Module 4 Communication

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
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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 nursing care requires skill in verbal and non verbal communication, listening and presence.

At the completion of this module, the participant will be able to: 1. Identify three factors that influence communication in the palliative care setting. 2. Describe important factors in communicating bad news. 3. Identify characteristics patient/families expect of health care professionals in caring for them in this setting.

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it is the interpretation of words that influences how others receive communication. MYTH: One can never give someone too much information. REALITY: We communicate when we are not consciously aware that we are communicating. REALITY: Communication is a two-way activity. Patient/Family Expectations _____________________________________________________________________________________________________________________ ELNEC Curriculum Module 6: Communication Page M6-3 © AACN & COH. This may also help dispel preconceived notions/myths about illness or treatment. MYTH: Words mean the same thing to our listener as they do to the speaker. REALITY: The majority of the messages we send are nonverbal symbols. the number one response was "how to talk to patients/families about dying. Nurses need to clearly understand the expectations of the patient/family and the physicians' plan of care in order to provide excellent care. MYTH: We communicate only when we consciously and deliberately choose to communicate. Initiating any plan requires an understanding of the patient/family's knowledge of the disease status and its prognosis. B. In a recent study when nurses were asked what they wish they were taught in nursing school curriculum related to the terminally ill. THE COMMUNICATION PROCESS • The lines of communication must be clear in order to develop an appropriate palliative care plan. REALITY: Words alone don't provide meaning. II. E." (Coyne. MYTHS/REALITIES OF COMMUNICATION Following are some common myths: A. C. A terminal illness is a family experience. 1999). MYTH: We communicate primarily with words.Module 4: Communication Faculty Outline I. REALITY: People can feel overwhelmed when they receive too much information. The role of communication includes imparting necessary medical information so individuals may make informed decisions related to care. 2000 . D. MYTH: Communication is a one-way activity. III. Good planning increases patient/family satisfaction. A. Individualized patient directed goals are based on the patient's needs and overall condition. DEFINITION/OVERVIEW • Communication with a patient/family unit is a crucial requirement to success in palliative care. Communication also involves strong collaboration between members of the interdisciplinary team.

3. ethnicity. b.1. it is important to communicate to patients and families that: a. technical aspects. you will consider the overall situation (support systems. f. communicates its goals to one another. You will not abandon them. c. social or economic status. 4. c. j. e. 2. d. d. b. You will help them explore their realistic options. disclosing feelings. Based on the expectations expressed by patients/families experiencing lifelimiting diseases. An understanding of the patient/family perceptions and beliefs insures that you will be a staunch advocate in helping him/her achieve their goals. locality and other issues). offering support. _____________________________________________________________________________________________________________________ ELNEC Curriculum Module 6: Communication Page M6-4 © AACN & COH. You will elicit and request their values and goals and will help as much as is possible to achieve these. When you don’t know what to do. d. e. Be aware and sensitive to cultural differences. Communication is an ongoing. age. you will seek help. asserting control. You will be honest and truthful. 2. g. f. which may be related to: a. allowing one to comfortably ventilate fears while initiating dialogue. The ability to communicate influences these therapeutic roles: a. B. e. b. g. past experiences. providing ongoing opportunities for fully informed choices. "What would I do if this was my family member?" k. sexual orientation. You will work to insure that the entire health care team understands the care plan. 2000 . When assisting families to make decisions. and contributes to its development. You will take the time to listen. continuous dynamic process. You will respond to their questions within a reasonable time and encourage their questions as well. gender. c. You will ask—"What would you like me to do? What are your expectations? What do you need?" h. You will ask yourself. Verbal and Non-verbal Communication 1. economics. religion. It includes verbal and non-verbal signals. i.

However.3. Sensitive listening is being present. 4. 2000 . some cultures will avoid direct eye contact.. Maintain undistracted eye contact. This requires ongoing assessment. the greater your energy and involvement.e. Being present and being silent are valuable communication skills. Guidelines for encouraging free conversation (Buckman. 2. 1998). c. voice intonation. 6. Get comfortable and relay to the family member that you want to spend some time with them (i. d. Listening 1. D. d. C. c. It's like walking up steps.. Expressive techniques such as play or art therapy help children to express their concerns. Determine how much the patient and family want and need to know. leaning forward). but mentally and emotionally as well. Eighty percent of communication is non-verbal. b. They may be too tired.the higher you climb. sitting down. nurses should plan on initiating patient and family meetings. Learn and maintain a comfortable distance for you and the patient or family member. body language. Focus back on the conversation as quickly as possible. 2. _____________________________________________________________________________________________________________________ ELNEC Curriculum Module 6: Communication Page M6-5 © AACN & COH. gestures. having all appropriate team members as well as the patient/ family members present. not just physically. Setting the right atmosphere a. b. Listening occurs at five different levels. 7. Examples of non-verbal signals include: a. 3. 5. When talking with children it is important to be honest and plan for time to understand the child's perception of the illness. Communication with children should be based on the developmental age of the child. As issues on conflicts arise. Interruptions are bound to happen. 1. Does the patient or family member want to talk? a. each requiring greater energy and involvement. eye contact.

