Advance/Anticipatory Care Planning~Communication Skills and Challenges


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Communication Skills and Challenges
Dr John Walley
Palliative Care Consultant

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Advance/Anticipatory Care Planning~Communication Skills and Challenges

  1. 1. Advance/Anticipatory Care Planning (ACP) Communication Skills and Challenges Dr John Walley Palliative Care Consultant
  2. 2. Aims <ul><li>Aimed to go alongside other training in ACP </li></ul><ul><li>To build on your previous communication skills training </li></ul><ul><li>Specifically focusing on two areas </li></ul><ul><ul><li>Timing of ACP conversations </li></ul></ul><ul><ul><li>Communication challenges </li></ul></ul>
  3. 3. ACP <ul><li>Consider the aims of ACP with this patient </li></ul><ul><ul><li>How will ACP benefit this individual or family? </li></ul></ul><ul><ul><li>Help them understand more about their illness and its likely course </li></ul></ul><ul><ul><li>Allow them to plan for the future and provide support where this is needed </li></ul></ul><ul><ul><li>Enable them to prepare their loved ones for what is ahead </li></ul></ul><ul><ul><li>Enable them to express fears or concerns </li></ul></ul><ul><ul><li>Enhance their autonomy and sense of control (which may have been threatened by their illness) </li></ul></ul>
  4. 4. ACP <ul><li>Communication skills are essential then: </li></ul><ul><ul><li>Often dealing with complex concerns, including medical, social, psychological and and spiritual ones </li></ul></ul><ul><ul><li>Addressing issues around illness and death are usually upsetting for patients to some degree </li></ul></ul><ul><ul><li>There is much to be gained for the person in front of you and it can be very satisfying for you when it goes well. </li></ul></ul>
  5. 5. ACP – when? <ul><li>When the person has been diagnosed with a life-limiting condition but is well </li></ul><ul><ul><li>Can be undertaken as part of a general health review or on discussion at a follow up visit after a diagnosis is given </li></ul></ul><ul><ul><li>May be appropriate, especially if the patient is aware that their condition may deteriorate rapidly </li></ul></ul><ul><ul><li>Can be felt to be premature by the patient or their family </li></ul></ul><ul><ul><li>Many other issues may be pressing at this time such as treatment decisions </li></ul></ul><ul><ul><ul><li>Eg A patient diagnosed with metastatic cancer deciding about palliative chemotherapy </li></ul></ul></ul>
  6. 6. ACP – when? <ul><li>When things change - disease </li></ul><ul><ul><li>Performance status or function – often the most obvious thing to the patient and their family. Naturally leads to questions about what is happening. How quickly is this happening? How urgent is it? </li></ul></ul><ul><ul><li>Deterioration in their underlying condition – for example the development of metastatic disease in cancer or renal failure in a patient with heart failure or type 2 respiratory failure in COPD </li></ul></ul><ul><ul><li>GSF triggers </li></ul></ul>
  7. 7. ACP – when? <ul><li>When things change - place </li></ul><ul><ul><li>Repeated admissions to hospital </li></ul></ul><ul><ul><li>Discharge home after a serious illness with a high chance of recurrence </li></ul></ul><ul><ul><li>Admission to a care or nursing home </li></ul></ul>
  8. 8. ACP – when? <ul><li>“surprise” question </li></ul><ul><li>Sometimes acute changes take place and force the issue </li></ul><ul><ul><li>Admission with a rapid deterioration </li></ul></ul><ul><ul><li>New diagnosis of an advanced disease </li></ul></ul>
  9. 9. ACP – when? <ul><li>Cues </li></ul><ul><ul><li>Talking about funerals and plans for the future </li></ul></ul><ul><ul><li>When they say that they know they are not going to get better </li></ul></ul><ul><ul><li>Expressing concern about how their loved ones will cope with their care or death </li></ul></ul><ul><li>When the patient asks </li></ul><ul><ul><li>Although be careful to use questions about the future as a starting point </li></ul></ul>
  10. 10. ACP – when? <ul><li>Not all patients will want to talk about ACP </li></ul><ul><ul><li>This needs to be respected </li></ul></ul><ul><li>Many will wish to leave decisions to care professional </li></ul><ul><ul><li>But may be able to provide some guide </li></ul></ul><ul><li>Some will chose to leave decisions to family members </li></ul>
  11. 11. ACP – who? <ul><li>Trusted health care professional </li></ul><ul><ul><li>GP or district nurse: although they may not feel they have sufficient knowledge or information to undertake this, but have access and time </li></ul></ul><ul><ul><li>Hospital staff: may have the knowledge, but not the time as review clinics are not set up for the length of consultation required </li></ul></ul><ul><ul><li>Specialist nurse: may have the time and the knowledge, but may be concerned about communication skills. </li></ul></ul><ul><ul><li>TEAM approach </li></ul></ul><ul><ul><ul><li>Agree what the future is likely to hold </li></ul></ul></ul><ul><ul><ul><li>Who’s the best person to ACP with the patient? </li></ul></ul></ul>
  12. 12. ACP – getting started <ul><li>Remember your basic communication skills: </li></ul><ul><li>Ensure you have time and peace and quiet </li></ul><ul><ul><li>If taken by surprise, either slow down or arrange to come back… and then do! </li></ul></ul><ul><li>Gather all the appropriate information you can </li></ul><ul><ul><li>If you don’t you may get caught out </li></ul></ul>
