IPOS LECTURE Communication skills as the first level of ... · IPOS promotes global excellence in...

IPOS LECTURE Communication skills as the first level of psychosocial care

Luzia Travado, PhD Psycho-oncology, Champalimaud Clinical Center, Lisbon, Portugal

International Psycho-Oncology Society, Past-President

Founded in 1984, IPOS was created to foster the science and practice of psychosocial

oncology to improve the care of people affected by cancer worldwide.

IPOS promotes global excellence in psychosocial care of people affected by cancer

through partnerships, research, public policy, advocacy and education.

Through its Federation, IPOS represents more than 7,000 professionals in more than

60 countries.

www.ipos-society.org

Lisbon, Portugal

SUMMARY

• Communication skills in oncologists education

• Impact of cancer and distress in cancer patients

• Levels of psychosocial support

• Intl distress management guidelines

• Communication skills as psychosocial care

• Communication and basic communication skills

• SPIKES protocol

• Handling difficult conversations

IPOS - Luzia Travado

CST

• Questions

Patient

Emotional and Psychological problems

fear, sadness, worries, despair, loss of autonomy and control, change

of self-image

Problems with the health care system

impersonal treatment, lack of time, lack of intimacy, terminology hard

to understand

Physical symptoms and functional problems

pain, fatigue, dysfunction, sexual, apetite, sleep, psychosomatic

symptoms, disabilities

Impact of Cancer and its consequences

Family and interpersonal

uncertainty regarding social roles and tasks, separation from partners,

children

Social, financial, and occupational strain

Responsibility of important social and occupational functions, new

dependencies

Existential and spiritual problems

Confrontation with the mortality of one’s own life, search for meaning,

consolation; spiritual, religious, philosophical explanations

Koch & Mehnert, IPOS 2005 www.ipos-society.org

DISTRESS in Cancer

Distress is a multifactorial unpleasant emotional

experience of a psychological (i.e., cognitive,

behavioral, emotional), social and/or spiritual

nature that may interfere with the ability to cope

effectively with cancer, its physical symptoms, and

its treatment. Distress extends along a continuum,

ranging from common normal feelings of

vulnerability, sadness and fears to problems that

can become disabling, such as depression, anxiety,

panic, social isolation and existential and spiritual

crisis.

NCCN Clinical Practice Guidelines in Oncology,

Distress Management, 1997-2018

L Travado

DISTRESS CONTINUUM

Sub-sindrome

15-20%

Severe Distress

Psychosocial morbidity

25 - 45%

Maladjustment Anxiety

Depression Adapted from J.Holland, IPOS, 2005


( Early Breast Cancer = 32 %; Advanced Breast Cancer = 60%)

Normal Distress

adaptation

35 - 45%

Worries Fears Sadness

Recommended 4-tiered Model of Professional

Psychological Assessment and Support

Level Group Assessment Intervention

1 All health and social

care professionals

Recognition of

psychological

needs

Effective information giving

compassionate communication

and general psychological

support

2

Health and social care

professionals with

additional expertise

Screening for

psychological

distress

Psychological techniques such as

problem solving

3

Trained and

accredited

professionals

Assessments for

psychological

distress and

diagnosis of

some

psychopathology

Counselling and specific

psychological interventions such

as anxiety management and

solution-focused therapy, delivered

according to an explicit theoretical

framework

4

Psycho-oncologists or

Mental health

specialists

Diagnosis of

psychopathology

Specialist psychological and

psychiatric interventions such as

psychotherapy, including CBT

NICE guidance. Improving Supportive and Palliative Care for Adults with Cancer: The Manual 2004.

N=4496 cancer patients before treatment; 35,1%

Consequences of Psychological Morbidity in

Cancer Patients: impact on Clinical outcomes

Deterioration of Quality of Life

Reduced compliance w/ treatment

Less efficacy of chemotherapy

Higher perception of pain and other symptoms

Shorter survival expectancy

Longer hospital stay and increased costs

Burden for the family

Higher risk of suicide

Parker et al., Psychooncology, 2003; Colleoni et al., Lancet, 2000; Walker et al., EJC, 1998; Spiegel et al., Cancer, 1994; Faller et al., Arch Gen Psychiatry, 1999; Watson et al., Lancet, 1999; Pitceathly & Maguire, EJC, 2003; Prieto et al., J Clin Oncol., 2002; Henriksson et al., J Affect Dis, 1995; Grassi et al. 2005; McDaniel et al. 1995, Ehlert 1998,

Saupe & Diefenbacher 1999, Linton 2000, Cavanaugh et al. 2001, Härter et al. 2001, Carlson & Bultz, 2004; Watson et al., 2005

adapted from Grassi & Yosuke, IPOS online curriculum: www.ipos-society.org

IPOS Statement on Standards and Clinical Practice Guidelines in Cancer Care (2009 updated 2014)

Psychosocial cancer care should be recognised as a universal human right;

Quality cancer care must integrate the psychosocial domain into routine care;

Distress should be measured as the 6th vital sign after temperature, blood pressure, pulse, respiratory rate and pain.

