that
they had been able to express their emotions to the ICU
clinicians, as compared to 75% of family members in the
customary practice group.
In addition, among family members who initially disagreed
with the decision to forgo life-sustaining treatments, those
in the VALUE group were more likely to concur with the
decision at a later time.
Finally, 90 days after the family meeting, VALUE group had
less anxiety and depressive symptoms than those in the
control group.
Mularski, et al.
Six Types of Physician Communicators
1. The inexperienced messenger
2. The emotionally burdened
3. The rough and ready expert
4. The benevolent but tactless expert
5. The “distanced” doctor
6. The empathic professional
Talking about Resuscitation Preferences
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CPR is symbolically important for both providers and patients.
Doctors have strong feelings about performing CPR in patients
who they think have a poor prognosis, as it evokes feelings of
mutilating bodies.
Conversely, families view CPR as the only thing that can stave off
their loved one’s death. They overestimate CPR’s success and
overemphasize its life prolonging effect and thus demand that
physicians try.
Considerations in Discussions about Resuscitation Preferences
What people care about regarding CPR:
 The patient’s pre-CPR quality of life: if a patient was not happy
with his/her QOL before CPR, s/he is unlikely to be happy with it
after CPR.
 The patient’s post-CPR quality of life: In studies, most patients
do not want CPR if after CPR they will not be sentient. Therefore,
it is important for clinicians to know the data about CPR
outcomes for different populations.
 The probability of the CPR “working”: Studies show that
patients are likely to overestimate CPR’s success rate.
Considerations in Discussions about Resuscitation Preferences
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Studies have shown that when educated about CPR success
rates, over 50% of patients changed their mind about whether
they would want it.
Patient’s shown videos of CPR made those decisions more stable
over time and increased even more the rate of DNR orders.
Considerations in Discussions about Resuscitation Preferences
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Symbolically, CPR means life.
Not doing CPR means the patient is going to die.
Raising the issue of CPR may make the patient’s dying more
real for the family, leading to an emotional reaction.
Empathy, rather than giving facts, is most likely to help the
family cope with this information.
Considerations in Discussions about Resuscitation Preferences
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You do not need to ask patients about every component of CPR
or ACLS: purpose of discussing CPR is to make sure that decisions
reflect and promote patient’s goals.
Therapeutic decisions are typically viewed in a hierarchical
fashion from aggressive (CPR or mechanical ventilation) to less
aggressive (IV medications in the hospital) to even less aggressive
(oral medications at home).
 If patients or surrogates want to forgo ventilation, you
probably do not have to ask about CPR. It almost surely does
not make sense, and you can tell them that given their goals,
CPR would not make sense, and you would not do it. Not true
in reverse.
Considerations in Discussions about Resuscitation Preferences
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Make a recommendation
Once you understand the patient’s values and goals,
make a recommendation regarding what you think
should and should not be done.
 The key here is to spend as much time talking about
what you WILL do to achieve the patient’s goals as
what you think should not be done
Recognize that your recommendation may lead to
negative reaction.
 Instead, try to hear the request for “everything” as a
distress signal that requires more exploration.
 Reluctance to face painful emotions connected with
the patient’s loss of health and potential impending
death, preferring instead to keep hope alive by
avoiding any such discussion.
Indications for a Family Conference
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When a course of treatment needs to be changed
When the patient cannot participate
When the medical situation is rapidly changing
When family members disagree about the course of treatment
What Makes Family Meetings Hard?
1. Families bring complicated relationships and interactions to the
meeting.
2. Family members
 Have their own motivations and interests,
 Have their own personal emotional needs,
 Have different preferences for information or decision making,
and
 May disagree about the right course of action.
Conducting a Family Conference
1. Prepare for the conference (participants, room with privacy, clear
purpose from all teams together, phones on vibrate)
2. Introduce everyone present and the purpose of the meeting
3. Assess what the family knows and expects (Ask-tell-Ask)
4. Describe the clinical situation (Ask-Tell-Ask)
5. Ask the family for questions and concerns (Ask-Tell-Ask and NURSE)
6. Allow silence
7. Propose goals for the patient’s care, and be prepared to negotiate
8. Provide a concrete follow-up plan
9. Summarize decisions
10.Document the family meeting
in the chart
Modified from EPERC Fast Fact # 16 http://www.eperc.mcw.edu/fastFact/ff_16.htm
Documentation
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Who was there
What was discussed
What the family said about the patient’s goals
What treatment plan was decided on
What outcomes will be used to determine the plans success
When the next meeting is
Whether there was disagreement among the family
Any strong emotions that were expressed
“Just the facts, ma’am.”
