communicate. care. cure. (sample pages)

7/27/2019 Communicate. Care. Cure. (Sample Pages)

1/18

C o m m u n i c a t e .

C a r e . C u r e .

Edited by

Dr A l e xa n d e r Th o m a s & D r N a g e s h R a o


2/18

R e c e n t s tu d i e s h a v e s h a w n t h a t h e a lt h c a r e o r g a n is a t i o n s l o s e s u b s t a n ti a l a m o u n t s o f m o n e y a n n u a l l y a s a r e s u l t

o f i n e f fe c t i v e o n d i n e f f ic ie n t c o m m u n ic a tio n . T h i s is n o t s u r p r is in g , a s t h e i m p o r t a n c e o f c o m m u n i c a t i o n i n

h e o lt h c a r e h a s n o t l o r g e l y b e e n r e c o g n i s e d . A r e s u lt o f th i s i s t h a t h e o l t h c a r e - p r o v id e r s o r e n o t g iv e n fo r m a l

t r o i n i n g i n e f f e c t i v e c o m m u n ic a t i o n . T h i s b o o k a r g u e s , t h e r e f o r e , t h a t a d d r e s s i n g c o m m u n ic a t io n i s s u e s a m o n g th e

v a r i o u s s t a k e h o l d e r s i n a h o s p i t a l - t h e p a t ie n t , t h e p a t i e n t ' s fa m i l y , h e a lt h c a r e - p r o v i d e r s , h e a lt h c a r e a d m i n i s t r a t o r sa n d s u p p o r t s t a ff - i s t h e k e y t o s o l v i n g s y s t e m i c p r o b l e m s .

T h e c h a p t e r s a n d i l l u s tr a tio n s i n C o m m u n i c a t e , C a r e , C u r e a r e c o n t r i b u t e d b y p h y s ic i a n s , n u r s e s , a p h a r m a c i s t ,

a d m i n is t r a to r s a n d c o m m u n ic a t i o n e x p e r t s . T h e b o o k i s r e p l e t e w i t h t y p i c a l r e a l- li f e s c e n a r io s th o t r e a d e r s c a n

e a s i l y id e n ti f y w i t h . I t a im s t o in c r e a s e a w a r e n e s s a b a u t t h e s ig n ifi c a n c e o f c o m m u n i c a t i o n i n h e a lt h c a r e a n d w i l l

s e r v e a s a g u id e t o e f fe c t i v e a n d e f fic ie n t c o m m u n ic a t i o n t h a t k e e p s i n m in d th e i n t e r e s t s o f t h e m o s t i m p o r t a n t

s ta k e h o l d e r i n h e a l t h c a r e - t h e p a t i e n t .

" A d i a g n o s t i c , p r e s c r ip t i v e a n d p r o g n o s t i c c o m p e n d i u m o n t h e r o l e o f c o m m u n i c a t i o n a n d c a r e f o r c u r e -w e l l - w r i t t e n a n d w e l l - r e s e a r c h e d . "

D r N a r o t l a m P u r i

C h a i r m a n , N o t i o n a l A c c r e d i t a t i o n B o o r d fo r h o s p i t a l s a n d H e o lt h c a r e P r o v i d e r s

" T h e b o o k w a l k s t h e w a l k a n d t a l k s t h e t a l k o f h e a l t h c o m m u n ic a ti o n . A m u s t- r e a d , m o s t p r a c t i c a l . "M a jo r G en e ra l J .K . G rew a l , V S M

F o rm e r A d d i t i o n a l D i r e c to r - G e n e r o l , M i l i t a r y N u rs in g S e r v ic e , A r m e d F o r c e s M e d ic a l S e r v i c e s o f I n d i o

" M e d ic in e i s a s c ie n c e , b u t th e p r a c t i c e o f m e d ic in e i s o n a r t . T h e a r t i n v o l v e s e f f e c t i v e c o m m u n ic a ti o n , c o n c e r n ,c o m p a s s i o n a n d e m p a t h y f o r t h e p a t i e n t . T h i s b o o k p r e s e n ts th e s e o f t o v e r lo o k e d a s p e c t s c o n c i s e ly , e l e g a n tl y a n d

r e a d a b ly . T h i s b o o k s h o u l d b e r e a d a n d p r a c ti s e d b y d o c to r s , n u r s e s a n d h e a l t h c a r e m a n a g e r s a l i k e ."Dr K .K . Ta l w ar

