The EPECO TM Education in Palliative and Endoflife

The EPEC-O TM Education in Palliative and End-of-life Care - Oncology Project The EPEC-O Curriculum is produced by the EPECTM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

E P E C O EPEC - Oncology Education in Palliative and End-of-life Care - Oncology Module 7 Communicating Effectively

Overall message A structured approach to communicating helps the oncologist perform this important role

Objectives l Demonstrate ability to apply a 6 -step protocol for delivering information Know what to do at each step

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Importance l l Most people want to know Strengthens physician-patient relationship Fosters collaboration Permits patients, families to plan, cope

6 -step protocol. . . 1. Getting started 2. Find out what the patient knows 3. Find out how much the patient wants to know Adapted from Robert Buckman

. . 6 -step protocol 4. Share the information 5. Respond to patient, family feelings 6. Plan, follow-up Adapted from Robert Buckman

Step 1: Getting started. . . l Plan what you will say Confirm medical facts Don’t delegate l Create a conducive environment

. . . Getting started l Allot adequate time Prevent interruptions l Determine who else the patient would like present If child, patient’s parents

Step 2: What does the patient know? l Establish what the patient knows Child’s parents l l Assess ability to comprehend new bad news Reschedule if unprepared

Step 3: How much does the patient want to know. . . l Recognize, support various patient preferences Decline voluntarily to receive information Designate someone to communicate on his or her behalf

. . . Step 3: How much does the patient want to know l People handle information differently Race, ethnicity, culture, religion, socioeconomic status Age and developmental level

Advance preparation l Initial assessment l Preparation for critical tests What does the patient know? (step 2) How does the patient handle information? (step 3)

When family says ‘don’t tell’. . . l Legal obligation to obtain informed consent from the patient l Promote congenial family alliance l Honesty with a child promotes trust

. . . When family says ‘don’t tell’ l Ask the family: Why not tell? What are you afraid I will say? What are your previous experiences? Is there a personal, cultural, or religious context? l Talk to the patient together

Step 4: Share the information. . . l Say it, then stop Avoid monologue, promote dialogue Avoid jargon, euphemisms Pause frequently Check for understanding Use silence, body language

. . . Step 4: Share the information l Don’t minimize severity Avoid vagueness, confusion l Implications of “I’m sorry”

Step 5: Respond to feelings. . . Normal reactions l Affective response Tears, anger, sadness, love, anxiety, relief, other l Cognitive response Denial, blame, guilt, disbelief, fear, loss, shame, intellectualization l Basic psychophysiologic response Fight-flight

. . . Step 5: Respond to feelings. . . l Be prepared for Outburst of strong emotion Broad range of reactions l Give time to react

. . . Step 5: Respond to feelings l Listen quietly, attentively l Encourage descriptions of feelings l Use non-verbal communication

Step 6: Planning, follow-up. . . l Plan for the next steps Additional information, tests Treat symptoms, referrals as needed l Discuss potential sources of support

. . . Step 6: Planning, follow-up l l Give contact information, set next appointment Before leaving, assess: Safety of the patient Supports at home l Repeat news at future visits

When language is a barrier. . . l Use a skilled translator Familiar with medical terminology Comfortable translating bad news l consider telephone translation services

. . . When language is a barrier l Avoid family as primary translators Confuses family members How to translate medical concepts Modify news to protect patient Supplement the translation l Speak directly to the patient

E P E C O Summary A structured approach to communicating helps the oncologist perform this important role