b. "If I understand what you're saying. Attentive listening a. 2000 . There are times when there isn’t anything to say. Saying nothing and remaining close can sometimes offer more comfort than words. Your presence and "being with" are vital forces. b. fidgeting. _____________________________________________________________________________________________________________________ ELNEC Curriculum Module 6: Communication Page M6-6 © AACN & COH.. A patient who is frowning. It also relieves pressure for the nurse in that he/she doesn't have to have all of the answers. It may mean that they are in deep thought about something painful or sensitive." we do really care." or "Tell me more". we can see their pain and it matters to us. This can be done by using simple methods: 1) Nodding one's head. They may have had a conversation with someone else you are unaware of that meets their needs." It is helpful to extend touch or hold their hand when discussing this so they can know that while we "don't know. c. d. Silence and nonverbal communication 1) Silence doesn't always mean the person doesn't want to talk. c. Don't interrupt. 2) Sometimes you may not know what to say. you're feeling. Give the person time without making them feel rushed. and their joys. 2) Comments like "I see." The person feels relieved because they can sense when the nurse doesn't feel comfortable." or.. I wish I had an answer. Avoid misunderstandings 1) If you are sure you understand what the person is saying. 3. Encourage the patient or family member to talk. Don't be afraid to share your feelings 1) It's okay to say things like "This is difficult for me to talk about" or "I don't know what to say. f. 2) "Help me understand what you mean" is a gentle way to clarify. e... 3) Repeating 2-3 words from their last sentence. Don't anticipate what may be said. ". ask him/her to clarify for you. but I don't. Ask if they feel like talking before attempting to engage them in a deep conversation. 4) Reflection .. 2) Many patients/family members have asked variations of "Why is this happening?" It is okay to say "I don't know. If you are unsure."So you mean were shocked by the diagnosis". and breathing deeply may be at a loss for words to express their anxiety.. their heart. acknowledge so." 5) Listening to patients and families is much like providing the attention you would give a good friend who is sharing their concerns. Listen patiently until there is a break in the conversation. 3) Sometimes nonverbal communication techniques are used because the person doesn't know how to express his/her needs. listen.

. I found this to be helpful. do it unassumingly. etc. The crisis of impending death in a loved one affects the family member's ability to hear and understand information. Lack of experience with death in the family may be a new experience and existing coping skills are not helpful. and grief in family members experiencing terminal illness. FACTORS INFLUENCING COMMUNICATION • Factors that may make effective communication difficult can occur within the patient/ family unit. d. b. (such as one's home) may provoke anxiety. _____________________________________________________________________________________________________________________ ELNEC Curriculum Module 6: Communication Page M6-7 © AACN & COH. Don't change the subject.. and the cost of other caregiving activities may rob families of financial security..g." c." i. Perceived or real lack of support among family members may contribute to feelings of distress and being overwhelmed with the current situation. 2. c. Inability to care for family member. e. Financial concerns brought about by payment of medical expenses.. "When I went through this with my friend. lost time from work. Patient/Family Unit 1. "Have you thought about. Financial/Educational/Physical a. and the health care professional. stress. "A friend of mine once tried. 2000 . either physically or emotionally may lead to distress in family caregivers and patients' feelings of abandonment and isolation. h. a. this is a natural response we often use to avoid difficult conversations. IV.. society. These factors include: A. Family Systems a. ongoing fear of losing and actual loss of treasured items obtained throughout a lifetime. Financial insecurity. mother. Encourage Reminiscing 1) Giving patients and families an opportunity to reminisce and "tell their story" provides reassurance that their lives had meaning. New coping skills may be required to deal with this difficult experience. Take your time in giving advice 1) Try not to give advice if at all possible unless asked for. b.. 2) Reminiscing helps to ease the intensity of the present reality by incorporating memories and the reality of the relationship with that person. 2) If you do give advice." b. Lack of continuity among caregivers (actual or perceived) can occur when family members interpret information received from the health care team in different ways.

