Lecture 3 - Communication

 • Keeping then normality of life as long as possible

 • Living it with loved ones

 • Not to be a burden

 • Not just being a patient

 • Not to be in pain

ONLY 16 %

possible reasons:

-          Time of the study: it wasn’t really normal for physicans to communicate those issues proberly

-          There wasn’t really that much palliative care teams

-          Insufficient communication with physicians

-          But even if the communication is there  (and good), it can be not enough (patients sometimes need more repetition and time to process / digest the issues, often denial from the patient)

• protects clients and their right to make decisions for themselves

• —> shared sdecision maing (non hierachical discussion between hysician and patient, not from above)

• also protects staff

• not only happens in hospitals, also in nursing homes (talk about their wishes, do they want to die in the facility etc)

• determines care according to the families wishes

• assists in clinical decisions during care

• DNR orders and advance directives

• QoL

• prevent hospitalization

• increase use of hospice and palliative care

1. interview with patient ( one big interview & ongoing conversations / reassurance if you got it right)

2. documentation

• guidelines for conversations regarding goals of care

• reframe

• emotions

• map

• align

• propose a plan

-          Start with asking

-           How do you understand? What do you think?

-          How do you see the situation

-          Important for the introduction of the change in treatment

-          Prepare for emotions

-          Be empathic

Not all questions need answers:  Am I going to die? Why me? Is it fair? “Im so sorry for that” important “im sorry that we meet under that circumstances, I would be so pleased if I could do more for you”

• accept emotions , any feelings, any thoughts

• no judgemental attitude

• express understanding

• reflect what has been said

•   Paraphrasing, Mirroring, Working with silences, Open questions

• explore the mindset/ how do you feel about xyz)

o   NEVER say:

•  „It will get better.

• „Do not cry.“

• „I know how you feel.“ (better: I can imagine … never the same situation)

•    „Do not tell me that you want to die.“ à people in palliative care may either be “ready” to die/ have a good reason bc theyre suffering or they want to talk about it

•  Better: „I see that you are upset, what can I do for you?“

—> NURSE (Name, Understand, Respect, Support – we are here for you/ we will help you with dealing-, Explore

• map priorities!

-          What is important to you now? And what else? What are you worried about? What can we do next time to avoid a repeat of the situation?

-          Be open to desires of patient

-          Summarize up what we have learned and linking it to desired care options

-          Advantages and risks are discussed here

-          You don’t have to discuss everything here, once they priorize their needs (e.g. go home) you don’t have to discuss possibilities in the hospital etc.

• formulating a plan or recommendation for next steps

• explore what is possible for the next steps

if youre mom would be sitting here, what would she want?

- How was your mom? What would be important to her? —> Helps remembering the members whats important for the beloved one

-          When is a good time?

• Hospitalization,

• return from hospital

• Deterioration of heaalth

• Death of another client

• Visiting family • Adaptation process

– when there is a change in the condition in the patient (if you can predict the disease e.g. cancer it gets worse with time) —> adeteration (VErschlimmerung/abbau), sudden hospilitasation, situation gets worse… nursing home: death of another client is an opener for other clients (preparing for future, frame it this way, just check in with the priorities- magic phrase “now everything is fine, we justwant to check the priorities)

• Relationship and trust are important

• Competence must be guarded

• Training is important

• Do not underestimate preparation!!

• Special type of professional interview

• Keep the structure REMAP

• Set a clear goal in advance

• Can be conducted repeatedly

• Keep a record of the results and pass the information on to the rest of the team

possible participants: patient, family carers/friends, members of the team

• Good communication skills

• Do not favor anyone

• Preparation is important

• Good start • Tell at the beginning how much time we have

• Role of the facilitator - sticks to the topic, clarifies ideas, prevents conflicts and misunderstandings, keeps track of time, involves all participants, checks understanding, consensus and summarizes at the en

-          Family meeting: Mostly held by nurses/social workers (not all about medical/professional/„hard“ questions)

1) comfort care booklet (information about problems and solutions treating people with dementia, benefits of treatment, risks, can help family care givers to decide if it makes sense to participate), booklet was sent to the families one week before family meeting

follow up questions to the booklet, guidance for families what to ask (questions that might be important for them / common, expl.: Can you tell me how much time beloved one has left? Can you tell me what term supportive care means?)

2) Training of nursing staff o delivering the FCDS intervention (teaches the REMAP structure and difficult topics – how to communicate death, how to frame/ discuss it)

3) Delivery of family care conference in a nursing home (the staff itself lead the intervention, not „professionals“ from outside the

 home)

o   Increase in satisfaction with care (measured by family carers)

o   Decrease in uncertainty of carers (booklet etc helped families to know more about the situation and to discuss it; more information eases the process of decision-making for the patient later)

o   Barriers on the part of staff (afraid that they are not competent enough for intervention/Talks, not enough education/Training for those conversations, time availability, extra time, extra hours)

o   Barriers on the part of family members (denial of the problem, fear of the topic, family conflict – especially if there is tension/different opinions between the children/family members, low motivation)

o   Logistical barriers (convenient time for family conferences, lack of time)

• Future care planning is a vague concept

• Care planning is not given sufficient importance (even for eldery people, they dont feel like they need it now, dont feel “too sick”)

• Importance of family (often seniors want to leave the decision making to their families, “they will know”)

• Medical language (patients need easier language to decide difficult things!

• The right approach

• Credibility of staff

• Understandable language

• Listen

• Space to prepare

• Be honest about care options

• Talking about goals of care can scare patients, it's good to explain why we want to talk to them about it

• Talk about current and future care (variability in health status) • Choose clear language

• Talk to patients sensitively but honestly

• Map family ties early and involve the family, anticipating that some older people want to leave decision-making to them