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INTRODUCTION

Key Clinical Questions

  • image What are some practical methods of breaking bad news at any stage of disease?

  • image How do you maintain hope while discussing goals of care in the context of a poor prognosis?

Palliative care requires excellent communication skills. Clinicians navigate difficult situations including prognostication, breaking bad news, discussing hospice, and planning for the end of life, while acknowledging and addressing physical, psychological and spiritual distress for both the patient and family. Before focusing on details for each of these situations, physicians must establish basic goals of care. Communication strategies may vary based on individual preferences of the patient and family, cultural norms, the context of the situation, and the patient’s stage of disease. The latter may be divided broadly into the time of diagnosis, the transition toward palliative care, and the time leading up to and including the patient’s death. This chapter will describe approaches to communication for situations that arise commonly in the treatment of patients with life-threatening illnesses.

GENERAL COMMUNICATION SKILLS

Communication skills are essential for all physicians, as they develop rapport, gather and relay information, and help patients make informed decisions. It is important to keep in mind that the parties involved often have divergent perspectives, stemming from diverse generational, educational, socioeconomic, cultural, and spiritual backgrounds, which can have a profound effect on physician-patient/family interactions. Thus, diverse viewpoints may coexist within any one seemingly similar group. For this reason, it is essential to elicit individual communication preferences, rather than assuming that these fall neatly into a specific category.

All clinical interactions have emotional as well as informational elements. The exploration of a patient’s previous experiences may add invaluable information or insight to the conversation, as certain experiences, such as having been a caregiver for a dying family member, increase the patient’s readiness to have his or her own end-of-life discussions. Effective communication requires that clinicians recognize their own emotions in addition to those of patients and families. Likewise, communication has verbal and nonverbal components and it is important to recognize and respond to nonverbal cues in addition to listening for verbal ones and eliciting concerns. Respect and empathy are paramount, and both can be expressed verbally or nonverbally in very little time. In contrast to entering a room looking at the chart instead of the patient, the simple gesture of making introductions to everyone present speaks volumes as one begins the clinical relationship.

COMMUNICATION PRACTICES

While each encounter between clinician, patient, and family will be unique, there are basic communication skills that may facilitate difficult conversations. Open-ended questions promote greater understanding and are used to start the “Ask-Tell-Ask” approach, which lends itself to almost any clinical interaction (Back et al, 2008). When first communicating with a patient about a particular issue, such as diagnosis or prognosis, start by asking what the patient understands about her illness. After ...

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