IPOS LECTURE Communication skills as the first level of psychosocial care
Luzia Travado, PhD Psycho-oncology, Champalimaud Clinical Center, Lisbon, Portugal
International Psycho-Oncology Society, Past-President
Founded in 1984, IPOS was created to foster the science and practice of psychosocial
oncology to improve the care of people affected by cancer worldwide.
IPOS promotes global excellence in psychosocial care of people affected by cancer
through partnerships, research, public policy, advocacy and education.
Through its Federation, IPOS represents more than 7,000 professionals in more than
60 countries.
www.ipos-society.org
Lisbon, Portugal
SUMMARY
• Communication skills in oncologists education
• Impact of cancer and distress in cancer patients
• Levels of psychosocial support
• Intl distress management guidelines
• Communication skills as psychosocial care
• Communication and basic communication skills
• SPIKES protocol
• Handling difficult conversations
IPOS - Luzia Travado
CST
• Questions
Patient
Emotional and Psychological problems
fear, sadness, worries, despair, loss of autonomy and control, change
of self-image
Problems with the health care system
impersonal treatment, lack of time, lack of intimacy, terminology hard
to understand
Physical symptoms and functional problems
pain, fatigue, dysfunction, sexual, apetite, sleep, psychosomatic
symptoms, disabilities
Impact of Cancer and its consequences
Family and interpersonal
uncertainty regarding social roles and tasks, separation from partners,
children
Social, financial, and occupational strain
Responsibility of important social and occupational functions, new
dependencies
Existential and spiritual problems
Confrontation with the mortality of one’s own life, search for meaning,
consolation; spiritual, religious, philosophical explanations
Koch & Mehnert, IPOS 2005 www.ipos-society.org
DISTRESS in Cancer
Distress is a multifactorial unpleasant emotional
experience of a psychological (i.e., cognitive,
behavioral, emotional), social and/or spiritual
nature that may interfere with the ability to cope
effectively with cancer, its physical symptoms, and
its treatment. Distress extends along a continuum,
ranging from common normal feelings of
vulnerability, sadness and fears to problems that
can become disabling, such as depression, anxiety,
panic, social isolation and existential and spiritual
crisis.
NCCN Clinical Practice Guidelines in Oncology,
Distress Management, 1997-2018
L Travado
DISTRESS CONTINUUM
Sub-sindrome
15-20%
Severe Distress
Psychosocial morbidity
25 - 45%
Maladjustment Anxiety
Depression Adapted from J.Holland, IPOS, 2005
www.ipos-society.org
( Early Breast Cancer = 32 %; Advanced Breast Cancer = 60%)
Normal Distress
adaptation
35 - 45%
Worries Fears Sadness
Recommended 4-tiered Model of Professional
Psychological Assessment and Support
Level Group Assessment Intervention
1 All health and social
care professionals
Recognition of
psychological
needs
Effective information giving
compassionate communication
and general psychological
support
2
Health and social care
professionals with
additional expertise
Screening for
psychological
distress
Psychological techniques such as
problem solving
3
Trained and
accredited
professionals
Assessments for
psychological
distress and
diagnosis of
some
psychopathology
Counselling and specific
psychological interventions such
as anxiety management and
solution-focused therapy, delivered
according to an explicit theoretical
framework
4
Psycho-oncologists or
Mental health
specialists
Diagnosis of
psychopathology
Specialist psychological and
psychiatric interventions such as
psychotherapy, including CBT
NICE guidance. Improving Supportive and Palliative Care for Adults with Cancer: The Manual 2004.