C h a i r m a n , B o o r d o f G o v e r n o r s , M e d i c a l C o u n c i l o f I n d i o

" E f f e c ti v e , e th ic a l a n d e m p a th e t i c h e a l th c a r e r e q u ir e s . . . c o m p e t e n c e , c o m m i tm e n t , c o n c e r n , c o m p a s s io n , c o u r te s y

a n d , v e r y im p o r t a n t l y , c o m m u n i c a tio n , w h i c h . . . i s u s u a l l y t h e m o s t d e fi c i e n t c o m p o n e n t , u n d e r m i n in g t h e o t h e r

e l e m e n t s o f c a r e a n d e r o d i n g t h e p a t i e n t ' s m o r a l e . T h is b o o k n o t o n l y h i g h l i g h ts t h e n e e d f o r s t r e n g t h e n in g t h i s

v i t o l l i n k . . . b u t a ls o t e l l s u s h o w to d o i t b e s t . . . . "K . Sr in a th Re d d yP r e s id e n t , P u b l i c H e a l t h F o u n d a t i o n o f I n d i o a n d P re s id e n t , N o t i o n a l B o o r d o f E x a m i n a t i o n s

" M y p r o f e s s i o n a l c o lle a g u e s n e e d t h i s b o o k d e s p e r a te l y . . . . D o c to r s e s p e c ia l l y , d o n ' t c a r e f o r p h i lo s o p h ie s : w e w a n t

s t r a ig h r l o r w a r d , d ir e c t a n s w e r s . T h i s i s p r e c i s e l y h o w t h e b o o k h a s b e e n w r i t t e n . . . . T h i s b o o k . . . i s l i k e a G o o g le m a p

f o r a s o c i e t y t h a t h a s l o s t d i r e c t i o n . "F r o m th e F o r e w o r d b y D r D e v i P r a s a d S h e t l y

B an g al o r e B a p t is t H o s p i ta l

B e l l a r y R o a d , H e b b a l

B e n g a l u r u 5 6 0 0 2 4 , I n d i a

~ s o o

ISBN 978-93-5104-106-1

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 19789351041061


3/18

Commncat. Car. Cr.

A Guide to Healthcare Communication

Edited by

Alexander Thomas and Nagesh Rao

Bangalore Baptist Hospital

Bangalore

Communication Care Cure.indd 3 23/11/12 4:51 PM


4/18

Bangaor Baptt Hopta 2012

PuBlisHed 2012 By

Bangaor Baptt Hopta

Bar Roa, Hbba

Bangaor 560024, Karnataka

PuBlisHeRs NOTe

un atobographca, a rfrnc to nam, charactr,

pac, ncnt an organaton n th book ar thr th proct of auo manaon o a u fcouy. Any mbanc o acua

vnt, oca or pron, vng or a, ntr concnta.

All rights reserved.

No part of th pbcaton ma b rproc, tor

n a rtrva tm or tranmtt n an form or

b an man, ctronc, mchanca, photocopng, rcorng

or othrw, wthot th pror prmon of th pbhr.

Mancrpt tng: s. sah an Mna Bnan

Covr gn an traton an carcatr

n th book: Pravn Mhra

Covr photo: ua Kmar

t auo, o an uao a moa o b nf

a th athor of th work

Tpt n Paatno an Hvtca N b

go Koa

Prmaog Pbhng Ma

www.prmaog.com

Prnt an bon b

Brant Prntr

Bangaor



5/18


6/18

Chapter 9: In the Spirit of Please and Thank You

Using Courtesy and Etiquette in Healthcare Communication

Chapter 10: Hospital Talk

How Communication Flows in Healthcare Organisations

Epilogue

References

About the Authors

107

125

139

143

149



7/18

xix

Preface

dr vkram Kahyap, dr Olna tmm an dr glory Alexaner

owar he nal mecal en. We are alo raeful o s. sahu for

h lence, paence an panakn eor n brnn h book

together. Hi invaluable eitorial input tranforme our wor an

enure uniformity in tyle an eay reaing. We woul like to thank

dr Manju Chacko an a from he Qualy deparmen for all her

eor. We hank Kr thakkar, a uen from MiCA, who helpe u

in electing the title of the book. We thank Prof Pravin Mihra for hi

lluraon, coer en an carcaure, whch njec aly no he

book an make the repective author perpective vivi.