Endorsed by UICC and 75 cancer organizations worldwide

Since its adoption by IPOS and the IPOS Federation of

Nat’l Psycho-oncology Societies in 2010, the Standard has

been endorsed by 75 organisations worldwide.

In 2013 the Union for International Cancer Control (UICC)

revised the World Cancer Declaration to include the

codification of distress screening:

Target 8: Effective pain control measures, and distress

management, will be available to cancer patients in all

countries.

Integration of Psychosocial Oncology Care in Routine Oncology IPOS - Luzia Travado

Psycho-oncology services provide effective (evidence-based, RCT’s) interventions for:

(a) reducing distress and preventing psychosocial morbidity associated w/ cancer

(b) improving patients’ skills to cope with the demands of treatment and the uncertainty of the disease

(c) improving their Quality of Life

(d) improving clinical outcomes

>> And are cost effective as well as general health costs reductive

Psychosocial Oncology Care is an

important element of high-quality care

Integration of Psychosocial Oncology Care in Routine Oncology IPOS - Luzia Travado

Recommended 4-tiered Model of Professional

Psychological Assessment and Support

Level Group Assessment Intervention

1 All health and social

care professionals

Recognition of

psychological

needs

Effective information giving

compassionate communication

and general psychological

support

2

Health and social care

professionals with

additional expertise

Screening for

psychological

distress

Psychological techniques such as

problem solving

3

Trained and

accredited

professionals

Assessments for

psychological

distress and

diagnosis of

some

psychopathology

Counselling and specific

psychological interventions such

as anxiety management and

solution-focused therapy, delivered

according to an explicit theoretical

framework

4

Psycho-oncologists or

Mental health

specialists

Diagnosis of

psychopathology

Specialist psychological and

psychiatric interventions such as

psychotherapy, including CBT

NICE guidance. Improving Supportive and Palliative Care for Adults with Cancer: The Manual 2004.

Communication skills

are the cornerstone of doctor-patient relationship and a critical factor for comprehensive quality care in oncology

Michael Levy MD, ASCO 1998

Communication skills in cancer care Luzia Travado

The way in which health care professionals communicate with patients has implications for:

> Quality of relationship provider-patient

> Patient’s adjustment and clinical outcomes

> Patient’s satisfaction

> Professional’s satisfaction and well-being (less burnout)

> Health care economy

Communicating bad news to cancer patients Luzia Travado

Good communication skills can be taught and facilitate addressing patients’ concerns, fears and needs, detection of

emotional problems and provision of basic emotional support (1st level of psychosocial care) >> patient-centered care model.

Epstein RM, Street RL Jr. Patient-Centered

Communication in Cancer Care: Promoting

Healing and Reducing Suffering. National

Cancer Institute, NIH Publication No. 07-

6225. Bethesda, MD, 2007.

Effective patient-clinician

communication is central

to the delivery of

high-quality care.

It is crucial in the cancer

setting where patients

have to deal with stress,

uncertainty, complex

information, and life-

altering medical

decisions.

Communicating to cancer patients Luzia Travado, PhD


Communicating to cancer patients Luzia Travado, PhD

Gilligan et al., JCO, 2017


https://mediaplayer.mdanderson.org/video-full/494F4798-

A61C-11E3-977D-60D819FC683C (59’’)

MDAnderson I*Care Program Walter Baile

•What is the emotion that the patient is expressing?

Video: effective communication with patients - 1

https://mediaplayer.mdanderson.org/video-full/494F4798-A61C-11E3-977D-60D819FC683C











What is Communication?

•verbal and non-verbal behavior which conveys thoughts, attitudes,

feelings, ideas and information

•a circular process:

sender receiver (sender) receiver

•impossible not to communicate

(silence is a form of communication)

•influenced by several variables (e.g. beliefs, emotions, socio-cultural,

environmental context)

•persons (patients) are not passive recipients of information, they

actively construct ideas and meanings about what they are told


Doctor’s

knowledge (meanings about: health,

disease, treatment, future,

QoL, etc.)

Specialist in medicine

Patient’s knowledge (meanings about: health, disease,

treatment, future, QoL, etc.)