Loss of the ability to speak due to surgical intervention such as tracheostomy. g. be allowed to visit the sick parent if they choose. and the use of medical jargon contribute to information overload. Importantly. Past coping experiences predict how individuals cope in new situations. b. Patient and family members may wish to "hide" prognosis information in an effort to protect one another. should be addressed. d. The educational level and ability of the individual to read can influence individuals' ability to understand the potential impact of the illness as well as the ability to make informed decisions about treatment. Team members need to be prepared to assist families as they work through these concerns. Sleep deprivation and physical exhaustion negatively influence the caregiver's ability to attend to the communication process and to render necessary care required by the patient. Changes in family dynamics/roles during serious illness and expectations of death roles will evolve. Medication and psychological services used together are helpful. f. Fear of a future without a loved one and concerns about life after death are existential concerns that should be addressed by an interdisciplinary approach including counselors. 3. Coping/ Grief a. b. Spiritual concerns. to process information due to medication effects. children should be told the truth at a level they can understand. 4. h. and pre-existing conditions. 2000 . Anticipatory grieving of the loss of self or another are significant issues impacting communication for families experiencing terminal illness. c. Terminally ill patients are at risk for experiencing depression thus assessment of depressive symptoms should be ongoing. Too much medical information. e. chaplains. Team members should strongly encourage honesty among family members when discussing treatment and prognosis issues. and daily routines should be maintained as much as possible. such as those persons affected by brain metastases or stroke. Anger concerning the present situation and its impact on the family are important issues that should be addressed by the health care team. and others as appropriate. multiple care providers rapidly changing and complicated treatment protocols. d. however there are many cultural influences in communication at the end of life to be respected. perhaps related to potential regrets about earlier life decisions or lifestyle choices should be explored. _____________________________________________________________________________________________________________________ ELNEC Curriculum Module 6: Communication Page M6-8 © AACN & COH. e. or to verbally make wishes known due to their ability to process and communicate information. This conspiracy of silence should be addressed. disease processes.c. The ability to comprehend and the ability to communicate may be affected by medical interventions. Physical Limitations a.

j. g. Provide opportunities for individuals to ventilate these concerns. may cause some individuals to avoid difficult topics. Verbal and non verbal barriers can contribute to communication difficulties. This helps the person to "pull together" in preparation for active treatment or for a shift to palliative care. c. e. l. Unresolved personal grief issues. B. Health care professionals are trained to be responsible for patient outcomes. wishes. The developmental stage of the family and the ability of the family to deal with previous stressors will predict how they cope with the present situation. such as showing tears. Assisting families to maintain hope in the face of decline is important. f. Society often places unrealistic expectations for cure. Family caregivers require extensive support for the stress and burden of caregiving. Denial can be an effective coping strategy that allows the individual and family to integrate the impact of the diagnosis/prognosis. Fear of expressing emotion. Fear of being blamed for causing death is a real concern. Patients will experience loss of control as independence vanishes and physical functioning declines. may interfere with professional's ability to be objective. 2000 . An excellent teaching tool is use of videotaped role play used to provide an opportunity for students to become aware of their behaviors and communication style. Disagreement with patient/family decisions can negatively impact further communication with family members. These barriers may include. k. _____________________________________________________________________________________________________________________ ELNEC Curriculum Module 6: Communication Page M6-9 © AACN & COH.i. Health Care Professional • Health care professionals' behavior can influence communication outcomes. The use of caregiver support groups can help coping with these feelings. There are numerous ongoing emotional and physical stresses in the daily care of a loved one. Fear of one's own mortality can influence the professional's ability to address this subject. Communication Barriers: a. b. 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. i. but are not limited to: 1. Lack of personal experience with death and dying can increase reluctance to discuss this topic. Lack of knowledge/understanding of the patient/family's end of life goals. and /or needs may lead to inappropriate decisions being made that do not respect the values and goals of patients and families. h. Lack of knowledge/understanding of the patient/family's cultures may lead to poor communication. such as the loss of one's own parents. Caregiver guilt related to the effects of the illness on the loved one or the inability to halt its progression can be a difficult burden. d. A feeling of helplessness as one loses independence or watches the decline of self or a family member is distressing to all.