We are inebte to dr devi shetty, Pamabhuhan awaree, worl-renowne cariac urgeon an a pioneer in low-cot, quality healthcare

elivery, for penning hi heartfelt thought an inpiring forewor in the

mit of a buy an hectic cheule.

the alue of he book come from he exene healhcare nury

experence of auhor. th comme roup of people pen lon

hour n aon o her hecc cheule n an eor o mproe an

enhance he paen experence n hopal. i our hope ha h

book on healhcare communcaon wll be of bene o he ulmae

receer he paen.

Alexander Thomas and Nagesh Rao



8/18

Chapter 6

Tread with CareBeaking Bad News o Paiens, thei Family and relaives

Rajnish Samal

The doctor said: this-and-that indicates that this-and-that is wrong with you,

but if an analysis of this-and-that does not conrm our diagnosis, we must

suspect you of having this-and-that, then... and so on. There was only one

question Ivan Ilyich wanted answered: Was his condition dangerous or not?

But the doctor ignored that question as irrelevant.

Leo Tolstoy in The Death of Ivan Ilyich

Any information that can have serious and adverse impact on anindividuals life and future and also have indirect bearing onthe immediate family and society at large can be considered as

being bad news.1

Breaking bad news forms a necessary part of patient-professionalcaregiver communication. Done sensitively, it develops a constructiverelationship and a helping partnership between the patient, the relativesand the healthcare-provider. In the medical profession, there is no waywe can avoid this task. The need to deliver bad news exists in all clinical

specialities and settings diagnosis, explaining disease progression,change in functional status of an individual, response to therapy, poorprognosis of a disease and declaration of death.

In the attempt to learn the skills of communication, breakingbad news is a combination of active listening, using gestures andbody language and showing empathy, strengthened with years ofprofessional experience in clinical settings. The American poet WaltWhitman, in Song of Myself, says, I do not ask the wounded personhow he feels; I myself become the wounded person. While responding

to the patients emotions and going into a lot of distressing detail, one



9/18

72

Communicate. Care. Cure.

is entering a most private place in the patients world and witnessing

their psychological vulnerability. Delivering bad news affects not onlythe receiver of the bad news deeply but may also signicantly affect themessenger. Breaking bad news has an impact on everyone involved thepatient, the relatives, the physician and other healthcare professionals.Therefore, it is not for the inarticulate, unskilled healthcare professionalto blunder their way through such an important conversation, possiblyseriously traumatising the patient.

The skill of delivering bad news humanely can, however, be learnt,and its component skills transferred from an experienced senior

professional to an unskilled junior colleague. It is absolutely necessaryfor the healthcare professional to be prepared before proceeding todeliver bad news. It is recommended that a mature, experiencedsenior be allocated the responsibility, with a junior colleagueaccompanying the senior to the interview, for practical exposure andtraining. However, should a suitable person be unavailable, a team ofphysicians could be collectively designated to deliver the news.

The senior member should be capable of communicating well withthe patient and relatives and should go through the following phases:

Discuss the disease, diagnosis, prognosis and course of the illness

Get the patient and relatives involved, to discuss theirunderstanding and perception of the disease and how that mightaffect them

Explore the patients reaction to the bad news and determine towhat extent the patient wishes to participate in decision-making

Discuss the treatment plan with the patient and guide themregarding how to adhere to the plan of therapy

Offer and discuss counselling/psychotherapy or other ongoingsupport for the patient and relatives2

Disclosure of information

In communicating bad news, the healthcare-provider, the patientand the relatives should be in agreement regarding the nature of theinformation to be disclosed. An adult patient has the right to knowall details. Also, every patient also has the right to expect that nodetails will be falsied. Adult patients may also not wish to share anydetails with family and friends. Given these, the relatives may believe



10/18

73

Tread with Care

that certain aspects of the news should be withheld from the patient.In fact, it is advisable to understand the fears the relatives have, andtheir reasons for this, regarding divulging bad news to the patient. Thesituation must thus be duly considered and discussed, if the patient is anormal adult. In the case of minor, mentally deranged or seriously sickpatients, the views of the guardians would apply. Enlisting the supportof the family and relatives of the patient almost always makes matterseasier for the healthcare-provider, humane and just for all concernedand makes for continued family support and caregiving.

