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Communication
 

Communication

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    Communication Communication Presentation Transcript

    • Communication We must do better! John Welsh
    • What Is Communication
      • Verbal engagement
      • Visual engagement
      • Touch
      • Sensitivity
      • Caring
      • Assessing
      • Holistic approach
      • Being there
    • Importance of Communication
      • Vital for Understanding
      • Vital between patients/ carers and HCP
      • Vital for assessing need
      • Vital for assessing concerns/worries
      • Vital for assessing psychological reaction to situation
      • Vital for teamwork
    • Communication – Is It Done Well?
      • OP– Length of time patient spoke
      • 75% of consultations classed Dr centred
      • Paediatricians/ mothers. 25% did not mention major concern/worries.
      • Non-congruence
      • Failure to address psycho-social issues
    • Barriers to Good Communication
      • Lack of Training
      • Fear of reaction to bad news (patients/own)
      • Lack of Time –(Quality)
      • Incurability seen as a failure
      • Fear of difficult questions
    • Complaints
      • Poor communication a factor in most litigation and complaints
      • Many around time of distress/seriously ill
      • Many highlight lack of information
      • Many unhappy with manner of its delivery
      • This increases stressful situations
      • Arise when emotions are not recognised/ addressed
    • Stress and Communicating Bad News
      • Significant anxiety - 30% Oncologists
      • Associated with lack of
      • Management Training
      • Communication Skills Training
      • Ramirez A
    • Specific pitfalls to effective communication
      • blaming
      • changing the topic
      • being defensive
      • judging
      • placating
      • multiple or 'why' questions
      • ( Bradley 1990 ).
      • leading or closed questions
      • focusing on the physical
      • failing to explore psychological issues
      • offering premature/false reassurance or advice ( Booth 1999 ).
    • Specific pitfalls to effective communication
      • Progressed
      • Positive / negative
      • Small cell lung cancer
    • Use Of Distancing Tactics
      • Normalization
      • Selective attention
      • Closed questions
      • Avoid cues
      • Premature reassurance
    • Levels of Communication
      • Facts
      • Feelings
      • Hidden Fears
    • Advanced communication skills
      • Man walks into a doctors....and the doctor says to him... "I`ve had the results of your tests back..and I`ve got some good news and bad news for you "What`s the bad news "You`ve got Aids" "Then what`s the good news?" "You`ve got Alzheimer's" "Thank god...for a minute ,I thought you were going to say I`ve got Aids"
    • Why train in communication skills?
      • Research suggests communication skills do not improve with experience alone ( Cantwell 1997 ).
      • Considerable effort and expense is being dedicated to improving communication skills ( DoH 2000 ).
      • Several studies show that communication skills can be taught ( Fallowfield 1990 ; Fallowfield 2001 ; Faulkner 1992 ; Langewitz 1998 ; Maguire 1990 ; Razavi 2000 ; Wilkinson 1999 ) and maintained over time ( Heaven 1996 ; Wilkinson 1999 ).
    • Helpful behaviours
      • Use of open questions, incorporating a psychological assessment, demonstrating empathy and using educated guesses ( Booth 1999 ).
      • Focusing, probing, paraphrasing, clarifying, confronting, exploring, summarising and closing have all been identified as useful communication techniques ( Bradley 1990 ).
    • Effective communication has many beneficial effects
      • Accuracy and completeness about symptoms and side-effects
      • Affects adherence to treatment
      • Influences emotional and physical wellbeing
      • Contributes to the satisfaction of both patient and clinician.
      • Communication is a core clinical skill.
      • In a career of 40 years, a hospital
      • Dr likely to interview 150 000 to 200 000 patients/ families.
      • LM Ong,, Soc Sci Med
      • MA Stewart, Can Med Journal
    • Palliative Care
      • The active total care of patients whose disease is not responsive to curative treatment. Control of symptoms and of psychological, social and spiritual problems is paramount. The goal of palliative care is the achievement of the best possible quality of life for patients and their families
    • Desire to Know Diagnosis
      • Increased in past >30 years
      • Cultural differences
      • No significant age or gender differences
    • Concerns after a Diagnosis of Cancer
      • Psychological 22%
      • Pain 14%
      • Weakness/Immobility
      • 11%
      • Rathbone
      • Dependency 69%
      • Worry about family 49%
      • Worry about pain 44%
      • Worry about being a burden 40%
      • Heaven 1996
    • General information preferences
      • Attitude to info Pall pats Non-pall pats
      • Leave to Dr 7.8% 7.1%
      • Only if good news 7.3% 3.9%
      • Info good or bad 84.9% 89%
      • Fallowfield
    • Need /want to know Fallowfield BMJ Pall % Non-pall %
      • Name of illness
      • Cancer or not?
      • Regular update
      • Chances of cure
      • All poss treatments
      • All poss side –effects
      • How treatment works
      • 87 91
      • 98 98
      • 90 93
      • 93 97
      • 94 95
      • 97 97
      • 91 93
    • Patients’ Views on End of Life Decisions
      • Adequate pain and symptom relief
      • Avoid inappropriate prolongation of dying
      • Achieving a sense of control
      • Relieve burden on relatives
      • Strengthen relationships with loved ones
      • Singer et al 1999 JAMA
    • Doctor/ Patient Relationship
      • Truthfulness/honesty
      • Mutual respect
      • Confidentiality
      • Genuineness
      • Empathy
      • Dependability
      • Non-judgemental
      • Befriending
      • Realistic Hope
      • Trust
    • Poll of population- who do you Trust
      • Teachers 65%
      • Police 55%
      • Doctors 94%
      • Politicians 20%
    • JHOs - Breaking Bad News
