Communication is the Foundation of Quality Palliative Care
In the late 19th century, Dr. Edward Livingston Trudeau, a health pioneer and founder of a tuberculosis sanatorium, had articulated a phrase that later went on to becoming a guiding principle of ethical medical practice, and in many ways laid the foundation for the concept of palliative care; “to cure sometimes, to relieve often, to comfort always.” In an age, when medical practitioners increasingly focus on interventions and treatments aimed at cure, the concept of ‘comforting’ often takes a backseat, and is not always seen to be in the domain of what the health care professional is required to do.
To comfort is the cornerstone of quality palliative care, and to comfort is often presumed to be synonymous with communicating. Communication is often considered a soft skill that one either acquires through experience or is something one is innately good at. It is usually not perceived as a skill that requires special attention or training. Yet, while it is true that some individuals are innately empathetic and natural born-listeners, it is also true that quality communication is something that can indeed be learnt, and that requires an appreciation of several aspects. The most important of these is that, especially in the context of palliative care, communication is really less about speaking and more about listening.
Active listening involves trying to understand the perspective of the patient and the family members and care-givers, and being able to demonstrate empathy and appreciation of their point of view. A life-limiting illness can be a traumatic and stressful experience for the patient and his/her family, and it calls for the health care professional to enter that world with a sense of compassion and respect for the privacy and dignity of the individual. It is useful to remember that silence often is far more powerful in empathetic communication than speech. As health care professionals, we do not need to rush in with advice and information all the time but instead allow the patient to draw us into their world, to ﬁrst share their fears, concerns, and uncertainties, and then to build upon the trust and provide information as is needed, but at the appropriate time and pace. It would be well to remind ourselves of Cecily Saunders’ (well known for her role in the birth of hospice care) insight that ‘the real question is not ‘what do you tell your patients’ but rather ‘what do you let your patients tell you?’
Once a relationship of trust has been established, the health care professional will then come across a range of issues and themes necessary to communicate on, depending upon the patient, the context, the stage of illness, and other factors. The thematic span of issues ranges from providing advice on a variety of topics including treatment modalities, to sharing the decision- making and goals of care, discussing disease progression, and the aspect of end-of-life issues such as opportunities to say good bye, or to be at peace with oneself and family members. Often the topic needs to be broached about the practical aspects such as writing a will and securing the future of those who will be left behind, and such like.
Whatever be the aspect one is communicating on, it is essential to stay with the truth always. