March 2020 Communication Tips

March 2020 Communication Tips

 

Serious Illness Conversation Guide: Assess understanding and preferences

Happy March.

In January, I introduced Step 1 (asking permission) of the Serious Illness Conversation Guide (SICG). 

As a reminder, the SICG is a proven aid for busy clinicians to discuss Goals of Care with patients facing serious illness.  The SICG comes from Atul Gawande and his Ariadne Lab at Harvard.  Checklists work!

This month, I encourage you to try out Step 2 of the SICG:  Assess understanding and preferences

Once you’ve gotten permission to talk about the serious illness, you can take Step 2 by asking something like:

“What is your understanding now of where you are with your illness?”

or

“How much information about what is likely to be ahead with your illness would you like from me?”

Step 2 gets you on the same page as the patient.  Maybe they already know a lot.  Maybe they don’t really understand key parts of their illness or prognosis.

Also, as promised, periodically, I invite one of the cancer center’s many great communicators to share with all of us a communication pearl of wisdom from how they practice…. What they do to connect and communicate well with patients.

 

This month, Pelin Cinar, a GI Oncologist and Director of Quality & Safety, offers 3 Communication Pearls of Wisdom:
 

•   When I meet the patients for the first time, I always ask them what they like doing for fun. I tell them that we will always keep these in mind so that we can prioritize their QOL. I will note the hobby in their chart so that I can ask them about it the next time I see them.

•   I often have to give bad news due to the nature of treating a lot of patients with pancreatic cancer. I’ve realized over the years that at times, the best way to communicate is to know when to embrace silence and not say anything. After I share bad news, I will often pause and let the information settle in. The patients will then let me know when they are ready to hear more, ask questions or simply express their emotions. We don’t always have to jump to facts but be present with the patients as they face the most challenging time of their lives.

•   I always prep for clinic so that I know patients' history or their interim history since the last time they saw me. If they had a scan prior to the visit, I review the scan results immediately after I start the visit. My mom is a breast cancer and GIST survivor and every time she used to get a scan, she couldn’t sleep in peace until she knew that all was well. So, I ask the patients if they would like me to review the scan results as soon as I enter the room. The answer is always “Yes, please!”

I firmly believe everyone in the cancer center does some things great… so please do send me you own pearls of communication wisdom for me to share.

 

All My Best,

mike

 

 

COVID VitalTalk Tools

My best wishes to you and yours during this terrible time.

I’m putting out this special list of communication tips in the setting of the COVID emergency.

Below are some recommendations about talking with patients and families around COVID.  The recommendations are set up as what you might hear from a patient/family, and how you might initially respond.  (These recommendations come from the team at Vital Talk). 

I hope these might be helpful in the midst of all our fears and worry.

The recommendations are available online, here: https://docs.google.com/document/d/1uSh0FeYdkGgHsZqem552iC0KmXIgaGKohl7SoeY2UXQ/mobilebasic

Also, the recommendations are listed below:

Screening: When someone is worried they might be infected

What they say

What you say

Why aren’t they testing everybody?

We don’t have enough test kits. I wish it were different. 

Why do the tests take so long?

The lab is doing them as fast as they can. I know it’s hard to wait. 

How come the basketball players got tested?

I don’t know the details, but what I can tell you is that was a different time. The situation is changing so fast that what we did a week ago is not what we are doing today.

 

Triaging: When you’re deciding where a patient should go

What they say

What you say

Why shouldn’t I just go to the hospital?

Our primary concern is your safety. We are trying to organize how people come in. Please fill out the questions online. You can help speed up the process for yourself and everyone else.

Why are you keeping me out of the hospital?

I imagine you are worried and want the best possible care. Right now, the hospital has become a dangerous place unless you really, really need it.The safest thing for you is to ___.

 

Admitting: When your patient needs the hospital, or the ICU

What they say

What you say

Does this mean I have COVID19?

We will need to test you with a nasal swab, and we will know the result by tomorrow. It is normal to feel stressed when you are waiting for results, so do things that help you keep your balance.

 

How bad is this?

From the information I have now and from my exam, your situation is serious enough that you should be in the hospital. We will know more in the next day, and we will update you.

Is my grandfather going to make it?

I imagine you are scared. Here’s what I can say: because he is 90, and is already dealing with other illnesses, it is quite possible that he will not make it out of the hospital. Honestly, it is too soon to say for certain.

Are you saying that no one can visit me?

I know it is hard to not have visitors. The risk of spreading the virus is so high that I am sorry to say we cannot allow visitors. They will be in more danger if they come into the hospital. I wish things were different. 

How can you not let me in for a visit?

The risk of spreading the virus is so high that I am sorry to say we cannot allow visitors. We can help you be in contact electronically. I wish I could let you visit, because I know it’s important, but it is not possible now.

 

Counseling: When coping needs a boost, or emotions are running high

What they say

What you say

I’m scared.

This is such a tough situation. I think anyone would be scared. Could you share more with me?

I need some hope.

Tell me about the things you are hoping for? I want to understand more. 

You people are incompetent!

I can see why you are not happy with things. I am willing to do what is in my power to improve things for you. What could I do that would help?