One must also keep in mind country-specic legislation governingdisclosure. In certain countries, there are guidelines regarding disclosureof content to the patient and relatives. In other countries, it is illegalto hide from the patient any news regarding diagnosis, treatment and

prognosis.

In the following two typical scenarios, lets look at a few questionsfor which the answers go beyond clinical correctness.

Rakesh has moved jobs to meet the growing needs of his family. He is

good at his work but the sole breadwinner in the family. In the past

few months, Rakesh has had regular stomach upsets. Recently, he has

noticed that his stool is of a different colour and that it sometimes has

fresh blood. He hasnt told his wife yet about this but has privately

decided to go for a check-up. On evaluation, the doctor advises blood



11/18

74


tests and endoscopic tests, which Rakesh undergoes. He is shocked

when the doctor tells him that he has seen a mass in the colon which,on tissue analysis, reveals malignancy. The doctor also tells Rakesh

that he will need surgery and medical treatment thereafter. As he

hears the doctors diagnosis, Rakesh gapes in disbelief. He asks the

doctor to divulge the matter to neither his family nor his employer.

In the case above, the doctor is certainly bound by Rakeshs decisionregarding condentiality. But are there other factors to consider thatwould govern the doctors agreement to withhold information aboutRakesh from his family?

Mr Gupta leads a retired life. Over the past month, he has had

indigestion, vomiting and distension of the abdomen. Now he has

also developed jaundice, for which he is admitted for evaluation. The

tests ultrasound, CT scan, endoscopy, biopsy and blood tests are

taking painstakingly long, making him edgy and irritable. Mr Gupta

is still waiting for some of the reports. His 28-year-old son, Akash, is

clearly worried, too, and Mr Gupta wonders if Akash knows about

some reports that he doesnt. Are they hiding anything from me?

he thinks.

Should the physician use his discretion in deciding who shouldget what news and how much or must it be only the patient and therelatives who decide about the divulging of the news?

The formal process of breaking bad news

The process of breaking bad news can be divided into four stages,preparation,performance,palliation andplanning.

Preparation. Before breaking bad news, one must prepare oneself, the

place and the patient.The physician. The physician has a dual role: to be professional while

being sympathetic to the patient. Therefore, before setting out to discloseinformation about the illness, the doctor must be well-informed aboutthe disease and its prognosis, course and treatment. Because the newscan be shattering for the patient and the family, it is best if they hear itfrom a senior doctor who has been attending to the patient. It is vitalfor the doctor to meet the patient and relatives as soon as possible, sothat they are not kept waiting in suspense. Breaking the news earlierrather than later in the day may also help the doctor be at his best



12/18

75

Tread with Care

energy levels. The physician must also be prepared to spend sufcientuninterrupted and unhurried quality time with the patient and thefamily, neither letting his thoughts wander nor losing focus. During the

interview, interruptions and distractions should be avoided. To achievethis, the senior doctor could make prior arrangements for a colleagueto take all his calls so that a ringing pager or cell phone does not causeinterruptions and the conversation is as calm and unhurried as possible.The doctor also needs to guard against succumbing to misgivings abouthis own inadequacy, helplessness and fear of hurting the patient.

The place. The place of the interview is a key factor. As far as possible,such an interview should not be held in a hallway, where there is neitherprivacy nor condentiality but where, on the contrary, distractions and

hindrances abound. Even a ward is best avoided. Ideally, the discussionshould take place in a room set apart for the purpose, which is quietand affords maximum privacy. A secluded room, with enough space forthe physician, a colleague, the patient and a few relatives would sufce.Adequate seating arrangements, including the provision of appropriatecomfort for the patient, are essential. This not only helps the healthcare-provider to sit in close proximity to the patient, but also provides room forgestures and nonverbal communication such as an empathetic touch onthe shoulder of the patient. A glass of water and a box of face tissues helpconsiderably, as such little comforts often mean a great deal to the patient

Figure: 4 Stages in the process of breaking bad news



13/18

76


and the immediate family, who are never really prepared to receive the

bad news. However, when a suitable place is just not available, shift thepatient to a corner bed in the ward and cordon it off with curtains. If eventhat option does not exist, try having a private conversation in a cornerof the out-patient clinic.

