Effective Physician and Patient Communication Is Essential in Palliative Care

TORONTO, Ontario-Communication in palliative care is vital fortwo overlapping reasons, Robert Buckman, MD, said in his presentationat the pain management in palliative care workshop.

"If you aren't able to communicate with your patients, youcan't find out how bad their pain is," he said, "andif you can't find out how bad their pain is, there is zero chanceof your being able to relieve it effectively."

Dr. Buckman, a medical oncologist at Toronto Bayview RegionalCancer Center, views communication as a set of practical skillsthat health care professionals can learn and that can dramaticallyimprove their ability to assess pain and other factors impactingon the patient's quality of life.

However, such skills are often difficult to teach. "It'shard to explain your own personal skills and experiences to otherpeople," he said.

To provide a framework for teaching communication, Dr. Buckmanhas developed a model known as SCANS-Setting, Communication Skills,Acknowledgment, Negotiation, Summary.

Getting the setting right involves simple things, like sittingdown, turning off the TV, shutting the door, and drawing the screenaround a hospital bed. Maintaining eye contact is especially important,he said, "except when the patient is crying or deeply distressed,because in this situation, eye contact can be interpreted as aggression."

The most basic communication skill is silence: "When thepatient is talking, you don't talk," Dr. Buckman said. Whenit is the professional's turn to talk, he advises use of the threeR's: repetition (picking up one word from the patient'slast sentence to use in your next sentence); reflection("What I seem to be hearing from you is . . ."); andreiteration (paraphrasing what the patient says).

The Empathic Response

Dr. Buckman considers acknowledgment of the patient's emotionsas possibly the most important element of the SCANS model. "Whenthere is an emotion in the room expressed by a patient, you haveto acknowledge it. If you don't, your interview with the patientis dead in the water," he said.

The simplest method of acknowledging an emotion is to use theempathic response: Identify the emotion; identify the source ofthe emotion; and respond in a way that legitimizes the emotionand allows it to be discussed.

Dr. Buckman described the empathic response as a technique, nota feeling. "If the patient is crying or hurt, you don't haveto cry or feel hurt yourself," he said.

Furthermore, the technique is nonjudgmental. "You don't haveto agree with the patient's viewpoint," he said, "justacknowledge his feeling, acknowledge the cause of the feeling,and let him know that it is something the two of you can talkabout."

Negotiation involves the heart of palliative care in which theprofessional helps patients "match their shopping list ofneeds with what you have available to meet those needs."Some items on the patient's list will be unattainable. "Youdon't have the power to make a cancer diagnosis go away, for example,"he said.

The health care professional should close the interview with athree-point summary: First, provide a quick rehash of importantitems that were covered in the meeting. "This is labor intensiveand requires immense concentration," Dr. Buckman said.

Next, ask if there are any other questions that need to be addressed,and assure the patient that these last-minute concerns will headthe list of topics at the next meeting.

Finally, make a clear contract for the next meeting. This, hesaid, "is a major way of dealing with the patient's feelingof abandonment."