Communicating Difficult News
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- Margery Mills
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1 The Education in Palliative and End-of-life Care program at Northwestern University Feinberg School of Medicine, created with the support of the American Medical Association and the Robert Wood Johnson Foundation Communicating Difficult News Presented by Hope Hospice, part of the HopeHealth family of services. Kristin Keefe Clarkin, MD Ellen McCabe RN, CHPN Disclosure This presentation is provided for educational purposes only There is no financial disclosure or commercial interests to be disclosed by educators 1
2 Objectives Understand importance of clear and compassionate communication when speaking with seriously ill patients Understand the 6-step protocol for delivering difficult news Importance Most people want to know honest news more than they want to hear good news Strengthens clinician-patient relationship Fosters collaboration Permits patients, families to plan, cope and maintain hope 2
3 Importance 60% of people say that making sure their family is not burdened by tough decisions is extremely important 56% have not communicated their end-of-life wishes One conversation can make all the difference. Source: Survey of Californians by the California HealthCare Foundation (2012) Our Relationships to Hope Exploring the Potential/Impending Loss Need for accurate information offered in a sensitive fashion & sometimes repeated with patience. Objective presentation of care options Understanding of the benefits and burdens related to the care options 3
4 6-step protocol Getting started 2. What does the patient know? 3. How much does the patient want to know? Adapted from Robert Buckman... 6-step protocol 4. Sharing the information 5. Responding to patient, family feelings 6. Planning and follow-up Adapted from Robert Buckman 4
5 Step 1: Getting started... Create a conducive environment Plan what you will say confirm medical facts don t delegate... Step 1: Getting started Allot adequate time prevent interruptions Determine who else the patient would like present Determine what team members will be present 5
6 Step 2: What does the patient know? Establish what the patient knows Assess ability to comprehend new bad news Reschedule if unprepared Step 3: How much does the patient want to know?... Recognize, support various patient preferences decline voluntarily to receive information designate someone to communicate on his or her behalf 6
7 ... Step 3: How much does the patient want to know? People handle information differently race, ethnicity, culture, religion, socioeconomic status age and developmental level Step 4 : Share the Information Pay close attention to body language Give pt/family opportunity to process information Be prepared for responses that may vary from family to family 7
8 When family says don t tell... Legal obligation to obtain informed consent from the patient Promote congenial family alliance Honesty and transparency promotes trust When family asks don t tell part 1 8
9 Video clip Part 2... Step 5: Responding to feelings Listen quietly, attentively Encourage descriptions of feelings Use nonverbal communication Don t take reactions personally 9
10 Step 6: Planning, follow-up... Plan for the next steps additional information, tests treat symptoms, referrals as needed Discuss potential sources of support... Step 6: Planning, follow-up Give contact information, set next appointment Before leaving, assess: safety of the patient supports at home Repeat news at future visits 10
11 When language is a barrier... Use a skilled interpreter familiar with medical terminology comfortable translating bad news Consider telephone translation services... When language is a barrier Avoid family as primary interpreter confuses role of family members may not know how to translate medical concepts may modify news to protect patient may supplement the translation Speak directly to the patient 11
12 Communicating prognosis Some patients want to plan Others are seeking reassurance Communicating prognosis Inquire about reasons for asking What are you expecting to happen? How specific do you want me to be? What experiences have you had with: others with same illness? others who have died? 12
13 Communicating prognosis Patients vary planners want more details those seeking reassurance want less Avoid precise answers use ranges: hours to days months to years average Communicating prognosis Limits of prediction hope for the best, plan for the worst better sense over time can t predict surprises Reassure availability, whatever happens 13
14 Caregiver communication Maintain common chart or log book goals for care treatment choices what to do in an emergency things to do / not to do contact information An excellent resource for pt s and families Summary Most people want to have honest communication about their condition, whether it is good news or bad news 6 step approach helps clinicians and patients in providing information and planning next steps When language is a barrier, use a skilled translator 14
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