COMMUNICATION IN PALLIATIVE

CARE
 Objectives
• Describe the concepts and components of
communication in palliative care
• Describe the types of communication
• Describe the barriers to communication
• Discuss the principles of communication in pc
• Describe communication skills
• Discuss communication with children
q
• Describe the consequences of ineffective
communication - PC
p
• Discuss some special consideration in HIV and
AIDS
 GP task
One way
y communication

• Yesterday it rained cuts and dogs

• All th
the lladies
di were on ttop off th
the world
ld
• The commissioner will share his wealth
with girls and not the boys.
 WHAT IS COMMUNICATION?
• Is exchanging information
• It is the p
process by y which p
people
p attempt p to
share meanings of symbolic transmissions
• Communication (as a generic process) is a
two-way process between two or more persons
in which ideas, feelings and information are
shared,
h d with ith th
the ultimate
lti t aim
i off reducing
d i
uncertainties and clarifying issues.
• Communication only becomes complete when
there is feedback.
The Communication process;
Message
Medium R i
Receiver
Source

Feed back
 Types of communication
• Verbal communication is the exchange of
ideas through spoken expression in words. It is
a medium for communication that can entail
using the spoken word or written.
• Non-verbal communication involves the
expression of ideas, thoughts or feelings without
the spoken or written word. Usually expressed
i th
in the fform off body
b d llanguage(gestures,
( t ffacial
i l
expressions and where appropriate, touch)
• Both
B th verbalb l andd non-verbal
b l communication
i ti
are important in palliative care.
 • Talking
• Transmitting
• Repeating
• Summarising g

Verbal

Communication

• Listening
Non-Verbal • Transmitting
• Facial
expressions
• Gestures
• Reflected
f li
feelings
• Genuineness
• Respect
 Verbal and Non-Verbal
Non Verbal
Communication

• Includes body language, eye

contact gestures
contact, gestures, tone of voice
• N.B; 80% of communication is
nonverbal
b l
Ersek 1992
Ersek,
 Communication;
• Advises on the resources available to address
holistic needs and concerns;
• Provides patients with a sense of security,
security
consistency and comfort;
• Educates family members and care providers on
caring aspects
• Aims to improve
p relationships
p at all levels
• Ensures a good flow of information within and
between organisations
g involved in service
delivery
 E g; One needs to;
E.g;
• Greet the patient’s and relatives using
th i names
their
• Introduce yourself and your role
• Be clear with the purpose of the session
• The key things you wish to cover
• How long it is likely to take
 Example
p
• E.g. Hello Mr. John, My name is Mrs. Omondi
and I’m the nurse counselor for this unit. I’d like
to spend around 20 minutes or so with you to get
an idea of the main problems and concerns you
h
have. I’d lik
like tto ttake
k some notes
t as we go along.
l
Would that be all right?
N B Asking the patient ‘would
N.B. would that be alright’
alright ,
allows the patient to say, ‘ Well I’m feeling
absolutelyy exhausted after my y treatment;; could
you come back later?’
 Effective Communication in Palliative Care
• Id
Identifies
ifi and d aims
i to address
dd allll the
h needs
d off
the patient, family and care provider (i.e.
psychological spiritual
psychological, spiritual, social
social, cultural and
physical issues);
• Provides information according to the patient patient’s
s
preferences (whether good or bad news);
• Invites the patient to share their agenda in a
conversation;
• Aims to communicate the truth by means of
accurate essential information;
 Cont…
• Recognize that while a HCW has medical
authority, he or she does not have cultural or
spiritual authority.
• ? Role of a traditional healer (alternative
medicine)?
di i )?
 Power Dynamics
• As an authority figure expected to play the lead role, the
HCW must elicit shared decision making with patients and
families.
families
• Avoid jargon, which exaggerates the imbalance in
knowledge between the HCW and patient.
• Ensure that there are always more family members than
staff at family conferences or meetings.
• Ensure
E th
thatt you and
d the
th patient
ti t are att the
th same eye level.
l l
- If the patient is lying in bed, prop him or her up and sit
down, though preferably not on the bed, in order to
maintain comfortable personal space.
 Expectations

