Communication skills in

Palliative Care

Facilitator: Waheeda Mutalib

 Contents

1 Pain vs Suffering

Difficult conversations
2

3 Breaking bad news

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Pain vs Suffering

Suffering is not a question

which demands
an answer,

It is not a problem which

demands a solution,

It is a mystery which demands

a “Presence”.’ (Anonymous)

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Pain is the physical sensations or signals
(within your body) that tells you something is

happening within your body

Suffering is the interpretation or story that you

tell yourself about the pain (i.e thoughts,

judgements, beliefs etc).

 Difficult conversations
Illness in palliative care gets progressively worse

Patients are not responding to treatment

Palliative team manages patient and family

Palliative team often include the GP

 Difficult conversations

The GP is sometimes the doctor who conveys bad news

The GP receives the patient back from specialist investigation with the
diagnosis of a life-threatening condition.

The GP cares for the patient in context and also for other members of
the family who are affected by the diagnosis.
 Difficult conversations
Why discuss the future, in particular the end of life?

Being open about the future can help people enjoy a better quality of life
now.

They may:

• feel less anxious and have an idea of what to expect

• receive better care and support

• make informed choices

• be more prepared (as much as one can be) for now and the future

• make things easier for those left behind by putting affairs in order.
 Why discuss the future
I found it very
helpful and
cathartic to be
able to think,
If there are plan and
choices to discuss the
be made, I inevitable
want to
make them “My uncle wrote a little
book for his wife,
containing information
“I want to about things like what
organise do to if the boiler
Because our Dr was things now breaks down. He was
really clear about because I concerned about the
how dad was, it could feel practicalities and
meant that we were too ill to do wanted to make things
all able to spend so in the easier for her’’
time with him. We future”
didn't miss out on
that time together
 Why discuss the future

“Being told
what could “Talking about it
possibly allows you to
happen in the really sit down
future made us and evaluate
look at life what you want
differently. We to happen”
make the most
of each day
within the
limitations”
 What can happen if we avoid the topic?

Avoiding the subject altogether can make life harder both now and in the future.
Some examples below.

Missed Opportunities...

“We’ve all got

dreams. I’d love
to go on a cruise. “The less honest
If I knew I didn’t professionals are,
have long left I’d the more they limit
bring that cruise people’s
forward” opportunities and
options”

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Unnecessary stress and anxiety….

“The reason why I’d like to have this

conversation is that I get scared sometimes.
My whole working career was teaching.
During that time I could say what I was
“Dad didn’t sort out doing at 2pm on Tuesday 6th May! I know
his will or estate. things don’t always go according to plan
He had a conflict but I’d like to know about my prognosis so
with my brother and that I can plan. I mean one day I was sitting
didn’t reconcile, so on the settee reading the Sunday paper and
my brother’s now the next minute I was wondering why my
trying to sue me face was on the carpet. I hadn’t felt faint or
because he sick or in pain. I want to know ‘what is dying
disagrees with the like? And ‘am I going to wake up dead one
way I dealt with morning!’ These things can’t be planned but
things after Dad I’d rather be prepared’
died”
 Regrets…. “If conversations had
taken place and a little
bit of care put in place
we could have kept
“It is sad that Mum at home for
Dad spent his longer, and avoided the
last few days in dreadful and very sad
the wrong end of life experience
place, being “Because we weren’t told how that she had”
distressed and my husband’s heart failure
uncomfortable. might progress, we made bad
I’m left feeling decisions. We put our life
guilty, savings into a business. As the
wondering illness progressed, he became
whether I more and more reliant on me
should have and there was no one to take
done more” care of the business. It was a
nightmare. I’m still suffering f
inancially now, even though he
died some years ago”
 How can meaningful conversations happen?

● Be respectful: none of us truly knows what is going to happen after death, whatever our religious or spiritual
beliefs. So it’s important not to force our viewpoint onto the person. This is their experience.

● Be honest: remember honesty without compassion is cruelty– dying is a profound process that just needs us to
be there

● Use engaged body language: Be alert and attentive to what they are telling you, and the way they are
saying it. Listen to their tone of voice and be aware of changes to their facial colour; their willingness to engage
with you; their willingness to meet your eyes

● Watch their body language: is what they are saying really what they mean? Are they asking you something
with their body language that they are not expressing with words? If so, invite them to tell you what they really
want to say.

● Stay calm: you may feel embarrassed by this kind of emotional intimacy, or fearful of seeing your patient
become helpless and vulnerable. Breathe slowly to calm yourself.

