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Effective Communication with Families of Patients with Heart Problems

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Shiva Sharma, M.D Pediatric Cardiology Services * * * Being a parent one can understand the need for normality or require to know how close to normal can the surgery ... – PowerPoint PPT presentation

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Title: Effective Communication with Families of Patients with Heart Problems


1
Effective Communication with Families of Patients
with Heart Problems
  • Shiva Sharma, M.D
  • Pediatric Cardiology Services

2
Extensive data has linked effective
physician-patient communication to biological,
psychological, social, and legal outcomes of
care. It has been tied to better adherence,
shorter hospital stays, better efficiency and
cost effectiveness, less malpractice, and not
surprisingly, increased physician and patient
satisfaction
3
Outline
  • Case presentations followed by discussion of
    effective communication skills
  • Work up to more complex scenarios bad
    news/difficult situations and conversations
  • Prenatal Counseling
  • Medical error disclosure
  • Enhancement of quality of care
  • Increasing satisfaction Patient/Caregivers
  • Promoting excellence in physicians

4
Consider a case.
  • RH, 10 yr WM
  • F Hx of hyperchol. Dad MI at 35 yrs
  • Sedentary, obese, male, Mod.? LDL, ?HDL
  • TLC program initiated.
  • 2nd visit 10 ? in LDL,TG with TLC ?Wt.
  • Extended meeting with Dad and RH to understand
    their perspective, rationalize care, and elicit
    their partnership

5
The 4 Habits Model - Richard M. Frankel, PhD
  • Habit 1 Invest in the Beginning
  • Habit 2 Elicit the Patient's Perspective
  • Habit 3 Demonstrate Empathy
  • "... to know and understand, obviously is a
    dimension of being scientific ... to feel known
    and understood, is a dimension of caring and
    being cared for.
  • Habit 4 Invest in the End

6
Goals of 4 habits
  • Establish rapport build trust rapidly
  • Facilitate effective info. exchange
  • Demonstrate caring concern
  • Increase adherence to plan
  • Improve health outcomes
  • 120-160,000 interviews in a lifetime. Modest
    improvement in delivery of care can improve
    outcomes , satisfaction and cost.

7
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10
The 5 types of empathic responses
  • Reflection--"I can see that you are ... "
  • Legitimation--"I can understand why you feel ...
    "
  • Support--"I want to help."
  • Partnership--"Let's work together ... "
  • Respect--"You're doing great."

11
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13
Bad news
14
Conveying bad news and engaging in difficult
conversations with patients and their families
are pivotally important, although
anxiety-provoking components of clinical
practice Clinicians may fear they will not be
able to find the right words They will say too
much, too little, or the wrong thing altogether.
Further, clinicians worry that imparting
difficult news may diminish hope, compound a
familys suffering, or unleash emotional
responses
15
Consider a case
  • WT, 15yr, AA male
  • Exertional chest Pain
  • Abnomal EKG with T wave inversion
  • Echo Confirmed IHSS
  • Family conference

16
Review
  • What do patients want to know?
  • How do patients experience bad news?
  • How competent are physicians in giving bad news?
  • How should physicians give bad news?
  • Does how bad news is given make a difference?
  • Do cultural differences matter?

17
What do patients want to know?
  • 2,331 patients at UK cancer centers
  • 98 wanted to know if the illness was cancer
  • 87 patients preferred as much information as
    possible
  • Need to individualize delivery to patient needs

Jenkins, Br J Cancer 20018448-51
18
How do patients experience bad news?
  • Bad news results in a cognitive, behavioral, or
    emotional deficit in the person receiving the
    news that persists
  • Clinicians cant change the news
  • Clinicians can make the news worse, or they can
    help give realistic hopes

19
A variety of responses to bad news
  • 100 patients diagnosed with cancer
  • Shock 54
  • Fright 46
  • Accept 40
  • Sadness 24
  • Not worried 15

Lobb, Med J Aust 1999 290-4
20
People receiving bad news may not remember much
  • Three months after parents received bad news
  • 12 of 23 sets took in little or none of the
    information given
  • 4 of 23 sets denied that a separate information
    session had occurred
  • 10 of 19 sets remembered the information session,
    but didnt understand the content

Eden, Pall Med 1994 105-114
21
Medical jargon can make bad news worse
  • Technical language frequently unclear
  • 100 women with breast cancer
  • 73 misunderstood median survival
  • No agreement on what a good chance of survival
    meant numerically

Ford, Soc Sci Med 1996 1511-9
22
Physicians are inaccurate in detecting distress
  • 5 oncologists studied intensively
  • None predicted patient distress better than
    chance
  • One had negative predictive behavior
  • All very satisfied with their performance
  • Little probing about patient emotional state

23
Patient and clinician stress related to bad news
Clinician
Patient
Stress
Time
Encounter
Ptacek, JAMA 1996 496-502
24
The communication challenge
  • Physicians may feel discomfort with the intense
    emotions displayed by parents in response to the
    news, such as sadness, anger, and blame.
  • Physicians may feel guilty or inadequate
    regarding their inability to cure the child.
  • When the childs illness is sudden, little
    opportunity may exist to establish relationships
    with parents before communicating bad news, thus
    making it hard to anticipate parents
    informational and emotional needs.

