commucation with terminally.ppt

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COMMUNICATION BETWEEN COMMUNICATION BETWEEN DOCTORS, PATIENTS & THEIR DOCTORS, PATIENTS & THEIR

FAMILIESFAMILIES“BREAKING BAD NEWS”

R. SjamsuhidajatR. SjamsuhidajatTjakra Wibawa ManuabaTjakra Wibawa Manuaba

Sutrisno AlibasyahSutrisno AlibasyahPERIOPERATIVE COURSEPERIOPERATIVE COURSE

INDONESIAN COLLEGE OF SURGEONSINDONESIAN COLLEGE OF SURGEONS INDONESIAN COLLEGE OF ANESTHESIOLOGYINDONESIAN COLLEGE OF ANESTHESIOLOGY

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DOCTOR – PATIENT DOCTOR – PATIENT RELATIONSHIPRELATIONSHIP

No more paternalisticNo more paternalisticShould be on partnership basisShould be on partnership basisEqual positionEqual position

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Communication is not:Communication is not:as some would say, simply good as some would say, simply good manners, empathy, being nice or manners, empathy, being nice or pandering to the patients.pandering to the patients.

BUT…BUT…

it offers a much more effective it offers a much more effective consultation, and improved outcomes for consultation, and improved outcomes for

bothbothpatients and doctors. patients and doctors.

HOPEFULLY….NOTHOPEFULLY….NOTThe blind leading the blind?The blind leading the blind?

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ISSUES IN DOCTOR – PATIENTISSUES IN DOCTOR – PATIENT

COMMUNICATIONCOMMUNICATION

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Why teach and learn communication Why teach and learn communication skills?skills?

Is it important to study medical interview?Is it important to study medical interview?

(knowledge, communication skills, problem solving, (knowledge, communication skills, problem solving, physical examination)physical examination)

Are there problems in communication between Are there problems in communication between doctors and patients? doctors and patients? (discovering the reason for (discovering the reason for patient’s attendance, gathering information, explanation & patient’s attendance, gathering information, explanation & planning, patient adherence, medico-legal issues, lack of planning, patient adherence, medico-legal issues, lack of empathy & understanding)empathy & understanding)

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Why teach and learn communication Why teach and learn communication skills?skills?

Is there evidence that communication Is there evidence that communication skills can overcome these problems and skills can overcome these problems and make a difference to patients, doctors, and make a difference to patients, doctors, and outcomes of care outcomes of care (process of interview, (process of interview, patient satisfaction, patient recall & patient satisfaction, patient recall & understanding, adherence, outcome)understanding, adherence, outcome)

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Can you teach and learn communication skills?Can you teach and learn communication skills?

Is there evidence that communication can be Is there evidence that communication can be taught and learned?taught and learned?

Is there evidence that learning is retained?Is there evidence that learning is retained? Is the prize on offer to doctors and patients worth Is the prize on offer to doctors and patients worth

the effort? the effort? Will expanding the effort on communication Will expanding the effort on communication

skills teaching produce worthwhile rewards for skills teaching produce worthwhile rewards for both doctors and patients?both doctors and patients?

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The answers are ….definitelyThe answers are ….definitelyyesyes

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Underlying PremisesUnderlying Premises

-- Communication skills teaching and learningCommunication skills teaching and learning

need to be evidence based.need to be evidence based.

-- Unified approach to communication skillsUnified approach to communication skills

teaching in medicine is needed.teaching in medicine is needed.

-- Communication skills teaching should cross Communication skills teaching should cross

cultural and national boundaries.cultural and national boundaries.

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Underlying Premises…..Underlying Premises…..

- Coordinated approach to communication - Coordinated approach to communication

skills teaching skills teaching throughout medical education

is necessary.is necessary.

- A skill, based on approach to communication - A skill, based on approach to communication

skills teaching is essential.skills teaching is essential.

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HUMAN REACTION IN FACINGHUMAN REACTION IN FACINGDISEASES WITHOUT DISEASES WITHOUT

ANY HOPE OF RECOVERY….ANY HOPE OF RECOVERY….Patients, Families, &Patients, Families, &Health professionals.Health professionals.

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In critically ill patients :In critically ill patients :• We have to deal with stressful depressed

patient and families

• We have to deal with other colleagues ,other doctors, nurses who sometimesare also depressed

in a very tense and depressingsituation or atmosphere!

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How human being faces critical/severe How human being faces critical/severe diseases?diseases?

Emotional Changes.Emotional Changes.