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● Keep grounded: ground yourself by physically feeling your feet firmly on the floor. This will help you to be
present and accepting of what is happening

● Try indirect questions, such as ‘I wonder whether there’s anything you want to talk to me about?’ or ‘Perhaps
there’s something bothering you which you want to tell me about?

● Try leading questions: you can also gently ask leading questions to find out how they are feeling, such as, ‘If
you become really ill, would you like someone to sit with you, if so who?’ or ‘If you become ill, what medical care
would you like?’ or ‘Have you ever thought about what you want to do with your belongings?’ or ‘Have you thought
about what kind of service you would like at your funeral?’ Again, this provides the dying person with the choice to
respond or not.
● Don't fear tears: it’s okay for the patient to cry; crying is a natural response to emotionally charged
situations. Be understanding to allow the patient to grieve for the life he or she is leaving behind.

● Be quiet! Don’t feel you have to talk all the time. Just being there quietly at the bedside is important, and
can often be surprisingly peaceful.

● Communicate compassion through your attitude, using reflections

 Delivering bad news: what not to say or do

I know how u feel”. You don’t know that even if you have been in a similar situation

It could be worse

Look at the bright side

Avoid filling silences with chatter (Allow silences)

(After a silence use reflections..eg You were quiet right now.. what is going through your mind)

Your father (loved one) had a long life

Beware of the doctor’s tendency to offer solutions; don’t try to fix it right away
 Delivering bad news: what not to say or do

Anticipate your own feelings and reactions eg tears, your anxiety about doing this well

Anticipate the questions patients and families may ask and issues they may raise, especially issues
which you might find difficult
 BREAKING BAD NEWS

Following the

SPIKES
protocol

A 6 step strategy for delivering bad news

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A 6 step strategy for breaking bad news

1. S SETTING up the interview

2. P Assessing the patients PERCEPTION

3. I Obtaining the patients INVITATION

4. K Giving knowledge and information to the patient

5. E Addressing the patients EMOTIONS with empathy

6. S STRATEGY and summary

1. S SETTING up the interview

● Mentally Rehearse

● Arrange for some privacy

● Involve significant others

● Sit down

● Make connection with the patient

● Manage time constraints and interruptions

2. P Assessing the patients PERCEPTION

● Before you tell, ask

● What do they know so far

● Use open ended questions

● Find out the patient’s expectations before you give information

● What is their level of understanding (of the condition and its

seriousness)
-Dont correct pt
3. I Obtaining the patients INVITATION

● Ask the patient what they would like to know

● Get the patients permission to share information

● Break it down a little at a time

● different ways of asking for the invitation egAre you the sort of person
who likes the full details about your diagnosis?
-How much detail would you like to know?
-should this turn out to be more serious would you like to know everything?
4. K Giving knowledge and information to the patient

● Explain the diagnosis (be clear, use plain language, give information
in small chunks)

● Warn the patient that bad news is coming (eg“Unfortunately I've got
some bad news to tell you”)

● Speak at a level and language the patient understands (no medical

jargon)

● Speak slowly (don't rush), give information in small chunks

● Check the patients comprehension throughout

SOLER(Non verbal communication)
5. E Addressing the patients EMOTIONS with empathy

● Recognise and address patients emotions with empathetic responses

● Have empathy and provide emotional support

● Use your listening skills (active listening)

● Use your communication skills (reflecting, silence etc)

● Patients emotional reactions may vary (silence, disbelief, crying,

denial or anger)

● Allow patient to process the news and express their reactions

-give pamphlet for further questions
6. S STRATEGY and summary

● Set out a medical plan of action (strategy for the future)

● Go over the main parts of the consultation (summarise)

-give pamphlet for further questions

 What do Patients and Families Want

1. A clear and direct statement of the news regardless of whether it is good

or bad

Include accurate information about the probable course of the illness,

prognosis, and expected life span. They want this in direct and
non-technical language.

2. Time to talk in private, with the opportunity to ask questions and be

offered support

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 What do Patients and Families Want

3. Openness to emotion, with the physician being caring and kind,

compassionate and hopeful and confident;

openness includes allowing the patient and family to talk, listening

carefully, acknowledging the patients' strong feeling of sadness or anger,
and accepting the patient's feelings.

4. Ongoing involvement in decision making, to maintain a sense of control

in treatment decisions, pain management and the dying proces s.

https://youtu.be/qHGvjv_7PLU
 Thanks!

Does anyone have any questions?

You are welcome to post any question you

may have, on the discussion forum under the
palliative care block on Blackboard.

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