Professional Documents
Culture Documents
International Curriculum
FACULTY
GUIDE
Module 6
Communication
Copyright City of Hope and American Association of Colleges of Nursing, 2008; Revised 2011.
Module Overview
This module emphasizes the importance of good communication in end-of-life care. The
complexities of communicating with patients and families at this critical time are described along
with suggestions for care.
Key Messages
Communication is critical in all health care situations but is of special significance at the end
of life.
Strong collaboration and communication between professionals is a prerequisite to
communication with patients and families.
Palliative care requires skill in verbal and non-verbal communication, listening and presence.
Objectives
DEFINITION/OVERVIEW
Effective communication
Role of communication
Needs of patient
Needs of family
BARRIERS TO COMMUNICATION
MYTHS/REALITIES OF COMMUNICATION
TEAM COMMUNICATION
A. Interdisciplinary team
B. Resolving conflict
SUMMARY
Module 6: Communication
Faculty Outline
Slide 1
International
E L N E C Curriculum
End-
End-of-
of-Life Nursing Education Consortium
Module 6:
Communication
“Nature gave us one tongue and two ears so we could hear twice as much as we speak.”
Epictetus (55 A.D.-135 A.D.)
In studies where health professionals were asked what they wish they were taught in school curriculum related
to the terminally ill, the number one response was “how to talk to patients/families about dying” (Dahlin, 2010;
White et al., 2001).
Good pain and symptom assessment/management are dependent on excellent communication. It is important to
communicate well so you can advocate for your patients and their family.
Communication
Communication
• Terminal illness is a family
experience
• Imparting information so individuals
may make informed decisions
• Requires interdisciplinary
collaboration
Kimberlin et al., 2004
E L N E C International Curriculum
Communication also involves strong collaboration between members of the interdisciplinary team.
Slide 3
Barriers
Barriers to
to Communication
Communication
• Fear of mortality
• Lack of experience
• Avoidance of emotion
• Insensitivity
• Sense of guilt
E L N E C International Curriculum
Fear of one’s own mortality, from both patient and health care provider perspective, resulting in avoidance of
discussing death and dying.
Lack of personal experience with death and dying can increase reluctance to discuss this topic.
Fear of health care providers expressing emotion, such as showing tears, may cause some individuals to avoid
difficult topics.
Health care provider insensitivity, demonstrated by interrupting communication; patronizing; not allowing
patients/families the opportunity to express their views.
Sense of guilt for failure to cure patient, fear of being blamed for causing death, or guilt at inability to change
outcome are real concerns. Society often places unrealistic expectations for cure.
Slide 4
Barriers
Barriers to
to Communication
Communication (cont.)
(cont.)
E L N E C International Curriculum
Fear of not knowing the answer to a question or whether to be honest when answering a question are two
significant barriers to open communication.
The healthcare provider’s personal grief issues (e.g., loss of a family member or pet; loss of a marriage; loss of
dreams; cumulative loss/grief that has not been addressed).
Ethical concerns, which may lead to disagreements between patients, family members, or health care providers
related to care, are difficult to discuss but should be addressed openly and, if necessary, with the assistance of
an ethics consultation team/ethics committee.
Slide 5
Myths
Myths of
of Communication
Communication
• Communication is deliberate
• Words mean the same to
sender/receiver
• Verbal communication is primary
• Communication is one way
• Can’
Can’t give too much information
E L N E C International Curriculum
Patient/Family
Patient/Family Expectations
Expectations
• Be honest
• Elicit values and goals
• Team communication
• Take time to listen
E L N E C International Curriculum
There are important cultural issues regarding truth telling and communication.
Slide 7
E L N E C International Curriculum
When assisting families to make decisions, you will consider the overall situation (support systems, economics,
technical aspects, locality and other issues).
You will respond to their questions within a reasonable time and encourage them to ask questions, as well.
You will ask—“What would you like me to do? What are your expectations? What do you need?”
When you do not know what to do, you will seek assistance.
You will ask yourself, “What would I do if this was my family member?”