Negative Emotional Changes ( no moreNegative Emotional Changes ( no more

hope, anger, disbelief, rejection/ hope, anger, disbelief, rejection/ denial……and denial……and

…………………………finally acceptance.finally acceptance.

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Emotional changesEmotional changes

Usually temporaryUsually temporary Depending on Depending on Emotional Stability, past Emotional Stability, past

experiences, psychological maturity, internal experiences, psychological maturity, internal representation, cognitive processing, traumatic representation, cognitive processing, traumatic stressor and probably education?stressor and probably education?

Awareness of Emotional reaction.Awareness of Emotional reaction. Return toward “normal balance” (in Return toward “normal balance” (in

majority cases)majority cases)

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Severe Physical / PsychologicalInjuries

Emotional Reaction

Emotional ProcessingEmotional Processing

Awareness of Emotional Reaction

ReturnsReturns

Towards Normal BalanceTowards Normal Balance(majority of cases)(majority of cases) PTSD (PTSD (small percentage)small percentage)

DEPRESSED!DEPRESSED!

?

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In Facing a Serious & Critical Disease / In Facing a Serious & Critical Disease / TERMINAL Condition TERMINAL Condition

To Fly (to run awayTo Fly (to run awayFrom the situation)From the situation)

To Fight (to face, to accept &To Fight (to face, to accept &to cope with the condition)to cope with the condition)

HUMAN BEING REACTIONHUMAN BEING REACTION

Painful Intrusive RecollectionPainful Intrusive Recollection

Human reaction would be….Human reaction would be….

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STRESS / DEPRESSIONSTRESS / DEPRESSION

Suppressed into Suppressed into SubconsciousnessSubconsciousness- Becoming chronicBecoming chronic- Change of value systemChange of value system- ReappraisalReappraisal- Disturbance of emotional processingDisturbance of emotional processing- Failure to complete the emotional processingFailure to complete the emotional processing

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By Understanding The Whole By Understanding The Whole Psychological Process in Critical Psychological Process in Critical Situation, e.g. Terminal CancerSituation, e.g. Terminal Cancer

BETTER COMMUNICATIONBETTER COMMUNICATION-Clearer Clearer -More effective & efficient communicationMore effective & efficient communication-Honesty & openness.Honesty & openness.-TrustTrust-Mutual respectMutual respect-PolitenessPoliteness-AdherenceAdherence-Collaboration.Collaboration.-More accurate informationMore accurate information-Prevention of violent situationPrevention of violent situation-Informed consentInformed consent-Legal aspectsLegal aspects

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RELAXED & CORRECT POSITION DURING MEDICAL INTERVIEW.RELAXED & CORRECT POSITION DURING MEDICAL INTERVIEW.

EQUAL (LEVEL) EYE CONTACT.EQUAL (LEVEL) EYE CONTACT.

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BREAKING BAD NEWS….BREAKING BAD NEWS….

CONDITIONINGPLANNINGEXPLANATION

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CONSIDERATION IN BREAKING BAD NEWS CONSIDERATION IN BREAKING BAD NEWS

SHOULD THE PATIENT BE TOLD : “HE/ SHE IS BE TOLD : “HE/ SHE IS SERIOUSLY ILL or having cancer?SERIOUSLY ILL or having cancer?

HOW MUCH THE PATIENT THE PATIENT SHOULD KNOW ABOUT ABOUT HIS/ HER CONDITION.HIS/ HER CONDITION.

SHOULD THE FAMILY KNOW ABOUT THE ILLNESS KNOW ABOUT THE ILLNESS HOW MUCH THE FAMILY SHOULD KNOW ABOUT HOW MUCH THE FAMILY SHOULD KNOW ABOUT

THE ILLNESS.THE ILLNESS. SHOULD PATIENT KNOW THAT HIS/ HER ILLNESS KNOW THAT HIS/ HER ILLNESS

CAN NOT BE TREATED/ CURED. HOW MUCH THE PATIENT AND THE FAMILY HOW MUCH THE PATIENT AND THE FAMILY

SHOULD KNOW ABOUT THIS.SHOULD KNOW ABOUT THIS.

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CONSIDERATION IN BREAKING BAD NEWSCONSIDERATION IN BREAKING BAD NEWS

DIVERGENCE BETWEEN PATIENT AND DOCTOR’S BETWEEN PATIENT AND DOCTOR’S PERPECTIVES… PATIENT & FAMILY HOPES OF PERPECTIVES… PATIENT & FAMILY HOPES OF GOOD NEWS. AND ….DOCTOR’S NEWS (Tuckett et GOOD NEWS. AND ….DOCTOR’S NEWS (Tuckett et al, 1985)al, 1985)

The Doctor must change the news…how?The Doctor must change the news…how? MOST DOCTORS will find this duty very difficult!!!MOST DOCTORS will find this duty very difficult!!! Psychological Sequelae of BREAKING BAD NEWSPsychological Sequelae of BREAKING BAD NEWS

DEVASTATING and LONG LASTING (Finley & DEVASTATING and LONG LASTING (Finley & Dallimore 1991). Many reports expressing doctor’s Dallimore 1991). Many reports expressing doctor’s deficiencies in this matter.deficiencies in this matter.