N=4496 cancer patients before treatment; 35,1%
Consequences of Psychological Morbidity in
Cancer Patients: impact on Clinical outcomes
Deterioration of Quality of Life
Reduced compliance w/ treatment
Less efficacy of chemotherapy
Higher perception of pain and other symptoms
Shorter survival expectancy
Longer hospital stay and increased costs
Burden for the family
Higher risk of suicide
Parker et al., Psychooncology, 2003; Colleoni et al., Lancet, 2000; Walker et al., EJC, 1998; Spiegel et al., Cancer, 1994; Faller et al., Arch Gen Psychiatry, 1999; Watson et al., Lancet, 1999; Pitceathly & Maguire, EJC, 2003; Prieto et al., J Clin Oncol., 2002; Henriksson et al., J Affect Dis, 1995; Grassi et al. 2005; McDaniel et al. 1995, Ehlert 1998,
Saupe & Diefenbacher 1999, Linton 2000, Cavanaugh et al. 2001, Härter et al. 2001, Carlson & Bultz, 2004; Watson et al., 2005
adapted from Grassi & Yosuke, IPOS online curriculum: www.ipos-society.org
IPOS Statement on Standards and Clinical Practice Guidelines in Cancer Care (2009 updated 2014)
Psychosocial cancer care should be recognised as a universal human right;
Quality cancer care must integrate the psychosocial domain into routine care;
Distress should be measured as the 6th vital sign after temperature, blood pressure, pulse, respiratory rate and pain.
Endorsed by UICC and 75 cancer organizations worldwide
Since its adoption by IPOS and the IPOS Federation of
Nat’l Psycho-oncology Societies in 2010, the Standard has
been endorsed by 75 organisations worldwide.
In 2013 the Union for International Cancer Control (UICC)
revised the World Cancer Declaration to include the
codification of distress screening:
Target 8: Effective pain control measures, and distress
management, will be available to cancer patients in all
countries.
Integration of Psychosocial Oncology Care in Routine Oncology IPOS - Luzia Travado
Psycho-oncology services provide effective (evidence-based, RCT’s) interventions for:
(a) reducing distress and preventing psychosocial morbidity associated w/ cancer
(b) improving patients’ skills to cope with the demands of treatment and the uncertainty of the disease
(c) improving their Quality of Life
(d) improving clinical outcomes
>> And are cost effective as well as general health costs reductive
Psychosocial Oncology Care is an
important element of high-quality care
Integration of Psychosocial Oncology Care in Routine Oncology IPOS - Luzia Travado
Recommended 4-tiered Model of Professional
Psychological Assessment and Support
Level Group Assessment Intervention
1 All health and social
care professionals
Recognition of
psychological
needs
Effective information giving
compassionate communication
and general psychological
support
2
Health and social care
professionals with
additional expertise
Screening for
psychological
distress
Psychological techniques such as
problem solving
3
Trained and
accredited
professionals
Assessments for
psychological
distress and
diagnosis of
some
psychopathology
Counselling and specific
psychological interventions such
as anxiety management and
solution-focused therapy, delivered
according to an explicit theoretical
framework
4
Psycho-oncologists or
Mental health
specialists
Diagnosis of
psychopathology
Specialist psychological and
psychiatric interventions such as
psychotherapy, including CBT
NICE guidance. Improving Supportive and Palliative Care for Adults with Cancer: The Manual 2004.
Communication skills
are the cornerstone of doctor-patient relationship and a critical factor for comprehensive quality care in oncology
Michael Levy MD, ASCO 1998
Communication skills in cancer care Luzia Travado
The way in which health care professionals communicate with patients has implications for:
> Quality of relationship provider-patient
> Patient’s adjustment and clinical outcomes
> Patient’s satisfaction
> Professional’s satisfaction and well-being (less burnout)
> Health care economy
Communicating bad news to cancer patients Luzia Travado
Good communication skills can be taught and facilitate addressing patients’ concerns, fears and needs, detection of
emotional problems and provision of basic emotional support (1st level of psychosocial care) >> patient-centered care model.
Epstein RM, Street RL Jr. Patient-Centered
Communication in Cancer Care: Promoting
Healing and Reducing Suffering. National
Cancer Institute, NIH Publication No. 07-
6225. Bethesda, MD, 2007.
Effective patient-clinician
communication is central
to the delivery of
high-quality care.
It is crucial in the cancer
setting where patients
have to deal with stress,
uncertainty, complex
information, and life-
altering medical
decisions.
