3. OBJECTIVES OF LEARNING
By the end of this discussion, the students shall be able
to:
I. Define communication.
II. State the types of communication
III. The skills used in communication and its barriers
IV. Barriers to communication
V. State the qualities/ attitudes needed for effective
communication
VI. Challenges for ineffective communication among
care providers
VII. Communication in children
4. COMMUNICATION IN PALLIATIVE CARE
Communication (as a generic process) is a two-way process between two or more
persons in which ideas, feelings and information are shared, with the ultimate aim
of reducing uncertainties and clarifying issues.
Communication only becomes complete when there is feedback.
Types of communication
1. Verbal communication
Verbal communication is the exchange of ideas through spoken expression in
words. It is a medium for communication that can entail using the spoken word,
such as talking face-to-face, on a telephone, or through a formal speech; similar
communication can occur through writing.
2. Non-verbal communication
Non-verbal communication involves the expression of ideas, thoughts or feelings
without the spoken or written word. This is generally expressed in the form of body
language that includes gestures and facial expressions and, where appropriate,
touches.
NB: Both verbal and non-verbal communication is important in palliative care
6. NB. Little communication actually takes place verbally,
facial expressions gestures and posture form most of
our communication and are a graphic part of our
culture and language. Studies show that during
interpersonal communication 7% of the message is
verbally communicated, while 93% is non-verbally
transmitted. Of the 93% non-verbal communication:
• 38% is through vocal tones
• 55% is through facial expressions
There are four major skills in communication:
1. Listening
2. Checking Understanding
3. Asking Questions
4. Answering Questions
7. (a)Listening. The first and perhaps the most important skill is to be a good
listener. We have to be able to listen in order to understand the patient and
family needs.
How well do we listen?
Show that you are listening by using the following techniques:
• Pay attention to the person you are communicating to.
• Use body language to show that you are paying attention.
The following acronym can help to remember the key points about suitable
body language that indicates paying attention: (ROLES)
• R - Relaxed
• O - Open
• L - Lean forward
• E - Keep eye contact
• S - Sit near the person
Tips for effective listening:
• Encourage the person to talk and (especially on nodding your head or use an
appropriate facial express ion.
• Do not yawn, fidget, look around or out of the window or do any other things that
indicate boredom or impatience.
• Observe the persons non-verbal communication and reactions, this can help
interpret the person’s feelings
8. Continue...
• Use silence constructively. Sometimes a person may stop talking.
He/she may be thinking about the situation, do not hurry them to
talk
It is very important not to interrupt the person when he/she is talking
=-. Listen and try to understand what the person is saying verbally.
Remember accurately what the person has said.
Listen with empathy (put yourself in their shoes and not judge them)
9. Barriers to effective listening:
Distractions: phones ringing, people coming into the room etc.
Judgmental fixations: judging patient by imposing one’s own
values/morality (often religious).
Filtered listening: interpreting what you are bearing through your own
experiences, culture and background.
Prejudice and preconceived bias: judging someone by the way they dress,
their tribe, gender, profession
(b) Checking understanding
It is important to check that we have understood them correctly
as it:
Lets them know we have been listening carefully.
Lets them know we are trying to understand.
Gives an opportunity to them to think again about the problem.
Helps them to think about how to cope with the problem.
10. How do we check understanding?
Paraphrasing what the parson has said as key points during the
conversation, by using words hke; You have told me that
Clarifying what the person has said, by checking you have
understood correctly. using words like, ‘So, you mentioned you are
worried about three things but school fees is the biggest problem, is
that right?”
Reflecting by identifying the feelings of the person, using words like,
It seems you are very worried about this
Summarizing. This happens during and at the end of the
conversation. Expressing in brief and highlighting the key points of
the story the person has told you.
11. c) Asking Questions
We ask questions in order to help the person:
Explore his/her problems more fully.
Think more about his/her situation and perhaps find a way of
coping with their problems.
Explain what she already knows or understands about a situation
i.e. facts about HIV/ cancer
See that we are trying to understand them and the problem they
are facing.
Prioritize problems and thus help to focus the session.
Move at their pace and enable dialogue between the counselor
and the person seeking help.
12. How do we ask questions?
There are two kinds of questions:
I. Closed questions: These questions usually receive no more than a ‘Yes’ or
“No” answer and are generally very specific e.g. Are you married? ’No’:
‘Do you have pain” “Yes’.
II. Open ended questions: These are questions which invite a person to talk
and explain. They usually begin with; What, Where, When, Row? e.g. How
did you feel when you were told your diagnosis? Open ended questions
permit the person to choose how to respond, and examine the situation
more clearly.
Points to remember when asking questions;
• It is helpful to use a mixture of open and closed ended questions. Closed
questions help to structure the session and identify facts, and open
questions help the patient to express feelings, opinions and experiences.
• Ask one question at a time, it is confusing to ask so many questions at a
go.
• Use key words from the person’s explanation to phrase another question.
• Be tactful when asking personal or sensitive questions as it can take time
to develop trust, and some questions can be asked later once trust has
built up.
• Use simple and clear language when asking questions.
