© pcc institute, 2015 palliative care communication a resource of the palliative care communication...

© PCC Institute, 2015

Palliative Care Communication

A Resource of the Palliative Care Communication Institute

www.pccinstitute.com Presented By:

Dr. Elaine Wittenberg & Dr. Joy Goldsmith

http://www.pccinstitute.com/


Changing Healthcare Landscape

• Patient populations are changing– 1/3 of all Veterans involved in combat and exposed to

experiences related to death and dying during duty– 1/3 of adult population are family caregivers– By 2050, 1 in 13 adults age 65 and older will be

nonheterosexual, and 42% of older Americans will belong to a racial or ethnic group

• Healthcare delivery structure is changing– ODTAA - One Damn Thing After Another (Gawande, 2014)– Patients will have longer medical histories, more complex care

management, increased care interventions, and multiple providers


Key Communication Tasks

• Palliative care communication involves patient-family-provider conversations about:– Goals of care– Transitions in care– Life-altering news– Providing social, psychological, & spiritual support

• The COMFORTTM SM Communication Curriculum provides a variety of tools to accomplish these communication tasks


COMFORTTM SM

• COMFORTTM SM is an acronym that stands for the seven basic skills of palliative care communication– Communication (clinical narrative practice)– Orientation & Options– Mindful Communication– Family Caregivers– Openings– Relating– Team


Module C: Communication(Clinical Narrative Practice)

• Be aware of the patient/family life experience and incorporate that experience into your communication with them–Reflect on the patient’s life before illness (ask

them about their life)–Remember the patient as an individual (listen

to their story and consider what is missing)–Re-author the story (restate their story in

sharing new information)


Module: Communication

• Re-author the story– Explicitly recognize the patient’s life

“Fifty years of marriage is a special life accomplishment and providing care to your husband is a special commitment”

– Elaborate on the illness in the context of the patient’s life

“You can be treated with chemotherapy, but it will be hard on you, making it difficult to care for him, and it will not get rid of your cancer”

– Acknowledge the loss/change in life“After caring for him for so long, your inability to care for him will be a major loss and you will need help”


Module O/O: Orientation & Options

When explaining treatment options, it is necessary to help the family understand the disease trajectory– Orientation• Describing the big picture of a diagnosis• Summarizing the disease path

– Options• Sharing options for treatment and care


• Conversations about options of care need to match the health literacy of the patient and family– Health Literacy includes the language you use

when communicating with patients/family, the context of the interaction, culture, communication skills level, and technology



• For patient/family, the words used in everyday life make sense of health and illness; Use plain language to explain pain medication and symptoms.

• Plain Language Planner for Palliative Care©

(PLP-PC) is available at www.pccinstitute.com



Module M: Mindful Communication

• Sometimes information doesn’t have to be shared, and just “being with” patients can convey support and caring

• Mindful communication involves being aware of how others reaction, avoiding judgment, and adapting your own nonverbal communication to convey support and empathy


• Be aware of your nonverbal communication–Use of touch–Use of space and distance–Physical appearance–All aspects of the voice–Use of and perception of time– The presence of physical and environmental

objects




• Notice signs of stress for yourself or colleagues, which compromises communication– Ignoring or delaying patient/family requests– Withdrawing from patients/colleagues– Quick emotional reactions to others– Overreactions to colleagues– Calling in sick to avoid feelings


Module F: Family Caregivers

• Family caregivers are often involved in care planning discussions

• There are 4 specific caregiver communication styles:

• Manager• Carrier• Partner• Lone

Wittenberg-Lyles, E., Goldsmith, J., Ferrell, B., & Ragan, S. (2012). Communication in Palliative Nursing. New York, NY: Oxford University Press.

Wittenberg-Lyles, E., Washington, K., Demiris, G., Parker Oliver, D., & Shaunfield S. (2013). Understanding social support burden among family caregivers. Health Commun. [Epub ahead of print]. Doi: 10.1080/10410236.2013.815111



Manager Caregiver• Heavily prepared and brings research material • Directives about treatment plans • Example communication about pain from this

caregiver:“His dosage of Dilaudid every four hours for break through pain. This isn’t sufficient.”


Manager Caregiver

• Provider Communication–Use medical terminology to compliment high

literacy of caregiver–One-on-one meetings for other family

members



Carrier Caregiver• Heavy and trusting reliance and dependence • High frequency of questions with little challenge

to answers • Example communication about pain from this

caregiver:“My mom wants to know if she can have more pain medication.”


Carrier Caregiver

• Provider Communication– Prioritize support resources– Address caregiver burden in team meeting

and with caregiver



Partner Caregiver• Various family members present at different

times • Offers to help the team of providers • Example communication about pain from this

caregiver:“We all have different ideas about how to manage her pain.”