You will take the time to listen (Coyne et al., 2010; Quill, 2000).
Slide 8
Verbal
Verbal and
and Non-Verbal
Non-Verbal
Communication
Communication
• Includes body language, eye contact,
gestures, tone of voice
• 80% of communication is nonverbal
Dahlin,
Dahlin, 2010
E L N E C International Curriculum
Communication includes verbal and non-verbal signals. Eighty percent (80%) of communication is non-verbal
(Dahlin, 2010).
Communication
Communication
• Ask how much patient/family want to
know
• Initiate family meetings
• Illness can strengthen or weaken
relationships
• Base communication with children on
developmental age
E L N E C International Curriculum
Through on-going assessment, determine how much the patient/family need/want to know.
Illness can strengthen family relationships and/or cause their frailties to surface in unexpected ways.
Families with ambivalent relationships (i.e. violence, abuse, divorce, and separation) will have a harder
time coping with negative feelings, anger and guilt.
These factors complicate communication with the older adult and their family.
Cultural Differences in
Communication Related to:
• Sexual orientation
• Religion
• Age
• Ethnicity
• Gender
• Tribes
E L N E C International Curriculum
Also consider:
Past experiences with illness, hospitals, healthcare team, etc.;
Social or economic status;
Language (primary and secondary). Remember that some people may read a foreign language better than
speaking it and visa-versa;
Country of origin.
Slide 11
Listening
Listening Steps
Steps
Helping Others/
Active
Empathizing
Analyzing & Evaluating
E L N E C International Curriculum
Listening is being present, not just physically, but mentally and emotionally as well.
Listening/being present occurs at five different levels, each requiring greater energy and involvement. It’s like
walking up steps….the higher you climb, the greater your energy and involvement (Ray, 1992).
Slide 12
Attentive
Attentive Listening
Listening
E L N E C International Curriculum
Don’t interrupt.
Listen as you are providing the attention to a good friend who is sharing their concerns, their heart, and their
joys.
Slide 13
Attentive
Attentive Listening
Listening
E L N E C International Curriculum
Don’t change the subject—this can be a natural response we often use to avoid difficult conversations.
Encourage reminiscing, let them tell their story—this is a powerful reassurance that their lives had meaning.
E L N E C International Curriculum
Presence
Presence
Requires:
• Acknowledging vulnerability
• Intuition
• Empathy
• Being in the moment
• Serenity and silence
Dahlin,
Dahlin, 2010; Stanley, 2002
E L N E C International Curriculum
Being present and being silent are valuable communication skills (Dahlin, 2010; Stanley, 2002):
Knowing and being comfortable with oneself;
Knowing the other person;
Connection;
Affirmation and valuing;
Acknowledge vulnerability;
Utilize intuition;
Empathy and a willingness to be vulnerable;
Being in the moment;
Serenity and silence.
Slide 16
Guidelines
Guidelines for
for Encouraging
Encouraging
Conversation
Conversation
• Setting the right atmosphere
• Does the patient/family want to
talk?
• Attentive listening
Dahlin,
Dahlin, 2010; Duhamel & Dupris,
Dupris, 2003
E L N E C International Curriculum
Set the right atmosphere (Buckman, 2001; Dahlin, 2010; Duhamel & Dupuis, 2003).
Get comfortable and relay to the family member that you want to spend some time with them.
Sit down on “eye-to-eye” level
Lean forward
Uninterrupted eye contact—if culturally relevant
Silence pagers or cell phones
Does the family want to talk? (Buckman, 2001; Duhamel & Dupuis, 2003)
Perhaps someone else from the interdisciplinary team has spoken with the patient and/or family today and
answered all questions.
Ask their permission before engaging in a lengthy conversation.
Family may feel over-loaded with information.
Patient may be experiencing pain and other symptoms that would make it difficult for them to engage in
conversation.
Caregivers may be exhausted and not ready for conversation.
