Communication

1. 18-Nov-11 RCH 1 Communication Peter Martin Director of Palliative Care, Barwon Health Clinical Associate Professor, Melbourne Uni Senior Lecturer, Flinders Uni Why I got interested, my background, moving from undergrads to postgrads. Challenges of particular contexts, much work looking at what health profs can do. More work about empowering pts & carers / family.Why I got interested, my background, moving from undergrads to postgrads. Challenges of particular contexts, much work looking at what health profs can do. More work about empowering pts & carers / family.

2. 18-Nov-11 RCH 2 Scope Prevalence & impact of sub-optimal communication Communication principles that underpin good practice Goals of care The role of the family meeting Individual & Institutional Initiatives to improve communication This will be deficient as at best will only cover two components of this, evidence base of impact, demonstration examples but no experience; also some debate about communication and interpersonal skills being separate and requiring different assessment and trainingThis will be deficient as at best will only cover two components of this, evidence base of impact, demonstration examples but no experience; also some debate about communication and interpersonal skills being separate and requiring different assessment and training

3. �The occasion when, in the intimacy of the consulting room, a patient who is ill, or who believes himself to be ill, seeks the advice of a doctor whom he trusts. This is a consultation and all else in the practice of medicine derives from it.� Sir James Spence Founder of �Social Paediatrics�

4. 18-Nov-11 RCH 4 Sydney Morning Herald Friday Dec 1st �Doctors and nurses are unwilling or unable to talk to pts about their fears and anxieties� lack of emotional support Communication failure was the biggest concern in report of states health systemSydney Morning Herald Friday Dec 1st �Doctors and nurses are unwilling or unable to talk to pts about their fears and anxieties� lack of emotional support Communication failure was the biggest concern in report of states health system

5. 18-Nov-11 RCH 5 Impact of Poor Communication Diminishment of patient autonomy Less accurate diagnosis More complex psychological adjustment ? anxiety, distress, depression More stress at work for health professionals Higher risk of burnout Less job satisfaction for health professionals Less compliance to treatment; more doctor shopping Less than 50% of issues may be elicited Less than half of psychological morbidity is recognised Decreased patient satisfaction More litigation

6. 18-Nov-11 RCH 6 Communication Myths Training does not help You must have training when �young� No evidence about importance of communication skills Technical and knowledge skills are more important for patient satisfaction It wastes clinician time Talking is not seen as work; important to look busy with tasks; this is mostly from nursing literature �I will open up a can of worms that I cannot fix� An issue for medicine and nursing particularly Discussing difficult issues will increase distress of patient and family

7. 18-Nov-11 RCH 7 Basics of Good Practice Tailoring information to pts style Eliciting the emotional, social & spiritual impact to pt & family of the problem (s) Determining how much pt wants to participate in decision making Internal summary; periodically summarise Checking their understanding Allows patient to correct and misunderstandings Open ended versus closed questions One study the ration was 1:5.8 Safety netting: Explain what will happen if plan not working of if things do not improve

8. 18-Nov-11 RCH 8 Basics of Good Practice-2 Being overt about implications of treatment decisions Using verbal & non-verbal skills; show empathy Active listening and eye contact Feedback your intuitions about how they are feeling �I am sensing that you are angry, can you tell me about that?� Multiple modalities of information Written as well as verbal, web sites, tapes

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12. 18-Nov-11 RCH 12 You little �PEARLER� All in the context of how to respond to emotion instead of redirecting or pursuing clinical detail PEARLS Partnership Empathy Apology Respect Legitimisation Support For fear of Sounding like Steve IrwinFor fear of Sounding like Steve Irwin

13. 18-Nov-11 RCH 13 Common Mistakes Using Terms such as �do everything� or �do nothing� Contrast as one seen as positive and the other negative Could be reframed as benefits vs...... risks for different approaches �do nothing� implies what will be taken away in contrast to what will be gained. Using euphemisms for death or dying Inferring poor prognosis through unnecessary complex physiological parameters / detail Interrupting the patient as they are about to ask something Shown that interrupting means consultation takes longer Average time before a doctor interrupts is 18 seconds whereas if they talk uninterrupted for 4 mins they will tell you 90% of their concernsAverage time before a doctor interrupts is 18 seconds whereas if they talk uninterrupted for 4 mins they will tell you 90% of their concerns