• Realize that both parties have

expectations,
t ti andd they
th are nott necessarily
il
the same.
• Understand that the patient wishes to hear
a certain message, and the HCW wishes
to convey one, but they are not always the
same.
 Key aspects targeted in communication
• All aspects which make an individual complete
complete,
i.e. psychological, spiritual, social, cultural and
physical
• Prognosis and goals of care
• Disclosure,
Disclosure diagnosis
diagnosis, prognosis
• Patient’s fears and concerns
• Disease progression and end end-of-life
of life care issues
e.g aggressive treatments in the end-of-life stage,
decisions on readmission, review of medications,
family rituals and the family’s role
 Cont…
• Patient and family styles and practices for
copingg with g
grief, loss and bereavement
• Discussions about the future- will writing
p
• End-of-life issues and the anticipation of the
death of a child patient- honestly discussions
with the child and their family.
• The opportunity to say goodbye and express last
feelings and wishes.
• Bereavement counselling and support for
children
 Communication Skills
• There
Th are mainly
i l 3 types off communication
i i skills,
kill
1. Expressive skills
2. Listening skills
3. Skills for managing the overall process of
communication.
- The Basic fundamental of all these types of
communication
i ti iis emotional
ti l skills.
kill
When the Health Care Worker (HWC) is the
Sender:
– Recognize that communication starts with the self,
identifying your own barriers and baggage.
– Be prepared by having the correct facts and,
and if
possible, a suggested plan of action.
– Demonstrate honesty, consistency, and
trustworthiness.
– Speak with confidence and believe your own
message.
message
– Think before you speak!
– Do not talk down to the patient or relatives.
– Create a comfortable atmosphere conducive to
communication.
 Cont…
–BBring
i bbarriers
i iinto
t th
the open.
– Do not share your own feelings of sadness or
hopelessness.
– Move at the person’s own pace. Do not force a
person to listen to more information if he or she is not
i
interested
d or readyd ffor iit.
– Check that the message is received and understood.
When the HCW is the Receiver:
– Listen well and actively.
– Show persons that you enjoy their humour, but avoid
making culturally inappropriate jokes.
 Reflection on listening
You are not listening to me when …
• You do not care about me.
• Say you understand before you know me well enough.
• You
Y haveh an answer ffor my problembl b
before
f I’I’ve fifinished
i h d
telling you what my problem is.
• You
ou cut meeooff be
before
o e I’ve
e finished
s ed spea
speaking.
g
• You finish my sentence for me.
• You feel critical of my vocabulary, grammar, or accent.
• You are very eager to tell me about something.
• You tell me about your experience, making mine seem
unimportant.
nimportant
• You are communicating to someone else in the room.
• You refuse my thanks by saying you haven’t
haven t really done
anything.
 You are listening to me when …
• Y
You come quietly
i l iinto my private
i world
ld and d llet me
be.
• You
Y reallyll ttry tto understand
d t d me even if I’ I’m nott
making much sense.
• You grasp my point of view even when it’s it s against
your own sincere convictions.
• You realise that the hour I took from you has left
you a bit tired and drained.
• You allow me the dignity of making my own
decisions, even though you think they might be
wrongg.
 Cont…
• Y
You ddo not take
k my problem
bl ffrom me, bbut allow
ll
me to deal with it in my own way.
• You
Y h hold
ld b
back
k your ddesire
i tto give
i me good d
advice.
• You do not offer me religious solace when you
sense I am not ready for it.
• You give me enough room to discover for myself
what is really going on.
• You accept my gift of gratitude by telling me how
good it makes you feel to know you have been
helpful.
p
 Questioning
• U
Use mainly
i l open-endedd d questions,
ti i th
i.e. those th
thatt are
thought provoking, that invite a person to talk and
explain
p a situation, and that offer the opportunity
pp y for a
variety of responses. Such questions might be ‘What
makes you feel bad?’, ’How did you feel when you were
diagnosed with cancer?’
cancer? or ‘What
What worries you the most?’
most?
• You can use some closed-ended questions if
necessary: these are brief and restricting and are used
to obtain facts rather than knowledge of feelings – for
instance, ’Does this part of your body hurt?’
• Avoid leading questions: these suggest a preferred
answer or desired response – e.g. ‘You must be feeling
a lot of pain, mustn’t you?’
 Barriers to communication
Can h
C happen at every stage off the
h process...
• Language and culture
• Making judgments statements.
• Conflicting medium
• Recipient Problem
• Lack of self awareness of the HCW expressing
frustration, hopelessness, and disempowerment
about the health care system.
• Fear of discussing the illness
Communicating with Children
• It is important to note that communication with children;
– Uses an honest and open approach as the basis of all
communication
i ti
– Enables parents to be central to a child’s well-being;
guided by the age and wishes of the child
– Provides information to a child and their family about
the signs and symptoms of approaching death in a
manner appropriate
i t tto th
their
i iindividual
di id l needs
d and
d
circumstances.
 Process of Communicating with
Children;
• Introduce self as the person who talks to & helps children