Factors
Factors Influencing
Influencing Communication
Communication
E L N E C International Curriculum
Cultural Issues
Slide 18
Healthcare
Healthcare Professionals
Professionals Influence
Influence
Communication
Communication Outcomes
Outcomes
• Be aware of behaviors and
communication style
• Lack of personal experience with death
and dying
• Fear of not knowing the answer
• Lack of understanding patient’s and
family’
family’s end-
end-of-
of-life goals
• Language barriers
E L N E C International Curriculum
Family
Family Meetings
Meetings
E L N E C International Curriculum
Discussion:
Are family conferences a part of your culture?
Adapted from:
Baile, W.F., Buckman, R., Lenzi, R., Glober, G., Beale, E.A., & Kudelka, A.P. (2000). SPIKES: A six-step
protocol for delivering bad news: Application to the patient with cancer. The Oncologist, 5(4), p. 302-311.
Last retrieved January 21, 2011 on-line at http://theoncologist.alphamedpress.org/cgi/reprint/5/4/302
Slide 21
Communication
Communication Strategies
Strategies to
to
Facilitate
Facilitate End-of-Life Decisions
End-of-Life Decisions
• Initiate end-of-life discussions
• Use words such as “death” and
“dying”
dying” or “very sick”
sick”
• Maintain hope
• Clarify benefits and burdens
• Be honest
E L N E C International Curriculum
Team
Team Communication
Communication
• Intra-
Intra-team communication is
vital, especially between RN and
MD
• Should occur frequently
• Document
• Expect conflicts
E L N E C International Curriculum
Discussion:
What professions are a part of the health care team in your setting?
Slide 23
Resolving
Resolving Conflict
Conflict
• Try to take a step back
• Identify your own emotions
• Define the conflict
• Obtain agreement on the conflict
• Talk about it
• Patient’
Patient’s best interest should always be
foremost
Dahlin,
Dahlin, 2010
E L N E C International Curriculum
Anytime you work with a team, be prepared for conflict. This does not always have to be a negative encounter.
Many times, conflict brings out discussions that might not have otherwise, been planned (Dahlin, 2010).
Identify your own emotions and try to describe them, not display them.
Check that the conflict is not about “YOU”—about you “getting your own way;
Be prepared that you may disagree with the decisions of patient/family;
After family members have been provided all the information/options, it is their responsibility to make the
decision they think is best for the patient.
Summary
Summary
• Communication is complex
• The ultimate objective is the patient’
patient’s
best interest
• Patient’
Patient’s and their families must be
involved in communication
• Primary healthcare provider to promote
communication among team members,
patients and family
E L N E C International Curriculum
Communication is a complex process in all circumstances, but becomes truly challenging in advanced disease.
Remember that each team member’s main objective should be to ADVOCATE for what he/she believes is in
the patient’s best interest.
True advocacy has been achieved when the patient and family have a primary role in the plan of care.
The primary healthcare provider’s role is to promote clear open communication among team members and the
patient and family.
Collaboration
E L N E C International Curriculum
SUMMARY:
“Words are both better and worse than thoughts; they express them and add to them; they give them power for good
or evil; they start them on an endless flight, for instruction and comfort and blessing, or for injury and sorrow and
ruin.”
Tryon Edwards (1809-1894)
Back, T., Arnold, B., & Quill, T. (2003). Hope for the best, prepare for the worst. Annals of
Internal Medicine, 138(5), 439-443.
Baile, W. F., Buckman, R., Lenzi, R., Glober, G., Beale, E. A., & Kudelka, A. P. (2000).
SPIKES- A six-step protocol for delivering bad news: Application to the patient with
cancer. Oncologist, 5(4), 302-311.
Buckman, R. (2001). Communication skills in palliative care. Neurologic Clinics, 19(4), 989-
1004.
Buckman, R. (2005). Breaking bad news: The S-P-I-K-E-S strategy. Community Oncology,
2(2), 138-142.
Coyne, P. J., Bobb, B., & Drew, J. (2010). Palliative care. In B. St. Marie (Ed.), Core curriculum
for pain management nursing (2nd ed.). Philadelphia: W. B. Saunders Co.