14. 18-Nov-11 RCH 14 What is the average time before a Doctor interrupts a pt / family? A)10-20 secs B)20-60secs 1-3 mins >3 mins Average time before a doctor interrupts is 18 seconds whereas if they talk uninterrupted for 4 mins they will tell you 90% of their concernsAverage time before a doctor interrupts is 18 seconds whereas if they talk uninterrupted for 4 mins they will tell you 90% of their concerns

15. 18-Nov-11 RCH 15 Other common errors Not listening to families� concerns / opinions Underestimate prevalence of limited literacy Tolerate silences & pauses Make recommendations Families may feel they have �pulled the plug� Guilt, bereavement issues In US 40-45 million people are at lowest level of literacy, i.e. gd 5In US 40-45 million people are at lowest level of literacy, i.e. gd 5

16. 18-Nov-11 RCH 16 Blocking Behaviours by HP Offering advice and reassurance before issues identified Not addressing distress as �it is normal� Families may feel that H Profs don�t care they are upset Changing the topic

18. Calgary-Cambridge guide Broad agendas Structure the consultation Build Rapport Specifics Initiate the session Gather Information Examination Explanation & Plan Close

19. Initiating the session Introduce yourself in context Explain what a Registrar is? Ensure they are comfortable If �others� present ask them to introduce themselves and their relationship to the patient: Never guess!! They may give you cues Set out broad agenda and time limits up front Change environment as needed Sit down when at all possible

20. Gather Information Check! Their understanding of illness Remember the average illness narrative is 4 minutes and gets you 90% of patient concerns Priorities Remember and acknowledge cues during and at end Patient�s agenda Clarify never guess Style of information giving Modes Verbal, written, audio, video, web

21. Mismatched Agendas If serious mismatch rarely should you push on Consent for disease modifying treatment vs patient / carer focus on CAMs Chemo vs Apricot Kernels Explore hopes and fears Personal goals Previous experiences �my mum had terrible nausea and vomiting� Align goals when possible Explore what can be concurrent vs sequential Share your thoughts without alienating patient

22. Basics of giving information Exclude, limit and or explain jargon Small sections of information Then check their understanding Then you summarise and allow them to correct The health professional should own the misinterpretation �Sorry I didn�t explain that well� Validate and acknowledge emotions NAME IT!!!!!!! Explore impact beyond the bio-medical If �bad news� check how much they want to hear Topic for later Lack of organic disease dx in 50% of people with chest pain, fatigue, abdominal pain and headache at 6 months�Lack of organic disease dx in 50% of people with chest pain, fatigue, abdominal pain and headache at 6 months�

23. Signposting Check when moving between sections �Now we have discussed your headaches in detail can we talk about you�re the �funny turn�?� Summarise each section as well Also can allow you to say �can we come back to that later when we talk about your X?� We might need to spend more time about that when we meet next; is that OK?�

24. Balance of amount and type of information Differential Diagnosis Aetiology Prognosis Treatment / management All aspects Lifestyle etc Patient empowerment important

25. Aiding recall Deliver in small chunks Summarising (Patient and Doctor) Concise Language Uses graphics and or other explanation when needed

26. Shared decision making I suggest this; how do you feel about that? �What are your preferences?� Be open to negotiating Choices balanced with recommendations Check if plan OK with them Safety netting Explain unwanted or unexpected outcomes as well How to get help if worried Final concise summary

27. Explanatory Frameworks Check with patient about what they think the problem is due to: I think I am depressed This is how my brothers brain tumour started off I don�t think it is anything to worry about as I feel well (painless jaundice) �were you worried it may be something serious?� �what do you think may have caused this� Then integration of the �disease� and how it is effecting the patient-�illness�

28. Doctor and Patient The Personal Aspect Ask permission �can I ask� As well as social / family issues �what is important to you?� �what are your hobbies, interests or passions?� Explain why �If I understand more about your life it can help inform decisions that we need to make together� Explore: �Fishing�, intuition that something else Normalise for the population Often people with this illness are worried that this will impact on: Relationship, finances, work, body image, hobbies etc