take phone off the hook).j. Professional insensitivity demonstrated by interrupting communication. g. and ability/manner of speaking. good communication is a vital part of this task. d. Plan what is to be said ahead of time and organize your thoughts. turn off TV. When breaking bad news. with the assistance of an ethics consultation team/ethics committee. It is very important to involve family members in communication about decisions related to treatment or withdrawal of treatment in the palliative care environment. Don’t make assumptions about this. which may lead to disagreements between patients. k. and not allowing patients/families to express their views. Find out what the patient/family already know. 2000 . h. l. read and write. Be sensitive/respectful of cultural/social issues. Anticipate questions family members may ask. c. Breaking bad news • Talking about death is a difficult task in our culture. 2. such as standing away from the patient or avoiding eye contact. patronizing. Evaluate patient/family's ability to speak. Continually assess and reassess patients/families understanding of information. emotional status. b. turn off pagers. f. e. ask team members who have established rapport with the family to attend. is inappropriate and should be confronted by other team members. While physicians generally break the initial “bad news. educational level.e. and listen.” nurses constantly are in a position of reinforcing that news and providing clarification. Use language that they will understand. or health care providers related to care. Knowledge of previous family coping mechanisms will be helpful in planning the team response. Find out how much the individual wants to know. sit down. Establish rapport. k. the following tasks should occur: a. Professionals need to work on improving skills such as to sitting at eye-level and using good eye contact when communicating with patients and their families. _____________________________________________________________________________________________________________________ ELNEC Curriculum Module 6: Communication Page M6-10 © AACN & COH. create communication barriers before verbal interaction has begun. In the event this hasn't occurred. i. Evaluate the individual's/family's body language. j. are difficult to discuss but should be addressed openly and if necessary. family members. Control the environment as much as possible (i. hear. Set aside appropriate time. Ethical concerns. Professionals who keep physical and/or emotional distance from patients.

R. 3. _____________________________________________________________________________________________________________________ ELNEC Curriculum Module 6: Communication Page M6-11 © AACN & COH. Intra-team communication is vital. 2. MacDonald (Eds). Each member should be involved in all parts of all communication processes. & N. V. Hanks. Try to take a step back. B. Communication between nurse and physician is critical. Oxford Textbook of Palliative Medicine. TEAM COMMUNICATION A. In D. Doyle. G. (1998).W. An essential mechanism for communication to all team members is documentation in the medical record. Written communication should demonstrate team member roles and goals for each case. Resolving conflict (Buckman. Culture should be considered when evaluating these responses.3. regularly scheduled team meetings are an appropriate tool for carrying out this activity.C. as it will likely negatively effect patient care. Interdisciplinary Team 1. Inter-team conflict may arise in any setting and efforts to resolve conflict should take place. Communication among team members should occur on a daily basis. 2000 . 5. 4. 1998) 1. Communication in palliative care: A practical guide. Some adaptive and maladaptive responses may include: Adaptive Humor Denial Abstract anger Anger against disease Crying Fear Fulfilling an ambition Realistic hope Sexual drive Bargaining Maladaptive Guilt Pathological denial Anger against helpers Collapse Anxiety The impossible 'quest' Unrealistic hope Despair Manipulation Adapted: Buckman. New York. The interdisciplinary team’s goals should be consistent with those of the patient/family. NY: Oxford University Press • Cultural mores dictate what is adaptive or maladaptive behavior.

Try to obtain agreement on that area of difference. SUMMARY • Communication is a complex process in all circumstances. Find a colleague and talk about it. Try to define the area of conflict that is unresolved. Identify your own emotions and try to describe them. _____________________________________________________________________________________________________________________ ELNEC Curriculum Module 6: Communication Page M6-12 © AACN & COH. The nurse's role is to promote clear open communication among team members and the patient and family. not display them. but becomes truly challenging in advanced disease. 5. Ongoing assessment of communication outcomes is vital. VI. even if it cannot be resolved. 2000 .2. True advocacy has been achieved when the patient and family have a primary role in the plan of care. Remember that each team member's objective is to advocate for what he or she believes is in the patient's best interest. 4. 3.

listen to you as you describe what they should expect from the hospice experience. Discussion Questions: 1. Jones' family physician who tells you that the patient assured him that she talked to her family about her prognosis. 2000 . She and her family. You talk with Mrs. You call Mrs. Jones” You have received a hospice referral for Mrs. Jones who admits that she has told her family she is very stable and expected to have many years of life remaining. Jones who has ALS (amyotrophic lateral sclerosis). The family does not seem to understand why you are discussing end of life issues with them. Jones has in fact not told her family. What strategies would promote continuity of care and improve communication? 2. How might a family meeting be helpful in this case? _____________________________________________________________________________________________________________________ ELNEC Curriculum Module 6: Communication Page M6-15 © AACN & COH.Module 4: Communication Case Study Case Study “Mrs. You determine that Mrs. who are confused and anxious. She asks you to help her break the reality of her poor prognosis to her family.

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