• Take some time to get to know the child (play a game, talk a
bit)
• If child is not verbalizing, divert & introduce child to other
materials in the room that can be used for communication
• Allow child to explore toys/activities/room at his/her own pace
• Ask about the demographic data of child (name, age, No. of
siblings,
ibli school,
h l ffavorite
it ffood,
d th
the parents,
t b bestt ffriends)
i d )
• Don’t feel rushed when working with the child. If you are
impatient, the child will sense this!
• Use of self by adjusting to child’s physical level
 Cont…
• Utilizing play, drawing & other art mediums
• Observe what toys the child is handling
• Ask open-ended questions regarding the toys
and regarding what you observe the child doing
with the toys (What is happening there?)
• Actively participate with the child in playing with
toys
• Notice the theme of the child’s pplayy ((e.g.
g themes
of nurturing and aggression)
 Consequences of ineffective communication in pc
• Not communicating accurate essential information to
patients may provoke greater problems / Risks
• Protectinggppatients from the realityy can lead to inconsistent
messages being given by other members of the inter-
disciplinary team.
• Hiding the truth often leads to conspiracies of silence that
build up to a heightened state of fear, anxiety and confusion,
rather than provide one of calmness.
• Poor communication is a threat to patient care and can lead
both to mistrust and to a source of staff stress.
• Not comm
communicating
nicating abo
aboutt the nat
nature
re and serio
seriousness
sness of an
illness can lead to a lack of planning for the future – e.g. not
writing a will, not planning who will take care of the children.
 Be Aware …
• Most attempts by service providers to protect patients
from the reality of their situation create further problems
for patients,
patients their relatives,
relatives and their friends
friends.
• Realistic hopes and aspirations can only be generated
from honest disclosure.
• The extent to which patients and families cope with
information relating to illness largely depends on how
effectively it is delivered and the relationship created
between them and the care provider.
• Considerable suffering g is caused byyppoor
communication; much of this is avoidable.
 Why is it good to tell the truth?
• To maintain a relationship of trust. Lying
destroys trust.
• To reduce uncertainty. People usually cope
better with truth than with uncertainty, even if the
t th is
truth i painful.
i f l
• To prevent unrealistic hope. Sometimes people
spend d much h ti
time and d money going
i ffrom clinic
li i tto
clinic looking for treatment because no one has
been brave enough to tell them that there is no
cure for their illness.
 Cont…
Cont
• To give opportunity for mending difficult
relationships or exploring spiritual issues.
• To allow p
patients and families to pprepare
p for the
future
 Questions for Discussion:
• In the Kenyan context, is it true that
patients
ti t “want
“ t to
t know”?
k ”?
• How do we work with families who want to
shield their patient- colluding?
• What are the advantages g to truth-telling?
g
• What are the obstacles?
 SOLER/ROLES
Non-verbal
N b l body
b d language
l to
t show
h you are attending
tt di
• S- sit squarely to communicate presence and availability
• O- open
p posture
p to signify
g y that yyou are open
p to the client
and to what the client is saying. This is seen by others as
a non-defensive posture.
• L- leaning forward towards the client is a natural sign of
involvement
• E- eye contact. There should be eye contact but this
should not be confused with starring. It is a way of
communicating
i ti your presence, iinterest
t t and
d th
thatt you wantt
to hear what the other person wants to say.
• R- being relaxed and natural when doing all the above is
i
important.
t t It means becoming
b i comfortable
f t bl withith your body
b d
and the situation
 RESPONDING SKILLS-(CLEAR)
• C- Clarify
– Clarify what you say. Explain your point so that the patient can
understand
• L- Listen
- Listen to your patient and show them you are listening by giving
them you attention and not getting distracted while they are
talking
• E- Encourage
– Encourage the patient to speak freely by asking open-ended
questions.
questions
• A- Acknowledge
– Acknowledge what your patient is saying. Let them feel that what
theyy sayy is important
p and valuable,, or that it was okay
y for them to
talk to you
• R- Reflect and repeat
 E.g. ‘In
In finishing, I’d
I d just like to check that I’ve
I ve
understood the main points you have told me. You
went to your doctor three years ago and were
referred to the hospital for surgery for cancer of
your bowel. At the time there seemed every hope
that the cancer had been clearedcleared, but recently
some secondary deposits have occurred. This was
something of a shock to you and your family family, but
you have been able to talk about it, though not yet
to yyour daughter
g who is at university. y This is a
concern to you, but your main problem is the
abdominal discomfort you are currently getting.
 Summary
• It is good to check we have understood and
summarize what the patient has said,
• e.g.
g “Do yyou mean that...”
• “I think what you are saying is...”
So the main things worrying you are
• “So are...”.
 Conclusion
¾“Suffering is not a problem that demands a
solution, it is not a question that demands
an answer, it is a mystery that demands
presence”
¾All what entails in palliative care is “to cure
sometimes, to relieve often, to comfort
always.”