 DO NOT EDITORIALIZE in the
medical record!
Watch Your Language!!!
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Guilt and the fear of abandonment are particularly common in
family meetings.
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American culture stresses doing, and thus the default for many
families is to want to do more to try to improve their loved
ones health.
Watch Your Language!!!
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Asking people if they want to be “aggressive” or “do everything”
intimates that choosing comfort care is “giving up.”
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Similarly talking about withdrawing “care” or “stopping life
supports” may feel like talking about abandoning their loved one.
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Remind them of everything you WILL DO: IVF, Abx, Comfort,
Hygiene…
Major Challenges to Discussions of Limiting
Life-Sustaining Treatment
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Families may perceive the decision to forgo LST as the cause of
death, with accompanying burdens of responsibility and guilt.
Families may fear that limitation of LST will be accompanied by
intractable suffering including severe pain or dyspnea.
There is a fear that limiting LST raises ethical or legal concerns.
Teachings of certain religions may be interpreted as prohibiting
decisions to limit LST.
Death is uncertain, and its timing is unpredictable after withdrawal
of treatments that were initiated to sustain life.
Withdrawal of LST
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The median time to death from the first decision to limit
therapy is approximately 15 hours in ICU patients.
Following the decision to limit the most active form of
therapy, the median time to death if the therapy is
withheld is 14.3 hours and 4.0 hours if the therapy is
withdrawn.
11% of patients survive to discharge.
Discussing What Happens After a Decision
to Forgo Life-Sustaining Treatments
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Talk about the Timing of Forgoing LST
Attend to the family’s social and religious needs
 people who would like to say good-bye.
 how to talk to children about the patient’s death
 any religious or spiritual traditions
 preferences regarding whether they want to be
present during the withdrawal
Describe the Process of Discontinuing LST and Dying
Summarize and Ask for Questions:
Navigating Conflict with Families
Address common patterns of conflict between the family and
the health care team:
 The family is acting out of guilt or fear of being responsible
for a decision that will shorten the life of the patient.
 The family does not trust the health care team.
 The family is hoping for a miracle.
Is it YOU???
Consider ineffective or dysfunctional communication by health
care providers as a primary cause of the family’s
misunderstanding.
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Attend to your own responses to the family.
How do poor patient outcomes affect you?
Calibrate your own practice style.
Is a dispute over life support a power struggle, a matter of
resource allocation or an issue of conscience?
Be aware that clinicians have issues too.
Consider that the health care team’s internal disagreements
may be contributing to the problem.
Discussing “medically inappropriate treatments”
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Be rigorously honest about the limits of your own ability to predict
the future.
Always ask yourself whether a dispute about limiting LST is about
resource allocation, the goals of medicine, or a power struggle
about who gets to decide, rather than an issue of prognostication.
Make the assumption that the family's intentions are also to
provide the best care for the patient.
Emphasize that you hope the patient will improve, even if your
medical judgment is that such improvement is extremely unlikely.
Ask if there is anything you can do to help the family.
Pitfalls: Common Barriers to Good Communication
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Making assumptions about what the family knows and
doesn’t know
Ignoring the context of the communication encounter
Launching into your agenda first without negotiating the
focus of the interview
Giving pathophysiology lectures
Pitfalls: Common Barriers to Good Communication
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Talking about procedures like CPR before discussing the big
picture of disease status, patient values, patient and family
wishes
Addressing withdrawal or withholding of life-support with
the family without first assessing their understanding of
their loved one’s medical condition
Focusing on interventions without trying to understand the
patient’s preferences or rationale
Pitfalls: Common Barriers to Good Communication
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Not finding out the family’s information needs and styles
Pushing the family to make a decision, before they have
had a chance to grieve the loss
Don’t ask the family what they want to do…
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Rather ask what is in the best interest of the patient or
what the patient would want them to do
Pitfalls: Common Barriers to Good Communication
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Expecting families to make a decision in the 1st discussion
Trying to explore goals and future decisions at the same
time you are giving bad news
Forcing families to talk about the future or Resuscitation
preferences when they are not ready
Pitfalls: Common Barriers to Good Communication
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Overlooking the stress of caregiving.
