Advance/Anticipatory Care Planning~Communication Skills and Challenges

Advance/Anticipatory Advance/Anticipatory Care Planning (ACP)Care Planning (ACP)

Communication Skills and ChallengesCommunication Skills and Challenges

Dr John WalleyDr John Walley

Palliative Care ConsultantPalliative Care Consultant

AimsAims

Aimed to go alongside other training in Aimed to go alongside other training in ACPACP

To build on your previous communication To build on your previous communication skills trainingskills training

Specifically focusing on two areasSpecifically focusing on two areas Timing of ACP conversationsTiming of ACP conversations Communication challengesCommunication challenges

ACPACP

Consider the aims of ACP with this patientConsider the aims of ACP with this patient How will ACP benefit this individual or family?How will ACP benefit this individual or family? Help them understand more about their illness and its Help them understand more about their illness and its

likely courselikely course Allow them to plan for the future and provide support Allow them to plan for the future and provide support

where this is neededwhere this is needed Enable them to prepare their loved ones for what is Enable them to prepare their loved ones for what is

aheadahead Enable them to express fears or concerns Enable them to express fears or concerns Enhance their autonomy and sense of control (which Enhance their autonomy and sense of control (which

may have been threatened by their illness)may have been threatened by their illness)

ACPACP

Communication skills are essential then:Communication skills are essential then: Often dealing with complex concerns, Often dealing with complex concerns,

including medical, social, psychological and including medical, social, psychological and and spiritual onesand spiritual ones

Addressing issues around illness and death Addressing issues around illness and death are usually upsetting for patients to some are usually upsetting for patients to some degreedegree

There is much to be gained for the person in There is much to be gained for the person in front of you and it can be very satisfying for front of you and it can be very satisfying for you when it goes well.you when it goes well.

ACP – when?ACP – when? When the person has been diagnosed with a When the person has been diagnosed with a

life-limiting condition but is welllife-limiting condition but is well Can be undertaken as part of a general health review Can be undertaken as part of a general health review

or on discussion at a follow up visit after a diagnosis or on discussion at a follow up visit after a diagnosis is givenis given

May be appropriate, especially if the patient is aware May be appropriate, especially if the patient is aware that their condition may deteriorate rapidlythat their condition may deteriorate rapidly

Can be felt to be premature by the patient or their Can be felt to be premature by the patient or their familyfamily

Many other issues may be pressing at this time such Many other issues may be pressing at this time such as treatment decisionsas treatment decisions

• Eg A patient diagnosed with metastatic cancer deciding Eg A patient diagnosed with metastatic cancer deciding about palliative chemotherapyabout palliative chemotherapy

ACP – when?ACP – when?

When things change - diseaseWhen things change - disease Performance status or function – often the most Performance status or function – often the most

obvious thing to the patient and their family. Naturally obvious thing to the patient and their family. Naturally leads to questions about what is happening. How leads to questions about what is happening. How quickly is this happening? How urgent is it?quickly is this happening? How urgent is it?

Deterioration in their underlying condition – for Deterioration in their underlying condition – for example the development of metastatic disease in example the development of metastatic disease in cancer or renal failure in a patient with heart failure or cancer or renal failure in a patient with heart failure or type 2 respiratory failure in COPDtype 2 respiratory failure in COPD

GSF triggersGSF triggers


When things change - placeWhen things change - place Repeated admissions to hospitalRepeated admissions to hospital Discharge home after a serious illness with a Discharge home after a serious illness with a

high chance of recurrence high chance of recurrence Admission to a care or nursing homeAdmission to a care or nursing home


““surprise” questionsurprise” question Sometimes acute changes take place and Sometimes acute changes take place and

force the issueforce the issue Admission with a rapid deteriorationAdmission with a rapid deterioration New diagnosis of an advanced diseaseNew diagnosis of an advanced disease


CuesCues Talking about funerals and plans for the futureTalking about funerals and plans for the future When they say that they know they are not When they say that they know they are not

going to get bettergoing to get better Expressing concern about how their loved Expressing concern about how their loved

ones will cope with their care or deathones will cope with their care or death When the patient asksWhen the patient asks

Although be careful to use questions about Although be careful to use questions about the future as a starting pointthe future as a starting point


Not all patients will want to talk about ACPNot all patients will want to talk about ACP This needs to be respectedThis needs to be respected

Many will wish to leave decisions to care Many will wish to leave decisions to care professionalprofessional But may be able to provide some guideBut may be able to provide some guide

Some will chose to leave decisions to Some will chose to leave decisions to family membersfamily members

ACP – who?ACP – who? Trusted health care professionalTrusted health care professional

GP or district nurse: although they may not feel they GP or district nurse: although they may not feel they have sufficient knowledge or information to undertake have sufficient knowledge or information to undertake this, but have access and timethis, but have access and time

Hospital staff: may have the knowledge, but not the Hospital staff: may have the knowledge, but not the time as review clinics are not set up for the length of time as review clinics are not set up for the length of consultation requiredconsultation required

Specialist nurse: may have the time and the Specialist nurse: may have the time and the knowledge, but may be concerned about knowledge, but may be concerned about communication skills.communication skills.

TEAM approachTEAM approach• Agree what the future is likely to holdAgree what the future is likely to hold• Who’s the best person to ACP with the patient?Who’s the best person to ACP with the patient?

