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  1. What are some practical methods of breaking bad news at any stage of disease?

  2. 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. Communication strategies vary based on the 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 among 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.

Communication skills are essential for all physicians, as they develop rapport, gather and relay information, and help patients make informed decisions. Although communication in medicine often involves the family as well as the patient, this is particularly the case in palliative care. The parties involved often have divergent perspectives, stemming from diverse generational, educational, socioeconomic, cultural, and spiritual backgrounds, that can have a profound effect on physician–patient/family interactions. It is important not to generalize and to realize that 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. 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.

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 assessing what the patient knows (and identifying and acknowledging any associated emotions), tell the patient any additional information and/or clarify misconceptions. Perhaps most importantly, follow up by asking another question to both ensure that the patient understands and that you have understood the emotional impact on the patient. When in doubt, it is useful at ask, “Do you have any questions?”

The communication of bad news is difficult for both the clinician and patient. Although ...

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