Title: Effective Communication with Families of Patients with Heart Problems
1Effective Communication with Families of Patients
with Heart Problems
- Shiva Sharma, M.D
- Pediatric Cardiology Services
2Extensive 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
3Outline
- 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
4Consider 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
5The 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
6Goals 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.
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10The 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."
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13Bad news
14Conveying 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
15Consider a case
- WT, 15yr, AA male
- Exertional chest Pain
- Abnomal EKG with T wave inversion
- Echo Confirmed IHSS
- Family conference
16Review
- 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?
17What 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
18How 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
19A 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
20People 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
21Medical 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
22Physicians 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
23Patient and clinician stress related to bad news
Clinician
Patient
Stress
Time
Encounter
Ptacek, JAMA 1996 496-502
24The 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.
25SPIKES 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.
26Prenatal counseling
27As 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.
28Case 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.
29Parental 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) -
30Fetal counseling
- Help families cope with the news of CHD
- Help families understand prognosis/diagnosis.
- Make transition to post natal life as seamless as
possible
31Fetal 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
32Medical 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
35The 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.
36The 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.
37The 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
38Simplified Summary
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40Parental requirements
- Normality
- Certainty
- Health information
- Partnership
41What parents look for
- Delivery of information
- Levels of support
- Relationship with the caregiver
- Management of events
42Delivery 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
43Relationship with physician/ caregiver
- Establish rapport and trust by LISTENING to
parents patients - Partner with parents
- Including older child in conversation
- Treat as individuals.
44Levels of support
- Contact numbers
- Open access
- RN contact
- Web based support groups
- Other families in the area with similar diagnosis
- - School staff
45Management of events
- Parents want control over events
- Access to specialized RN, MD, CHOA type hot line.
- Information for school
46Development of professional competence
47Professional 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.
48Dimensions 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
49Dimensions 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
50Dimensions 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
51Dimensions 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
52Training 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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57Relationship 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.
59Learning 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 -
60Giving bad news
- Reviewing the evidence
- Recommendations for clinicians
- Cultural considerations
61The 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.
62The 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