Communication issues in Oncology Ondrej Slama MOU Brno Importance • Most people want to know • Strengthens physician-patient relationship • Permits patients, families to plan, cope Issues.. • Diagnosis • Prognosis • Care planning Six-step protocol . . . 1. Getting started 2. Finding out what the patient knows 3. Finding out how much the patient wants to know 4. Sharing the information 5. Responding to patient, family feelings 6. Planning, follow-up Adapted from Robert Buckman Step 1: Getting started . . . • Plan what you will say – Confirm medical facts – Don’t delegate . . . Getting started • Allot adequate time – Prevent interruptions • Determine who else the patient would like present – If child, patient’s parents Step 2: What does the patient know? • Establish what the patient knows • Assess ability to comprehend new bad news • Reschedule if unprepared Step 3: How much does the patient want to know . . . • People handle information differently – Race, ethnicity, culture, religion, – Age and developmental level • Recognize, support various patient preferences – Decline voluntarily to receive information – Designate someone to communicate on his or her behalf When family says “don’t tell” . . . • Legal obligation to obtain informed consent from the patient • Promote congenial family alliance . . . When family says “don’t tell” • Ask the family: – Why not tell? – What are you afraid I will say? – What are your previous experiences? – Is there a personal, cultural, or religious context? • Talk to the patient together Step 4: Sharing the information . . . • Say it, then stop – Avoid monologue; promote dialogue – Avoid jargon, euphemisms – Pause frequently – Check for understanding – Use silence, body language Common language Medical Language Common Language Cure The cancer is gone and won’t come back. Control Slow or stop the growth for a time. Complete response / Remission There is no evidence of cancer, but it could come back. Partial response The cancer is still there, but smaller. Stable disease The cancer is the same. Progressive disease The cancer is worse. Step 5: Responding to feelings . . . Normal reactions • Affective response – Tears, anger, sadness, anxiety, relief, other • Cognitive response – Denial, blame, guilt, disbelief, fear, loss, shame, intellectualization • Basic psychophysiologic response – Fight-flight . . . Step 5: Responding to feelings . . . • Be prepared for – Outburst of strong emotion – Broad range of reactions • Give time to react . . . Step 5: Responding to feelings • Listen quietly, attentively • Encourage descriptions of feelings • Use nonverbal communication Step 6: Planning, follow-up . . . • Plan for next steps – Additional information, tests – Treat symptoms, referrals as needed • Discuss potential sources of support . . . Step 6: Planning, follow-up • Give contact information, set next appointment • Before leaving, assess: – Safety of the patient – Supports at home • Repeat news at future visits Cultural differences • Who gets the information? • How to talk about information? • Who makes decisions? • Ask the patient. • Consider a family meeting. When the physician cannot support a patient’s choices • Typically occurs when goals are unreasonable, impossible, illegal • Set limits without implying abandonment • Make the conflict explicit • Try to find an alternate solution Decision-making capacity . . . • Implies the ability to understand and make own decision • Patient must – Understand information – Use the information rationally – Appreciate the consequences – Come to a reasonable decision for him/ herself . . . Decision-making capacity • Any physician can determine • Capacity varies by decision • Other cognitive abilities do not need to be intact When a patient lacks capacity ... • Proxy decision maker • Sources of information – Written advance directives – Patient’s verbal statements – Patient’s general values and beliefs – How patient lived his/her life – Best-interest determinations