Part 1
Communicating with the patient
Chapter 1
Basic issues in communication
All around my bed is a great big curtain;
Thereās someone there behind it, but I donāt know who.
It sounds to me like doctors, but I canāt be certain,
And specialists and nurses, too.
Theyāre talking very quietly and muttering together
About the need for surgery, or therapy, or what.
It all sounds pretty dodgy, and I donāt know whether
Iām the subject of their little plot.
Christopher Matthew1
Introduction
Much has been written on the subject of communication with cancer patients, and many training courses are available, which serves to highlight the importance of this topic.
There are a number of issues that can arise when we are speaking to patients. These include the following possible problems:
ā¢ anger
ā¢ collusion
ā¢ confidentiality issues
ā¢ denial
ā¢ distancing oneself from the patient
ā¢ getting too close to the patient
ā¢ refusal to talk.
C Consider
What are the perceived problems with our communication skills when dealing with cancer patients?
Patients sometimes say that:
ā¢ they were told too little
ā¢ they were told too much
ā¢ they were told too quickly
ā¢ they were not able to understand what was said
ā¢ they did not believe what they were told.
A Assess
ā¢ What does the patient already know about their illness and prognosis?
ā¢ Who gave the patient this information?
ā¢ How accurate is this information?
Be aware of the risk that patients may sometimes quote verbatim what was said to them. Does this mean that they understood the message and its implications? We can teach parrots to recite sentences accurately, but they donāt necessarily understand the meaning!
ā Remedy
It is important to establish ācommon groundā before entering into further discussion, especially when one has bad news to impart.
ā¢ Find out, preferably in their own words, exactly what the patient knows about their diagnosis, their expectations of the treatment available and their prognosis.
ā¢ How much do they want to know now and how quickly do they wish to be told?
There are some basic ārulesā that can be quickly summarised as follows.
Ambiguity must be avoided at all costs. Use language that your patient understands.
Check the patientās understanding by asking them to summarise the conversation in their own words. Repetition of phrases does not prove understanding of the message.
In this respect, let us share a true story. WF was attending an outpatient clinic as a patient when this happened.
An elderly Scottish woman emerged from the consultantās room beaming with happiness. She approached WF and said āWhat a lovely doctor and what good news he gave me. He is going to give me the ācream oātherapyā. Poor you, youāll only be getting the milk!ā
Before WF had an opportunity to explain that she might have misunderstood the term āchemotherapyā, the patient had scuttled out of the waiting room.
As a patient, what was WFās responsibility?
Cue-based questions like āWhat was that like for you?ā can invite open honest sharing.
Listening can be active or passive.
ā¢ āActiveā listening involves eye contact and appropriate body language to encourage the patient to talk.
ā¢ āPassiveā listening offers less of your attention, and patients may tend to say less.
Note taking is essential, but patients may think that you are paying less attention to them. Agree with the patient that you may take notes, why you are taking them and who else may see them (assure them of the confidentiality of the notes that are written), and let them see that you are still giving them your full attention.
Observe the patient. Do their verbal and non-verbal messages say the same things?
Questions should be āopenā to encourage the patient to offer the information in their own words. āClosedā questions have only one possible answer (e.g. āWhat is your date of birth?ā). These do not encourage the patient to āopen upā and talk freely. Leading questions should be avoided, as they often result in biased answers intended to please the person who is asking.
Summarise the consultation at the end, making sure that the patient has taken in what you were saying.
Time is always the enemy! No matter how much time you have, the patient may think you are too busy to talk. Reassure them if you have time to have a full discussion. If not, agree a mutually acceptable time for a return visit to discuss the issues in depth.
Another anecdote. WF was attending for radiotherapy. An elderly woman emerged from the treatment room and saw him sitting outside.
āDo I look all right?ā she asked in a conspiratorial whisper.
WF, recognising that he is a mere man, assured the lady that she looked fine.
