Communication in

terminally ill patients

(Palliative care)
 Outline
1. Breaking bad news
2. Discussing prognosis
3. The transition from definitive care to
palliative care
4. End-of-Life discussion
5. Being with a dying patient.
 Terminal illness
*Definition  an advanced stage of a disease with
an unfavorable prognosis and no known cure.
the life expectancy is estimated to be 6 months or
less
• Examples of terminal illnesses
• advanced cancer
• multiple organ failure syndrome
• AIDS
• Cardiac condition
 Palliative Care
• Palliative care is an approach that improves the
quality of life of patients and their families facing
the problem associated with life-threatening
illness, through the prevention and relief of
suffering by means of early identification and
impeccable assessment and treatment of pain
and other problems, physical, psychosocial and
spiritual.

WHO
 What are the
Components of
Palliative care?
• Pain management
• Symptom management
• Social, psychological, emotional and spiritual
support
• Caregiver support
1. Discussing
prognosis
2. Transition from
Definitive Care to
Palliative Care
 Discussing prognosis
• Identify any concerns that the patient has for the
future
“Am I going to die?”
“It is likely that the cancer will shorten your life”
• Be realistic when discussing any proposed
treatments
State the difference between a “treatment” and a “cure”
• Avoid giving specific time frames
“How long have I got?”
“Well, it may be months rather than years, but it is unlikely to be a few
weeks”
• If the patient will ultimately die of the disease, offer
to explain signs and symptoms of deteriotation but
avoid frightening details
“You may notice that you are more short of breath or more easily tired”
 Common Pitfalls
• Inadequate time or information
• Failure to elicit the patient’s understanding of the
situation and their coping strategy
• Breaking bad news at the doctor’s rather than patient’s
pace
• Platitudes and false re-assurance about the future
• Allowing collusion with relatives
• Allowing denial to remain unchallenged when it is
causing difficulties for the patient and their relatives
• Removing all hopes
2. The Transition From

Definitive Care to
Palliative Care
 The Transition From Definitive
Care to Palliative Care
Need to work on patient’s current concerns:
• Control of pain
• Control of body functions (eating, nausea,
breathing, anxiety, constipation)
• How to talk with spouses and children about the
impact of this changes
• How to find sources of personal support
• How to avoid side effects of medicines and fears
of addiction
• Life tasks still undone
 Principles
• Assure the patient that you will not abandon
him/her
• Explain the patient’s physical and emotional
needs to the family
• Mastering the palliative care information
including the resources:
-Hospice Malaysia
- Perak Palliative Care Society (PPCS)
- Palliative Care Association of Kota Kinabalu
 Procedures
• Show empathy
- the patient will need to modify his/her goals
- suffer loneliness and fears, need someone to talk to
- help the patient through this difficult process
• Don’t rush. Stay there
• Familiar with the principles of palliative care and symptom
management
• Check to be sure that your patient’s values are honored.
- family visits
- spiritual advisors
- has an advocate for his/her needs
 Pitfalls to avoid
• Abandoning the patient when your curative
therapy reaches its endpoint
• Running away from grief
• Becoming angry when the brave patient who
bore pain nobly deteriorates into dependence
Make sure that the patient
knows that you will stay
with him/her.
3. End-of-Life
Discussions
 End-of-Life Discussions
• Must take place in both longstanding and new
doctor-patient relationships
• Need to know our patients’ preferance
• To reach plans that feel right to them and
seem possible to us.
 PRINCIPLES:
• Begin the discussion when the patient is feeling healthy
• Talk about the issue with the same forthright, and frank
attitude
• Understand how the patient’s values drive his/her specific
requests
• 2 sorts of advance directives :
- living wills
- appointment of another person as a legal representative
for health care decisions
*Both take effect only when the patient loses decision-making capacity
• Policies and laws dictate who can represent a patient who
has no decision-making capacity and no advance
directives.
 PROCEDURES
1. The sequence is
a) Bring up the topic
b) Ask what ideas and experiences the patient has about
advance directives
c) Ask who else might be available to speak for the patient if
he/she is not able to communicate
d) Make the discussion formal.
e) Ask the patient to complete documents.
f) Rediscuss it all in the future

*be sure that your patient is cognitively and emotionally capable of

making these decisions before beginning this discussion
• Most hospitals have policies that ask us to determine
resuscitation plans for all our admitted patients –a good
starting point
• Ask all your patients about their desires for resuscitation even
if they’re young.
• Even though the patients come to you already filled out some
forms about their desires in case of inability to communicate,
you still have to have a conversation about end-of-life issues
• Be sure that the key family members understand your
patient’s wishes.
 PITFALLS TO AVOID
• Shying away from discussions about dying and
death. Hoping that you aren’t on call when
the patient dies.
• Failing to document end-of-life discussions
with the patient.
• Leaving key players out of the discussion,
chancing explosive conflicts among relatives
at big decision points.
Discuss end-of-life issues
regardless of the patient’s
age, and document your
conversation.
4. Being with a dying
patient
 Being with a dying patient
PRINCIPLES:
• We must attempt to ensure the patient’s
comfort, even if at the cost of shortening life
somewhat. Dying need not be suffering
• Main focus must extend to the family and
friends of the dying patient. They need
comfort, support, and clear evidence that
their loved one is not suffering
 PROCEDURES:
• Be available. If possible, be on the scene to orchestrate
events at the deathbed.
• Just be there
• Practice empathy - ask how the family members are feeling.
• Ask to hear about the patient’s life.
The more the grieving relatives talk about the dying person,
the calmer and more soothed they will be.
• If you knew this patient enough to add to the narrative, you
can add your comments, especially the positive ones.
• If the patient is a potential organ donor
- confirm with his/her family members
- call the appropriate staff to talk with the family about the
process of
donation.
• If you were present at the death, you might want to consider
some sort of follow-up action, such as sending a card or even
attending the funeral.
 PITFALLS TO AVOID:
• Leaving arrangements and communication
with the family to the nurse.
• Avoiding anything personal. Talking with the
family about biomedical and technical issues.
• Missing the chance to hear the family’s
feelings and memories.
Sometimes just showing
up says more than words
 Reference
• Field guide to the difficult patient interview, 1999
• Communication skill for final MB, 2006
• WHO Definition of Palliative Care
• www.wikipedia.com
• www.bbc.com