Communicating to cancer patients Luzia Travado, PhD
Communicating bad news to cancer patients Luzia Travado
Communicating to cancer patients Luzia Travado, PhD
Gilligan et al., JCO, 2017
Communicating bad news to cancer patients Luzia Travado
https://mediaplayer.mdanderson.org/video-full/494F4798-
A61C-11E3-977D-60D819FC683C (59’’)
MDAnderson I*Care Program Walter Baile
•What is the emotion that the patient is expressing?
Video: effective communication with patients - 1
What is Communication?
•verbal and non-verbal behavior which conveys thoughts, attitudes,
feelings, ideas and information
•a circular process:
sender receiver (sender) receiver
•impossible not to communicate
(silence is a form of communication)
•influenced by several variables (e.g. beliefs, emotions, socio-cultural,
environmental context)
•persons (patients) are not passive recipients of information, they
actively construct ideas and meanings about what they are told
Communicating bad news to cancer patients Luzia Travado
Doctor’s
knowledge (meanings about: health,
disease, treatment, future,
QoL, etc.)
Specialist in medicine
Patient’s knowledge (meanings about: health, disease,
treatment, future, QoL, etc.)
Specialist in their own life
Dialetic
s
Dialectics between doctor and patient: open discussion by the
doctor/healthcare professional about the treatment options, their
benefits and risks, and the patient about their preferences, needs,
concerns and expectations >> patient-centered care approach
The clinical encounter
Doctor’s knowledge (meanings about: health,
disease, treatment, future,
QoL, etc.)
Specialist in medicine
Patient’s knowledge (meanings about: health,
disease, treatment, future,
QoL, etc.)
Specialist in own life
Dialetics
Dialectics between doctor and patient: open discussion by the doctor/healthcare professional about the treatment options, their benefits
and risks, and the patient about their preferences, needs, concerns and expectations >> patient-centered care approach
The clinical encounter
L Travado, CCC 2015
Basic communication skills*:
• active listening, eye contact, attentive posture
•open-ended questions (*’ask-before-you-tell’)
• clarification
• encouraging patients to express concerns and emotions
• screening for problem areas
• respond to cues
• respond to emotions: empathize – validate – explore
* Good Communication skills allow for patient-centered care, focused on patients’ preferences; it is important to tailor information to patients’ needs, as preferences for the amount, type and timing of information vary; importance of balancing honesty with hope and empathy
Communicating bad news to cancer patients Luzia Travado
Communicating bad news to cancer patients Luzia Travado
The Oncologist, 2000; 5:302-311.
Breaking Bad News
The main objective is to separate
THE MESSENGER from THE MESSAGE
so that even though the message is bad,
the messenger can be seen
as part of the support system
Walter Baile, IPOS, 2005
IPOS online curriculum
www.ipos-society.org
Communicating bad news to cancer patients Luzia Travado
S-P-I-K-E-S Protocol
Six Steps in Giving Bad News
SPIKES
Setting up the interview
Perception of the illness
Invitation
Knowledge: what and how much
Emotions: how to address
Strategy & Summary
Baile, Buckman et al, The Oncologist 2000
S-P-I-K-E-S Protocol
STEP 1: SETTING UP the interview
Goals: Prepare for the interview Create “rapport” Put patient at ease Facilitate information exchange
Procedures: Reflect Arrange uninterrupted time Who should be there? Sit down Kleenex handy Eye contact Patient should be ready Walter Baile, IPOS, 2005
IPOS online curriculum
www.ipos-society.org
S-P-I-K-E-S Protocol
STEP 2: Find out the patients PERCEPTION of the illness
Goals: To determine information gaps
To assess “denial” and its mimics To create rapport
To understand patient expectations and concerns
Procedures: Use open-ended questions: “Tell me what you’ve been told”; “I’d like to make sure you understand the reason for the tests” Correct misinformation and misunderstanding
Address “denial” Address unrealistic expectations
Define your role Walter Baile, IPOS, 2005
IPOS online curriculum
www.ipos-society.org
S-P-I-K-E-S Protocol
STEP 3: Get an INVITATION from the patient to give information
Goals: To determine how much information the patient wants and when to give it
To acknowledge that patient information needs may change over time
Procedure: Ask “Are you the type of person who wants information in detail or….”