13. d) Answering Questions
Points to remember when answering questions
• Behind every question, there is usually a problem, worry or concern’.
• Avoid answering “Yes” or ‘No’. It does not help the health professional to
effectively understand the client’s situation or what the patient and family
know about their illness.
• When answering the clients’ questions or discussing the clients’ concerns,
give information rather than advice or false reassurance.
• Avoid suggesting to the patient and family what to do, but put forward a
suggestion for discussion,
• Always give accurate information. Be honest, it is alright to say. ‘‘I don’t
know”.
• Answer questions using simple and clear language. Complicated medical
jargon can confuse the patient and their family.
• After giving information, check whether the person has understood the
information and ask the person what he intends to do about the situation?
• Remember people ask questions when seeking for help.
• Sometimes there is no obvious answer’ to give a question, such as ‘Why has
God done this to rue?” but listening to the patient and helping then,
explore the feelings behind this statement can be very helpful to him/her.
14. Qualities/ attitudes needed in
communication
The qualities needed in communication with patients and their families include the following:
• A desire to help - In order to communicate well with our clients we should have an inner
urge to help the patient and his/her family members.
• Patience - when patients and families come to us, they may be unsure of what to say to us.
Allow them to take their time while expressing themselves, This calls for a high degree of
patience although you may be busy.
• Honesty
• Genuineness - This involves being sincere and free from pretence with patients. Try to be
honest to patients and their family members if you are to win their trust.
• Openness
• Dependability - Information giving and communication must be accurate and clear. This will
enhance trust and future communication with the patient.
• The ability to put others at ease - this involves creating rapport with the patient.
• Respect for others and their decisions - handle each patient as an individual with respect for
their beliefs. values and attitudes. Refrain from judgment.
It is also important to have a positive attitude that is:
I. Non-judgmental
II. Accepting
III. Caring
IV. Empathy
V. Respecting
15. Summary of key points
• Effective use of communication skills and a positive attitude are part of the
therapeutic process, and often play a great part in patient well-being.
• Listening holistically, caring compassionately, and being present when
needed, may be the most meaningful gifts a professional career can give
particularly towards end of life.
Key aspects that should be targeted by communication in palliative care
• All aspects which make an individual complete, i.e. psychological, spiritual,
social, cultural and physical aspects;
• Prognosis and goals of care, as these are essential for quality care;
• Disclosure, diagnosis, prognosis, transition to palliative care and the holistic
care plan;
• A patient’s fears and concerns;
• Disease progression and end-of-life care issues, such as the use of
aggressive treatments in the end-of life stage,
• Decisions on readmission, review of medications, family rituals and the
family’s role;
• Patient and family styles and practices for coping with grief, loss and
bereavement, and the support required from care providers.
• Discussions about the future, as this is vital if patients are to be permitted
the dignity of deciding how to spend their remaining time.
16. In children
• The beliefs and values of a child patient and their family regarding
death and dying, and assistance to prepare and plan for death by
discussing expectations in order to reduce fear and encourage
involvement;
• End-of-life issues and the anticipation of the death of a child patient,
each being honestly discussed with the child and their family.
• Give the child the opportunity to say goodbye and express last
feelings and wishes.
• Bereavement counseling and support for children.
17. Principles to help care providers communicate effectively
• Communicate with sensitivity, empathy, compassion and support to the patient and family.
• Listen attentively and allow tears and emotions to be expressed without rushing the patient.
• Check for understanding, because miscommunication is common as a result of language,
culture, the environment and stress.
• Take into account the family and its ethnic, cultural and religious roots.
• Family meetings are useful for identifying and meeting the patient’s and the family’s
informational and care needs, as well as for understanding the family’s dynamics.
• Debriefing is available for caregivers who need support following the death of a patient
whom they have been caring for.
• Pay attention to the patient, family members and fellow care providers.
• Be aware of the importance of non-verbal communication such as facial expressions.
• Use clear and suitable language (i.e. that which is understood by the patient), and use an
interpreter where necessary.
• Ask appropriate questions and allow the patient and family to ask questions each time you
see them
• Ensure that the patient and family have understood what you are saying, and that you have
understood what they are saying, by asking questions, paraphrasing, summarizing etc.
• It is easy to unintentionally miscommunicate and not understand others, due to common
physical, psychological and socio-cultural barriers such as language, culture, stress,
environment etc. Care providers must identify and address any such barriers for effective
communication to happen.
18. Benefits of Effective communication:
• Identifies and aims to address all the needs of the patient, family and care
provider (i.e. psychological, spiritual, social, cultural and physical issues);
• Provides information according to the patient’s preferences (whether good
or bad news);
• Invites the patient to share their agenda in a conversation;
• Aims to communicate the truth by means of accurate essential information;
• Facilitates appropriate referrals, inter-disciplinary assessment, continuity of
care, discharge planning, end-of-life care and bereavement support, as well
as conflict resolution and stress management;
• Advises on the resources available to address holistic needs and concerns;
• Provides patients with a sense of security, consistency and comfort;
• Educates family members and care providers on how to manage pain,
distress and other symptoms in the patient and how to communicate
effectively;
• Aims to improve relationships at all levels, including those involving family
members, care providers and the community;
• Documents as appropriate the main discussions with the patient, family and
other care providers;
• Ensures a good flow of information within and between organisations
involved in service delivery;
19. Benefits of Effective communication:
• Family members often recall in detail the sensitivity (or lack of it) of
the doctor and staff as their relative was dying. These memories
affect the grieving process: how the family was told about what was
being done, how they were informed of the changes in the medical
situation, and especially how attentive the doctor and staff were in
controlling the patient’s distress and physical symptoms.