  13. 13. ACP – getting started <ul><li>Build rapport </li></ul><ul><ul><li>Make eye contact </li></ul></ul><ul><ul><li>Use the patient’s name </li></ul></ul><ul><ul><li>Acknowledge emotion </li></ul></ul><ul><ul><li>Try to pick up cues </li></ul></ul><ul><ul><li>Make sure they’re ready for the conversation – it’s important, but is it for today? </li></ul></ul><ul><ul><li>Are there people they wish to be there whilst the conversation is taking place </li></ul></ul>
  14. 14. ACP – getting started <ul><li>Make sure they’re ready </li></ul><ul><li>“it seems like you may have some worries or concerns for the future, do you want to talk about that today?” </li></ul><ul><li>“if we are going to talk about how things may go with your health, is there anyone you’d like to have with you whilst we chat?” </li></ul>
  15. 15. ACP – getting started <ul><li>Opening questions: </li></ul><ul><li>“Could you tell me what the most important things are to you at the moment?” </li></ul><ul><li>“Can you tell me about your illness and how you are feeling?” </li></ul><ul><li>“What worries or concerns do you have about the future?” </li></ul>
  16. 16. ACP – getting started <ul><li>Always try and find out what the person knows about their illness and what is likely to happen in the future. This enables you to assess their health understanding and will give you a starting point for subsequent discussions. If someone is unaware that their illness is likely to get worse and shorten their life, breaking this bad news may be more than enough for that conversation and ACP may be for another day. </li></ul><ul><li>“ When you were in the hospital, what did people tell you about your illness? Did they speak much about what the future may hold? What’s your feeling about how this illness may go? Do you want to know more about it? Do you want to have that conversation today?” </li></ul>
  17. 17. ACP – getting started <ul><li>On the whole people diagnosed with cancer have an expectation that it will progress – the word has associations. Patients with Heart Failure or COPD may not associate their conditions with a shortening of their lives, even if they have been very ill in hospital </li></ul><ul><li>This is not always the case, so always tread carefully and don’t make assumptions </li></ul>
  18. 18. ACP – communication style <ul><li>Active listening </li></ul><ul><ul><li>Nodding, leaning forward </li></ul></ul><ul><ul><li>Tell me more about that; how did that make you feel? </li></ul></ul><ul><li>Use of silence </li></ul><ul><li>Acknowledge emotion </li></ul><ul><ul><li>Was that hard for you? </li></ul></ul><ul><ul><li>I can see that this is difficult. Thank you for telling me. Do you feel able to talk some more? </li></ul></ul><ul><li>Pick up cues </li></ul><ul><ul><li>Reflect back – “you said this… what did you mean by that? </li></ul></ul><ul><ul><li>Open questions </li></ul></ul><ul><ul><li>Clarify </li></ul></ul><ul><ul><li>Check – “when you said that, you seemed to be upset about what was said – is that right?” </li></ul></ul>
  19. 19. ACP – out of your depth <ul><li>Patients may wish to discuss things that you know little about </li></ul><ul><ul><li>Don’t panic </li></ul></ul><ul><ul><li>Don’t pretend </li></ul></ul><ul><ul><li>Listen, clarify the issue </li></ul></ul><ul><ul><li>Ask whether you can take this information to other members of the team who may know the answer </li></ul></ul><ul><ul><li>Maintains trust </li></ul></ul><ul><ul><li>Patients don’t expect us to know everything, but they need us to listen. </li></ul></ul>
  20. 20. ACP – communication style <ul><li>Use summary to check your understanding throughout the consultation </li></ul><ul><ul><li>Allows the patient to know they’ve been heard </li></ul></ul><ul><ul><li>Allows the patient to tell you if you’ve picked them up wrong </li></ul></ul><ul><li>Check the patient wishes to continue </li></ul><ul><ul><li>Emotional or tired: </li></ul></ul><ul><ul><li>Is that enough for today? </li></ul></ul><ul><ul><li>Be willing to spread ACP over a number of conversations </li></ul></ul>
  21. 21. ACP – concluding the conversation <ul><li>Clarify future plans </li></ul><ul><li>Agree actions </li></ul><ul><li>Family </li></ul><ul><ul><li>It’s important they are aware of the plan when possible and preferably agree with it’s content </li></ul></ul><ul><ul><li>Check with the patient if its OK to talk to them – it’s the patient’s confidential information </li></ul></ul><ul><ul><li>The patient will chat with them – expect the family to ask you about the conversation </li></ul></ul><ul><ul><li>Start from the beginning – find out what they know and their expectations </li></ul></ul>
  22. 22. ACP – concluding the conversation <ul><li>Confirm the conversation is complete </li></ul><ul><li>Arrange “follow-up” </li></ul><ul><ul><li>Questions may arise after you’re gone </li></ul></ul><ul><ul><li>They may change their mind! </li></ul></ul><ul><li>Document </li></ul><ul><ul><li>Content of the discussion </li></ul></ul><ul><ul><li>Make sure the people who need to know know (GP, hospital team, out of hours service) </li></ul></ul>
  23. 23. Thank you for listening Advance/anticipatory care planning Communication Skills and Challenges