ACP – getting startedACP – getting started

Remember your basic communication Remember your basic communication skills:skills:

Ensure you have time and peace and Ensure you have time and peace and quietquiet If taken by surprise, either slow down or If taken by surprise, either slow down or

arrange to come back… and then do!arrange to come back… and then do! Gather all the appropriate information you Gather all the appropriate information you

cancan If you don’t you may get caught out If you don’t you may get caught out


Build rapportBuild rapport Make eye contactMake eye contact Use the patient’s nameUse the patient’s name Acknowledge emotionAcknowledge emotion Try to pick up cuesTry to pick up cues Make sure they’re ready for the conversation Make sure they’re ready for the conversation

– it’s important, but is it for today?– it’s important, but is it for today? Are there people they wish to be there whilst Are there people they wish to be there whilst

the conversation is taking placethe conversation is taking place


Make sure they’re readyMake sure they’re ready ““it seems like you may have some worries it seems like you may have some worries

or concerns for the future, do you want to or concerns for the future, do you want to talk about that today?”talk about that today?”

““if we are going to talk about how things if we are going to talk about how things may go with your health, is there anyone may go with your health, is there anyone you’d like to have with you whilst we you’d like to have with you whilst we chat?”chat?”


Opening questions:Opening questions: ““Could you tell me what the most Could you tell me what the most

important things are to you at the important things are to you at the moment?”moment?”

““Can you tell me about your illness and Can you tell me about your illness and how you are feeling?”how you are feeling?”

““What worries or concerns do you have What worries or concerns do you have about the future?”about the future?”


Always try and find out what the person knows about Always try and find out what the person knows about their illness and what is likely to happen in the future. their illness and what is likely to happen in the future. This enables you to assess their health understanding This enables you to assess their health understanding and will give you a starting point for subsequent and will give you a starting point for subsequent discussions. If someone is unaware that their illness is discussions. If someone is unaware that their illness is likely to get worse and shorten their life, breaking this likely to get worse and shorten their life, breaking this bad news may be more than enough for that bad news may be more than enough for that conversation and ACP may be for another day. conversation and ACP may be for another day.

““When you were in the hospital, what did people tell you When you were in the hospital, what did people tell you about your illness? Did they speak much about what the about your illness? Did they speak much about what the future may hold? What’s your feeling about how this future may hold? What’s your feeling about how this illness may go? Do you want to know more about it? Do illness may go? Do you want to know more about it? Do you want to have that conversation today?”you want to have that conversation today?”


On the whole people diagnosed with cancer On the whole people diagnosed with cancer have an expectation that it will progress – the have an expectation that it will progress – the word has associations. Patients with Heart word has associations. Patients with Heart Failure or COPD may not associate their Failure or COPD may not associate their conditions with a shortening of their lives, even if conditions with a shortening of their lives, even if they have been very ill in hospitalthey have been very ill in hospital

This is not always the case, so always tread This is not always the case, so always tread carefully and don’t make assumptionscarefully and don’t make assumptions

ACP – communication styleACP – communication style Active listeningActive listening

Nodding, leaning forwardNodding, leaning forward Tell me more about that; how did that make you feel?Tell me more about that; how did that make you feel?

Use of silenceUse of silence Acknowledge emotionAcknowledge emotion

Was that hard for you?Was that hard for you? I can see that this is difficult. Thank you for telling me. Do you I can see that this is difficult. Thank you for telling me. Do you

feel able to talk some more?feel able to talk some more? Pick up cuesPick up cues

Reflect back – “you said this… what did you mean by that?Reflect back – “you said this… what did you mean by that? Open questionsOpen questions ClarifyClarify Check – “when you said that, you seemed to be upset about Check – “when you said that, you seemed to be upset about

what was said – is that right?”what was said – is that right?”

ACP – out of your depthACP – out of your depth

Patients may wish to discuss things that you Patients may wish to discuss things that you know little aboutknow little about Don’t panic Don’t panic Don’t pretendDon’t pretend Listen, clarify the issueListen, clarify the issue Ask whether you can take this information to other Ask whether you can take this information to other

members of the team who may know the answermembers of the team who may know the answer Maintains trustMaintains trust Patients don’t expect us to know everything, but they Patients don’t expect us to know everything, but they

need us to listen. need us to listen.

ACP – communication styleACP – communication style

Use summary to check your understanding Use summary to check your understanding throughout the consultationthroughout the consultation Allows the patient to know they’ve been heardAllows the patient to know they’ve been heard Allows the patient to tell you if you’ve picked them up Allows the patient to tell you if you’ve picked them up

wrongwrong

Check the patient wishes to continueCheck the patient wishes to continue Emotional or tired:Emotional or tired: Is that enough for today?Is that enough for today? Be willing to spread ACP over a number of Be willing to spread ACP over a number of

conversationsconversations

ACP – concluding the conversationACP – concluding the conversation

Clarify future plansClarify future plans Agree actionsAgree actions FamilyFamily

It’s important they are aware of the plan when It’s important they are aware of the plan when possible and preferably agree with it’s contentpossible and preferably agree with it’s content

Check with the patient if its OK to talk to them – it’s Check with the patient if its OK to talk to them – it’s the patient’s confidential informationthe patient’s confidential information

The patient will chat with them – expect the family to The patient will chat with them – expect the family to ask you about the conversationask you about the conversation

Start from the beginning – find out what they know Start from the beginning – find out what they know and their expectationsand their expectations

ACP – concluding the conversationACP – concluding the conversation

Confirm the conversation is completeConfirm the conversation is complete Arrange “follow-up”Arrange “follow-up”

Questions may arise after you’re goneQuestions may arise after you’re gone They may change their mind!They may change their mind!

DocumentDocument Content of the discussionContent of the discussion Make sure the people who need to know Make sure the people who need to know

know (GP, hospital team, out of hours service)know (GP, hospital team, out of hours service)

Thank you for listeningThank you for listening

Advance/anticipatory care planningAdvance/anticipatory care planning

Communication Skills and ChallengesCommunication Skills and Challenges

Advance/Anticipatory Care Planning~Communication Skills and Challenges

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