Partner Caregiver

• Provider Communication– Facilitate large family meetings, focus on

education, use medical words



Lone Caregiver• Leary and potential for defensiveness • Talk that fixates on immediate physical needs of

patient • Example communication about pain from this

caregiver:“How much stuff are you giving him? He can’t even stay awake. I have to sit with him 24 hours a day and I’m exhausted.”


Lone Caregiver

• Provider Communication– Use simple words and pictures to address

low health literacy– Do not use large team meeting format


Module: Openings

To help patient/family begin a transition in care, take advantage of openings that can begin those conversations.Openings are created when patient/family:– shares their feelings– confides in you– tell you who and what you can and cannot tell– asks you to convince patient to do something

or to hide diagnosis/prognosis


Module: Openings

• Address the Topic– Listen for opening and talk about it!

• Comment on the Topic– Identify and state similarities

• Connect Topic to Quality of Life– What is the safest quality of life domain (physical,

psychological, social, or spiritual) to discuss?– Choose the quality of life domain that naturally

connects to the safe domain to transition topics


Module R: Relating

• Provide support for decision-making by talking about uncertainty and identifying multiple goals in communication

• Uncertainty can create multiple goals and dilemmas for patients/family

• Multiple goals exist because task and relational communication impact how our words are received and interpreted– Task communication is the content of the message and

relational communication includes nonverbal communication


Module R: Relating

• Patient MAP (Modes to Access Preferences)– Talk about Uncertainty– Review goals and uncertainty– Track goal progress


Module R: Relating

• Talk about uncertainty– Consider the source• A health event or occurrence resulting in loss of function• Lengthy or short trajectory of illness• Healthcare staff or family• Emphasis on immediate outcome (e.g., treatment choice,

place of care) or end-of-life outcome (e.g., death and dying)


Module R: Relating

• Review goals and uncertainty– Varying levels of uncertainty exist

“What do you want to accomplish the most right now?”

– Uncertainty can come from relationships“Down the road, which goal will have mattered most to you? To your

family?”

– Need to reduce uncertainty (not always!)“What could you do to make yourself feel better about your current situation?”

• Track goal progress– Always address uncertainty and progress in each subsequent

visit


Module T: Team

• Team communication is necessary to deliver holistic, patient-centered care

• Teamwork involves the strengths of all team members

• Groupthink: When collaboration is missing– Groupthink is a negative communication pattern

that describes teams that lack problem-solving ability, rarely engage in brainstorming, and have few discussions about decision-making


Module T: Team

• Groupthink caused by:–Power dynamics or hierarchy due to

differences in age, education, experience, or position– Self-censorship among team members due to

terminology or procedures–Organizational constraints (high caseloads,

lack of administrative support, no place for meetings)


Module T: Team

What challenges does your team face?

What processes facilitate excellent team work?


Module T: Team

Positive Team Communication• Team members readily assist each other in tasks• Team members engage in conflict resolution as a team• Each team member feels comfortable voicing concerns• Team members have equal contribution in care planning• Team members self-reflect on team processes and make

adjustments• Team members advocate for the team with other

colleagues• Mutual respect among all team members


Module T: Team

• Team-based communication practices– Identify strengths of other team members– Watch for signs of fatigue among colleagues– Identify 2-3 key terms for patient/family education

and translate them as a team– Address patient safety concerns/issues– Designate team time for sharing frustrations about

plans of care (e.g., difficult patient/family, stress)


Module T: Team

• Check your team’s interprofessional pulse*– Who presents cases during team meetings? What

dimension of care is presented first?– How are disagreements processed and resolved?– Are each discipline’s assessments, interventions, and other

recommendations taken into account in care planning?– How are decisions made in team meetings?– Is there a blend of expertise, a shared base of knowledge

that is carried within and used by all members, or does each discipline act independently and simply report back to the team?

*Based on research by Soltura & Piotrowsk, 2011


Module T: Team

• Review each discipline’s standardized measures so that each team member understands the language and meaning of the measure

• Leadership should be rotated among core disciplines monthly (agenda, leading case review)

• Develop team assessment and evaluation


Additional Resources

Visit the Palliative Care Communication Institutewww.pccinstitute.com– Plain Language Planner for Palliative Care©

– Textbook of Palliative Care Communication– Health Communication iOS App– COMFORT Communication VideosTM SM

http://www.pccinstitute.com/


Thank you

“We think our job is to ensure health and survival. But really it is larger than that. It is to enable

well-being and well-being is about the reasons one wishes to be alive.”

Atul Gawande, Being Mortal, 2014

© pcc institute, 2015 palliative care communication a resource of the palliative care communication...

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