Over-focusing on the single legal surrogate decision-maker.
Focusing solely on what you are not going to do
Pitfalls: Common Barriers to Good Communication
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Expressing frustration with a family that makes a thoughtful
choice about LST that diverges from your recommendation
Don’t try to convince the family that their decision is
unreasonable.
Responding to family distress by reflexively offering more
aggressive ICU care
Offering reassurance prematurely
 It is not always “going to be okay.”
Pitfalls: Common Barriers to Good Communication
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Ignoring emotions
Ignoring your own feelings
Watch yourself for distancing behaviors
Pitfalls: Common Barriers to Good Communication
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Feeling you are responsible for maintaining the patient’s hope
Feeling that after the family decides to forgo LST that your job
is done
Talking too much
Pearls: Ideas to Facilitate Giving Bad News
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Attend to affect and provide opportunities for patients/families
to talk about their values.
Avoid vague terms—and when you hear the family use them ask
them to define them.
Ask the family about their questions and concerns at several
points during key discussions.
Pearls: Ideas to Facilitate Giving Bad News
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Eliciting the patient and/or family’s concerns can help them feel
heard and help you address their primary worries.
Family members may have different needs
Ensure shared understanding of the goals of care by asking
“why” when patients/families ask for specific treatments or
express their goals.
Pearls: Ideas to Facilitate Giving Bad News
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Attend to the emotions underlying the questions and reassure
them that you will provide information about prognosis so they
don’t think you’re being evasive.
Be aware of your own emotions such as sadness, guilt,
disappointment, or shame.
Try to accept that being empathic, interested, and affirming are
powerful verbal techniques that the patient and/or family
recognize as demonstrations of your support.
Pearls: Ideas to Facilitate Giving Bad News
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You can help your patient and/or family members:
 Hope for the best.
 Prepare for the worst.
 Attend to the present.
Express non-abandonment
Express support for the family’s decisions
Remember that you are offering to let people talk about this
issue, not forcing them to “give up.”
Helpful Phrases
In evaluating misunderstanding:
 “Tell me what others are telling you about what is going on
with your dad?”
 “I want to make sure that we are on the same page. Can
you please take a minute to tell me what you understand is
going on with your dad."
Helpful Phrases
Dealing with denial
 "I can sense how much you were hoping for good
news.”
 "I wish things would have worked out differently.”
 "This must be devastating for you.”
 Dealing with “miracles”
 "Can you tell me more about what a miracle would look
like for you?”
 “Besides a miraculous cure, are there other things you
are hoping for?”
Helpful Phrases
Dealing with guilt
 "I am not asking you to make a medical decision. I want you
to help me understand what your dad would have said if he
were sitting here and could understand what we have been
talking about.”
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"I can see how hard this is for you. I respect that you’re trying
to follow your dad's wishes even though you would want
something different for yourself.”
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"I would never ask a family to give up on a patient or loved
one. Sometimes, however, love and respect require that we
let someone go.”
Can We Talk?
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Think of clinical examples of times when a patient and family have had
difficulty making a treatment decision.
Think about a time you participated in a family conference to discuss
treatment decisions that was less than ideal… and an effective one.
What are some of the difficulties encountered when working with
patients and their families?
Additional References
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http://www.eperc.mcw.edu/EPERC/FastFactsandConcepts
Back AL, Arnold RM, Quill TE. Hope for the Best, and
Prepare for the Worst. Ann Intern Med 2003;138(5):439443.
Quill TE, Arnold RM, Platt F. “I Wish Things Were Different”:
Expressing Wishes in Response to Loss, Futility, and
Unrealistic Hopes. Ann Intern Med 2001;135(7):551-555.
Quill TE, Arnold R, Back AL. Discussing Treatment
Preferences With Patients Who Want “Everything”. Ann
Intern Med. 2009;151:345-349.
Credits
Photographs use for the cover are allowed by the morgueFile free photo agreement and the Royalty Free usage agreement at
Stock.xchng. They appear on the cover in this order:
Wallyir at morguefile.com/archive/display/221205
Mokra at www.sxc.hu/photo/572286
Clarita at morguefile.com/archive/display/33743
Microsoft Powerpoint Images and Clipart:
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