29. Something to broaden our thoughts? ELPD

30. Death! �Death should simply become A discreet but dignified exit Of a peaceful person From a helpful society Without pain & suffering And ultimately without fear� (Philippe Ari�s)

31. Triggers for palliative care referral Pain control is the most common trigger for referral1 despite palliative care services being much broader Introducing palliative care as part of team early may aid in adjustment1,2 1. Weissman, Griffie, 1994; 2. Baile et al, 1999

32. Early referral to palliative care Compared with usual care, patients and kin who received a series of staged discussions about treatment goals and palliative care options ceased futile active treatment earlier with no decrease in survival time1 1. Lilley et al, 2000

33. Prognostic Information People with advanced cancer tend to be overly optimistic about their prognosis1 One study of seriously ill people showed only 20% of clinician/patient pairs agreed that doctor had communicated that illness was incurable2 Another study showed that 63% of doctors either would not provide a survival estimate or give one which was different from their private view, usually overly optimistic3 1. Sapir et al, 2000, 2. Fried et al, 2003, 3. Lamont & Christakis, 2001

34. Treatment Information Overly optimistic perception of prognosis lead to requests for futile treatment1 Information provision about prognosis and palliative treatment options is not linked to increased anxiety2 90% of palliative patients wanted to know chances of a cure and all treatment options3 1. Weeks et al, 1998, 2. Tattersall et al, 2002, 3. Fallowfield et al, 2002

35. Introducing palliative care services In a survey of people with metastatic cancer1 When were discussions of palliative care wanted? - when first told cancer had spread(33%) - in next few consultations (19%) - later, at their request (33%) - never (11%) - unsure (10%) 1. Haggerty et al, 2004

36. 18-Nov-11 RCH 36 Hope versus Reality: Getting the balance right. Time to adjust to Diagnosis & Prognosis; however sometimes the pace is set by other circumstances Be aware if short time frame this may add to complexity Acknowledging this will add to feeling of empathy Need to give hope without colluding to avoid discussing difficult issues Redirecting hope to comfort, dignity & meaning if required Demoralisation as a concept Broaden the diversity of things to hope for.

37. Hope Fostering false hope of a cure may hinder sensible treatment and lifestyle decisions1 Limiting prognostic information may be hope reducing2 Patients with metastatic disease want messages of hope as well as clear and honest prognostic information3 1. The et al, 2000, 2. Sardell & Trierweiler, 1993, 3. Butow et al, 2003

38. Establishing Hope Availability of up to date treatments to slow down cancer or relieve symptoms1 Emphasis on positive, achievable treatment outcomes2 Reassurance that the person will not be abandoned1 Willingness to call in other doctors 1 1. Sardell & Trierweiler, 1993, 2. Butow et al, 2003

39. Establishing Hope Discussion of extraordinary survivors 1 Discussion of the meaning of person�s life and realistic future goals 1 Normalising death and encouraging preparation for this possibility 1 1. Butow et al, 2003

40. 1. Diagnosis of advanced incurable disease and treatment with palliative intent Explain symptom control and anti-cancer treatment can be given simultaneous Work from assumption: �There is never a time when nothing can be done� Provide realistic reassurance and hopes for the future

41. 3. Referring to palliative services Use the term �palliative care� explicitly Correct patient misperceptions of the term Provide information about palliative care relevant to their situation Positively promote the holistic nature Refer to palliative care services as part of the multidisciplinary team State that you will not abandon the patient Follow steps for �Treatment with palliative intent� or �End of anti-cancer treatment�Follow steps for �Treatment with palliative intent� or �End of anti-cancer treatment�

44. Doctor and Patient Anxiety

45. Doctor and Patient Distress

46. Doctor and Patient Anger

47. Doctor and Patient Depression

48. 18-Nov-11 RCH 48 Goals of Care May not be explicit in an acute medical setting Usually a diagnostic or problem orientated approach Aged care, Rehabilitation & Pall Care often goal orientated Patients & families may not have considered what the goal is / or should be Discussions around goal of care may be pivotal and symbolic for pt / family Worth investing time to �get right� first time If handled badly may escalate tensions between family and treating team