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How Much The Patient and The FamilyHow Much The Patient and The FamilyShould know about their Critical Condition.Should know about their Critical Condition.

THE PATIENT AND THE FAMILY THE PATIENT AND THE FAMILY SHOULD KNOW ENOUGH ABOUT their Critical Illness/ Condition. ABOUT their Critical Illness/ Condition.

THEY SHOULD KNOW THAT THEIR CONDITION CAN THEY SHOULD KNOW THAT THEIR CONDITION CAN NOT/ DIFFICULT TO BE CURED, …THAT THE NOT/ DIFFICULT TO BE CURED, …THAT THE PATIENT WILL DIE? (THE PATIENT OR THE FAMILY PATIENT WILL DIE? (THE PATIENT OR THE FAMILY ONLY ?). ONLY ?).

IN THE CASE OF INDONESIA, PROBABLY THE IN THE CASE OF INDONESIA, PROBABLY THE FAMILY SHOULD KNOW MORE?.FAMILY SHOULD KNOW MORE?.

IN OTHER COUNTRIES (USA) THE PATIENT MUST IN OTHER COUNTRIES (USA) THE PATIENT MUST BE TOLD FIRST.BE TOLD FIRST.

DO NOT EVER TELL THE PATIENT, HOW LONG HE/ DO NOT EVER TELL THE PATIENT, HOW LONG HE/ SHE WILL LIVE !!!!!.SHE WILL LIVE !!!!!.

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KEY CORE SKILL FOR BREAKING BAD NEWSKEY CORE SKILL FOR BREAKING BAD NEWSEXPLANATION & PLANNING..

PreparationPreparation SummarizingSummarizing Negotiating the AgendaNegotiating the Agenda ListeningListening Picking up CuesPicking up Cues The use of SilenceThe use of Silence Discovering the patient’s concern and ideasDiscovering the patient’s concern and ideas Encouraging the expression feelingEncouraging the expression feeling Picking up the non verbal cuesPicking up the non verbal cues Building rapportBuilding rapport

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KEY CORE SKILL FOR BREAKING BAD NEWS.KEY CORE SKILL FOR BREAKING BAD NEWS.

ConditioningConditioning EmpathyEmpathy AcceptanceAcceptance Discovering the patient starting pointDiscovering the patient starting point Discovering the patient’s feeling Discovering the patient’s feeling Gauging what and how much information to giveGauging what and how much information to give Discovering whether a patient is a seeker or and Discovering whether a patient is a seeker or and

avoider of informationavoider of information Giving supportGiving support Giving clear jargon- free explanationGiving clear jargon- free explanation Chunking and checking information givingChunking and checking information giving

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Suggestion for Breaking Bad News.Suggestion for Breaking Bad News.

PREPARATION :PREPARATION :

- Set Up appointment as soon as possible- Set Up appointment as soon as possible

- Un interrupted time- Un interrupted time

- comfortable & familiar atmosphere- comfortable & familiar atmosphere

- Invite spouse, family, friends as appropriate- Invite spouse, family, friends as appropriate

- adequately prepared for patient background, - adequately prepared for patient background, educationeducation

situation, records.situation, records.

- Doctor should put aside personal feeling. - Doctor should put aside personal feeling.

2828PLEASE NOTICE THE BARRIER BETWEEN DOCTOR – PATIENT!PLEASE NOTICE THE BARRIER BETWEEN DOCTOR – PATIENT!

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PLEASE NOTICE THE POSITION OF DOCTOR – PATIENT.PLEASE NOTICE THE POSITION OF DOCTOR – PATIENT.

IT IS CLOSER, FAMILIAR, AND THERE IS NO BARRIER…BETTER.IT IS CLOSER, FAMILIAR, AND THERE IS NO BARRIER…BETTER.

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BEGINNING THE SESSION.BEGINNING THE SESSION.

- summarizing where things have reached to date- summarizing where things have reached to date

- Discover what has happened since last seen- Discover what has happened since last seen

- Calibrate how the patient is thinking/ feeling- Calibrate how the patient is thinking/ feeling

- Negotiate an agenda.- Negotiate an agenda.

