Recognise that serious illness conversations are often difficult to have, they are easy to avoid. Understand that we need to create ‘a space’ (in time and location) in which to initiate such conversations.
Understand that we communicate both verbally and Non Verbally.
- Up to 60% of communication is nonverbal for example or facial expression (pictures here of different facial expressions /body postures etc); body posture; body movements or gestures, the use of touch (link here to the use of touch) or the way we dress or wear make-up.
- We can all perhaps recall people saying ‘pass me my spectacles please….. I can’t hear you properly’ this isn’t a mistake but rather it acknowledges the significant part of communication that is non-verbal.
- Approximately 33% of our communication is the tone, intonation and pace of our words/ speech (? Video(s) for each of these tools)
- We have already acknowledged that serious illness conversations are in essence breaking bad news. Much is written in the literature about breaking bad news and several strategies exist. For example: SPIKES, SAGE & THYME, ‘Breaking bad news: a ten step approach’ (Kaye 1996) [? Links to strategies] many of these are acronyms (which involves trying to remember what the various letter stand for). If you have adopted one of these methods of breaking bad news / undertaking a serious illness conversation (which is in essence breaking bad news) and you find that the strategy works well for you, then please do not think you need to change.
- We would ask that you reflect on the strategy and review whether it might be refined further e.g. by the adoption of perhaps the hypothetical question (see below).
- The toolkit below seeks not to replace any strategy that you might have learned or adopted but can be integrated into your usual practice.
Some key principles in serious illness conversations
- ‘Ask before you tell’…. Find out what the patient/ family knows. What is their understanding of the illness/ situation/ accident?
- Having ascertained what is known, one needs to elicit ‘how much information /detail do they want to know?’
- The above steps are crucial as they identify the starting point and direction of information sharing. The information sharing should be guided by what the patient/ family want to know. That is not to say that as the rapport build that one could not gently guide the information sharing. However it needs to start with the patient/ family agenda.
- Inherent in gaining this information is permission from the patient/ family that they wish to proceed with the conversation.
Cardiff 6 point toolkit (Video(s) for each of these tools)
- Comfort encompasses many aspects of any consultation/ communication.
- Comfort includes
- the physical setting of the consultation (e.g. an area conducive to sensitive exchange of information)
- The lighting of the room (recognising that a significant portion of communication is non-verbal)
- The physical/ psychological comfort of those involved
- Bad news is inherently ‘uncomfortable and upsetting’ to the patient/ family and can evoke strong emotions such as tears or sobbing, be mindful that if patients do show emotions, this is a normal reaction, do not attempt ‘to make bad news good news’ by saying something like ‘there, there it will be ok’ or feeling compelled due to your own unease to say something to ‘make it better’
- Question style
- Question style during a conversation/ communication is crucially important.
- Question styles include
- Open questions
- Very useful at the start of the consultation to explore the patients understanding/ agenda and build rapport.
- Examples of open questions are ‘how are things?’; ‘how are you today?’; ‘how do you feel things are going?’
- Focussed questions
- These do just as the name suggests; they focus down on a particular area e.g. Tell me more about the pain you mentioned? You mentioned that your son had strong views about organ donation can you tell me about these?
- Open questions
- Hypothetical questions
- Are a type of focussed question which involves a possibility or probability for the future e.g. Have you ever wondered what might happen when the chemotherapy stops being as effective as we would like? Have you wondered why you have symptoms of ……..?
- Recent evidence has indicated that these are a HIGHLY EFFECTIVE TOOL in encouraging patients/ families to engage with difficult issues/ conversations.
- Direct questions
- These narrow matters down further and are often used to clarify. E.g. do you vomit in the morning? Did your brother talk to you about organ donation? Did your mother’s doctors complete a ‘do not attempt resuscitation form’?
- Multiple questions
- These are often a series of short questions rolled into one sentence, they are best avoided as the patient /family do not know whether to answer the first/ last or those in between. They can often cause confusion and give the sense of a rushed interaction rather than a paced conversation in which the patient / family feel listened to.
- Closed questions
- Such questions usually have a ‘yes’ /’no’ answer and whilst occasionally useful E.g. May I sit down? They are of limited use in building a rapport with patients/ families.
- Leading questions
- These are questions which infer (or lead) to an answer e.g. since starting the medicine how much better is your pain? Such questions are best avoided.
- As a general rule think of questions as a funnel (picture of funnel here maybe) the more open the funnel (or more open the question) the more can be poured in and the more narrow the funnel (or more narrow the question) becomes the less that can go through. Same with questions – the more open the question the more the patients/ family are likely to say.
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