• Effective communication fosters a very strong relationship between
the caregiver and the patient as well as family members.
• Truthful communication about the future is also vital if patients are
to be permitted the dignity of deciding how to spend their
remaining time.
• Good communication maintains effective professional relationships,
which fosters a high standard of care
• Communication is seen as a therapy, which is used to help the
patient to either cope with or solve the problem.
20. Possible consequences of ineffective communication in
palliative care
• Not communicating accurate essential information to patients may
provoke greater problems.
• Protecting patients from the reality of their situation often creates
further problems and can lead to inconsistent messages being given
by other members of the inter-disciplinary team.
• Hiding the truth often leads to conspiracies of silence that usually
build up to a heightened state of fear, anxiety and confusion, rather
than provide one of calmness.
• Poor communication is a threat to patient care and can lead both to
mistrust and to a source of staff stress.
• Communicating effectively is essential for engaging the patient and
their family in their care.
• Not communicating about the nature and seriousness of an illness
can lead to a lack of planning for the future – e.g. not writing a will,
not planning who will take care of the children.
21. Special considerations in HIV and AIDS
• A diagnosis of HIV presents the affected individual with the prospect of a life-
threatening illness along with the stigma associated with the disease.
• There are strong emotions associated with HIV and AIDS which increase anxiety
and therefore impact on effective communication – e.g. the fear of rejection by
others, the fear of infecting others, anger and a sense of betrayal, a sense of shame
for having contracted the disease, worry about how to cope, worry about the
family.
• Disclosure of their status is an important topic to explore with patients – they may
be trying to maintain a position of respect with their children, or be afraid of being
abandoned if the family finds out their status.
• Adherence to the specified drug regimen is key to the success of ART, and good
provider–patient communication is key to adherence.
Communication issues that are key to successful adherence include:
Proper education and counseling before initiation of ART
Information on HIV and its manifestations, benefits and side effects
Involvement of peer support in the patient’s treatment
Psychosocial support to minimize stigma
Culturally appropriate adherence programs.
Support groups across the African region have proved to be successful in providing
emotional and peer support, and in helping individuals to cope with HIV and AIDS.
22. Barriers to communication
• Impairments e.g. some illnesses may affect the hearing or
vocal capacity of patients.
• Limited knowledge especially by the service provider.
• Extreme pain on the side of the patient may affect
communication.
• Conspiracy of silence - some careers may choose not to
disclose information to the patient or vice versa.
23. Communication in children palliative care
• The life of the very young child is centered in the family and in the people
who care for him or her. His/her development depends on the attention
and care they are given.
• Through talking and playing with, and watching others, and taking part in
household life he/she develops physically and emotionally. As he or she
grows, so does their understanding of language and capacity to express
thoughts and feelings.
• In most societies children soon have a network of relationships with people
of different ages, both adults and children. Besides the immediate family
they learn to communicate with the extended family, friends, and
neighbors.
• They need these rich social opportunities as well as the care and guidance
of intimate adults to develop emotionally and intellectually. Often adults
make the mistake of thinking that children under the age of seven or eight
arc too young to notice what are going on.
• Disclosure is a particular challenge with children and adolescents, with their
care givers often not wanting them to know their diagnosis.
• Adherence in children, particularly if they are not aware of their illness, can
be a challenge.
24. Good communication skills while dealing with children
• Good listening skills
• Showing interest in the child
• Age related communication
• A non-judgmental attitude
• Empathy
• Maintaining confidentiality
• Being open and honest with the child
• Respect the child and families culture and beliefs
• Being patient with the child and allowing them time to express
themselves.
25. Principles of answering difficult questions in children
• Where possible, communication with children needs to be with people they
trust, people who love them and give them a sense of security. Therefore it
is important that you build a relationship with the child so that they trust
you.
• Treat each child as an individual. Start by assessing what they already know
and understand. Use games, stories, writing etc as appropriate.
• Always answer a question with a question until you know what exactly is
being asked.
• You can use the "WPC Chunk" technique (Warn, Pause, Check, Chunk):
Warn the child that you want to say something that he might find difficult
Pause: wait until he gives you a sign that it is OK to continue. If you get the
OK, break a small "chunk" of the news to him
Check: after you have broken the chunk of news, check back that he has
understood and whether he wants to continue
Repeat the process, one chunk at a time, until he signals he has had enough
or until all the bad news has been broken
Although it can be hard to answer some of the difficult questions that
children ask, children can tell when you are avoiding answering them, and it
is also important never to lie to a child.