I want to talk to your boss.

I can see you are frustrated. I will ask my boss to come by as soon as they can. Please realize that they are juggling many things right now. 

Do I need to say my goodbyes?

I'm hoping that's not the case. And I worry time could indeed be short. What most pressing on your mind?

 

Deciding: When things aren’t going well, goals of care, code status

What they say

What you say

I want everything possible. I want to live.

We are doing everything we can. This is a tough situation. Could we step back for a moment so I can learn more about you? What do I need to know about you to do a better job taking care of you?

I don’t think my grandfather would have wanted this.

Well, let’s pause and talk about what he would have wanted. Can you tell me what he considered most important in his life? What meant the most to him, gave his life meaning?

I don't want to end up being a vegetable or on a machine.

Thank you, it is very important for me to know that.Can you say more about what you mean?

I am not sure what my grandfather wanted—we never spoke about it.

You know, many people find themselves in the same boat. This is a hard situation. To be honest, given his overall condition now, if we need to put him on a breathing machine or do CPR, he will not make it. The odds are just against him. My recommendation is that we accept that he will not live much longer and allow him to pass on peacefully. I know that is hard to hear. What do you think?

 

Resourcing: When limitations force you to choose, and even ration

What they say

What you say, and why

Why can’t my 90 year old grandmother go to the ICU?

This is an extraordinary time. We are trying to use resources in a way that is fair for everyone. Your grandmother’s situation does not meet the criteria for the ICU today. I wish things were different. 

Shouldn’t I be in an intensive care unit?

Your situation does not meet criteria for the ICU right now. The hospital is using special rules about the ICU because we are trying to use our resources in a way that is fair for everyone. If this were a year ago, we might be making a different decision. This is an extraordinary time. I wish I had more resources.

My grandmother needs the ICU! Or she is going to die!

I know this is a scary situation, and I am worried for your grandmother myself. This virus is so deadly that even if we could transfer her to the ICU, I am not sure she would make it. So we need to be prepared that she could die. We will do everything we can for her.

Are you just discriminating against her because she is old?

No. We are using guidelines that were developed by people in this community to prepare for an event like this—clinicians, policymakers, and regular people—so that no one is singled out. These guidelines have been developed over years--they weren’t done yesterday. I know it is hard to hear this.

You’re treating us differently because of the color of our skin.

I can imagine that you may have had negative experiences in the past with health care simply because of who you are. That is not fair, and I wish things had been different. The situation today is that our medical resources are stretched so thin that we are using guidelines that were developed by people in this community, including people of color, so that we can be fair. I do not want people to be treated by the color of their skin either.

It sounds like you are rationing.

What we are doing is trying to spread out our resources in the best way possible. This is a time where I wish we had more for every single person in this hospital.

You’re playing God. You can’t do that.

I am sorry. I did not mean to give you that feeling. I am just a clinician doing the best I can. Across the city, every hospital is working together to try to use resources in a way that is fair for everyone. I realize that we don’t have enough. I wish we had more. Please understand that we are all working as hard as possible.

Can’t you get 15 more ventilators from somewhere else?

Right now the hospital is operating over capacity. It is not possible for us to increase our capacity like that overnight. And I realize that is disappointing to hear.

 

Anticipating: When you’re worrying about what might happen

What you fear

What you can do

That patient’s son is going to be very angry.

Before you go in the room, take a moment for one deep breath. What’s the anger about? Love, responsibility, fear?

I don't know how to tell this adorable grandmother that I can’t put her in the ICU and that she is going to die.

Remember what you can do: you can hear what she’s concerned about, you can explain what’s happening, you can help her prepare, you can be present. These are gifts.

I have been working all day with infected people and I am worried I could be passing this on to the people who matter most.

Talk to them about what you are worried about. You can decide together about what is best. There are no simple answers. But worries are easier to bear when you share them.

I am afraid of burnout, and of losing my heart.

Can you look for moments every day where you connect with someone, share something, enjoy something? It is possible to find little pockets of peace even in the middle of a maelstrom.

I’m worried that I will be overwhelmed and that I won’t be able to do what is really the best for my patients.

Check your own state of being, even if you only have a moment. If one extreme is wiped out, and the other is feeling strong, where am I now? Remember that whatever your own state, that these feelings are inextricable to our human condition. Can you accept them, not try to push them away, and then decide what you need

 

 

Grieving: When you’ve lost someone        

What I’m thinking

What you can do

I should have been able to save that person.

Notice: am I grading myself? Could I step back and just feel? Maybe it’s sadness, or frustration, or just fatigue. Those feelings are normal. And these times are distinctly abnormal.

OMG I cannot believe we don’t have the right equipment / how mean that person was to me / how everything I do seems like its blowing up

Notice: am I catastrophizing? Is all this analyzing really about something else? Like how sad this is, how powerless I feel, how puny our efforts look? Under these conditions, such thoughts are to be expected. But we don’t have to let them suck us under. Can we notice them, and feel them, maybe share them?

And then ask ourselves: can I step into a less reactive, more balanced place even as I move into the next thing?