BAOJ Palliative medicine Anuradha Lele Mookerjee, et al., BAOJ Pall Medicine 2017 3: 1 3: 027
Short Communication
Art of Sensitive Communication in Patient and Family Centered Care Anuradha Lele Mookerjee1, Meera Rajput2 and Vijay Rajput3* 1
Associate Professor of Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA Undergraduate Student, University of Pittsburgh, PA, USA
2
Professor & Chair of Medicine, Associate Dean, Academic & Student Affairs, Ross University School of Medicine, Miramar, Florida, USA
3
Abstract Caring and communicating sensitively with the patient and the family members, has demonstrated to be a complex interaction of medical science closely interfacing with the political, social, cultural and economic systems. Most levels of patient care require rapid decision making that is often based on incomplete or ambiguous information. This coupled with a lack of prior compassionate, honest and transparent patient-physician relationship; can cause difficulty in establishing trust between the two parties. When caring for patients who have poor decision-making capacity, the physician is faced with added challenges and often needs to rely on the family members to guide during the decision-making process. Effective communication skills are crucial at every step of the way; since they enable strong bonds and enable patient-centered comprehensive and coordinated care, with better outcomes. Sensitive communication with patients and their families encompass various medical situations which include conversations about goals of care, withdrawal or withholding of treatment, end of life care, withholding of Artificial Nutrition Hydration (ANH), Brain Death and DCD (Donation after cardiac death). In certain cultures, terminal and critical illness is experienced equally by both the patient and their family. The sensitive communication exchanged between physicians and patients and families requires strong collaboration between all inter-professional team members who are involved in the care of the patient. A high level of language ability is required for both giving and understanding medical directives and other instructions. Both oral speaking and receptive listening skills are necessary for effective communication between the health care provider and the patient and caregivers.
Introduction Effective communication for all sensitive situations is the corner stone for individualized patient centered care, leading to more efficient health care delivery and more desirable patient outcomes. To provide best available care, health care professionals should understand the personal narrative of their patient’s illness and offer the best possible treatment options available at that moment. Care givers along with the patients; express greater satisfaction of care, better compliance with treatment plans and enhanced recall and understanding of the information received, when they perceive that their physician has communicated honestly. Physicians’ poor communication skills and lack of understanding, have been the cause of many a malpractice claim. Doctors who are trained outside the United States must recognize the nuanced differences BAOJ Pall Medicine, an open access journal
between U.S. spoken English and English from their home country. There are significant regional language variations within the U.S. and across patient populations that need to be considered as well.
Guidelines for Effective Facilitation of Sensitive Communication Sensitive communication with patient and their families must entail a universal, holistic and a multidisciplinary approach. A physician must be able to discuss sensitive issues in a tactful and reassuring manner. The physician must also be able to communicate with other hospital team members and staff. The medical or surgical attending should be accompanied by the nurse, the social worker, the nurse manager, the chaplain and any other team member who will be useful in building a valuable trust in having a meaningful conversation. Prior to meeting the family, the patient care team should discuss their position and perception about the prognosis and come to a consensus regarding goals of care. It is important to note that, face to face dialogue is far superior to communication over the phone, unless the family is living far and cannot be at the bedside. Patients and families may get their information from the internet, so it is important for physicians to educate themselves from internet sites, and offer help and clarification about the clinical situation. It is important to carve out plenty of quality time and have immense patience to navigate the difficult circumstances. Challenging situations can lead to complex ethical dilemmas. At this juncture, the hospital Bio- ethics committee should be consulted to iron out the differences, and to reach a meaningful outcome. One study *Corresponding author: Vijay Rajput, Academic & Student Affairs, Ross University School of Medicine, 2300 SW 145THave, Suite, 200, Miramar, Florida, USA, Tel: 609 5606009;E-mail:
[email protected] Sub Date: February 20, 2017, Acc Date: February 28, 2017, Pub Date: February 28, 2017. Citation: Anuradha Lele Mookerjee, Meera Rajput and Vijay Rajput (2017) Art of Sensitive Communication in Patient and Family Centered Care. BAOJ Pall Medicine 3: 027. Copyright: © 2017 Anuradha Lele Mookerjee, et al. This is an openaccess article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Volume 3; Issue 1; 027
Citation: Anuradha Lele Mookerjee, Meera Rajput and Vijay Rajput (2017) Art of Sensitive Communication in Patient and Family Centered Care. BAOJ Pall Medicine 3: 027.
found that care givers, physicians and other health care workers found ethics consultations helpful and would request hospital ethics committee consultations in the future[1].When there is a need for facilitating conflicts, and building a consensus on the patient’s care plan; the department of Patient relations, the Pastoral care services and the Risk management team should also be consulted and invited for the family meeting. The Power of Attorney (POA) determination of surrogate decision maker, writing of the Living will and Advance directive should be operated with a judicious multidisciplinary approach. One must acknowledge the patient’s socioeconomic and cultural backdrop and be prepared to handle any bio-ethical dilemmas with the help of the bio-ethics committee.
