Surgeons Scope Magazine - December 2022

LEARNING HOW TO COMMUNICATE BAD NEWS IS ONE OF THE SKILLS TAUGHT IN THE HUMAN FACTORS IN PATIENT SAFETY PROGRAMMES AT RCSI

There is emerging evidence that the quality of the relationship between the clinician and the patient predicts objective improvements to the patient’s outcome. It has been known since the 1960s that a supportive conversation with an anaesthesiologist directly prior to a surgical procedure results in a reduced requirement for pre-operative sedation and post-operative prescriptive pain relief. Other patient outcomes include, improvements in control of blood pressure, pain (including headache), weight and blood sugars, improved adherence to treatment recommendations, shorter time spent in hospital, and reductions in return visits to the out-patient clinic.

This is the evidence which guides the training delivered to surgeons and healthcare professionals as part of the Human Factors in Patient Safety programmes at RCSI. The programmes are led by Professor Eva Doherty, Director of Human Factors in Patient Safety and faculty in the Department of Surgical Affairs, and are delivered to the surgical, emergency medicine and ophthalmology trainees, the scholars on the online interprofessional Postgraduate Diploma/MSc and participants on the Continuous Professional Development Support Scheme.

Professor Eva Doherty, Director of Human Factors in Patient Safety

A central component of all of these courses is communication skills training and in particular training in the skills to help manage di cult conversations which include the breaking of bad news. Communication skills, which are frequently considered to be counter-intuitive, are the focus as there is evidence that they enhance the quality of the clinician-patient relationship, save time and lead to higher levels of patient satisfaction and lower rates of complaints and litigation. Difficult conversations such as bad news telling requires using these same skills with more emphasis compared to less difficult conversations.

Allowing a patient to speak uninterrupted permits an assessment of the patient’s problem and expectations.

COUNTER-INTUITIVE SKILLS OF EFFECTIVE COMMUNICATION

Seventy-five different healthcare communication skills have been identified, each with a body of evidence to support their use in healthcare conversations. The principal skills are described here.

The beginning of the interaction is important. Patients expect clinicians to have prepared for the conversation they are about to have. The initial greeting with an introduction is the clinician’s opportunity to make a connection. Evidence from social psychology literature has shown that human beings assess each other’s personality traits within the first few milliseconds. The #hellomynameis campaign refers to an awareness campaign initiated by Dr Kate Granger who was a physician in the UK with a rare, terminal sarcoma. Kate was surprised by how few healthcare professionals introduced themselves to her while administering care, and she initiated the #hellomynameis campaign to highlight the importance of introductions. The campaign has since been adopted by the national health services in both Ireland and the United Kingdom. Introductions should be conducted giving the clinician’s full name and subsequently first names may be used.

The patient’s expectations and agenda should be identified at this stage using open questions in comparison to closed questions that result in brief or yes/ no responses. Open questions and screening questions (“What else?”) should continue to be used until a complete account of the patient’s concerns has been reached. Evidence indicates that clinicians interrupt patients after the first 11-18 seconds following the patient’s response to the first open question. These interruptions are often motivated by a concern that the patient will speak for too long whereas the evidence is that patients will stop talking after approximately 90 seconds. Allowing a patient to speak uninterrupted permits an assessment of the patient’s problem and expectations. This prevents misunderstandings and allows for any unrealistic expectations to be handled in a sensitive manner before they become problematic.

Periodic summarising is a process skill that is not routinely used by many clinicians but is an effective method of checking, understanding and also communicating to the patient that the clinician is listening attentively and that they understand. At an early point in most conversations, patients will give clues about the emotional impact of what is being described and this should be acknowledged as early as possible. Contrary to what is commonly believed, this will result in shorter consultations and more satisfied patients.

Clinicians will need to convey a diagnosis or an opinion that may not be expected by the patient and can be experienced as bad news. While a terminal diagnosis is obviously bad news, other revelations such as laboratory/imaging results or treatment delays, etc. may also constitute bad news. Signposting this news using a warning shot is an effective method of directing the patient’s attention to what is important and preparing the patient to hear something unexpected. Signposting in general is an e ective skill to use to explain why clinicians are asking certain questions or why certain examinations/tests/treatments are being recommended and is an e cient method of including the patient. For example: “I have something you might not be expecting to discuss today”. The use of this specific skill has been shown to be associated with a reduced likelihood of a malpractice claim.

Silences in conversations allows for patients to have time to express their emotions and ask questions. “What questions do you have?” rather than “Have you any questions?” is more likely to encourage patients to ask questions, particularly patients who may not wish to delay a busy clinician.

During the conversation, it may be necessary to go over different options to patients. Shared decision-making (SDM) is most beneficial when there is equipoise, in other words when there is more than one option available which is of equal benefit. If this is the case, then the patient can be encouraged to describe their preferences in accordance with their beliefs, lifestyle, age, and cultural background. is decision-making process should be supported by the clinician to guide the correct choice. Many patients may need to consider lifestyle changes to improve their own health and their motivation for such change can be assessed using motivational interviewing (MI) techniques.