Walter Baile, IPOS, 2005
IPOS online curriculum
www.ipos-society.org
S-P-I-K-E-S Protocol
STEP 4: Giving the patient KNOWLEDGE and information
Goals: To prepare the patient for the bad news
To ensure patient understanding
Procedures: Forecast the arrival of bad news— “I’m afraid I have some bad news for you….”
Give the information in small chunks
Check for patient understanding
Avoid jargon
Address all questions Walter Baile, IPOS, 2005
IPOS online curriculum
www.ipos-society.org
S-P-I-K-E-S Protocol
STEP 5: Responding to patient EMOTIONS
Goals: To acknowledge emotional responses
To facilitate emotional “recovery”
To acknowledge our own emotions
Procedures: Expect emotions and be prepared for them
Use empathic response to emotions such as crying
Clarify emotions you are not sure about
Validate patient feelings
Walter Baile, IPOS, 2005
IPOS online curriculum
www.ipos-society.org
E-V-E
Each response to an emotion should be one of these
• EXPLORING
• VALIDATING
• EMPATHIZING
Three techniques for addressing EMOTIONS
Walter Baile, IPOS, 2005
IPOS online curriculum
www.ipos-society.org
Addressing Patient Emotions
Technique Example Outcome
Exploring “Can you tell me what
you are thinking right
now?”
Patient feels you are
interested
Validating “It’s very common for
patients to feel this
way.”
Patient feels “normal”
Empathizing “I can see how
upsetting this is to
you.”
Patient feels you are
“tuned-in”
Empathizing+Validating+Exploring= SUPPORT
Walter Baile, IPOS, 2005
IPOS online curriculum
www.ipos-society.org
S-P-I-K-E-S Protocol
STEP 6: STRATEGY and SUMMARY
Goal:
To ensure that there is a clear, negotiated plan for the future
Procedures:
Make treatment recommendations
Check patient understanding
Provide options for treatment
Understand barriers and concerns
Communicate your role
Walter Baile, IPOS, 2005
IPOS online curriculum
www.ipos-society.org
Communicating bad news to cancer patients Luzia Travado
https://mediaplayer.mdanderson.org/video-full/494F4798-
A61C-11E3-977D-60D819FC683C (59’’>3:30’- 4:45’)
MDAnderson I*Care Program Walter Baile
•What is the emotion that the patient is expressing? •What steps skills and techniques did you see happening in this encounter? •What did you see that you like and what didn’t you like? •What would you do next after the patients express her emotions?
Video: effective communication with patients - 2
E-V-E
Each response to an emotion should be one of these
• EXPLORING
• VALIDATING
• EMPATHIZING
Three techniques for addressing EMOTIONS
Walter Baile, IPOS, 2005
IPOS online curriculum
www.ipos-society.org
Exploring questions
• Patient says:
– “Tell me, what will the end
be like?”
– “I feel like such a burden to
my husband”
– “I’m just not going to take
anymore chemo…”
– “Don’t tell my father about the
recurrence. He can’t take it”
– “I prefer that you help me to
die than to endure this more”
• You can say:
– “What has been worrying
you?”
– “Burden…?”
– “Tell me more about it…”
– “Can you tell me what you
think might happen?”
– “Can you please explain me
this a bit more? What is your
concern? Your fear? adapted from Baile W (MDACC). IPOS 2005.
The objective is to clarify what the patient is implying, feeling
or asking when it is not obviously clear
Validating statements
• Patient says:
– “I’m really undecided whether
to risk another surgery”
– “I feel guilty about putting my
family through this again”
– “Those steroids can really
make me feel weird”
• You can say:
– “A lot of patients struggle with
the same decision…”
– “That’s often something I
hear from my patients”
– “They’re known to do that”
Baile W (MDACC). IPOS 2005.
