Knowledge
Briefly summarize events leading up to this point. Provide a warning statement to help lessen the shock and facilitate understanding, although some studies suggest that not all patients prefer to receive a warning. Use nonmedical terms and avoid jargon. Stop often to confirm understanding. Stop and address emotions as they arise. Use empathic statements to recognize the patient’s emotion. Validate responses to help the patient realize his or her feelings are important. Ask exploratory questions to help understand when the emotions are not clear. Summarize the news to facilitate understanding. Set a plan for follow-up (referrals, further tests, treatment options). Offer a means of contact if additional questions arise. Avoid saying, “There is nothing more we can do for you.” Even if the prognosis is poor, determine and support the patient’s goals (e.g., symptom control, social support).
“Before I get to the results, I’d like to summarize so that we are all on the same page.” “Unfortunately, the test results are worse than we initially hoped.” “I know this is a lot of information; what questions do you have so far?” “I can see this is not the news you were expecting.” “Yes, I can understand why you felt that way.” “Could you tell me more about what concerns you?” “I know this is all very frightening news, and I’m sure you will think of many more questions. When you do, write them down and we can review them when we meet again.” “Even though we cannot cure your cancer, we can provide medications to control your pain and lessen your discomfort.”
Emotions
Strategy and summary
Case Study 2 Terry is the oldest of five siblings. He has been the primary caregiver for his father, Ralph, who is 87 and lives alone following the death of his wife four years previous. Ralph has congestive heart failure, hearing loss, and type 2 diabetes. He was recently admitted to the hospital for pneumonia. While in the hospital, he had a transient ischemic attack, which caused him to become easily confused. Then, possibly due to a micro-stroke, he lost his ability to swallow. Ralph’s attending physician advised the placement of a percutaneous endoscopic gastrostomy (PEG) tube to supply nutrition and hydration. But Ralph had made it clear in his advance directive that he did not want a feeding tube, and he reiterated that desire to Terry. “I’m not afraid to die,” he said. “It’s time to call it quits.” Terry was torn. Some of his siblings were unhappy with the prospect of refusing the tube placement—they were afraid Ralph would die before they got a chance to see him. But Terry knew his father would fight any efforts to force him to change his mind, and Terry didn’t want his last days with his father marred by conflict. Questions 1. What would be a possible response to Ralph’s expression about not being afraid to die that would employ the technique of reflective listening? _____________________________________________________________________________________________ 2. How could you work with Ralph to establish a set of care goals that would be appropriate for either course of action (i.e., having, or not having, the PEG placed)? _____________________________________________________________________________________________ 3. If Ralph refuses the PEG, what steps could you take to make his final weeks more comfortable? _____________________________________________________________________________________________ Culturally Sensitive Communication
Communicating effectively with both patients and their loved ones requires an awareness of some of the cultural differences that can create unexpected barriers or misunderstandings. End-of-life discussions are particularly challenging because of their emotional and interpersonal intensity. Many physicians are unfamiliar with common cultural variations regarding physician- patient communication, medical decision making, and attitudes about formal documents such as code status guidelines and advance directives. 25 Although cultural differences certainly exist, generalizations about specific cultures are not always
applicable to specific patients because there is wide variation in the ways that individuals adhere or adopt the stereotypical beliefs, values, or attitudes of a particular culture. In fact, research suggests that when compared with whites of European descent, ethnic minorities exhibit greater variability in their cultural beliefs and preferences. 26 Clinicians should be aware that different cultures may place different emphasis—or disagree completely— with principles of medical conduct that they take for granted. For example, in the United States, legal documents such as advance directives and durable
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Book Code: CA23CME
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