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SHARING THE INFORMATIONSHARING THE INFORMATION- ASSESS THE PATIENT’S UNDERSTANDING- ASSESS THE PATIENT’S UNDERSTANDING- GAUGE HOW MUCH THE PATIENT WISHES TO KNOW- GAUGE HOW MUCH THE PATIENT WISHES TO KNOW- GIVE WARNING ….CONDITIONING - GIVE WARNING ….CONDITIONING I am afraid we have I am afraid we have some bad news to tell; I am afraid it looks more serious some bad news to tell; I am afraid it looks more serious than we hope… than we hope…- GIVE BASIC INFORMATION, simply and honest…repeat - GIVE BASIC INFORMATION, simply and honest…repeat important points.important points.- Relate your information to the patient’s framework- Relate your information to the patient’s framework- Do not give too much information too early; do not - Do not give too much information too early; do not pussyfoot but do not overwhelm pussyfoot but do not overwhelm- Give information in small chunks; categorize information- Give information in small chunks; categorize information- Watch the pace; check repeatedly for understanding, feeling - Watch the pace; check repeatedly for understanding, feeling

asas you proceed.you proceed.- Use proper language, avoid jargon! - Use proper language, avoid jargon!

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BEING SENSITIVE TO THE PATIENT.BEING SENSITIVE TO THE PATIENT.- Read the non-verbal cues : face, body language- Read the non-verbal cues : face, body language silence, tearssilence, tears- Allow for “shut down” (when patient turn off,- Allow for “shut down” (when patient turn off, stop listening, silence) stop listening, silence) give time & space; give time & space; allow denial.allow denial.- Keep pausing to give patient time to ask - Keep pausing to give patient time to ask question. question.- Gauge the patient’s need for further information- Gauge the patient’s need for further information patient will react variously, demand patient will react variously, demand differently. differently.- Encourage expression of feeling : I am sorry that was - Encourage expression of feeling : I am sorry that was difficult for you…. difficult for you….

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A HAUNTED SITUATION?A HAUNTED SITUATION?

A PROVOCATIVE ATMOSPHERE FOR CONSULTATION?A PROVOCATIVE ATMOSPHERE FOR CONSULTATION?

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PLANNING & SUPPORT.PLANNING & SUPPORT.- - Having identified all the patient’s specific concern Having identified all the patient’s specific concern

offer specific help by breaking down overwhelming offer specific help by breaking down overwhelming feeling into manageable concerns, prioritizing…feeling into manageable concerns, prioritizing…- Identify a plan for what is to happen next- Identify a plan for what is to happen next- Give a broad timeframe for what may lie a head.- Give a broad timeframe for what may lie a head.- Give hope tempered with realism (“preparing for the- Give hope tempered with realism (“preparing for the worst and hoping for the best”)worst and hoping for the best”)- Ally yourself with the patient (“we can work on this - Ally yourself with the patient (“we can work on this together….. Between us”), i.e. co-partnership with the together….. Between us”), i.e. co-partnership with the patient, advocate the patient.patient, advocate the patient.- Emphasize the quality of life- Emphasize the quality of life- Safety net. - Safety net.

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BEING SENSITIVE TO THE PATIENT……BEING SENSITIVE TO THE PATIENT……- - Response to the patient feeling and predicament with Response to the patient feeling and predicament with

acceptance, empathy, and concern.acceptance, empathy, and concern.- Check the patient’s previous knowledge about the - Check the patient’s previous knowledge about the information given. information given.- Specifically elicit all the patient’s concern- Specifically elicit all the patient’s concern- Check the understanding of information given, e.g. : - Check the understanding of information given, e.g. : “would you like to run through what you are going to “would you like to run through what you are going to tell your wife/ family” tell your wife/ family” - Be aware of unshared meaning, e.g. : what cancer - Be aware of unshared meaning, e.g. : what cancer

meansmeans or the patient compared what it means to the physician.or the patient compared what it means to the physician.- Do not afraid to show emotion & distress (physician - Do not afraid to show emotion & distress (physician human being ).human being ).

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FOLLOW UP & CLOSING.FOLLOW UP & CLOSING.

- - Summarize and check with patient.Summarize and check with patient.

- Do not rush patient to treatment.- Do not rush patient to treatment.

- Set up early further appointment, offers telephone - Set up early further appointment, offers telephone calls,calls,

- Identify support systems : involve relatives and - Identify support systems : involve relatives and friends,friends,

religion or cultural leader or other related professional religion or cultural leader or other related professional

- Offer to see/ tell spouse or others.- Offer to see/ tell spouse or others.

