1. The EPEC-O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation. Education in Palliative and End-of-life Care - Oncology The Project EPEC-O TM

2. EPECEPECOOEPECEPECOOO EPECEPECOOEPECEPECOOO Module 7 Communicating Effectively Module 7 Communicating Effectively EPEC - Oncology Education in Palliative and End-of-life Care - Oncology

3. Overall message A structured approach to communicating helps the oncologist perform this important role

4. Objectives l Demonstrate ability to apply a 6-step protocol for delivering information Know what to do at each step l Demonstrate ability to apply a 6-step protocol for delivering information Know what to do at each step

5. Video

6. Importance l Most people want to know l Strengthens physician-patient relationship l Fosters collaboration l Permits patients, families to plan, cope l Most people want to know l Strengthens physician-patient relationship l Fosters collaboration l Permits patients, families to plan, cope

7. 6-step protocol... 1. Getting started 2. Find out what the patient knows 3. Find out how much the patient wants to know 1. Getting started 2. Find out what the patient knows 3. Find out how much the patient wants to know Adapted from Robert Buckman

8. .. 6-step protocol 4. Share the information 5. Respond to patient, family feelings 6. Plan, follow-up 4. Share the information 5. Respond to patient, family feelings 6. Plan, follow-up Adapted from Robert Buckman

9. Step 1: Getting started... l Plan what you will say Confirm medical facts Don’t delegate l Create a conducive environment l Plan what you will say Confirm medical facts Don’t delegate l Create a conducive environment

10. ... Getting started l Allot adequate time Prevent interruptions l Determine who else the patient would like present If child, patient’s parents l Allot adequate time Prevent interruptions l Determine who else the patient would like present If child, patient’s parents

11. Step 2: What does the patient know? l Establish what the patient knows Child’s parents l Assess ability to comprehend new bad news l Reschedule if unprepared l Establish what the patient knows Child’s parents l Assess ability to comprehend new bad news l Reschedule if unprepared

12. Step 3: How much does the patient want to know... l Recognize, support various patient preferences Decline voluntarily to receive information Designate someone to communicate on his or her behalf l Recognize, support various patient preferences Decline voluntarily to receive information Designate someone to communicate on his or her behalf

13. ... Step 3: How much does the patient want to know l People handle information differently Race, ethnicity, culture, religion, socioeconomic status Age and developmental level l People handle information differently Race, ethnicity, culture, religion, socioeconomic status Age and developmental level

14. Advance preparation l Initial assessment l Preparation for critical tests What does the patient know? (step 2) How does the patient handle information? (step 3) l Initial assessment l Preparation for critical tests What does the patient know? (step 2) How does the patient handle information? (step 3)

15. When family says ‘don’t tell’... l Legal obligation to obtain informed consent from the patient l Promote congenial family alliance l Honesty with a child promotes trust l Legal obligation to obtain informed consent from the patient l Promote congenial family alliance l Honesty with a child promotes trust

16. ... When family says ‘don’t tell’ l 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? l Talk to the patient together l 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? l Talk to the patient together

17. Step 4: Share the information... l Say it, then stop Avoid monologue, promote dialogue Avoid jargon, euphemisms Pause frequently Check for understanding Use silence, body language l Say it, then stop Avoid monologue, promote dialogue Avoid jargon, euphemisms Pause frequently Check for understanding Use silence, body language

18. ... Step 4: Share the information l Don’t minimize severity Avoid vagueness, confusion l Implications of “I’m sorry” l Don’t minimize severity Avoid vagueness, confusion l Implications of “I’m sorry”

19. Step 5: Respond to feelings... Normal reactions l Affective response Tears, anger, sadness, love, anxiety, relief, other l Cognitive response Denial, blame, guilt, disbelief, fear, loss, shame, intellectualization l Basic psychophysiologic response Fight-flight Normal reactions l Affective response Tears, anger, sadness, love, anxiety, relief, other l Cognitive response Denial, blame, guilt, disbelief, fear, loss, shame, intellectualization l Basic psychophysiologic response Fight-flight

20. ... Step 5: Respond to feelings... l Be prepared for Outburst of strong emotion Broad range of reactions l Give time to react l Be prepared for Outburst of strong emotion Broad range of reactions l Give time to react

21. ... Step 5: Respond to feelings l Listen quietly, attentively l Encourage descriptions of feelings l Use non-verbal communication l Listen quietly, attentively l Encourage descriptions of feelings l Use non-verbal communication

22. Step 6: Planning, follow-up... l Plan for the next steps Additional information, tests Treat symptoms, referrals as needed l Discuss potential sources of support l Plan for the next steps Additional information, tests Treat symptoms, referrals as needed l Discuss potential sources of support

23. ... Step 6: Planning, follow-up l Give contact information, set next appointment l Before leaving, assess: Safety of the patient Supports at home l Repeat news at future visits l Give contact information, set next appointment l Before leaving, assess: Safety of the patient Supports at home l Repeat news at future visits

24. When language is a barrier... l Use a skilled translator Familiar with medical terminology Comfortable translating bad news l consider telephone translation services l Use a skilled translator Familiar with medical terminology Comfortable translating bad news l consider telephone translation services

25. ... When language is a barrier l Avoid family as primary translators Confuses family members How to translate medical concepts Modify news to protect patient Supplement the translation l Speak directly to the patient l Avoid family as primary translators Confuses family members How to translate medical concepts Modify news to protect patient Supplement the translation l Speak directly to the patient

26. EPECEPECOOEPECEPECOOO EPECEPECOOEPECEPECOOO A structured approach to communicating helps the oncologist perform this important role Summary