The patient. The patient also plays a pivotal role in making theconversation a success. Firstly, for the doctor to be able to get the messageacross, the patient should be in a sufciently t state to comprehend theinformation being given. It is worth asking the patient if they would likecertain relatives to be present during the conversation. The patient may

decline to receive any information, requesting one or more relatives toreceive the news instead. This should be respected and, only over time,with permission from the patient, should the doctor share informationgradually with the patient.

Performance. This stage concerns the actual event of breaking the badnews.

Delivering bad news is unduly challenging, demanding andupsetting if any of the parties concerned is improperly or insufcientlyprepared. It is wise, therefore, to attend to the mechanics of sharing badnews. All parties should be introduced to one another from the outset.



14/18

77

Tread with Care

Allow only a restricted number of people to sit in on the meetings,

whether from the patients or the care-providers side, and try to ensurethat the same individuals are present for future discussions also.

The patient and relatives expect the news to be shared with themwith directness and concern. The doctor should use language that issimple, sensitive and straightforward, free from jargon and advancedmedical terminology (e.g. piece of tissue for examination instead ofbiopsy, spread instead of metastasis, etc). Flow charts, diagramsand pictures can be very useful in explaining and reinforcing themedical information to be conveyed. Wherever advisable and possible,

use audiovisual inputs also.

Although the doctor should provide as much (rather than as little)information as possible, care should be taken to not cause informationoverload on the patient or the family. Instead, a series of informationcapsules may be planned. While sharing the news, deliver it withappropriate pauses to ensure that the information is sinking in. Askquestions, particularly during the initial phase of the conversation, toelicit the level of understanding and understand the emotions evokedin the patient and relatives. Be prepared to repeat yourself patiently.

The doctor should be on the lookout for the patient expressingemotions such as gloom, shock, grief, guilt, self-reproach, desolationand denial. An understanding of the gestures and body language of thepatient and the relatives is also essential and informative. In response,the doctor may make empathetic statements such as:

I can see how upsetting this is for you.

I know this is not good news for you.

Im sorry to have to tell you this.

This is very difcult for me also. I can help you share it with your parents, if you wish.3

Palliation. Palliation has to do with furnishing supportive responses topatients when they react to the bad news being broken to them.

Being involved with the patient helps the physician to takea major leap in strengthening trust and preparing the patient forfurther treatment. After getting the bad news, the patient may gothrough one or more phases of intense, deep emotion. Patientsmay evince a ght/ight response, including displaying extreme



15/18

78


aggression, distress or withdrawal, refusing to go ahead with anymore discussion and repeatedly asking questions such as Why is

this happening to me?While explaining that these emotions are normal and appropriate

to experience, the doctor may ask the patient to describe their feelings.Holding the hand of the patient, gently touching their shoulder inreassurance or engaging in compassionate eye contact play a major rolein expressing empathy, acknowledging the pain and offering comfortand encouragement.

Pausing at strategic points during the discussion allows the patientto comprehend and assimilate the information shared and prepare

questions for the next phase. Empathising and active listening help thepatient give vent to their thoughts and feelings.

Periods of silence, too, are important. They allow one to get intouch with ones emotions and particularly help the doctor to enterthe patients world with deeper understanding. During these periodsof silence, the healthcare-provider should observe what the patient isdoing, hear what they are saying, try to feel what they feel and sensewhat they would like to but cannot verbalise. By using the techniqueof silence, the care-provider helps the patient to work through their

emotional state.



16/18

79

Tread with Care

Planning. This phase allows the planning of treatment and continued

care for the patient.

Planning forms the nal phase of the process of breaking bad newsto a patient and should commence after the patient and relatives havehad the needed time to compose themselves and collect their thoughts(the sign that they have assimilated the news). At this point, check forany unanswered questions the patient and relatives might still have, andaddress them.

