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Learning modules

Activity 3: Communication principles

Providing support to people with life-limiting illnesses requires you to use communication skills that enable you to understand the meaning of the illness and its effects on the person. It also requires being able to identify the person's concerns and why he or she may be distressed.

Some people may not be used to discussing personal psychological issues and may find these conversations difficult. There are some general communication strategies that may help facilitate discussion about existential and psychological concerns, and demonstrate respect for the person's individuality.

Table 1 shows key strategies that can be used when communicating with a person with a life-limiting illness and their family. The acronym PREPARED is used to convey these strategies.

Table 1

P Prepare for the discussion, where possible
R Relate to the person
E Elicit patient and caregiver preferences
P Provide information tailored to the individual needs of both patients and their families
A Acknowledge emotions and concerns
R (foster) Realistic hope (e.g. peaceful death, support)
E Encourage questions and further discussions
D Document
 

Prepare for the discussion:

  • ensure facts about the patient’s clinical circumstances are correct
  • try to ensure privacy and uninterrupted time for discussion
  • mentally prepare
  • negotiate who should be present during the discussion e.g. "Is there anyone else you would like to be here with you while we talk?"

Relate to the person:

  • develop a rapport
  • show empathy, care and compassion during the entire consultation e.g “This has been a tough time for you and your family...”
  • broach the topic in a culturally appropriate and sensitive manner
  • make eye contact (if culturally appropriate), sit close to the patient, use appropriate body language, allow silence and time for the patient to express feelings.

Elicit patient & caregiver preferences:

  • identify the reason for this consultation and elicit the patient’s expectations
  • clarify the patient’s or caregiver’s understanding of their situation and establish how much detail they want to know
  • consider cultural and contextual factors influencing information preferences.

Provide information:

Provide information that is tailored to the individual needs of both patients and their families.

  • offer to discuss what to expect, in a sensitive manner, giving the patient the option not to discuss it
  • give information in small chunks at the person’s pace
  • use clear, jargon-free, understandable language
  • engage in active listening i.e. attend to the patient fully, reflect what you think they have said e.g "If I’ve heard you right, you seem to be saying..."
  • explain the uncertainty, limitations and unreliability of prognostic and end-of-life information e.g. "I know that often people expect doctors to know what is going to happen, but in truth we can often only take educated guesses and can often be quite wrong about what the future holds, and especially how long it is. What we can be sure about is ... and what we don’t know for sure is ..."
  • avoid being too exact with timeframes unless in the last few days
  • consider the caregiver’s distinct information needs, which may require a separate meeting with the caregiver (provided the patient, if mentally competent, gives consent)
  • try to ensure consistency of information and approach provided to different family members, the patient and clinical team members
  • use the words 'death' and 'dying' where appropriate.

Acknowledge emotions & concerns:

  • explore and acknowledge the patient’s and caregiver’s fears, concerns and their emotional reaction to the discussion e.g. “What worries you most about?” or "What is your biggest concern at the moment?”
  • be willing to initiate and engage in conversations about what may happen in the future and the dying process e.g. “Do you have any questions or other concerns?
  • respond to the patient’s or caregiver’s distress regarding the discussion, where applicable.

Realistic hope:

  • be honest without being blunt or giving more detailed information than desired by the patient
  • do not give misleading or false information to try to positively influence a patient’s hope
  • reassure the patient that support, treatments and resources are available to control pain and other symptoms, but avoid premature reassurance
  • explore and facilitate realistic goals and wishes and ways of coping on a day-to-day basis, where appropriate.

Encourage questions:

  • encourage questions and information clarification; be prepared to repeat explanations
  • check understanding of what has been discussed and whether the information provided meets the patient’s and caregiver’s needs
    e.g. "We’ve spoken about an awful lot just now. It might be useful to summarise what we’ve said ... Is there anything from that that you don’t understand or want me to go over again?"
  • leave the door open for topics to be discussed again in the future.

Document:

  • write a summary in the medical record of what has been discussed
  • speak or write to other key health care providers involved in the patient’s care. As a minimum, this should include the patient’s general practitioner[1].

Expert Opinion

Thinking points


REFERENCES

1. Clayton, J., Hancock, K., Butow, P., Tattersall, M., Currow, D. (2007). Clinical practice guidelines for communicating prognosis and end-of-life issues with adults in the advanced stages of a life-limiting illness, and their caregivers. MJA, 186 (12), S77-S108. Retrieved September 15, 2010, from www.mja.com.au/journal/2007/186/12/clinic al-practice-guidelines-communicating-prognosis-and-end-life-issues-adults.  Reproduced with permisson.