Dynamic Communication with Patients, Families and Health Care Teams Sensitive Communication is a continuous dynamic process and is not just a single encounter with patients and families. Ongoing communication between family members and the health care team is imperative since it helps caregivers cope with the difficult situation at hand. One beneficial solution could be the presence and participation of family members during patient care rounds in critical care units with physicians and nurses [2]. The health care team needs to be prepared to deal with conflict, anger, sadness, guilt and a multitude of emotions. There have been times when the healthcare professionals were not able to acknowledge or address a family’s emotions in an intensive care unit family conference where end of life issues were discussed [3]. When physicians have difficulty accepting death as an outcome, the family members may experience a sense of abandonment and have difficulty coping with their loss. The enduring support with a recommended action plan from the multidisciplinary team members enables the family members to cope with their grief. A simple telephone call or a letter of condolence can help improve bereavement outcomes in the families[4]. Physicians who listen to family members and are respectful of their viewpoints develop trust and ultimately arrive at a shared plan of care. Focusing on the essential clinical issues, and acknowledging the cultural and religious beliefs of the family members enables a better sense of mutual understanding and leads to more positive outcomes. Physicians who acknowledge family members and patients’ feelings verbally usually avoid any type of misunderstanding from nonverbal communication[5].
The Art of Sensitive Communication Surrounding End of Life Issues Sensitive communication between healthcare professionals and the care giver about the prognosis at end of life is complex and has many confounding variables like language, culture, socioeconomic barriers, and ethical and legal understanding of life and death in that community or region. It is recommended that senior faculty or nursing staff with expertise in the art of sensitive communication should facilitate the family meeting where sensitive material is being communicated. All current and key team members should be present or available to answer any questions from family members. Setting the right environment by introducing all the health care team members is also critical for physicians to build relationships. Solarium or quiet rooms close to the hospital floor should be private and supplied with enough chairs and tissue boxes. Mobile BAOJ Pall Medicine, an open access journal
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phones should be on silent. Phone calls should only be taken in a case of emergency. Physicians should allow family members to talk and develop their understanding of current goals of care and their perception of quality of care for their loved ones. Physicians who receive brief narratives about the life story of the patient often find it easier to navigate the difficult crossroads. Physicians should identify opportunities to share information with patients and caregivers and ask the caregivers what they know about their loved one’s clinical situation. . The team should identify any preconceived myth which may impede communication in that specific clinical situation. The steps in communication need to be conscious and deliberate. Words and sentences can have different meanings to both speakers and listeners, so it is important for physicians to pay extra attention. Words alone do not provide meaning; physicians or patients may have to provide a clearer interpretation of what they mean. It is also ideal to maintain a comfortable distance all the time. Nodding one’s head can be helpful but there may be cultural differences about head nodding. The health care team involved in sensitive communication must overcome barriers such as fear of one’s own mortality, lack of personal experience with death, fear of expressing emotions, and lack of knowledge regarding patient’s clinical plan of care. Previous studies have shown that the physician has been reluctant to discuss prognosis with the surrogate, since the family’s understanding of prognosis is not based on hard scientific data [6]. Hence, the physician’s take on the matter can be equally important in identifying the possible road blocks in this situation and his or her expectations from patient’s families. Both health care professionals and caregivers feel uncomfortable with the concept of ‘uncertainty’ in prognosis especially when limiting or withdrawing treatments. In general, the uncertainty factor provokes an intimidating emotion. Caregivers and families need time to come to grips with reality. In the fast-paced, critical care setting the healthcare team and the surrogate need to establish goals of care based on current available information and then re-establish newer goals of care as new information arises. Frequently reestablishing a set list of goals of care and keeping the surrogate well informed of the justification of medical intervention can ease burden from the surrogates [7]. Ongoing real time communication can help the surrogates focus on their personal emotions, and corroborate short and long term future goals of care. One U.S. study found that most physicians believed that family interests should be considered in making decisions for patients who lack decision- making capacity [8]. The physicians need to realize that closure is the essential key component when dealing with surrogates and family members. The staff members should be supported and trained for enhancing listening skills, maintaining cultural awareness and employing reflective practice [9].