Specialist in their own life

Dialetic

s

Dialectics between doctor and patient: open discussion by the

doctor/healthcare professional about the treatment options, their

benefits and risks, and the patient about their preferences, needs,

concerns and expectations >> patient-centered care approach

The clinical encounter

Doctor’s knowledge (meanings about: health,


QoL, etc.)

Specialist in medicine

Patient’s knowledge (meanings about: health,


QoL, etc.)

Specialist in own life

Dialetics

Dialectics between doctor and patient: open discussion by the doctor/healthcare professional about the treatment options, their benefits

and risks, and the patient about their preferences, needs, concerns and expectations >> patient-centered care approach

The clinical encounter

L Travado, CCC 2015

Basic communication skills*:

• active listening, eye contact, attentive posture

•open-ended questions (*’ask-before-you-tell’)

• clarification

• encouraging patients to express concerns and emotions

• screening for problem areas

• respond to cues

• respond to emotions: empathize – validate – explore

* Good Communication skills allow for patient-centered care, focused on patients’ preferences; it is important to tailor information to patients’ needs, as preferences for the amount, type and timing of information vary; importance of balancing honesty with hope and empathy



The Oncologist, 2000; 5:302-311.

Breaking Bad News

The main objective is to separate

THE MESSENGER from THE MESSAGE

so that even though the message is bad,

the messenger can be seen

as part of the support system

Walter Baile, IPOS, 2005

IPOS online curriculum



S-P-I-K-E-S Protocol

Six Steps in Giving Bad News

SPIKES

Setting up the interview

Perception of the illness

Invitation

Knowledge: what and how much

Emotions: how to address

Strategy & Summary

Baile, Buckman et al, The Oncologist 2000


STEP 1: SETTING UP the interview

Goals: Prepare for the interview Create “rapport” Put patient at ease Facilitate information exchange

Procedures: Reflect Arrange uninterrupted time Who should be there? Sit down Kleenex handy Eye contact Patient should be ready Walter Baile, IPOS, 2005




STEP 2: Find out the patients PERCEPTION of the illness

Goals: To determine information gaps

To assess “denial” and its mimics To create rapport

To understand patient expectations and concerns

Procedures: Use open-ended questions: “Tell me what you’ve been told”; “I’d like to make sure you understand the reason for the tests” Correct misinformation and misunderstanding

Address “denial” Address unrealistic expectations

Define your role Walter Baile, IPOS, 2005




STEP 3: Get an INVITATION from the patient to give information

Goals: To determine how much information the patient wants and when to give it

To acknowledge that patient information needs may change over time

Procedure: Ask “Are you the type of person who wants information in detail or….”





STEP 4: Giving the patient KNOWLEDGE and information

Goals: To prepare the patient for the bad news

To ensure patient understanding

Procedures: Forecast the arrival of bad news— “I’m afraid I have some bad news for you….”

Give the information in small chunks

Check for patient understanding

Avoid jargon

Address all questions Walter Baile, IPOS, 2005




STEP 5: Responding to patient EMOTIONS

Goals: To acknowledge emotional responses

To facilitate emotional “recovery”

To acknowledge our own emotions

Procedures: Expect emotions and be prepared for them

Use empathic response to emotions such as crying

Clarify emotions you are not sure about

Validate patient feelings




E-V-E

Each response to an emotion should be one of these

• EXPLORING

• VALIDATING

• EMPATHIZING

Three techniques for addressing EMOTIONS




Addressing Patient Emotions

Technique Example Outcome

Exploring “Can you tell me what

you are thinking right

now?”

Patient feels you are

interested

Validating “It’s very common for

patients to feel this

way.”

Patient feels “normal”

Empathizing “I can see how

upsetting this is to

you.”

Patient feels you are

“tuned-in”

Empathizing+Validating+Exploring= SUPPORT





STEP 6: STRATEGY and SUMMARY

Goal:

To ensure that there is a clear, negotiated plan for the future

Procedures:

Make treatment recommendations

Check patient understanding

Provide options for treatment

Understand barriers and concerns

Communicate your role





https://mediaplayer.mdanderson.org/video-full/494F4798-

A61C-11E3-977D-60D819FC683C (59’’>3:30’- 4:45’)

MDAnderson I*Care Program Walter Baile

•What is the emotion that the patient is expressing? •What steps skills and techniques did you see happening in this encounter? •What did you see that you like and what didn’t you like? •What would you do next after the patients express her emotions?

Video: effective communication with patients - 2












E-V-E

Each response to an emotion should be one of these

• EXPLORING

• VALIDATING

• EMPATHIZING

Three techniques for addressing EMOTIONS




Exploring questions

• Patient says:

– “Tell me, what will the end

be like?”

– “I feel like such a burden to

my husband”

– “I’m just not going to take

anymore chemo…”

– “Don’t tell my father about the

recurrence. He can’t take it”

– “I prefer that you help me to

die than to endure this more”

• You can say:

– “What has been worrying

you?”