25
SPIKES model for delivering bad news
  • S - setting up the interview. This portion of
    the protocol recommends a mental rehearsal for
    physicians before delivering the news
  • P assessing the patients perception. This
    portion of the protocol encourages the physician
    to use open-ended question to assess how much the
    patient/parent knows before breaking the news.
  • I obtaining the patients invitation. This
    step involves asking the patient/parent at the
    time of testing how they would like the results
    to be explained.
  • K giving knowledge and information to the
    patient.
  • E - addressing the patients emotions with
    empathetic responses.
  • S- strategy and summary.

26
Prenatal counseling
27
As prospective parents, when you learn your baby
has a congenital heart defect, the news can be
devastating. Feelings of helplessness, confusion,
fear and mourning over the loss of a healthy baby
occur. In addition, extremely difficult and life
changing discussions and decisions need to take
place in a relatively short period of time.
28
Case history (Fetal)
  • MJ is a 25 yr WF. 18 wks gestation fetus found to
    have CHD and told about it.
  • Fetal echo HLHS confirmed with MA and AA
  • Extended Family conference with Mom and Dad.

29
Parental stress following prenatal diagnosis
ofCongenital Heart Disease
  • Earlier studies have reported
  • Increased maternal anxiety with prenatal
    diagnosis of any fetal anomaly (Detraux et
    al,1998)
  • Considerable psychological distress in
    mothers(as compared to fathers) which may be
    markedly underestimated by healthcare providers
    (Leithner et al, 2004). This may require
    professional help in the perinatal period. (Skari
    et al, 2006)

30
Fetal counseling
  • Help families cope with the news of CHD
  • Help families understand prognosis/diagnosis.
  • Make transition to post natal life as seamless as
    possible

31
Fetal counseling (cont.)
  • Try not to overwhelm the parents
  • Challenge to provide the information in a way
  • that is easily understood
  • Only a small fraction of what is said is likely
  • to be retained
  • Typically go through normal anatomy and
  • physiology and then go through the defect
  • Benefit of multi-disciplinary approach

32
Medical error
33
Respect for patient autonomy is a cornerstone
of the Codes of Medical Ethics of the American
Medical Association (AMA) and encompasses the
rights of patients to receive all information
necessary to make informed and educated decisions
about their care. Disclosure of adverse
events is implicit in this principle, because
without it patients are not fully informed.
Failure to disclose threatens the trust inherent
in a doctorpatient relationship. Research on
patients, family members, and attorneys suggests
that patients are less likely to sue if
disclosure has taken place
34
  • What do patients actually expect after an
    injurious medical error has occurred?
  • Numerous studies in adults have examined this
    question, and five key messages have emerged.
    Patients want
  • An explicit statement that an error occurred
  • To be told what the error was
  • To be told why the error occurred
  • To know what will be done to prevent recurrences
  • An apology

35
The 7 Ws of disclosure
  • Why disclose?
  • To preserve patient autonomy and
    patient-physician trust
  • Because ethically it is the right thing to do
  • Who should disclose?
  • Health care worker with whom the patient has a
    trusting relationship, usually the responsible
    physician
  • Others involved in the incident (eg, nurse,
    pharmacist may be included)
  • If the physician cannot disclose, another health
    care worker with an established relationship with
    the patient or a member of the hospital
    leadership or quality and safety program should
    do the disclosure.
  • A senior hospital administrator may need to be
    involved in serious cases.
  • The patients primary nurse should be included in
    the discussions to be able to support the patient
    after the disclosure has occurred.

36
The 7 Ws of disclosure (cont.)
  • To whom should the communication be made?
  • To the patient
  • If this is not possible, to family members or
    substitute decision makers
  • What types of events should be communicated?
  • Any incident that has resulted in harm to the
    patient
  • Other incidents at the discretion of the
    responsible physician
  • What information should be communicated?
  • Acknowledge that the event occurred and give the
    facts.
  • Take responsibility and apologize.
  • Commit to finding out why.
  • Explain what impact the event will have on the
    patient now and in the future.
  • Describe steps being taken to mitigate the
    effects of the injury.
  • Describe steps being taken to prevent a
    recurrence.

