Palliative care is a field that is rich with opportunity and the need for clear, unambiguous and direct communication. The nature of the illness that brings a palliative care team into the management of a patient and family – the ‘unit of care’ – makes it all the more likely that difficult conversations will already have taken place. The breaking of bad news, such as the diagnosis of metastatic cancer or WHO stage 4 HIV/AIDS, has often taken place in suboptimal circumstances and the palliative care team sometimes has to revisit the conversation to assist the patient to come to terms with the diagnosis and the way the diagnosis was given.

The general practitioner is sometimes the doctor who conveys bad news, but also receives the patient back from specialist investigation with the diagnosis of a life-threatening condition. Both situations require excellent communication, which the GP is well placed to offer, as the patient feels secure with the doctor who has been responsible for the care until then and who will continue with that care in the future. This principle of continuing care is well established in family medicine and primary care. The GP cares for the patient in context and also for other members of the family who are affected by the diagnosis.

A palliative care team is sometimes available to assist the GP in the task of caring for the patient with life-threatening disease. The GP and palliative care team should co-operate closely to be effective. Ideally, the palliative care team comprises four professionals working together to provide care in all domains: the doctor diagnoses and treats, the professional nurse administers medication and gives nursing care, the social worker is both a counselling professional and expert in social support, and the spiritual counsellor facilitates spiritual care. This team needs to have special expertise and sensitivity in communication with the patient and the family.

Good management includes excellent diagnosis and treatment of the underlying illness, pain and symptom management and takes place in a calm atmosphere with opportunities for the patient to spend time with his/her family. There are a number of care needs present from the time of diagnosis; therefore excellent communication is an early priority in palliative care, particularly when the patient is cared for at home and is under the care of the primary care doctor. Factors that assist with communication should be considered.

Principles of communication

Palliative care requires effective use of communication skills throughout the trajectory of illness and after bereavement. Effective communication incorporates attitudes of authenticity, sensitivity, compassion and empathy, all of which assist health care professionals to support patients, families and each other. Some of these communication skills are the following:

Listening. Communication will be suboptimal without hearing and understanding the patient. Listening allows the patient to feel that he/she is being heard, and for the concerns and fears of the patient to be aired. The patient’s understanding can be checked and the need for further disclosure may be made clear.

Silence is closely linked to listening. The use of silence as a communication tool is valuable and offers the patient a chance to reflect on the situation and then to ask questions or express concerns.

Attending is a skill that follows closely on listening, and gives a clear message that the interaction is patient centred. It is the act of being physically, psychologically and emotionally present with the patient and the family. Non-verbal cues such as eye contact and an open posture are helpful.

Acknowledging is another aspect of communication that applies to difficult conversations – even more than other types of interaction. The validation of emotional responses and the normalisation of these responses without a judgemental attitude are part of this acknowledgement.

Containment of the emotional response assists patients to reflect and explore their pain and feelings. The use of a metaphorical container1 allows the emotions of these highly charged conversations to be expressed freely while being directed into the ‘container’.

Who needs these communication skills?

All doctors need these skills, but oncologists, HIV clinicians, and especially GPs require special competence in communication to manage patients with life-threatening disease. If communication is poor, the patient’s perception will be affected negatively, and tensions may arise in the care team and family.

Doctors should take care to involve other team members in the medical and communication aspects of the care, but the doctor’s role requires special communication skills, particularly in the taking of the history, which may be distressing if not done with sensitivity. The working diagnosis may anticipate the definitive diagnosis of a life-threatening illness; therefore careful communication is very important at this stage.

Paediatric palliative care requires special communication skills. When communicating with children who receive palliative care the doctor must take account of specific factors such as the developmental stage of the child, the child’s level of understanding, and the child’s interpretation of illness or treatment. Doctors may try to engage parents and the child in decision making but face challenges when parents push their own agenda and fail to consider the best interest of the child. The converse may also pertain if doctors are autocratic and leave parents with feelings of powerlessness, anger and guilt, particularly in the event of a child’s death.

The hospice professional nurse concerned with palliative care will visit patients at home to assess their needs and provide nursing care. Palliative care nurses are at the forefront of provision and monitoring of care, as they spend most of their working time interacting with patients and family. The nurse is a point of reference for information required by all who work with the patient and is therefore pivotal to palliative care and a link that can either positively or negatively affect patient outcomes.