49. 18-Nov-11 RCH 49 Methods to assist resolution Family meeting / case conference; later! Spending sufficient time Using other professional disciplines Help families reflect on �what would the patient want�

50. 18-Nov-11 RCH 50 Reflect on �what would the patient want� Some helpful questions may include: Asking each member of family: �Tell me what sort or person is X?� �What are their interests, hobbies or passions?� �Did they ever state their views on being in this situation; possibly after a news item or TV program?� Maybe they had friend or relative in this situation �How much did they value they value their independence?� If they could speak now and knew there was little hope of independent living and recovery; what would they want us to do regarding their treatment?� �What spiritual beliefs were important to them; how would that influence their decisions?�

51. 18-Nov-11 RCH 51 Resolution - 2 Though an attempt to achieve complete consensus is desirable it is not always achievable Often agreement between treating team and next of kin May not be agreement between next of kin and siblings, children Increasingly seen with spouse of 2nd marriage and children to 1st marriage Estranged children Social work may help resolve this and many have interest / additional training in family therapy Notion of the minority / disenfranchised �being heard� by team is important even if outcome remains the same

52. 18-Nov-11 RCH 52 Resolution - 3 Being open to review patient progress over time This can be difficult when occupying an acute bed Encouraging another treating unit to review the patient if helps family move towards goal Important that the family sees the other team as being neutral; rarely this may mean from another �agency� If there is no progress towards resolution being open to involving the public advocate in non-confrontational way; not as threat The knowledge that you offer neutral process may resolve issue

53. 18-Nov-11 RCH 53 Family issues Sensitive to clinician anger / frustration Being defensive will add to families concerns Either about current team or previous treating unit �Being heard� is vital Good level of evidence Many family members may have only got medical information 2nd hand or in piecemeal fashion, worth going over from start and emphasising pivotal points while family present Acknowledgement of emotional, social and financial impact on them

54. 18-Nov-11 RCH 54 Patient & Family Perceptions That in a setting such as ICU where end-of-life decisions are common Families rate communication skills as one of the most important skills most rate it as more important than clinical skills

55. 18-Nov-11 RCH 55 Family Conferences Many treatment decisions are made with families Awareness of explicit hierarchy of decision making Although legal next of kin retains responsibility consensus among family should be initial goal Communication occurs in many settings but the �family meeting� is often a focus for decisions Evidence that in over half family still did not understand diagnosis, prognosis or treatment In 75% drs missed cues from family about concerns That in same cohort drs thought they had done a �good job�

56. 18-Nov-11 RCH 56 Family Conferences-2 Role of nurses Majority of communication concerns raised by family could / should (?) be addressed by nurses Data is that nurses are no better at end-of-life (EOL) discussions than doctors Nurses rank these discussions as both some of the most rewarding and frustrating parts of their jobs Large variation in role nurses have in family meetings Some qualitative data to suggest nurses help prompt patient questions at family meeting Nurses also initiate / identify need for family meeting Also facilitate organising and coordinating it Afterwards may consolidate, clarify and reinforce information

57. 18-Nov-11 RCH 57 Family Conferences-3-Preperation �Clinicians should approach the family meeting with the same care & planning that they give to other (ICU)procedures� Encourage families to list key questions before meeting Private venue free of pages & phones (family as well!) Review the medical information Ensure that treatment consensus is reached within the treating team(s) prior to meeting May need separate case conference Brief each other about known dynamics within family Determine which disciplines should be present Clarify who has what role, some may be there to support family members specifically Identify who will chair the meeting Reflect on your own emotions to pt & family

58. 18-Nov-11 RCH 58 An outlined agenda Introductions in context Normalise the meeting Set goals of meeting up front Ascertain what family knows Review �progress� of pt to date Avoid too much medical detail Use �checking� at key points to confirm understanding Repeat your understanding of their concerns Ask them to summarise what you have told them Be open about prognosis Avoid emotive language Acknowledge uncertainty Use the principle of substituted judgement: �What would your �X� want?� Facilitate discussion from family members Include hope Consider redirecting hope to concepts such as dignity & comfort Highlight alternative such as symptom relief Acknowledge their emotions Summarise agreed treatment plan at conclusion Ask if they have any questions at the end

59. 18-Nov-11 RCH 59 Individual Initiatives by H Prof Insight Commitment to on-going development Programs Literature Feedback & reflective practice Clinical Supervision Well established in Psychiatry / Psychology Why not in ICU, Pall Care etc?