37
The 7 Ws of disclosure (cont.)
  • When should communication take place?
  • As soon as the event is recognized and the
    patient is physically and emotionally capable
  • Ideally within 24 hours after the event is
    recognized
  • Where should the communication take place?
  • In a private and quiet area

38
Simplified Summary
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40
Parental requirements
  • Normality
  • Certainty
  • Health information
  • Partnership

41
What parents look for
  • Delivery of information
  • Levels of support
  • Relationship with the caregiver
  • Management of events

42
Delivery of information
  • Verbal , one on one basis
  • Nonverbal communication, eye contact
  • Simple language at level with parents
  • Supplemental visual, written, websites to give.
  • Check out www.pted.com

43
Relationship with physician/ caregiver
  • Establish rapport and trust by LISTENING to
    parents patients
  • Partner with parents
  • Including older child in conversation
  • Treat as individuals.

44
Levels of support
  • Contact numbers
  • Open access
  • RN contact
  • Web based support groups
  • Other families in the area with similar diagnosis
    -
  • School staff

45
Management of events
  • Parents want control over events
  • Access to specialized RN, MD, CHOA type hot line.
  • Information for school

46
Development of professional competence
47
Professional competence is defined as the
habitual and judicious use of communication,
knowledge, technical skills, clinical reasoning,
emotions, values, and reflection in daily
practice for the benefit of the individual and
community being served.
48
Dimensions of professional competence
  • Cognitive
  • Core knowledge
  • Basic communication skills
  • Information management
  • Applying knowledge to real-world situations
  • Using tacit knowledge and personal experience
  • Abstract problem-solving
  • Self-directed acquisition of new knowledge
  • Recognizing gaps in knowledge
  • Generating questions
  • Using resources (eg, published evidence,
    colleagues)
  • Learning from experience

49
Dimensions of professional competence
  • Technical
  • Physical examination skills
  • Surgical/procedural skills
  • Integrative
  • Incorporating scientific, clinical, and
    humanistic judgment
  • Using clinical reasoning strategies appropriately
    (hypothetico-deductive,
  • pattern-recognition, elaborated knowledge)
  • Linking basic and clinical knowledge across
    disciplines
  • Managing uncertainty
  • Context
  • Clinical setting
  • Use of time

50
Dimensions of professional competence
  • Relationship
  • Communication skills
  • Handling conflict
  • Teamwork
  • Teaching others (eg, patients, students, and
    colleagues)
  • Affective/Moral
  • Tolerance of ambiguity and anxiety
  • Emotional intelligence
  • Respect for patients
  • Responsiveness to patients and society
  • Caring

51
Dimensions of professional competence
  • Habits of Mind.
  • Observations of ones own thinking, emotions, and
    techniques
  • Attentiveness
  • Critical curiosity
  • Recognition of and response to cognitive and
    emotional biases
  • Willingness to acknowledge and correct errors

52
Training physicians team to deliver effective
care
  • Heart of medicine is patient-physician encounter
    to heal the whole patient
  • PERCS (Program to Enhance Relational and
    Communication Skills)
  • MD RN, MSW, Students non-hierarchical
  • Promote self awareness, self assessment

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54
Summary
  • Quality of care depends a lot on good
    communication with families
  • Good communication depends a lot on listening to
    our patients and showing empathy.
  • Good listening means good care.
  • Parents are not looking for how much you know
    but how much do you care.

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57
Relationship Centered Care
Report of the Pew-Fetzer Task Force on Advancing
Psychosocial Health Education
58
  • Reflection--"I can see that you are ... "
  • Legitimation--"I can understand why you feel ...
    "
  • Support--"I want to help."
  • Partnership--"Let's work together ... "
  • Respect--"You're doing great."

Cohen-Cole SA, Bird J. Building rapport and
responding to patient's emotions. In Cohen-Cole
SA. The medical interview the three-function
approach. St Louis, MO Mosby Year Book 1991. p.
21-7.
59
Learning objectives
  • 1. Best practices for
  • a) information delivery
  • b) management of parental anxieties
    expectations
  • c) communication of rare conditions (
    the unknowns)
  • d) communication of bad news
  • e) empowering families/patients
  • 2. Pre natal Counseling
  • 3. Team Approach Coordinating care and
    support

60
Giving bad news
  • Reviewing the evidence
  • Recommendations for clinicians
  • Cultural considerations

61
The communication challenge (cont.)
  • Prognostic uncertainty may lead to reluctance in
    providing information about outcomes.
  • While bad news may be best provided in the forum
    of a family conference, such conferences are
    time-consuming and require advanced planning.
  • Additionally, societal and family expectations
    that death is avoidable through advanced
    technology work against physicians credibility
    when discussing the inevitability of a childs
    death, especially when trust has not been
    established.

62
The communication challenge
  • Conveying bad news and engaging in difficult
    conversations with patients and their families
    are pivotally important, although
    anxiety-provoking components of clinical
    practice
  • Clinicians may fear they will not be able to find
    the right words
  • They will say too much, too little, or the wrong
    thing altogether.
  • Further, clinicians worry that imparting
    difficult news may diminish hope, compound a
    familys suffering, or unleash emotional responses
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