Part C – Communications tips and examples
[Voice Over] The doctor-patient relationship is the cornerstone of good medical care. Good communication improves accuracy and efficiency of clinical practice as well as patient satisfaction. During the medical interview we know that doctors interrupt early, seek specific information and struggle to effectively respond to emotions. This leads to the doctor commonly missing issues that are important to the patient. Communication skills are not innate but can be taught and learned. What do our clinicians think about communication in CPR decision-making?
Part C
1. Improving communication
Patient/Doctor scenarios
Dr Peter Saul, Intensive Care Specialist John Hunter Hospital, NSW
It’s not easy to just encapsulate how to communicate about end of life, but there are two simple things that can be said. One is that you have to know what it is that you're trying to say, and you also need to develop some skills in how to say it. So there is what you need to say and how you need to say it, and those are the two wings of the bird. If you don't have one or other of those it won't run very well.
Dr Barbara Hayes, Palliative Care Physician & Clinical Leader, Advance Care Planning, Northern Health, Victoria
I think it's really important that when we have a discussion that as a clinician we have all the information when we meet with the patient so that it's an informed discussion.
Dr Peter Saul, Intensive Care Specialist John Hunter Hospital, NSW
I think you have to be sure about who you’re talking to. In other words the patient and whoever else they want there or family members that are the key decisions makers to all of this lot. And then the the most important thing of all is to open with an open-ended conversation starter something like "you must have talked to a lot of people over the last few days. Can you tell me in your own words what you think is going on. You know, what you think is happening here?" I think is very important that you don't provide yes/no options all the time and I think is important that people feel like any discussion about end-of-life is embedded within a general conversation about the patient's wellbeing.
Dr Barbara Hayes, Palliative Care Physician & Clinical Leader, Advance Care Planning, Northern Health, Victoria
We need to find out how much the patient wants to know and be involved in the discussion.
Mr Frank Prokop, Executive Director , Health Consumers Council of WA
It's extremely important to engage with information and communication skills that are appropriate to your audience.
Dr Derek Eng, Palliative Care Physician
We know from a lot of research that a patient will communicate emotional content far quicker than they will cognitive and intellectual content and the important thing in that is that as clinicians we're not really taught about how to deal with emotions and really I think that's the root of why these conversations are difficult or can be challenging.
Dr Peter Saul, Intensive Care Specialist John Hunter Hospital, NSW
There are a number of mnemonics out there that you can use, all of which are quite valuable and I would strongly recommend adopting a mnemonic approach.
Dr Barbara Hayes, Palliative Care Physician & Clinical Leader, Advance Care Planning, Northern Health, Victoria
Trust, I think, is really important in CPR decision-making as it is with many other aspects of communication. Patients need to be able to trust the technical knowledge that we provide and our recommendations. They need to be able to trust we have the best interests at heart and for CPR they also need to be able to trust that if they have an order to withhold CPR that we still will provide high-quality care and that doesn't mean they'll miss out.
Dr Peter Saul, Intensive Care Specialist John Hunter Hospital, NSW
The main indicator, however, of successful communication and the main take-home message about successful communication is that you spend more time listening than you spend talking. You know that you've achieved something when you actively listen to the other person and that they feel actively listened to and there is a general feeling that if you spend 75 percent of your time listening and 25 percent of your time talking you’ll be regarded by that person as a successful communicator.
Successful Communication
75% Listening
25% Talking
Narrator
[Voice Over] The better our communication skills, the better we will care for our patients. We can emphasise to the patient what will be done, before discussing what won't be done. We can then align our treatments to meet the patient's goals of care. Learning communication skills is complex. It requires learning about tools, practising using the tool and then applying to clinical practice and seeking feedback.
The clinician then starts the cycle again, further refining communication expertise. What follows are two doctor-patient interviews in the same patient. Two tools are introduced:
Ask-Tell-Ask promotes the doctor to ask open questions to get the patient perspective and their agenda, then from there the doctor can build on, giving them information that is particular to them and useful to them.