These techniques include asking the patient to quantify how much difference such changes would make to them and then how able they feel to make these changes. Patients who offer low evaluations will need further discussion over a longer period of time. Adherence to treatment recommendations is low among many patient groups and can be enhanced through the expert use of communication and MI skills. Choosing Wisely is a campaign that originated in the United States in 2012. The aim of the campaign is to equip clinicians and patients with the communication skills to make optimal healthcare decisions which will ultimately prevent the use of unnecessary tests and treatments.

‘Teach-back’ is a phrase used to describe a skill which the clinician should use towards the end of the conversation and promotes patient adherence. It requires the clinician to check the patient’s understanding of what has been discussed so far. There are different ways this can be achieved. For example, by saying “I want to check that I have done a good job explaining all this to you. Can you tell me what you understand about it all so far?” or “I expect you will go home and tell your wife/husband/son/daughter/family member what we have discussed, what will you tell them?” The clinician can try out different ways of checking a patient’s understanding to discover the best way for themselves.

Care should be taken to present information using language that is matched to the patient’s information needs. The clinician may have to accommodate to the patient’s age, cultural background and to the presence of any disabilities such as deafness, eyesight problems or intellectual disabilities. A significant proportion of patients have health literacy issues and so may not be able to read patient information leafets. Many patients are reluctant to disclose these issues and this will require sensitive awareness. Getting to the end of the conversation requires the specific identification of the future plan and remaining issues and questions. Safety netting is a concept which describes the management of uncertainty and is used to draw attention to what the patient should do if the plan goes wrong or if recovery does not progress as expected.

The skill of empathy does not come naturally and needs to be learned. Clinicians who see themselves as highly empathic are likely to offer solutions and advice rather than empathy ...

Patients who are experiencing strong emotions require containment in the form of empathy, genuine concern and effective use of silences. Skilled empathic responses for as long as it takes, place psychological limits around the patient and facilitate the development of security and psychological processing of the emotions. Empathy is not the same as sympathy. Sympathy is an emotional response whereby an individual feels an emotion in response to witnessing the emotions of another. It is possible to demonstrate empathy while not feeling that exact emotion. For example, it is possible to demonstrate that one can see/hear the patient’s fear and worry while not actually feeling afraid or worried. Empathy is therefore both an intellectual and an emotional skill. It should be expressed with sensitivity and genuineness which requires an emotionally intelligent capacity and the ability to regulate one’s own emotions. The skill of empathy does not come naturally and needs to be learned. Clinicians who see themselves as highly empathic are likely to offer solutions and advice rather than empathy when a patient is distressed. Counter to what might be expected, clinicians can save time if they take the earliest opportunity to demonstrate empathy.

Clinicians do not learn these important communication process skills if they have not been taught them. These counter-intuitive skills can be used with increased emphasis when breaking bad news. The evidence is that training in these skills not only leads to more satisfying conversations for all but also leads to reductions in clinician stress and burnout.

WHAT PATIENT-CENTRED STEPS CAN YOU TAKE WHEN YOU NEED TO DELIVER UNWELCOME NEWS?

Anne Jordan, End-of-Life-Care Coordinator in an acute Level 4 Hospital, Dublin, offers some practical techniques that you can use.

Anne Jordan, BSc Occupational Psychology, MSc Loss and Bereavement

Anne Jordan delivers ‘Dealing with Bad News’, a communications workshop for hospital staff, devised by The Irish Hospice Foundation and Hospice Friendly Hospitals.

Build a relationship Building a rapport based on trust when you are first treating a patient, establishes a good foundation for difficult conversations later on.

Establish some understanding of their needs before you break bad news Gain some understanding of their and their family’s situation, their religion, culture, home situation, so you can use your judgement as to how to approach communicating the medical position.

Find the appropriate physical setting It’s important to plan to communicate bad news as privately as possible, and to establish the patient’s wishes – do they want to know everything, do they want a family member to be present, their choice is important. There should be no interruptions.

Demonstrate empathy You will not feel the way the recipient of bad news feels or truly understand their emotions, but you can comfort and support them.

Understand the patient’s perspective Be aware of the patient’s, rather than your grasp of a specific situation, the patient’s concept of ‘worse’ may not be the same. Encourage the patient to describe what they already know and understand.

Speak in plain language Use conversational language, minimise medical terms.

Schedule enough time for your news and their questions Patients must be given a clear opportunity to ask questions. Remain available for more interaction After bad news is delivered, the patient’s ability to absorb subsequent information is often impaired. As the news sinks in and realities surface, the patient often wants and needs further discussion.

Optimise the next visit You can, for example, ask patients if they would like to bring a friend or relative on a follow-up visit, when matters will be addressed in more depth. Beyond helping your patient remember what was said during the visit, this additional person could potentially act as your advocate, helping you get your message across. (But make sure this third party doesn’t hijack the consent process).

Allow for hope Even a glimmer of hope is better than none at all.