60. 18-Nov-11 RCH 60 Initiatives by Patient / Family RCT of a question prompt sheet, endorsed or not by the medical oncologist Consultations where patients received a question prompt sheet and it was endorsed by the doctor were significantly shorter! (p=0.02) (about a 7 minute difference) Brown, Butow & Tattersall, BJC. 2001

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68. 18-Nov-11 RCH 68 Prompt Sheet Hyperlinks http://www.mja.com.au/public/issues/186_12_180607/cla11246_fm.pdf http://www.psych.usyd.edu.au/mpru/communication_tools.html

69. 18-Nov-11 RCH 69 Institutional Initiatives for Good Communication Pro-active instead reactive approach (i.e. compliant driven) Place of clinical audit and death review with greater emphasis on psycho-social endpoints Qualitative and quantitative data Policies that mandate / stipulate conversations with families Example of ICU protocol of family meeting occurring within set time after ventilation More advanced care planning More consensus re goals of care Less resource utilisation Discussions with family through multi-disciplinary approach Other disciplines bring diversity of approach Greater documentation of families & pts wishes

70. 18-Nov-11 RCH 70 Institutional Initiatives for Good Communication Tools have been used to facilitate process Goals of Care Assessment Tool GCAT This makes clinician document: Prognosis Whether pt or family aware of this Presence or absence of advanced care planning Family support & involvement Adequacy of pain & symptom relief Tool is triggered by change in pts course Patient / Family asks for DNR order Patient / Family asks for Palliative Care involvement New terminal diagnosis or other significant change / Dx Patient generated QOL tools facilitate more holistic discussion and lead to better pt & Dr. satisfaction

71. 18-Nov-11 RCH 71 Institutional Initiatives for Good Communication Educational Initiatives; evidence based; mostly undergrad VCCCP, the importance of actors; �it makes it real� Controlled and safe to practise Although many advanced training programs inclusive, little after the �hurdle� MRCP (FRACP?) RACP (FAChPM) mandated for advanced trainees May be senior clinicians who are most in need Professional Development Programs may be method of mandating this. Respecting Patient Choices ? Research Informational material for pts & families (www & written) Design of the wards where these discussions occur In US the managed care funds create incentives as the comm. skills of their drs comes after cost and waiting times GP training, psych. Onc etc have some component but stops when adv training stopsIn US the managed care funds create incentives as the comm. skills of their drs comes after cost and waiting times GP training, psych. Onc etc have some component but stops when adv training stops

72. 18-Nov-11 RCH 72 Team Dynamics Evidence that facilitating interaction between junior & senior medical staff led to greater discussion about goals of care Pts & families will only get the best care if we create a culture of asking open � / or difficult questions Role of internal vs. external debriefing Importance of recognising influence of personal anger / frustration by health professionals in their interaction with families Especially with families labelled �difficult� or �in denial� Countertransference in psychiatry terms Although nearly always present insight is key

73. 18-Nov-11 RCH 73 Summary Most decisions can be reached using good communication skills without conflict or unnecessary distress Family meetings appear to facilitate understanding, discussion and consensus When early conflict present it should be chaired by a senior clinician , important that senior staff are represented Senior nurses have pivotal role Allied health should be heavily involved in support of family Many families want the senior clinicians to take a degree of responsibility for decision while respecting their views Is guilt a huge factor for families?

74. 18-Nov-11 RCH 74 Bibliography& Acknowledgements �Communication in intensive care settings: The Challenge of futility disputes.� Fins et al: Crit Care Med 2001 Vol 29 No. 2 �The family conference as a focus to improve communication about end-of-life care in the intensive care unit: Opportunities for improvement� Curtis et al: Crit Care Med 2001 Vol 29 No 2 �Key communication skills and how to acquire them.� Peter Maguire, Carolyn Pitceathly: BMJ Vol 325 September 2002 �Patient-physician communication.� Maria Suarez-Almazor: Current Opinion in Rheumatology Vol 16, 91-95 Victorian Cancer Clinicians Communication Program Questions?