[Voice Over continues during slide show]
Ask-Tell-Ask
Explore their hopes and fears/concerns
Clarify goals and values
Align decisions with patient’s goals
NURSE is another tool which assists the clinician to respond effectively to emotions. When reviewing the scenarios consider what is done well and what is done poorly. Supportive resources are available to optimise the learning experience.
[Voice over continues during slide show]
Respond to emotional tools
NURSE
Name it
Understand the core message
Respect/Reassurance
Support
Explore
[Voice Over ends]
Patient/Doctor scenarios
Here we view a CPR flowchart: Would the patient Survive CPR? No? Discuss with patient CPR not being offered.
1. Improving Communication
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Patient/Doctor scenarios
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Dot and Dr Nick
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Dot and Dr Eng
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Additional scenario – Jo and Dr Eng
Scenario 1: Dot and Dr Nick
[Dr Nick] …Umm hi
[Dot] Hello
[Dr Nick] Mrs Roberts, yeah my name's Nick I'm one of the consultants
[Patient interrupts] Hello
[Dr Nick] I just wanted to have a quick..
[Patient interrupts] oh thank you yeah...
[Dr Nick] Do you mind if I grab a seat and we have a quick chat? Look, you're really not well at the moment.
[Dot] No
[Dr Nick] … and um there's something I need to ask you, is it er, if your heart stops are you wanting us to start up again?
[Dot] Course I do, course I do...yeah.
[Dr Nick] Well the trouble is it probably wouldn't make any difference I don't think we'd be able to get it started.
[Dot] Well that's nice, well you'd have to try, surely?
[Dr Nick] Well we could do…
Dot makes sounds of distress.
[Dr Nick] … but it'd ...you know it might put you through unnecessary suffering,
so I wouldn't want to do that to you.
[Dot] Well how would you know I mean, what about my family?
[Dr Nick] … um yeah that's a good point well guess and we could we could get them in and see what they think but...
[Dot] Well, yes, you must.
[Dr Nick] so you're wanting us to do it, are you?
[Dot] Get them in and of course you would try everything, surely?
[Dr Nick] Okay, well, we’ll keep doing everything we can then and see you know and see, see how you go?
[Dot] I can fight this, I can fight this.
[Dr Nick] … yeah okay then we'll keep going to
[Dot] … good, yeah, of course!
In the Emergency Department patient is unconscious and staff gather around her bedside.
[Off screen] Have we confirmed cardiac arrest?
[Nurse Off screen] Yes we have.
[ED Male Staff Member] We carry on fifteen to two. Vicky can you just get a defib?
[Vicky] Sure
[ED Male Staff Member] Can you just umm do a rhythm check for us please?
[flatline sound]
[Vicky] Hands off compressions.
[ED Male Staff Member] Okay we're still in asystole can we dump the charge?
Okay everyone, I think we've had twenty minutes of CPR, we have been in astysole throughout, I don't think this is survivable so I think we should stop resuscitation. Does everyone agree?
[Staff] Yes, yeah.
[ED Male Staff Member] Is there anyone who doesn't agree? Okay can we please ah remove all the monitors um we will need to pronounce this lady dead
Dr Peter Saul, Intensive Care Specialist John Hunter Hospital, NSW
To think that dying is failure is going to colour everything that you do. Dying is not failure - it's only a failure if you don't manage the dying process well and people go into that fearful, in pain, and not clear about what's happening and completely out of control.
Scenario 2: Dot and Dr Eng
[Dr Eng] Hi, Mrs Roberts. I'm Derek Eng.
[Dot] Hello Derek
[Dr Eng] Can I call you Dot, please?
[Dot] Dot? Yes, please.
[Dr Eng] I'll just have a seat and we can have a chat. How are you feeling?
[Dot] Oh, not bad. Not bad. Yes, bit short of breath as usual, but yeah I’ll get there.
[Dr Eng] Yeah, so, the breathing’s been difficult?