The objective is to legitimise the patient’s thoughts or feelings
Responding to emotions
Baile W (MDACC). IPOS 2005.
• The empathic response
– Identify the emotion (theirs or yours)
– Identify the source of the emotion
– Respond in a way that shows you have made a
connection
• You don’t have to feel the emotion yourself
• You don’t have to agree with the viewpoint
Empathic statements
• Patient (feels) says:
– (Defeated) “I just don’t know
how much I can take”
– (Sad) “I was expecting a
better result…”
– (Stunned) “You mean I need
more surgery?”
• You can say:
– “It sounds like it has been
pretty rough”
– “So was I. I know this comes
as a shock…”
– “I know you weren’t
expecting to hear this…”
Baile W (MDACC). IPOS 2005.
The goal is to acknowledge the patient’s feelings
Empathic statements
• Patient (feels) says:
– (Anger) “No one told me
it would take so long
to recover”
– (Happy) “It’s so great to have
a normal scan”
• You can say:
– “It’s been very frustrating
for you”
– “I can see, I’ve made
your day”
Baile W (MDACC). IPOS 2005.
The goal is to acknowledge the patient’s feelings
Pearls in difficult communications
• Invite the conversation – don’t force, don’t say
“we need to talk about…!”
• Respond to emotion – acknowledge the loss,
empathy
• Reaffirm your commitment to the patient
• Praise the patient and the family e.g., you’ve put
up with a lot of difficult treatments…”
• ‘Hope for the best prepare for the worst’ – in
advanced disease Baile W (MDACC). IPOS 2005.
Communication skills in cancer care Luzia Travado
Communicating bad news to cancer patients Luzia Travado
Communicating bad news to cancer patients Luzia Travado
PALiMo Recommendations
• PREPARE
• ASK
• LISTEN
• MOTIVATE (hope)
MBC2 Summit, 2017
Communication is a critical core competence essential in supporting patients and families
•can be learned and improved with training
•benefits patients (reduces anxiety)and professionals (reduces burnout)
•have been recommended to be part of routine education for healthcare professionals in cancer settings
•still enormous lack of formal training in academic settings and in continuous education:
EU survey conducted under EPAAC: 19/27 countries (70%) referred to having CST resources, and 17/27 countries (63%) said they provide CST during medical education
[Travado L, Reis JC, Watson M, Borras J. Psychosocial Oncology Care Resources in Europe: a study under the European Partnership on
Action Against Cancer [EPAAC]. Psycho-oncology, 2015 Dec 21. doi: 10.1002/pon.4044. [Epub ahead of print]
IPOS Luzia Travado PhD
Luzia Travado
IPOS – ESO Online Curriculum
Communication and Interpersonal Skills in Cancer Care by Walter Baile, MD (USA)
Anxiety and Adjustment Disorders in Cancer Patients by Katalin Muszbek, MD (Hungary)
Distress Management in Cancer Patients by Jimmie C. Holland, M.D, USA
Depression and Depressive Disorders in Cancer Patients by Luigi Grassi, MD (Italy) and Yosuke Uchitomi, MD, P.D (Japan)
Psychosocial Assessment in Cancer Patients by Uwe Koch, MD, PhD & Anja Mehnert, PhD (Germany)
Cancer: A Family Affair by Lea Baider PhD (Israel)
Loss, Grief and Bereavement by David Kissane MD (Australia)
Palliative Care for the Psycho-Oncologist by William Breitbart MD (USA)
Ethical Implications of Psycho-Oncology by Antonella Surbone MD, PhD, FAC (Italy)
Psychosocial Interventions: Evidence and Methods for Supporting Cancer Patients by Maggie Watson PhD and Barry Bultz PhD (UK, Canada)
Multilingual Curriculum on Psychosocial Aspects of Cancer Care (English, French, German, Hungarian, Italian, Spanish, Portuguese, Chinese, Japanese)
www.ipos-society.org
www.ipos2018.com
THANK YOU
Clinical practice guidelines: NCCN Distress Thermometer & Problem List
National Comprehensive Cancer Network, 2015