      • JHO’s
      • not right person 22%
      • Not all inform available
      • Hard dealing with emotions
      • Lack of privacy
      • Drs should judge who to tell 30%
    • Communication Training for Medical Students
      • GMC- Tomorrows Doctors
      • First year –verbal / non-verbal
      • Second year - giving info/results
      • Third year – Assessing/ result giving/ management plan
    • Breaking Bad News
      • Not simply a delivery of facts
    • Reaction to receiving bad news
      • Shock
      • Denial
      • Anger
      • Bargaining
      • Depression
      • Acceptance
      • Kubler-Ross 1962
    •  
    • Breaking Bad News
      • Environment
      • Preparation
      • Accompanied or not
      • Find out
      • Warning shot
      • Give the diagnosis
      • Pause
      • Discuss what happens next
      • Summarise
      • Arrange Follow – up
      • Home?
    • Breaking Bad News
      • Environment
      • Preparation
      • Accompanied or not
      • Find out
      • Warning shot
      • Give the diagnosis
      • Pause
      • Encourage ventilation of emotions
      • Encourage expression of concerns
      • Discuss what happens next
      • Summarise
      • Arrange Follow – up
      • Home?
    • Reaction to bad news
      • Uncertainty
      • Drastic negative view of previously expected future
    • Difficult questions
      • Will I die?
      • Am I dying?
      • How long have I got to live?
      • What is it like to die?
      • How/ What will I tell my children?
      • Will I have a lot of pain?
    • Initial goals in delivering bad news
      • Facilitate emotional ventilation
      • Achieve a common perception of the problem
      • Address basic information needs
      • Address immediate medical risks, including suicide
      • Respond to immediate discomforts
      • Ensure a basic plan for follow up
      • Anticipate what has not been talked about
      • Minimise aloneness and isolation (reassure about non-abandonment
    • ABCDE. A= Advance preparation
      • Arrange a time and place undisturbed
      • Prepare emotionally
      • Decide which words and phrases to use
      • Practice delivering the news
      • Arrange for a support person and appropriate family
      • Ask what the patient already knows and understands.
      • What is their coping style?
    • B=Build a therapeutic environment/relationship
      • Private, quiet place without interruptions
      • Provide adequate seating for all
      • Sit close enough to touch if appropriate
      • Reassure about pain, suffering, no abandonment
    • C= Communicate well
      • Be direct ("I am sorry, I have bad news")
      • Do not use euphemisms, jargon, acronyms "cancer" or "death“
      • Allow for silence
      • Use touch appropriately
      • Ask patient to repeat his or her understanding of the news
      • Arrange additional meetings
      • Use repetition and written explanations or reminders
    • D= Deal with patient and family reactions
      • Assess patient reaction
      • physiologic responses: flight/fight, conservation/withdrawal
      • Cognitive coping strategies: denial, blame, intellectualization, disbelief, acceptance
      • Affective responses: anger/rage, fear/terror, anxiety, helplessness, hopelessness, shame, relief, guilt, sadness, anticipatory grief
      • Listen actively, explore feelings, express empathy
    • E= Encourage and validate emotions (reflect back emotions )
      • Correct distortions
      • Offer to tell others on behalf of the patient
      • Evaluate the effects of the news
      • Explore what the news means to patient
      • Address further needs, determine the patient's immediate and near term plans
      • Make appropriate referrals for more support
      • Provide written materials
      • Arrange follow up
      • Process your own feelings
    • Conclusion
      • Importance of communication
      • Hear the persons Lament
      • Person centred approach
      • Support
      • Increased training
      • Bio-psychosocial-medical not biomedical
      • LISTEN and HEAR
    •  
    • Palliative Care
      • Affirms life and regards dying as a normal process.
      • Neither hastens nor postpones death
      • Provides relief from pain and other symptoms.
      • Integrates the psychosocial and spiritual aspects of care.
      • Offers a support system to help the family cope during the patients illness
    • Improving Satisfaction
      • A) Information verbally
      • B) Leaflet
      • C) Audio tape of consultation
      • A < B < C
    • Truth may hurt but deceit hurts more
      • ‘ I think the best physician is the one who has the providence to tell to the patients according to his knowledge the present situation, what has happened before, and what is going to happen in the future’
      • Clinicians are rarely taught how to deliver bad news
      • Following published recommendations might help clinicians to deliver bad news well
      • In addition to delivering bad news, clinicians can help patients manage its consequences
      • Important tasks include listening with compassion and understanding the meaning patients ascribe to bad news
      • Clinicians may also offer a number of specific responses to patients to help ameliorate suffering
    • Types of Doctor/Patient Relationship
      • Activity-Passivity
      • Guidance-Cooperation
      • Mutual-participation, partnership
    •  
    • Advance care planning
    • Impact of Specialist Palliative Care
      • Better symptom Control
      • Greater Family Satisfaction
      • Better Communication
      • Earlier discharge
      • Ellershaw
    • Questions
      • Closed
      • Facts
      • Open
      • Emotions
    • Communication with the cancer patient
      • Have clear objectives, assume nothing, and be flexible.
      • Introduce yourself and establish rapport.
      • Listen and ask open, but directive, questions.
      • Question and summarize until you have the whole picture.
      • Acknowledge and address issues.
      • Summarize and screen for other issues.
      • Be simple and clear, tailor the information to the patient.
      • Reinforce realistic hopefulness.