The social worker plays a crucial role in palliative care, but is not always fully utilised. Many doctors have a limited understanding of the role of the social worker and believe that they only process grant applications and child placements and perform other administrative tasks. The training of social workers focuses on communication and how to address individual needs. Social workers are skilled and knowledgeable about matters pertaining to professional counselling (involving psychological and social issues), policy, legal, family and children’s issues and have networking skills and access to resources. Proper attention to the psychosocial aspects of care by a social worker can improve the quality of life of the patient and family.

Spiritual counsellors. Spiritual care needs require sensitive and careful consideration during the palliative care stages of care. Patients must be assisted to explore their feelings around the legacy, hope and meaning they attach to their existence and illness. The patient should set the pace and extent of the discussion. The model of spiritual life that the patient wishes to explore should be respected. There should be a distinction between religious and spiritual care. This is an area in which a non-judgemental attitude in the professional carer will facilitate communication.

If a spiritual issue arises, the GP could refer to a spiritual counsellor to facilitate the challenging conversation in a safe environment. Spiritual counsellors embrace the care of all patients regardless of their religious affiliation but may not always be available – therefore GPs and other members of the palliative care team may be required to facilitate such a discussion.

When do we need to be aware of difficult conversations in clinical practice?

GPs and all doctors need to practise excellent communication at all times but when dealing with oncology patients with disease progression, children with special needs, patients who suffer abstract losses such as loss of dignity or identity, stigma, and gender definition (e.g. post-mastectomy or post-orchidectomy) and patients grappling with spiritual issues, good use of communication skills is critical. Under these circumstances patients need to be heard clearly and be supported. Careful and thorough communication at the very first contact is crucial and this is why the role of the GP cannot be underestimated: the trust that is won (or lost) is key to the future communication in the therapeutic relationship.

A method of conducting difficult conversations

NURSE is a helpful mnemonic to consider when responding to emotions of patients during difficult conversations at any stage of the illness.2

Naming. From observing the patient’s response, the professional names the emotion that is being presented. This demonstrates that the professional is present and aware of what is happening, e.g.‘It sounds as though you are disappointed by this’.

Understanding. During the communication process the professional uses skills of probing, asking questions and acknowledging what the patient says.

Respect. This is a powerful attitude in communication. It allows patients to share their authentic emotions and still feel accepted and valued. Acknowledging patients’ emotions with respect demonstrates empathy. Respect undergirds all the communication processes.

Support. Professionals in palliative care should speak truthfully with their patients and follow up on what has been communicated. Patients need to be reassured of available support and assisted on how they can access it.

Explore. Professionals in palliative care should continuously explore patients’ concerns by asking them to share more or elaborate on something they might have shared before.2

Self-awareness and self-care

Careful and compassionate communication may be challenging but rewarding, as the patient is better informed and emotionally prepared for future management. Care should be taken by the supportive and palliative care team not to be overwhelmed by the burden of emotion that is always present in these difficult conversations. GPs and other doctors should always work as part of a team to ensure excellent patient management, but also to ensure that they and each member of the team can access support whenever it is required.

Communicating with patients and their families will not always be perfect as factors like personal choice, family relations, inter-personal and other issues may intervene. During such times it is important that the doctor or other palliative care team member reminds him/herself that the most important task is to accompany individuals on their journeys and not to take over the journey.

Conclusion

Effective communication is a consistent thread that has to be maintained throughout all the stages of clinical care, by primary care doctors and all members of the team, especially in the palliative phase. Communication skills are universal and applicable to diverse populations and settings. All health care professionals need to improve their communication skills. Franks showed that effective communication skills result in patient and family understanding, involvement and co-operation as well as promoting self-esteem for the professionals involved.3

There are often moments when professionals in palliative care do not even need words, but have to present themselves, equipped with effective communication skills, especially the skill of silence and attending. This becomes a powerful demonstration and application of presence, care, compassion and empathy.

References available at www.cmej.org.za

IN A NUTSHELL

• Palliative care is a core competence for general practitioners and all primary care practitioners. This aspect of practice requires clear communication with patients, family members and professionals involved who need to understand each other as well as possible under the difficult circumstances.

• This article discusses the use of listening, silence, acknowledging and normalisation – some of the tools of communication that may be employed in a palliative care consultation at primary care level. These are specific communication skills that may be adopted and improved on by GPs, who are at the forefront of patient care. This article highlights these and offers an opportunity for us to improve our patient care by better communication.

• The value of the presence of the doctor in the consultation is emphasised.