[Dot] It has been, actually, yeah but…
[Dr Eng] So in fact uh I think you know we’ve chatted about the condition quite a bit before, um…
[Dot] Mmmm
[Dr Eng] I’m a bit worried that your breathing isn’t getting better the way that we would expect.
[Dot] Well, yes, but um…It's been like that before, I’ve bounced back, gone home, seen the grandchildren.
You have, and to your credit I think you've always been a fighter.
[Dot] Yes.
[Dr Eng] and you've always sort of bounced back.
[Dot] I intend to continue that way hopefully.
[Dr Eng] I hope so too. I guess I'm a bit worried that at some stage and it may be even now, that you don't bounce back the way you did. Is that something you ever to think about?
[Dot] Well, yes I do, actually. It worries me too.
[Dr Eng]: Does it?
[Dot] I try and fight it
[Dr Eng] Yeah and I think you know, you certainly do fight it and umm I’m not telling you not to and we’re certainly going to be helping you get better if we can. There are times though that when that when the lungs eventually fail that there is nothing else we can do to get it better…have you…are you aware of that?
[Dot] Well I didn't really think that far ahead [Dr Eng: No] mmm
[Dr Eng] It’s important for me to talk to you about that though so that you have a sense of you know what that might look like for yourself and for your family.
[Dot] Well, I do know that it’s getting bad but how far I don't know. What do you think what…what can we do?
[Dr Eng] So what we can do is make sure we umm try and improve your lungs try and help your breathing as much as we can and there is the palliative care team we can get to see you, to get your breathing as comfortable as possible. [Dot: yes] I guess it's important for you to realise that if you're heart and your lungs do fail that you might die. It's…it's unpredictable when that could happen.
[Dot] It's a bit of a shock but thank you for telling me. I kind of knew it deep inside [Dr Eng: Do you?] …that that this is happening, yes.
[Dr Eng] So I…I know this is quite shocking information umm the other important thing is you might have heard of CPR?
[Dot] Yeah, I have and I guess I was hanging on to that perhaps?
[Dr Eng] As a fallback, as a safety net?
[Dot] Yeah
[Dr Eng] So you are hoping that if… if we did CPR that other things would be better?
[Dot] Yes
[Dr Eng] Most people think that. I guess the reality of the situation is when people are very sick from their heart and their lungs, CPR isn't particularly effective. CPR isn't particularly effective.
[Dot] No, I probably realised that, just was hanging onto the hope.
[Dr Eng] Hope’s very important.
[Dot] Yeah it's been good of you to be straight with me, yeah.
[Dr Eng] Alright [Dot: yeah] Look, I understand that's not easy to take in. [Dot: mmm] Look if you have any questions at all about that I'm here for you to ask
[Dot] Thank you, thank you...thank you
Dr Barbara Hayes, Palliative Care Physician & Clinical Leader, Advance Care Planning, Northern Health, Victoria
I think cardiac arrest has to be the most gentle way a person could die... and people want often to die gently and peacefully and so doing CPR potentially takes that away from them. So it's really important that if we're going to provide CPR that it’s what the patients wants because we can maybe, umm, turn a very, umm, gentle dying into a very bad dying.
Professor Leon Flicker, Director WA Centre for Health and Ageing, Royal Perth Hospital, WA
And an end-of-life discussion and even end-of-life consequences can be a joyful experience for all concerned and if you are part of the equation and if you are part of the partnership you get a chance to share that and feel rewarded and vindicated in your decision to enter into a career in medicine.
Part C
1. Improving communication
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Patient/Doctor scenarios
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Dot and Dr Nick
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Dot and Dr Eng
Additional scenario – Jo and Dr Eng.
Joe Thompson age 78
[Voice Over] If you're in a journal club or workshop please be led by your educator.
5 myocardial infarcts
[Voice Over] If you're alone please reflect…
Ejection Fraction 28%
Stage 4 Kidney Disease
Poorly controlled diabetes
Diffuse PVD
[Voice Over] …are conversations done well or poorly? Has the ASK-TELL-ASK or the NURSE tool been used? How would you do things differently?
