August Spotlight — Palliative Care: Difficult Conversations

 

Submitted by Joanne B. Glusman, MSW, LSW, Bryn Mawr Hospital, Palliative Care Team Social Worker, and Faculty, Bryn Mawr Family Practice Residency Program

 

There are all sorts of “difficult conversations” clinicians have with patients. For some, it may be telling someone that they are or are not pregnant. For some, it may be that an injury will leave them unable to work for months. For others, it may be that they have a life limiting or terminal illness.

Giving such news is often difficult for providers, as many report little education on the specifics of how to do so. And yet, the manner in which difficult news is delivered can significantly affect how patients interpret their illnesses – and even their satisfaction with their providers.

According to the American Cancer Society, studies correlated the following as factors with greater patient satisfaction, in regard to receiving difficult or bad news: “physician sat with me, let me know the bad news was forthcoming, took my personality and emotionality into account and tried to empathize with what I was feeling.”  The manner in which news is delivered has been cited as one of the most important things families discussed after a traumatic death.

There are a number of guides to help practitioners conduct difficult conversations. All have the common themes of making sure we ascertain what patients understand about  their illness, their fears, goals and how much they want loved ones integrated into the conversation and decision-making. As noted in The Oncologist (August 2000), “The idea that receiving unfavorable medical information will invariably cause psychological harm is unsubstantiated.” In fact, not receiving accurate news is more likely to cause distress.

In an ASCO survey, 99% of participants found the SPIKES method for delivering bad news to be practical, useful and easy to understand.2

“S” Setting up the interview, which includes the preparation for the session: reviewing the plan, anticipating both patient and provider reactions, and remembering to sit and connect with the patient.

“P” – Assessing the patient’s perception. Ask before telling. Learning what the patient already understands helps the provider know where to start with info sharing.

“I” – Obtaining the patient’s invitation. Ask if it’s ok to review the test result you have received, and ask how much detail they prefer.

“K” – Giving knowledge and information to the patient. Providing patients with a warning that difficult news is coming helps to facilitate information processing.

“E” – Addressing the patient’s emotions. Observing and verbalizing emotions offers support and solidarity.

“S” – Strategy and summary. Have a clear plan can reduce anxiety, even if that plan is not curative.

Another approach to “verbal empathy” uses the acronym “NURSE”:

“N”Name the emotion (“you appear worried”)

“U” – Understand the emotion (“I see you are concerned about this”)

“R” – Respect the emotion (“You have shown a great deal of strength”)

“S” – Support the patient (“I want you to know that I am still your doctor, regardless of the plan you choose”)

“E” – Explore the emotion (“Tell me more about what is worrying you”)

Ariadne Labs (A Joint Center for Health & The Dana-Farber Institute) also has a clinician guide (“Serious Illness Conversation Guide”) that some practitioners find helpful in preparing for patient/family meetings.

While many providers may not feel equipped to have these in-depth and difficult conversations, those in the specialty of Palliative Care (PC) are trained to take on this task. PC teams include physicians, nurse practitioners, nurses, social workers and chaplains.  They work with attending physicians and the care team to facilitate these conversations. In addition to assisting with symptom management, palliative care specialists provide aide in advance care planning and goals of care. Supporting patients and their loved ones, as well as the entire patient care team, is all the focus of the PC team.

I recently joined Howard Kramer, MD, BMH cardiologist, in a meeting with the daughter of a woman with advanced heart disease whom he had been treating for years. Dr. Kramer sat with the family and said, “Being a good doctor sometimes means sharing treatments that can be helpful. Sometimes, being a good doctor is letting you know when those treatments are no longer working as they had. Helping your mom be comfortable and dignified is also my responsibility.”

While sad to hear that her mom had reached the end of the course of her disease, the daughter was grateful for the information and the way in which it was delivered. The patient returned home with the plan to focus on her comfort.

This is the essence of Palliative Care: working with clinicians to provide information and support, so that patients make their own health care decisions, based on their personal goals and needs.

Sources:

  • Communicating with Patients’ Families and Physicians about Prognosis and Goals of Care  Am J Crit Care July 2015 vol 24 no. 4 4e56-e64
  • SPIKES – A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer. The Oncologist August 2000 vol 5 no. 4  302-311
  • Communication About Cancer Near the End of Life. American Cancer Society published online September 2008 in Wiley Interscience (www.interscience.wiley.com)
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