Concepts

Hearing bad news and having complex, emotionally charged conversations affects how people receive and process information. Having complex conversations well is essential to good care for both patients and families.

Communication Microskills

Create a phrase library of questions and statements that you find work well for you, and practice them so they feel natural.

Non-verbal communication:

• Sit down
• Aim for an open posture
• Consider matching your body language to that of the person you are speaking to
  This is called “attunement”.

Demonstrating empathy:

• Use silence
  
  • Ensure the rest of the team knows there will be long pauses
  • If a silence feels too long, consider a “content-free statement” (e.g. “I can’t imagine how hard it is to hear this information.”)
• Normalisation of emotion
  Acknowledge and validate a wide variety of emotional responses and experiences. Avoid using the word normal, and contextualise it to the individual - “many people who [have been married for 50 years] find this hard.”
• Respect and praise
  Acknowledge persons achievements and their successes.
  • “You have done so well contacting us when you did.”
  • This is also an excellent tool to defuse hostility - its hard to stay angry at someone who is praising you
• Recognise and respond to emotion with emotion, not with facts
  Often, questions may seem like a request for more medical information, but are instead expressing an emotion, e.g. “What happens now?” Respond to feelings with empathy, and not with facts. More information can always be provided later.
• Check in
  
  • How they are feeling with what is being said?
  • What are their concerns?
  • Ask them to summarise
    
• Reflective listening
  Restate what someone has told you, prompting them to continue.

Delivering information:

• Ask-tell-ask
  Establish a baseline understanding, then provide information, then clarify. This results in better retention than a tell-ask-tell system.
• Use signposting
  Provide a framework for the conversation; either enumerated (there is a number of things I would like to discuss), or with headings.
• Avoiding jargon
  Even in titles - just say “Doctor” (not registrar, consultant, intensivist, etc). Simplify information.
• Keep messaging consistent
  Try and minimise different statements between the (multiple) medical and nursing teams.
• Use repetition
• Keep things concise
  Primacy-recency theory indicates that people will tend to remember the first and last things that you say.
• Chunking
  Deliver information in small packets, interspersed with silence for processing time
• Use a formative summary
  • Recap of part of a conversation
  • Can be done multiple times during a conversation
  • Ensures that both parties (clinician and patient, or clinician and clinician) keep the same shared mental model Consists of:
    • Preface Introduce the rational for the summary and invite corrections.
    • Summary
      • Disease perspective
        Clinical experience.
      • Illness experience
        Patient perspective.
    • Choice
      Decide the framing:
      • Clinician led e.g. “I think its important that we discuss x, as this is…”
      • Patient led e.g. “Which one of these would you like to discuss.”

Responding to Emotion

Understanding and responding to emotions is critical. It is important to:

• Listen
  Recognise that it is an emotional response, and don’t respond with information.
• Acknowledge
  Acknowledge the presence of the emotion. If you’re unsure if it will be helpful then you can avoid naming it too directly (e.g. “I feel this is frustrating for you.”) Normalise the emotional response.
• Support
  Offer support, and a solution if one is available.
• Thank
  Thank them for sharing the concern.

If an emotion has got to you, it is important to re-centre yourself to avoid escalating things. There are a variety of techniques to deal with this, consider:

• Recognise
  Note the emotion you have.
• Accept
  That you’ve had an emotional response.
• Reset
• Engage
  Continue the conversation.

Remote

Phone and video conversations are a common way to update family members. Extra considerations include:

If delivering bad news over the phone, consider a follow-up call after to check in.

• No visual stimulation
  Describe the surroundings in a reassuring way.
• No non-verbal communication
  Extra attention to empathic oral communication - state things that would be otherwise be conveyed silently.
  • “I’m listening.”
  • “I’d like to hear more about that.”
• Silence can be more difficult
  Need to signpost silence:
  • “I’m going to pause to let you take that all in.”
  • “Let me know when you’re ready for me to continue.”
• Technical factors
  • Call quality
  • Signal strength
• Check in before ending the call

Use of Interpreters

Professional interpreters are the best available option, although bilingual staff are acceptable in low-risk situations. Family and friends should be avoided.

Interpreters should be used when:

Family may request no interpreter if:

• Feel their understanding is good enough
• Be embarrassed
• Know the interpreter
• Fear loss of privacy
• Be uncomfortable with gender/religious/ethnic background
• Worry about cost

• Family requests
• When people cannot comprehend or respond to questions in English
• Stressful, complex, or unfamiliar situations
• When consent is required

Using an interpreter:

• Consider discussing aim of the meeting with the interpreter prior
  Clarify the use of any technical terms.
• Introduce both yourself and the interpreter
• Make confidentiality explicit
• Talk directly to the family
• Avoid jargon
• Use silence and short packets of information
  Regular check-ins and formative summaries.

Speaking with Children

Principles:

• Parents have the choice in determining what information is given to their children
  • Find out what the parents or guardians have already told them
  • We have a role to advocate for children
• Children should be allowed to choose whether or not to visit a loved one
  • Families may look for guidance
  • Those who choose not to visit can be supported in other ways
    • Write a message for someone else to read out
    • Draw a picture
  • Children who visit should be appropriately prepared
    • Describe appearance, smells, and sounds
    • Describe what the loved one will look like
    • Introduce them to the bedside nurse
  • Children should be able to leave when they wish
• Communicate at eye level
• Answer questions
• Be explicit in saying it is not their fault
  Children often blame themselves, even when this is irrational.

Safety Netting

Empowers the patient to advocate for themselves if there is an issue with care. This:

• Aims to empower disempowered patients
• Improves recognition of deterioration
• Maintains trust in the clinician-patient relationship
• Gives patients and families a pathway to raise concerns
• Should include:
  • Explicit things to look out for
    e.g. Side effects.
  • Pathways for escalation
  • Acceptance of responsibility

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References

1. CICM Communications Course. Course Notes. 2023.
2. Core Family Donation Conversation (FDC) Workshop. Course Notes. 2023.
3. Australian Government Organ and Tissue Authority. Family Donation Conversation Resource Guide V2.0. 2021.
4. Philpot SJ, Bilgrami I, Sullivan L. Communicating medical information over the telephone in critical care. Critical Care and Resuscitation. 2020;22(3).