E L N E C End-of-Life Nursing Education Consortium Geriatric Curriculum Module 6: Communication at the End of Life Part I: Basic Communication Objectives: Describe basic principles of communication Explore individual communication styles and communication within the interdisciplinary team Basic Principles of Communication Communication is a constant two-wayway Words and actions are interpreted by the receiver Much communication is nonverbal Listening is the most important part of communication 1
t Hospice Education Network - ELNEC: Geriatrics - Communication Module 6 Listening Steps Energy & Involvement Helping Others/ Active Empathizing Analyzing & Evaluating Information Retaining Information Understanding Hearing Ray, 1992 Nature gave us one tongue and two ears so we could hear twice as much as we speak. k Epictetus, 55 A.D. 135 A.D. Presence Knowing and being comfortable with oneself Knowing the other person Connecting Affirming and valuing Acknowledging vulnerability 2
Presence Using intuition Being empathetic ti Being in the moment Serenity and silence Factors that Influence Communication at EOL Culture Age Gender Personal & family experiences Culture influences The rules for communication (e.g., is eye contact okay?) How direct the communication around illness and death is allowed to be How openly emotions are expressed 3
Culture influences How people view illness and death The meanings of words (e.g., family, faith) How decisions are made and who speaks for the older adult/resident Age Consider the developmental stage of the patient when determining how to talk with him/her about dying. Ask the person what they prefer to be called. Be aware of age-related factors, such as poor hearing and eyesight, that may impair communication. Gender Men and women tend to communicate differently Culture and religion may affect the social status of men and women, which in turn influences how they interact with others Older women may prefer their husband or son to make decisions or talk with the healthcare team 4
Life Experiences People tend to die the way they have lived, for example: People who have never or rarely had the experience of trust probably won t trust you People who have gotten their way most of their lives will expect to get their way during the dying phase Summary EOL care depends on effective communication skills Many factors influence how people communicate and we need to be sensitive to these differences Listening is one of the most important parts of communicating 5
Module 6 Part II: Therapeutic Communication at the End of Life Challenges in Communicating with Dying Patients and Their Families Societal denial of death Lack of direct experience with death Older adults and families fears and emotions Dementia and other conditions that make conversations about the future and other abstract ideas difficult Challenges in Communicating with Dying Older Adults and Their Families Caregiver fears: Not having the answers Feeling helpless/ inadequate Upsetting the patient/family Fear of showing emotions Caregiver s personal fear of dying 1
Basic Concepts Use active listening Being present, rather than what you say, is most important Let the patient and the family lead you join in their journey; but emphasize that they are in charge Encourage reminiscing; let the older person and families tell their stories Let the patient know that their lives have meaning Active Listening is Demonstrated By: Body language Eye contact Echoing words Head nodding Leaning towards the speaker Not interrupting Paraphrasing facts and feelings Timing Make sure the patient/ resident and/or family is physically comfortable before starting a conversation. Whenever possible, use the older adults/resident s and family s timetable, not yours. 2
Asking Questions Ask only necessary questions Focus questions on the patient and family s concerns Respect privacy, including the privacy of the patient and family s emotions If you need to ask a sensitive question, explain first why you need to ask it Important Messages to Communicate to Someone at EOL Listen Respect Hopes, values, and goals Encourage questions Ways Dementia Can Impact the Person s Communication Aphasia Agnosia Anomia Apraxia Losing train of thought Word salad Withdrawal Perseveration Paraphrasia Using curse words Speaking less Reliance on nonverbal gestures Reverting to a foreign language 3
Tips for Communicating with Patients with Dementia Environment Treat person/resident as an adult Respond to emotions rather than words Behaviors When Talking with Patients With Dementia Smile Use humor Do not argue or confront Be positive Know the person/resident YOU do most of the work in communicating! We accept you and we will not abandon you 4
Messages to Give to the Dying I love you I forgive you Please forgive me Thank you Goodbye Byock, 1997 Communicating Hope at the End of Life Dimensions of Hope Accepting and moving beyond current suffering Setting goals and maintaining i i control Connectedness to other people Connectedness to God, something bigger than oneself 5
Accepting and Moving Beyond Current Suffering Prevent and manage symptoms Use lightheartedness and humor skillfully Support older patients and families in positive self talk Accepting and Moving Beyond Current Suffering (cont.) Engage the older adult in creative, joyous, aesthetic activities Encourage reminiscing Focus on past and present joys Share positive, hope-inspiring stories Setting Goals and Maintaining Control Help the older adult/resident and family: Identify, obtain, and revise goals Identify resources to achieve goals Maintain their sense of control Identify past successes Provide them with accurate information 6
Connecting with Others Provide time for relationships Affirm sense of self-worth Establish h& maintain i an open, respectful connection Hope is an act of collaboration. It cannot be achieved alone. We offer grains or fragments of hope to one another so that everyone s sense of possibility can grow. In this way we can do together what might seem impossible alone. Fischer, 1998 Connecting with One s Spirituality Help the older adult/ resident participate in religious rituals meaningful to him or her Assist in arranging clergy visits Help the older adult/ resident & family find meaning in the experience 7
Symbolic Language: I Want to Go Home Symbolic Language Explore with the family the possible meanings Don t contradict statements Don t assume delirium Summary There are many challenges to communicating openly at the EOL. We must meet these challenges to provide excellent care for the dying. The most important message to communicate to the dying is acceptance and a commitment to being there for them no matter what happens. 8
Summary (cont.) Be sensitive to the language and communication of the dying patient. There are many ways to sustain the patient and families hope at the EOL. 9
Module 6 Part III: Working with Families and Dealing With Conflict Working with Families at the End of Life Needs of the Family with Someone in Long-Term Care Participating Letting go/letting in Going through the stages of grief Achieving connection 1
There is the potential for growth and change throughout the family life cycle Older Adult & Family Emotions and Responses to Impending Death How can families be angry with us when we haven t done anything wrong? Conducting a Family Conference Gather the family/the team members/and resident (if possible) Establish purpose and goals Use attentive listening/ask open-ended ended questions Be sensitive to silence and nonverbal communication Acknowledge your feelings 2
Conducting a Family Conference (cont.) Avoid misunderstandings Don't change the subject Tk Take your time in giving ii advice di Dealing with Conflict at the EOL If You Get Caught in the Middle of a Conflict, Remember: There are many points of view in every situation Don t take sides Grief can be expressed as anger Anger may be directed at people who are safe targets (for example, staff) 3
Tips for Managing Your Own Responses Remove yourself from the situation Talk with other team members Make a plan for dealing with the conflict When You are Communicating With Someone Who is Upset Treat the person with respect Answer the person s s questions Stay calm; don t argue Use active listening skills Let the person talk Nurse/Physician Communication Preparation is essential! Physician is dependent on information provided d by the nurse When the nurse and physician do not communicate well the patient loses! Dahlin, 2010 4
The BASICS Approach B = Background A = Assessment S = Situation/symptom i I = Intervention C = Communication S = Successful outcome Berry & Miller, 2006 Strengthening Your Communication Skills Strengthen Your Skills Identify your communication style/your team member s What communication styles are easy/ difficult for you to deal with? Do you understand your role on the team and communicate it to the team? 5
Respect, Respect, Respect 6