Curtis, J. R., Patrick, D. L., Shannon, S. E., Treece, P. D., Engelberg, R. A. & Rubenfeld, G. D.
(2001). The family conference as a focus to improve communication about end-of-life
care in the intensive care unit: Opportunities for improvement. Critical Care Medicine,
29(2Suppl), N26-33.
Duhamel, F., & Dupuis, F. (2003). Families in palliative care: Exploring family and healthcare
professionals’ beliefs. International Journal of Palliative Nursing, 9(3), 113-119.
Friedrichsen, M. J., Strang, P. M., & Carlsson, M. E. (2001). Receiving bad news: Experiences
of family members, Journal of Palliative Care, 17(4), 241-247.
Goulette, Candy (2007). Doctors and nurses: Professional relationships make for better patient
care. Advance for Nurses, July 9, 2007, 21, 22, 36.
Griffie, J., Nelson-Marten, P., & Muchka, S. (2004). Acknowledging the ‘elephant’:
Communication in palliative care. American Journal of Nursing, 104(1); 48-57.
Kimberlin, C., Brushwood, D., Allen, W., Radson, E., & Wilson, D. (2004). Cancer patient and
caregiver experiences: Communication and pain management issues. Journal of Pain &
Symptom Management, 28(6), 566-578.
Quill, T.E. (2000). Initiating end-of-life discussions with seriously ill patients: Addressing the
“Elephant in the room.” Journal of the American Medical Association, 284(19), 2502-
2507.
Rabow, M. W., Hauser, J. M., & Adams, J. (2004). Supporting family caregivers at the end of
life. “They don’t know what they don’t know.” Journal of the American Medical
Association, 291(4), 483-489.
Ray, M. C. (1992). I'm here to help: A hospice worker's guide to communicating with dying
people and their loved ones. New York, NY: Bantam Books.
Stanley, K. J. (2002). The healing power of presence. Oncology Nursing Forum, 29(6), 935-
940.
Tulsky, J. A. (2005). Beyond advance directives: Importance of communication skills at the end
of life. Journal of the American Medical Association, 294(3), 359-365.
Vachon. M.L.S. (2010). The emotional problems of the patient in palliative medicine. In
G. Hanks N.I. Cherny, N.A. Christakis, M. Fallon, S. Kaasa, & R.K. Portenoy (Eds.),
Oxford textbook of palliative medicine, 4th edition (pp. 1410-1436). Oxford, UK: Oxford
University Press.
White, K. R., Coyne, P. J., & Patel, U. B. (2001). Are nurses adequately prepared for end-of-life
care? Journal of Nursing Scholarship, 33(2), 147-151.
Wilkerson, S., & Mula, C. (2003). Communication in care of the dying. In J. Ellershaw &
S. Wilkerson (Eds.), Care of the dying: A pathway to excellence. New York, NY: Oxford
University Press.
Ferrell, B. R., & Coyle, N. (Eds.). (2010). Oxford textbook of palliative nursing (3rd ed.). New York, NY: Oxford
University Press.
Chapter Author Title
4 Glass, Cluxton, Principles of Patient & Family Assessment
& Rancour
5 Dahlin Communication in Palliative Care: An
Essential Competency for Nurses
29 Ersek & Cotter The Meaning of Hope in the Dying
56 Hinds, Oakes, End-of-Life Decision-Making in Pediatric
& Furman Oncology
78 Ferrell A Good Death
Module 6: Communication
Case Studies
Module 6
Case Study #1
Mr. Jones: Breaking Bad News To Family
You have received a hospice referral for Mr. Jones, age 54, who has ALS (amyotrophic lateral
sclerosis). He and his family (wife and 3 children—ages 9, 16, 19), who are confused and
anxious, listen to you as you describe what they should expect from the hospice experience. The
family does not seem to understand why you are discussing end-of-life issues with them. You
call Mr. Jones' family physician who tells you that the patient assured him that he talked to his
family about his prognosis. You determine that Mr. Jones has in fact not told his family. You
talk with Mr. Jones who admits that he has told his family he is very stable and expected to have
many years of life remaining. He asks you to help him break the reality of his poor prognosis to
his family.