āI donāt glow, do I?ā
āNo, why should you?ā
āAll I know about radium is that my husband used a special paint to paint the instrument dials on war planes. I think it contained radium and the paint glowed green in the dark.ā
āI donāt glow in the dark, so you wonāt either.ā
āThatās good. I just wondered. He did great work. He used to suck his paintbrush to get a nice fine point to do fine work. Poor love died of cancer of the tongue. I donāt know how, for he never smoked.ā
On this occasion, because WF knew both the radiographers treating him, he recounted this story. The staff admitted that, due to pressure of time, the woman had not received an explanation of the treatment schedule, nor had she had the opportunity to discuss any fears or anxieties.
Before we criticise, however, remember that we all live in the real world. Donāt we all face the same enemy ā time, or lack of it?
Use the concept of working in TANDEM with the patient to help them to think about the questions they might wish to ask now or at a later time (see page 297). This allows them some control over how much they are told and how quickly they have to come to terms with the information.
E Extra information
It is a well-documented fact that on hearing the word ācancerā, the shock can be such that the rest of the conversation is lost and the patient may subsequently deny having been given significant pieces of information.2 Interviews have been taped so that the patient and their family can listen to them afterwards. Patients may complain that they were actually told too much, but at least this technique allows them to listen at their own pace, and to listen more than once, and it also avoids any misunderstanding or inaccurate reporting by the patient and their relatives about what was actually said.3
It is of interest that the use of taped interviews in a general practice setting increased patient recall, improved satisfaction with the treatment offered and helped patients to share the information with others involved in their care. However, it did not have any effect on adherence to the advice given or on anxiety associated with the presenting problem.4
References
1 Matthew C. āTouch and go.ā In: Now We Are Sixty (And A Bit). London: John Murray; 2003.
2 Fallowfield LJ, Baum M, Maguire GP. Effects of breast conservation on psychological morbidity associated with diagnosis and treatment of early breast cancer. BMJ. 1986; 293: 1331ā4.
3 Hogbin BJ, Fallowfield LJ. Getting it taped: the ābad newsā consultation in a general surgical department. Br J Hosp Med. 1988; 41: 330ā33.
4 Liddell C et al. Giving patients an audiotape of their GP consultation: a randomised controlled trial. Br J Gen Pract. 2004; 54: 667ā72.
Further reading
ā¢ Brewin T, Sparshott M. Relating to the Relatives. Oxford: Radcliffe Medical Press; 1996.
ā¢ Campbell S. A project to promote better communication with patients. Nurs Times. 2006; 102: 28ā30.
ā¢ Hobma S et al. Effective improvement of doctorāpatient communication: a randomised controlled trial. Br J Gen Pract. 2006; 56: 580ā86.
ā¢ Kirk P, Kirk I, Kristjanson LJ. What do patients receiving palliative care for cancer and their families want to be told? A Canadian and Australian qualitative study. BMJ. 2004; 328: 1343ā7.
ā¢ Lugton J. Communicating with Dying People and Their Relatives. Oxford: Radcliffe Medical Press; 2002.
ā¢ Sheldon F, Oliviere D. Family information and communication ā what works? Eur J Palliat Care. 2005; 12: 254ā6.
ā¢ Surbone A, Zwitter M. Communication with the cancer patient: information and truth. Ann N Y Acad Sci. 1997; 809. (This is a 500 page+ volume devoted to this subject, dealing with virtually every culture worldwide.)
Chapter 2
Listening effectively: āALWAYS REACTā
Jan Pederson
One of the best pieces of advice ever given to doctors, nurses or other health workers is that each time they see a patient, they ask themselves two questions.
1 What can I do for this patient?
2 What can I learn from this patient?
There is always something to do and there is always something to learn.
Anon.1
Introduction
There is so much more to listening than just the verbal messages that the patient gives us. Everyone constantly sends out non-verbal signals, and effective assessment involves picking up the cues and also being aware of our own ānon-verbal leakagesā of emotions and feelings.
Some years ago, when working as a district nurse with one of the authors (WF), I became fascinated by the vast numbers of simple but easily overlooked non-verbal signals that are being transmitted but frequently missed.
We agreed that it is only when you āalways listen with all your sensesā that these have any hope of being picked up, whether it is appropriate to deal with them or not at the time. We agreed to try to do this ā āalways,ā We were amazed both by the things we had missed and by the non-verbal messages that we ourselves might be transmitting.
This is a huge subject, and I can only scratch the surface layer, but here are ...