Article
Healthcare should:
Patients have personal wishes, needs and concerns that demand the understanding and respect of the healthcare professional (HCP). Involving patients as full partners in decisions about treatment leads to better health outcomes. Patients' attitudes to the benefits and risks from treatment, and the extent to which they find adverse effects tolerable, can differ markedly from assumptions made by HCPs. Effective healthcare communication incorporates not only medical and dental information, but also sensitive discussion of the patients' emotional and social well-being. Information provided must always be culturally sensitive and tailored to the patient's ability to understand.
Communication, especially breaking bad news, such as about cancer, can help all involved, and reduce the inevitable distress experienced. Hope is all-important and management must include especial attention to psychological reactions. Patients may or may not know, or may not want to know, that they have malignant disease and, even if they are aware of it, may not appreciate, or be willing to accept, the prognosis. Denial is common.
Many different people are involved, so that communication with patient, partners, family and friends can be essential. Provided the patient consents, all should be kept aware of:
Barriers to effective healthcare emanate mainly from:
The US National Cancer Institute have highlighted the key points (Table 1).
|
|
Communicating requires time and patience and expertise: language can be a huge barrier. One of the most obvious ways to assist communication is to have material available in relevant different languages and easily readable and understood.
Patient interviews are an opportunity to listen and ascertain the patient's feelings and concerns about healthcare and to explore what beliefs and practices are important to them.
Greetings can ‘make’ or ‘break’ the professional relationship especially, as is often the case, if the patient is older and/or from a different culture. Key points to remember include to:
For many people from non-Anglo-Saxon cultures, the customary greeting is a gesture other than the handshake. In addition, some may be uncomfortable shaking hands with a person of the opposite sex. Unless you are certain of their culture or religion, it is better to greet a patient with a handshake, seeing first if the person offers their hand, and then say ‘Good morning/afternoon’ and use their title followed by their last name.
Key communication skills
Several key skills underlie communication with all patients (Table 2).
|
|
Specific skills such as questioning styles, active listening, providing information and avoiding negative communication behaviours, such as the inappropriate use of closed questions, or offering premature advice/reassurance, are crucial to success.
Avoid also the use of:
Give any bad or unpleasant news tactfully and slowly, maintain confidentiality and check with the patient exactly who can be told about his/her condition, when, and what they can be told.
A key HCP should be identified who the patient can contact for further information and act as an advocate. Most important is verbal interaction, but alternative information sources (eg written leaflets, computer systems, DVDs etc) can help – especially younger patients. Macmillan Cancer Support can help in this regard (http://www.macmillan.org.uk).
Communicating risk
People with high-risk behaviours require not only to be encouraged to change these, but also to have explained to them the need for vigilance. HCPs may need to develop specific skills and willingness to engage in such discussions. A systematic review confirmed that personalized communications (especially when supported by written and visual materials) are more effective in promoting screening uptake than are generalized communications.
Communicating a cancer diagnosis
While a diagnosis of cancer may not be unexpected to the patient, it cannot fail to be distressing. Breaking bad news is difficult for patient and also the HCP.
The key principles in breaking bad news have been summarized as:
Patients tend to recall only a little of the information that they are given, and so at the initial diagnosis the focus should be on stating the news and dealing with the initial emotional responses. Arrange the follow-up meeting or discussion by telephone within 1 or 2 days.
Individuals diagnosed with oral cancer need information including:
Communicating bad news, especially across a language and/or cultural barrier can be time-consuming, difficult and frustrating. At the very least most patients will feel intimidated. It is important therefore, to:
Providing information about treatment and pre-treatment
Evidence indicates that the emotional and social domains are frequently neglected. Tailored information about support groups, financial issues and the impact of treatment on ability to work, function physically, relationships and quality of life can be helpful.
Communicating after treatment
It is important to discuss and plan the transition from patient to ‘survivor’ and deal with the inevitable fear of recurrence. Cognitive techniques, when coupled with specific strategies to identify triggers for seeking help and support from the HCP can be effective at stopping patients ruminating.
Discussing end of life
It is important to assess the patient's level of knowledge and desired knowledge, both about the disease process in general and specifically the expected time to death, and their philosophical approach to life, illness and death. The components of a ‘good death’ have been suggested to be:
Once the desires of the patient are clear, these should be discussed with family, carers and the HCPs and, as far as possible, the patient's wishes should be respected.