Discussion Questions:
1. What is your role now?
3. What strategies would promote continuity of care and improve team communication?
5. What special needs would you perceive the children having at this time? How would you
meet these needs?
Module 6
Case Study #2
Cindy: Disagreement
Cindy is a 36-year old female with pancreatic cancer has been hospitalized for two weeks. She
has been in the intensive care unit for the past 5 days. Her physical deterioration and suffering
had created anguish in her husband and in the health care team. The attending physician
discussed with the husband the likelihood of his wife having a cardiac and/or respiratory arrest,
described the actions the team would take for a full resuscitation as well as the varying levels of
resuscitation approved by the treatment setting, which included a do-not-resuscitate option, and
asked the husband to express his preferences regarding resuscitation. The husband initially
chose the do-not-resuscitate status for his wife and completed all of official paperwork to
implement that decision. During the next 12 hours, the husband actively solicited from nursing
and medical staff their definitions of do-not-resuscitate. He then contacted the attending
physician to rescind his decision, choosing instead to have a full resuscitation order in place. He
explained his decision change as, "When I saw that the nurses and doctors did not all define
resuscitation in the same way, I decided that I would not leave that in their hands. I am my
wife’s husband and I will be her husband to the end." This new decision was enacted and over
the next four days, the patient showed clear signs of dying. Her husband stayed with her in the
intensive care unit and witnessed the changes in his wife’s physical appearance. He began
commenting on those changes and on his wife's obvious suffering. Within two hours of her
death, the husband told the staff that he did not want his wife to be resuscitated. This
information was immediately conveyed to the health care team and a brief discussion with the
physician, husband, and nurse was convened to affirm this decision.
Discussion Questions:
1. What were the barriers to effective communication in this case?
2. How might these barriers have been eliminated?
Module 6
Case Study #3
Max: Communicating Sudden Death
Max Klein is an 84-year-old retired plumber who has brought his 83-year-old wife, Mary, to the
hospital complaining of chest pain. Mary's condition declines, she experiences cardiac arrest and
full resuscitation is attempted. During this time Max communicates to the social worker and
chaplain that "This just can't be. Mary is healthy as an ox." He doesn't want to notify his
children who live out of town "until she's stable because I know they'll get her straightened out."
Max seems anxious but distracted and talks incessantly about how Mary's been sick before but
"always gets better before you know it." After 2 hours of numerous procedures and attempts,
Mary dies.
Discussion Questions:
1. What are useful communication strategies while Mary is still receiving aggressive care to
communicate her status?
Valenzio Quartera is a 56-year-old man with widely metastatic prostate cancer. He is currently undergoing radiation therapy for bone metastasis.
His wife died one year ago from breast cancer. He currently lives at home with his twin daughters, age 15 years. As you, the radiation oncology
nurse, enter the treatment room, Mr. Quartera asks you, “Susie, you don’t think I’m going to die do you?” “What would happen to my daughters
if I die?”
Discussion Questions:
3. What would you recommend that he discuss with his daughters at this time?
4. What other members of the healthcare team would be appropriate to contact to help Mr. Quartera with his daughters?
Module 6
Case Study #5
“Mr. Ahmed: Active Treatment and Palliative Care?”
Mr. Ahmed is a 49-year-old with a recurrent brain tumor currently hospitalized after experiencing seizures. Mr.
Ahmed was diagnosed at age 44 and has had extensive surgery, chemotherapy, and radiation therapy. Three months
ago, his oncology team advised him and his family that there were no further treatment options and recommended
palliative care. The family was not interested in palliative care, they requested that “everything be done.” He has
experienced weight loss, increasing severe headaches, nausea and now seizures. Following a severe seizure last
week, his wife brought him back to the cancer center seeking possible new treatments and wonders if he can receive
palliative care, too. As Mr. Ahmed waits in radiology for a scan, you, as member of the oncology healthcare team,
come to see him as you heard he was in radiology. He tells you he is so tired of treatment and being taken far away
and just wishes his family would “give up and just let me be at home so I can play with my dog and be with my
friends.”