Additional Scenario: Joe and Dr Eng
[Joe]coughing
[Dr Eng] Mr Thompson
[Joe] G’Day
[Dr Eng] I’m Derek Eng, one of the specialists.
[Joe] Oh yeah, yeah.
[Dr Eng] Can I call you Joe?
[Joe] Yeah, yeah.
[Dr Eng] Great. Shall we have a bit of a chat?
[Joe] Yeah, go for your life. Someone has to.
[Dr Eng] So, Joe, you’ve been in hospital for 10 days I understand?
[Joe] Yeah, too right. Where, how long am I going to be in here?
[Dr Eng] Sure. Look I'll get to answering that question if I can, umm, as soon as possible will get you hopefully.
[Joe] Yeah, right!
[Dr Eng] Because we haven't had a chat before could you just take me through the last 10 days or just even a bit before that? [Joe coughing] What's happened with you?
[Joe] Well, I dunno I just had a heart attack and they brought me in here...and I've been here sitting in it and lying in this bed, taking their medicine and people come along and examine me take my pulse and all that sort of thing but I dunno what's going on really [coughs]. They haven't even fixed this cough.
[Dr Eng] Sure so it sounds like things have been happening but you don’t kind of have a clear sense of you know where it's going?
[Joe] Huh! Nah, I don't know if anyone does really? You know? Someone comes in and does something and then someone else comes and does the same bloody thing.
[Dr Eng] Yeah, so it's a bit confusing or frustrating?
[Joe] Yeah. I'd say frustrating yeah.
[Dr Eng] So look I'm here to help and I’m one of the specialists in the hospital as I said before and umm my job is to try and get you to, to work with the team, get you better and get you out hospital.
[Joe] Oh when?
[Dr Eng] As soon as possible.
[Joe] Right
[Dr Eng] Alright I know you'd like to know an exact day umm I'd like to be able to give that to you but at the moment there's a few things we need to get on top of .
[Joe] Well what, what sort of thing you got to get on top of?
[Dr Eng] For example the cough, we'd like to see you get a little bit better.
[Joe] Oh so would I.
[Dr Eng] Yeah. So look we're we're going to keep working hard to get you better.
[Joe] Good.
[Dr Eng] I think that's important for you to know.
[Joe] Mmm
[Dr Eng] The other important conversation is really what your sense of what we should do if your heart gets worse. So I'm not saying it's going to be now but potentially down the track.
[Joe] Well how would I know what you should do? I'm a bloody truck driver not a doctor. What, what have you got to give me?
[Dr Eng] Sure, so I realise that umm, a lot of people have a sense of CPR so if, you know, if you get sicker and sicker.
[Joe] CPR? Oh that's that stuff where they belt you in the chest.
[Dr Eng] That's right.
[Joe] And that works does it?
[Dr Eng] Well look that's a good question. A lot of people think it works but in the situation where the heart gets weaker and weaker with repeated heart attacks, when it comes down to the point where your heart stops, CPR is not effective.
[Joe] And any other way of starting it?
[Dr Eng] Umm I wish that was no there isn't there really isn't.
[Joe] So what else can you do?
[Dr Eng] When it comes time that your heart is not working we would make sure that you're absolutely comfortable free of pain, discomfort.
[Joe] Yeah and I'm still here or at home? Can I go home?
[Dr Eng] Yeah so these are different scenarios we're talking about; I know it’s confusing at this stage you are improving and we are going to get you home.
[Joe] Ah, well that's something.
[Dr Eng] It is useful than we've had a discussion about this.
[Joe] Ah, if I get weaker and weaker, can, do you want me back in here or can I stay home?
[Dr Eng] I think that's a good point and we can discuss that.
[Joe] And I'll have to discuss it with missus as well.
[Dr Eng] Sure, how about we then get your missus in and we can talk about a plan at home as well?
[Joe] Yeah. Yeah I think that's a good idea, okay so I'm going home.
[Dr Eng] Yes, you are.
[Joe] Good
[ENDS]