Sensitive Communication during Time Limited Therapy (TLT) Time Limited Therapy is an agreement between the clinician and the family to consider certain medical therapies over a defined period; especially when previous clinical outcomes are uncertain and ambiguous. The TLT can be used when the family is torn between the decision of stopping treatment and allowing the treatment Volume 3; Issue 1; 027
Citation: Anuradha Lele Mookerjee, Meera Rajput and Vijay Rajput (2017) Art of Sensitive Communication in Patient and Family Centered Care. BAOJ Pall Medicine 3: 027.
to continue while fearing the burden of prolonged aggressive treatment. TLT can help the health care team and the family to move forward with re-defining the goals of care. There are five strategic elements to handle the communication for TLT. These include clearly defining the clinical problem and prognosis; clarifying the patient’s goals of care and priorities; identifying objective markers of improvement or deterioration, agreeing on the time frame for re-evaluation; and coming to a consensus on potential actions to be taken at the end of TLT [10]. The structured dialogue at different time frames can help lessen the chance of conflict among treatment teams and family members. This process helps in establishing a dynamic channel of communication so everyone can speak with a common unified voice. Physicians should document the summary of the sensitive communication, which ensued among the health care team members and the family members in the official medical record. This documentation should be succinct and meaningful. There is no room for criticism or opinions about the behaviors or attitudes of patients or families in the medical record. Physicians should leverage resources from the Ethics committee and the Risk Management team when conducting sensitive communications and resolving conflicts.
Conclusion Sensitive communication with the patients and the family members is based on a continuous healing relationship interleaved with empathy, compassion, honesty and respect. Both oral speaking and receptive listening skills are necessary for effective communication between the health care provider and the patient and caregivers. The verbal communication based on the use of relevant spoken words, interlaced with the appropriate non-verbal communication, including body language, eye contact, mindful gestures, a calming tone of voice can all play a major role in developing a bonding relationship infused with trust. When conducting, the family meeting any disputes or differing opinions on goals of care between family members, should be approached sensitively and judiciously, always keeping the patient at the center, to reach the common goal. Listening to family members and being respectful of their viewpoints fosters a culture of trust and enables reaching a shared plan of care. Tailoring to the individual needs of the patient and the family members and acknowledging the patient’s socio-economic and cultural background along with fostering a culture of trust and transparency, can be the guiding principle in patient and family centered care of a critically ill patient.
Ten Recommendations to Augment Sensitive Communication 1. Sit next to the patient and family member, with the body leaning forward and the hand outstretched with a calm tone of voice. Use language that is appropriate, understandable and forthright.
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team members to reach common shared goals in the patient’s best interest. 4. Invite the patient, the family members and caregivers to introduce themselves, and share stories from the past. Try to ascertain the views of the family members regarding the patient’s situation 5. Be respectful and acknowledge all the socioeconomic, religious and cultural beliefs of the patient and family members. 6. Deliver the sensitive news with empathy, compassion, honesty and respect. Offer opportunity to absorb and clarify the information provided and pauses to answer any questions. 7. Foster a culture of trust and transparency to build bridges between patients and family members and the health care team 8. Give undivided attention and immense quality time from the moment you enter the room. Keep phones and pagers with someone outside the room. 9. Discuss Goals of care and understand the decision-making preferences of the patient with the family members. 10. Leverage resources and discuss difficult situations with help of the bioethics committee members and resolve conflicts with the help of patient relations’ managers and the risk management teams.
References 1. Schneiderman L, Gilmer T, Teetzel H (2003) Effect of Ethics Consultations on Nonbeneficial Life-Sustaining Treatments in the Intensive Care Unit. JAMA 290:1166-1172. 2. Davidson J, Powers K, Hedayat K (2007) Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004–2005. Crit Care Med 35(2): 605-622. 3. Curtis J, Engelberg R, Wenrich M (2005) Missed opportunities during family conferences about end-of-life care in the intensive care unit. Am J RespirCrit Care Med 171: 844-849. 4. Rabow M, Hauser J, Adams J(2004) Supporting Family Caregivers at the end of life: “They don’t know what they don’t know”. JAMA291: 483-491. 5. White DB, Engelberg RA, Wenrich MD, Lo B, Curtis JR (2007) Prognostication during physician-family discussions about limiting life support in intensive care units.Crit Care Med 35(2):442-448. 6. Christakis NA, Iwashyna TJ (1998)Attitude and Self-reported Practice Regarding Prognostication in a National Sample of Internists.Arch Intern Med 158:2389-2395. 7. Truog RD, Brett AS, Frader J (1992)The problem with futility. New England Journal of Medicine 326: 1560-1564.
2. Introduce all the members of the care team and explain the role of each member. If possible, have a Liaison mediator from this team who can help the family later, in navigating the health system.
8. Hardart GE, Truog RD (2004) Attitudes and preferences of intensivists regarding the role of family interests in medical decision making for incompetent patients. Critical Care Medicine131(7): 1895-1900.
3. Prior to the family meeting, each member could prepare the backdrop material individually, but should connect with all
10. Quill TE, Holloway R (2011)Time-Limited Trials near the End of Life. JAMA 306:1383-1384.
BAOJ Pall Medicine, an open access journal
9. (2017)Information for Families.
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