This document discusses communication strategies in palliative care, including dealing with ambivalence, resistance, and breaking bad news. It presents case studies and evaluates how motivational interviewing techniques can help address common challenges in palliative care consultations, such as discussing prognosis, treatment goals, and end-of-life decisions with patients who may have conflicting values or perceptions. While motivational interviewing is generally well-suited to palliative care discussions, not all its techniques directly apply, as palliative care aims to help patients make values-consistent choices rather than guide them to particular decisions. Ambivalence is common in palliative care, and communication is important for ethical practice.

1. Palliative care
motivational style?
Manuel Campíñez &
Jesús Novo
Family physicians

2. Some communication needs in
palliative and end of life care

3. Six functions of patient/family-clinician
communication in cancer settings
Fostering healing relationships
Exchanging information
Responding to emotions
Managing uncertainty
Making decisions
Enabling patient self-management

4. Changing the goals of care
Share information
Talking about prognosis
Talking about death and dying
Withholding and withdrawing life-supporting
medical treatments
Do no attempt resuscitation decisions
Stopping palliative chemotherapy
Dealing with inappropriate treatment requests

5. Dealing with
information needs
denial
disappointment (treatment unsuccessful)
loss of hope
despair (when life´s not worth living)
anger
communication problems within families

6. Vídeo de ambivalencia
en la toma de morfina

7. Doctor, do not
tell my husband
that is cancer
Breaking collusion
Acknowledge the collusion
and then explore and validate the reasons for it.
Establish the emotional cost of the collusion.
Ask permission to check what the patient knows
Seek the patient permission to convey his/her
awareness to their relatives
Maguire and Faulkner 1988

8. SPIKES protocol for breaking bad news
Setting up the interview: privacy, make connection,…
Assess patient’s Perception: ‘‘what have you been told
about your medical situation so far?’’
Obtain the patient’s Invitation: ask how patient wants to
get information
Give Knowledge and information to the patient
Address patient’s Emotions with empathetic responses
Strategy and Summary
Bayle et al 2000

9. An exercise…
with a palliative care situation

10. Small groups 5-7
Few minutes 5-7
Make a summary

11. Summary
CASE 1
68 year-old man, hospitalized for locally extended bladder
cancer. It has been rejected in the cancer evaluation
committee to follow on chemotherapy and the patient
was informed in this regard. Urologists requested transfer
to palliative care. When the palliative care specialist meets
the patient´s wife, out of the room, she tells him that the
patient knows the diagnosis and has also been informed of
the decision to stop chemotherapy , but she doesn't want
him to be moved to the palliative care unit because "that
means you are hopeless ."

12. Summary
CASE 2
48 year-old physician diagnosed with lung carcinoma
2 years ago. He has been treated with several lines of
chemotherapy with partial and no durable responses,
and at present is suffering from severe renal
toxicity that compels to stop that treatment. He has
been bedridden for several months and is
dependent for most activities of daily living. He is
hardly able to control the pain and that requires
high doses of opioids. He hopes to continue with
another line of chemotherapy because "you never
know".

13. Summary
CASE 3
57 year-old patient diagnosed with amyotrophic lateral
sclerosis, carrier of invasive home mechanical ventilation and
gastrostomy tube feeding for 2 years. He always said that he
wanted to go ahead as long as he maintains his ability to
communicate and relate in some way with the environment.
He only preserves ocular motility and very some weak
movement in one arm, so that he communicates very poorly,
and he does so with an adapted computer. His wife tells us
that on numerous occasions, "when his arm responds "
he has removed the vent pipe. He says "he wants to end ",
to "withdraw this torture" and that "life does not make sense".
However talks about plans for the future, is writing a book,
has the upcoming wedding of a nephew who would like to
attend and says that "his biggest problem is that his wife does
not understand his suffering“.

14. Summary
CASE 4
Antonio, 93, no cognitive impairment, very advanced
heart failure with severe dyspnea so from the last
hospital admission needs help for any activity. He
insists that he wants to die, that his life is lived, that
he does not wants to live if he is dependent on others
for everything and he does not want to return to
hospital. His family agrees and you assure him that
you will respect his wishes. Some days after he starts
to notice a pain in epigastrium and he asks if you
cannot do something to find the cause.

15. Summary
CASE 5
53 year-old woman suffering from breast cancer with bone
metastases treated with palliative radiotherapy and
chemotherapy. She suffers from important physical
deterioration so spends most of the day in bed with pain,
treated with high-dose of opioids. She knows her diagnosis
and says that the end is near. She clearly does not want to
have pain even if it means taking high doses "I know that I'll
be sleeping all day but I don't care: I have arranged all my
affairs." Three days later she calls because she has a lot of
pain and she couldn't sleep all night; when you ask her, she
confesses that she's taken fewer doses of painkillers
because “I have slept all day and things cannot be that
way”.

16. As the field of palliative care has matured,
communication strategies have developed to guide
common tasks…
These strategies do not directly address resistance or
ambivalence— two common situations in palliative
care consultations.

17. The MI philosophy and principles fit easily into palliative
care.
Most of palliative care involves discussing patients’
values and priorities.

18. Not all the MI techniques are applicable, however, in
part because palliative care clinicians do not guide
patients to make particular choices but, instead, help
patients make choices that are consistent with
patient values

19. The illusion of choice
• Information about prognosis is not accurate
• Choice is determined by system characteristics
and clinicians point of view
• Many patients find other values more
important than autonomy
• Patient express conflicting values
• Decisions are a process with cognitive,
emotional and moral components

20. Ambivalence is very common
in palliative care.

21. MI fits very well in palliative
care communication

22. Communication is the brush
bioethics are painted with

23. Is it always necessary to use MI
in equipoise in palliative care?