- Make written material available. - Make written material available.

( Buckman1994; Faulkner 1988)( Buckman1994; Faulkner 1988)

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SPECIAL ISSUESSPECIAL ISSUES

DOCTORS should always ask questions for DOCTORS should always ask questions for themselves :themselves :

- - Am I in position to give this patient accurate Am I in position to give this patient accurate

information?information?- Have I discovered the patient’s illness - Have I discovered the patient’s illness framework : his thought, feeling ……? framework : his thought, feeling ……?- Have I developed sufficient rapport with the - Have I developed sufficient rapport with the patient?.patient?.- What is the effect on the patient of what I am - What is the effect on the patient of what I am saying? saying?- Am I going at the pace of the patient?- Am I going at the pace of the patient?- Am I being flexible, supportive and empathic?- Am I being flexible, supportive and empathic?- Am I negotiating an effective plan for the future? - Am I negotiating an effective plan for the future?

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CULTURAL ISSUES.CULTURAL ISSUES.- Cross Cultural Perspective - Cross Cultural Perspective - Ethnic Complexities- Ethnic Complexities- Do not stereotype patients- Do not stereotype patients- Culture is a textured pattern of beliefs & - Culture is a textured pattern of beliefs & practices. practices.- Patient’s culture provide him/her ideas about- Patient’s culture provide him/her ideas about health and illness, notions about causality, etchealth and illness, notions about causality, etc- Modern doctors very often encounter problems- Modern doctors very often encounter problems relating to cultures, traditions etc. relating to cultures, traditions etc.

Chugh 1993; Myerscough 1992; Eleftheriadou 1996.Chugh 1993; Myerscough 1992; Eleftheriadou 1996.

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RELIGION AND SPIRITUAL GUIDANCE ARE RELIGION AND SPIRITUAL GUIDANCE ARE IMPORTANT FACTOR IN “BREAKING BAD NEWS” IN IMPORTANT FACTOR IN “BREAKING BAD NEWS” IN CRITICALLY ILL PATIENTS, WHEN THERE IS NO CRITICALLY ILL PATIENTS, WHEN THERE IS NO MORE HOPE FROM THE POINT OF MEDICAL VIEW.MORE HOPE FROM THE POINT OF MEDICAL VIEW.

- Religion and spiritual guidance will bring the- Religion and spiritual guidance will bring the

patient over and faster to the acceptance patient over and faster to the acceptance phase, and giving up to the Lord the fate for phase, and giving up to the Lord the fate for them them

4040Painful maybe, but a good supportive communication will helpPainful maybe, but a good supportive communication will help

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MAJORITY (70%) OF MEDICAL MAJORITY (70%) OF MEDICAL

LAW SUING IS LAW SUING IS

CAUSED BY PROBLEM CAUSED BY PROBLEM

OF DOCTORS – PATIENTS/ FAMILIESOF DOCTORS – PATIENTS/ FAMILIES

COMMUNICATIONCOMMUNICATION

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Examples of Medical Law - Suing Examples of Medical Law - Suing

““Rude way” of communicationRude way” of communication Mastectomy without biopsy Mastectomy without biopsy without sufficient without sufficient

medical information.medical information. Sterilization without proper consent.Sterilization without proper consent. Failure to diagnose in a very rare illness.Failure to diagnose in a very rare illness. Operation without consent.Operation without consent. Reprimand for doctor who speak too much.Reprimand for doctor who speak too much. Multiple misconduct of a doctorMultiple misconduct of a doctor Misconduct because of profession delegation.Misconduct because of profession delegation. Etc.Etc.

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…….AND MAY LORD GIVE US, THE HEALERS, THE.AND MAY LORD GIVE US, THE HEALERS, THE

STRENGTH TO SEE OUR FELLOW CRITICALLY STRENGTH TO SEE OUR FELLOW CRITICALLY

ILL PATIENTS AS A SUFFERING HUMAN BEING, ILL PATIENTS AS A SUFFERING HUMAN BEING,

AND THAT THEY NEED OUR BEST EFFORT AND AND THAT THEY NEED OUR BEST EFFORT AND

EXPERTISE TO HELP THEM OVERCOMING THEIR EXPERTISE TO HELP THEM OVERCOMING THEIR

PROBLEMS, …. AND NOT TO ADD ….PROBLEMS, …. AND NOT TO ADD ….

THANK YOU THANK YOU

commucation with terminally.ppt

Documents

communication skills

communication skillsteaching

patients attendance

ill patients

emotional stability

negative emotional changes

patient adherence

patient satisfaction