Thereafter, proceed with the management of the illness, establishinga step-by-step plan that includes appropriate referrals, gatheringadditional information or performing further tests. If the patient hasany immediate symptoms, then treatment should be administeredand a plan made for further therapy. This may include emotionaland practical support from family, friends, a social worker, a spiritualcounsellor, a peer support group, a professional therapist, a hospice, ahome health agency, etc. It reassures the patient that they are not beingabandoned and that a multidisciplinary team will be actively engagedwith them on an ongoing basis.

The physician should maintain accurate records and document the

salient features of the interview, for future reference the content of theinterview, the attitudes and behaviours of the patient and relatives, anyuntoward or exceptional events, future plans, etc.

It is important to convey to the patient and the family that thephysician or the medical team are close at hand. A system of regularfollow-up appointments must also be set up.

The real challenge which the physician faces in delivering badnews is in disclosing news of death. The culmination and climax of thedelivery of bad news actually begins in the face of death. It can be invarious situations explaining to the patient or the relatives that deathis imminent, explaining about a death which has suddenly happenedor a death which was expected.

Conveying news about death

Sometimes, the most challenging disclosure of bad news concernsdeath and dying. For the healthcare-provider, it is the supreme test ofhow well the physician has internalised and practised the four stages ofthe process of breaking bad news because it results in ultimate shock.



17/18

80


I am reminded of a fragment from words inscribed reportedly on anIrish grave: Death leaves a heartache no one can heal....

In breaking the news about death, the characteristics, principlesand phases discussed in this chapter apply. However, seven points

must be kept uppermost in mind:Sensitive communication. No specic timelines of involvement maybe decided between the physician and the patient and relatives. It maytake days, weeks or months for the medical team to bring the patientand relatives to a place from where they can cope with the inexorablerealities. Unhurried interaction is essential. The use of silence toacknowledge loss cannot be overemphasised. When patients areconscious and of sound mind it is good to ask them if they have anywishes they would like fullled.

Stress management. The event (i.e. the disclosure) is often extremelycontrary to normal human expectation. Patients and relatives arethrown into acute emotional and physical crises, as a result. Healthcare-providers need to manage the acute stress responses of the affectedpersons, including their own reactions.

Collaborative care. While, on many counts, the doctors presence and

medical care from the institution will be needed, the family and relatives

should be entrusted with taking charge of permissible palliativemeasures for the patient, e.g. administering pain-killers, treating

bed sores, feeding, shaving, sponging, putting on diapers, etc. This



18/18

81

Tread with Care

can bring empowerment and a sense of responsibility and belonging

between patient and caregiver and create a lasting bond between thepatients family circle and the healthcare organisation.

Signs of imminence. The signs of imminent death must be conveyedclearly to all concerned. Medical practice suggests that the doctor waits for

a couple of minutes before conveying the news simply, in straightforward

language, using no technical jargon, after which one stays for several

minutes with the family, taking care not to leave the room immediately.

Social and religious rituals. Patient, relatives and healthcare staff

should address the need for social and religious preparations for the

one who is dying.

Stigmatisation. On occasion, stigma is associated with death, and this,

too, requires wisdom, sensitivity and tact on the part of the healthcarestaff to handle. Typical situations include AIDS deaths, suicides and

culpable or accidental deaths. For the family, shame, guilt and anger are

added to shock, grief, denial, confusion and helplessness. It is therefore

crucial that healthcare-providers take a lead role in offering care andsupport in such situations.

Counselling. Help from a personal counsellor should be at hand toguide the patient and relatives through this nal journey. Although not

necessary in every case, counselling support goes a long way to help

the affected in coming to terms with permanent, ultimate loss.

Summary

This chapter has explored the seriousness, sensitivities and necessity of

breaking bad news in healthcare contexts to patients and their family

and relatives. It has shown, however, that the ability to break bad

news in a professional but humane manner regarding health issues is

a skill that may be learnt. Accordingly, the chapter suggests guidelines

and pointers to healthcare-providers on how they may break bad

news and recommends a number of practical steps, organised in four

phases preparation, performance, palliation and planning.

Take-home message

When we can do nothing to make a material difference to someones

pain, we can offer our presence.

communicate. care. cure. (sample pages)

Documents