Discussion Questions:
2. Is it possible for Mr. Ahmed to receive treatment and palliative care at the same time? If so, how would you
describe this to Mr. and Mrs. Ahmed?
3. How could you use attentive listening and presence with this patient and his wife?
4. Role play the scene of how you would respond to Mr. Ahmed’s last statement. In addition, role play how you
would describe palliative care to this family. Lastly, role play how you would elicit Mr. Ahmed’s end-of-life
goals (see Figure 1: Exercise to Elicit End-of-Life Goals and Figure 2: Questions to Ask Patients and Families
to Elicit End-of-Life Goals).
Module 6: Communication
Supplemental Teaching Materials/Training Session Activities Contents
Module 6
Table 1: Six-Step Protocol for Breaking Bad News
Adapted from:
Buckman, R. (1998). Communication in palliative care: A practical guide. In D. Doyle, G. W. C. Hanks, & N.
MacDonald (Eds.), Oxford textbook of palliative medicine (2nd ed, pp. 141-156). New York, NY: Oxford
University Press. Reprinted with permission.
Module 6
Figure 1: Exercise to Elicit End-of-Life Goals (30 minutes)
This exercise is a way to have participants focus on the importance of communication with
patients and families as it helps them to define what is important to them at this time in their
lives. It helps to clarify their values and end-of-life goals that will guide the interdisciplinary
care plan.
All participants: Read "Questions to Elicit Goals (Mod 6: Figure 2)" and discuss which
questions would be most helpful to them as the patient being asked and as the health professional
asking the questions.
2. Role Play: Ask participants to role play this communication in their triads. Let them
know there will be time at the end to discuss the quality and outcome of these
communications. 8 minutes
Health professional: Create dialogue using "Questions to Elicit Goals" or similar questions to
help a patient identify what is important to them at this time in their lives. Your patient is aware
of their limited life expectancy.
Patient: You are a patient who is aware of their limited life expectancy and you are beginning to
consider what you want to happen during this limited time of your life. Engage in dialogue with
the health professional.
Observer: Observe the verbal and nonverbal communication between the health professional
and the patient. Be ready to describe the quality and outcome of the dialogue.
3. Group Discussion: Facilitate group discussion to address the quality and intensity of
this dialogue. Point out how initiating dialogue can assist patients and families to
identify what is important to them and how we as professional caregivers can then direct
our care based on what they have communicated. 10 minutes
Patient: What did it feel like to answer these questions? Did they help you to focus on or
communicate your priorities?
Observer: Discuss the quality of the communication including the verbal and nonverbal
communication between the health professional and the patient.
Health professional: What did it feel like for you to have this dialogue?
Source:
The Hospice of the Florida Suncoast, February 2001. Reprinted with permission.
Module 6
Figure 2: Questions to Ask Patients & Families to Elicit End-of-life Goals
- What has been the most difficult for you about this illness?
- What do you know about your illness/disease? Is there anything else you would
like to know?
- How do you feel about your treatments (medications, radiation, chemo, DNR)?
- If you have pain, what would be an acceptable pain level for you on a 0-10 scale?
- What activities such as music, art, reading, massage, touch provide peace or
comfort to you?
- How and where do you want to live for the rest of your life?
- Is spiritual peace important to you? What would help you achieve spiritual
peace?
Adapted from:
The Hospice of the Florida Suncoast, February 2001 printed with permission.
Module 6
Figure 3: Recommendations for Conducting a Family Meeting
Source:
Rabow, M.W., Hauser, J.M., & Adams, J. (2004). Supporting family caregivers at the end of life: “They don’t know
what they don’t know.” Journal of the American Medical Association, 291(4), 487. Reprinted with
permission.