– “Burden…?”

– “Tell me more about it…”

– “Can you tell me what you

think might happen?”

– “Can you please explain me

this a bit more? What is your

concern? Your fear? adapted from Baile W (MDACC). IPOS 2005.

The objective is to clarify what the patient is implying, feeling

or asking when it is not obviously clear

Validating statements

• Patient says:

– “I’m really undecided whether

to risk another surgery”

– “I feel guilty about putting my

family through this again”

– “Those steroids can really

make me feel weird”

• You can say:

– “A lot of patients struggle with

the same decision…”

– “That’s often something I

hear from my patients”

– “They’re known to do that”

Baile W (MDACC). IPOS 2005.

The objective is to legitimise the patient’s thoughts or feelings

Responding to emotions


• The empathic response

– Identify the emotion (theirs or yours)

– Identify the source of the emotion

– Respond in a way that shows you have made a

connection

• You don’t have to feel the emotion yourself

• You don’t have to agree with the viewpoint

Empathic statements

• Patient (feels) says:

– (Defeated) “I just don’t know

how much I can take”

– (Sad) “I was expecting a

better result…”

– (Stunned) “You mean I need

more surgery?”

• You can say:

– “It sounds like it has been

pretty rough”

– “So was I. I know this comes

as a shock…”

– “I know you weren’t

expecting to hear this…”


The goal is to acknowledge the patient’s feelings

Empathic statements

• Patient (feels) says:

– (Anger) “No one told me

it would take so long

to recover”

– (Happy) “It’s so great to have

a normal scan”

• You can say:

– “It’s been very frustrating

for you”

– “I can see, I’ve made

your day”


The goal is to acknowledge the patient’s feelings

Pearls in difficult communications

• Invite the conversation – don’t force, don’t say

“we need to talk about…!”

• Respond to emotion – acknowledge the loss,

empathy

• Reaffirm your commitment to the patient

• Praise the patient and the family e.g., you’ve put

up with a lot of difficult treatments…”

• ‘Hope for the best prepare for the worst’ – in

advanced disease Baile W (MDACC). IPOS 2005.

Communication skills in cancer care Luzia Travado

PALiMo Recommendations

• PREPARE

• ASK

• LISTEN

• MOTIVATE (hope)

MBC2 Summit, 2017

Communication is a critical core competence essential in supporting patients and families

•can be learned and improved with training

•benefits patients (reduces anxiety)and professionals (reduces burnout)

•have been recommended to be part of routine education for healthcare professionals in cancer settings

•still enormous lack of formal training in academic settings and in continuous education:

EU survey conducted under EPAAC: 19/27 countries (70%) referred to having CST resources, and 17/27 countries (63%) said they provide CST during medical education

[Travado L, Reis JC, Watson M, Borras J. Psychosocial Oncology Care Resources in Europe: a study under the European Partnership on

Action Against Cancer [EPAAC]. Psycho-oncology, 2015 Dec 21. doi: 10.1002/pon.4044. [Epub ahead of print]

IPOS Luzia Travado PhD

Luzia Travado

IPOS – ESO Online Curriculum

Communication and Interpersonal Skills in Cancer Care by Walter Baile, MD (USA)

Anxiety and Adjustment Disorders in Cancer Patients by Katalin Muszbek, MD (Hungary)

Distress Management in Cancer Patients by Jimmie C. Holland, M.D, USA

Depression and Depressive Disorders in Cancer Patients by Luigi Grassi, MD (Italy) and Yosuke Uchitomi, MD, P.D (Japan)

Psychosocial Assessment in Cancer Patients by Uwe Koch, MD, PhD & Anja Mehnert, PhD (Germany)

Cancer: A Family Affair by Lea Baider PhD (Israel)

Loss, Grief and Bereavement by David Kissane MD (Australia)

Palliative Care for the Psycho-Oncologist by William Breitbart MD (USA)

Ethical Implications of Psycho-Oncology by Antonella Surbone MD, PhD, FAC (Italy)

Psychosocial Interventions: Evidence and Methods for Supporting Cancer Patients by Maggie Watson PhD and Barry Bultz PhD (UK, Canada)

Multilingual Curriculum on Psychosocial Aspects of Cancer Care (English, French, German, Hungarian, Italian, Spanish, Portuguese, Chinese, Japanese)


http://www.cancerworld.org/CancerWorld/home.aspx?id_sito=1&id_stato=1

www.ipos2018.com

THANK YOU

Clinical practice guidelines: NCCN Distress Thermometer & Problem List

National Comprehensive Cancer Network, 2015

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