1. An introduction to effective Communication in End of Life Care
Before embarking on teaching communication skills you are strongly encouraged to complete rhe NHS Glos communications workbook and attend the study day. Resources and calendar of events available from –
Calendar -
The main eolc web page is ….
Trainers in communication should be experienced, knowledgeable, trained and have the skills to do so.

2. Ground Rules Give time for everyone to have their say
Confidentiality – stays in the room. No real names to be used for residents, relatives or other professionals
Time keeping
Respect each others views
Mobiles
Housekeeping arrangements

3. Aims
Explore some essential skills of communication in end of life care
Identify barriers to effective communication

4. End of Life Care Strategy - Communication
All staff in health and social care, and the voluntary and independent sectors, need some training to ensure they are able to communicate effectively with people who are dying and their carers about issues surrounding end of life care (DOH 2008 p.113)

5. COMMUNICATE What do you understand by this word? Brainstorm
Encourage everyone to contribute.

6. What do we want from communication?
Information – delivered in a language we can understand
Honesty
Companionship
Opportunity to reflect

7. Exercise 1
Why is effective communication so important in relation to end of life care?
Take 5 minutes to discuss in groups why you think it is important
Flip chart
Central to high quality patient care
Ensures all involved in care are aware of plans/wishes/needs of an individual
Helps understand residents concern’s and feelings
Gives time to residents – especially those who have communication problems (speech, hearing, sight)
Broach sensitive subjects – e.g. losses associated with moving into a home
Explain illnesses to residents and families
Explain care options to residents and families
Reduces confusion/lack of clarity
Builds good relationships within home and external agencies (GPs, DNs, etc etc)
Extra points
Good skills are the same whatever the subject or with whom we are communicating with – those with communication disabilities
Responding appropriately important
Talking about sensitive issues can help to relieve distress
Active non judgemental listening is a crucial component of good communication

8. Essential communication skills
Listening skills
Verbal
Language – words used
Paralanguage – how it is said, tone, pitch, clarity
Non-verbal
what we understand and transmit from body language
Three part involvement session
Listening skills – 2 people back to back. A holds a picture of a house, B has to draw it from listening to A describe it – can mention shapes and sizes only(
Or talk for 3 mins (two people) and relay back to group what has been said to them – cannot make notes
2 Verbal
language –
Open questions
Require more than ‘yes’ or ‘no’
Often start with ‘how’ ‘what’ ‘why’ or ‘tell me’
Closed questions
More direct and specific
Limits information given
Examples
‘if your condition deteriorates do you want to stay at home?’ As apposed to ‘if your conditions deteriorates where would you most like to be cared for?’
‘do you want your friends to visit when you are close to death?’ as apposed to ‘who would you like with you and who would you like to visit when you are close to death?
‘do you want to be resuscitated?’ as apposed to ‘is there anything you would like to avoid happening to you?’
Get attendees to say ‘how are you’ – Mandy and Maggie to try first!! See how it feels
4 Non-verbal
Practicing Communication skills (15 – 20 minutes)
In 2s
A – describe their first day at work
B – listen and demonstrate that he/she is listening and ask a question, if appropriate
A – answer and carry on a describe the event
B – reflect back what has been understood
Switch roles after 7 – 10 minutes
Learning point of this exercise is to participants listen without talking or interrupting directly or indirectly (looing at watch, out of the window) and demonstrate that they are listening
Get pairs to feed back
Non verbal – use the information in slide 13!!!!
Gestures
Illustrates speech, emotions
Posture
Demonstrates, emotions and mood. Supports or opposes the spoken word
Eye contact
Important for building satisfying relationships
Facial expressions
Displays emotions
Touching
Develops caring relationship
Personal space
Can feel threatened if too close
&

9. Listening Skills Plan the environment Be Attentive
Hear what an individual is saying
Use appropriate body language
Environment
Plan – peace and quiet, no interruptions – private – do not talk in corridors etc etc
Attentive – eye contact, sit at same level
Hearing -

10. Effective skills - language
Questioning –open, closed, leading and multiple
Encouragement
Picking up on cues
Reflection
Silence
Clarification/Summarising
Open questions
Require more than ‘yes’ or ‘no’
Often start with ‘how’ ‘what’ ‘why’ or ‘tell me’
Closed questions
More direct and specific
Limits information given
Leading questions
Need to be avoided – puts words into people’s mouths e.g. ‘I suppose you are nervous…?’
Multiple questions
can cause confusion and reduces time for answering e.g. ‘how are you feeling? Pain any better? Did the pills work?’
Encouragement
shows an interest in the conversation – encourages continuation with the conversation
Picking up on cues
Residents dropping hints
Requires staff having the ability to pick up on these e.g. ‘I didn’t like staying in hospital, don’t want to go back’
Reflection
Promoted further discussion
Silence
Very powerful, gives time to assess what has been said
Clarification/summarising
Ensures that the meaning of the conversation has been understood

11. Paralanguage – Tone of voice Volume Pitch
Try saying ‘are you ok?’ considering some of the above to the person next to you and see what response you have..
Tone – can change the meaning of words
Volume – no need to shout
Pitch – can change the meaning of a word, sentence

12. Non-Verbal Communication
Is the message or response not expressed or sent in words
Over 65 percent of the social meaning of the messages we send are communicated non-verbally.
Actions speak louder than words.
Think of some examples…….
Demonstrate some non verbals such as aggression, impatience,

13. Non-verbal behaviours
Personal space
Facial expressions
Posture
Gestures
Touching
Personal Space
Can be invasive if someone gets too close
Need to sit squarely, can lean forward to encourage conversation and make someone feel understood
Facial expressions
Display emotions – can conflict or support (smiling, frowning etc)
Posture
Demonstrates attitudes, emotions and moods
Supports or conflicts the words spoken
Gestures
Illustrates speech – hands, fingers, movements
Touching
Expresses emotions
Can help develop a caring relationship – be careful!!

14. Non-verbal Communication!!

15. Barriers or blocks to effective communication especially at EoL
Could break into 3 groups. Ask them to list all the barriers they can think of under their heading.
Ourselves- Poor communication skills, poop preparation, planning
Them – what do they want to know, want to hear, are they ready? Level of understanding
Environmental –available time, difficult environments, lack of privacy, other people, lack of staff,

16. Barriers to effective Listening
Feeling stressed by other concerns
Environment noisy or disturbed
Not feeling confident
Low motivation – bored or tired
Being in a hurry to pass the person on
Interjecting with own experiences
Formulating answers to queries before hearing exactly what is needed

17. ‘Verbal's’ for you to avoid
Mumbling
Passing judgement or giving unwanted advice
Interrupting
Discussing your own experiences
Jumping to conclusions
‘I understand’
Confusing people with multiple questions
Using jargon

18. Useful Tools Listening skills - active not passive
Use of Questions - open not closed
Reflecting Back
Clarifying
Reinforcement/Encouragement
Paraphrasing
Silence
Listening – to pick up on cues – concentrate
Questions – provides the space for an individual to express themselves
Reflecting back – promotes discussion – around a problem and leads into in depth conversations
Clarifying – to ensure that meaning is understood ‘what do you mean by that?’
Reinforcement/encouragement – shows interest and understanding, encourages the person to continue
Paraphrasing – summarising/interpreting
Silence – very powerful – gives both parties time to assimilate (digest) what has been said

19. Identifying emotions…
Anger
Sadness
Surprise
Guilt
Anxiety
How easy is this? Could they identify these in residents, family, staff?

20. Remember to look after yourself too…
Understand that looking after a dying person will put added strain onto you and the team
Beware of your own emotions, if a specific task is difficult, find someone who can help
There may be events in your life that mean you are not the best person to help this client/relative on this day – that’s ok.
COMMUNICATION IS THE KEY: informal chats, supervision, reflective meetings or talking to another professional may help

21. Dealing with limits of your knowledge/remit
Its OK to
To admit you don’t know something:
Who might know?
How will it be followed up?
Explain likely time -frame of response
Its NOT OK to
Block a question by:
- Ignoring it
- Dismissing it
- ‘Jollying the client
along’
Guess / say something you’re not really sure of

22. Issues for Individuals in your care
Discuss in groups what you think the dangers are if staff do not possess effective communication skills
Increased anxiety
Wishes not taken into account
Poor quality of care
Symptoms not controlled

23. Scenario What would you do??? You have been caring for Mary for
several months. She has become gradually
more frail both physically and mentally. On
this occasion, she seems quite agitated
and tells you “that woman has been horrible to
me. She shouts at me, hasn’t given me
anything to eat and won’t let me have a bath.”
What would you do???
Give the group 10 mins to discuss – split into small groups or pairs
Could this be role played out the front?
Try and set this up at the front between you and a willing volunteer.
Try and use some of the techniques already covered.
Ask them afterwards what worked well or not.

24. ‘Hello, ward P, can I help?’
Pause for thought!
A 75 year old lady rings her local NHS hospital and had the following conversation:
‘Hello, I’d like some information on a patient Mrs Tiptree. She was admitted last week with chest pains and I would like to know if her condition has deteriorated, stabilised or improved’
‘Do you know which ward she is on?’
‘Yes, ward P, room 2B’
‘I’ll put you through to the nurses station’
‘Hello, ward P, can I help?’
Just read this out…

25. ‘Oh, thank you, I’m so pleased and happy!’
Continued……..
‘Yes, I’d like some information on a patient Mrs Tiptree. She was admitted last week with chest pains and I would like to know if her condition has deteriorated, stabilised or improved’
‘I’ll just check her notes. Yes, I’m very pleased to say Mrs Tiptree has improved. She has regained her appetite, her observations are stable, and following a few more checks we are hoping to discharge her tomorrow’
‘Oh, thank you, I’m so pleased and happy!’
‘Are you a close relative?’

26. no-one tells you anything at all in this place!!!!’
‘No I’m Mrs Tiptree in room 2B,
no-one tells you anything at all in this place!!!!’
Does this happen in a Care home?
Can it happen in a Care Home?
What can we learn from this?
Should it happen?

27. Remember help is always at hand for you
Discuss/explore and explain what help there is in this particular Care home with regard to communication
Refer people on to the Glos NHS Communication workbook and skills workshop for further training.

28. Useful Information www.endoflifecareforadults.nhs.uk
Ellershaw J, Wilkinson S (2008 edition) Care of the dying ‘A pathway to excellence’ Oxford University Press
Local hospices
End of Life Care Learning Resource Pack, Housing 21: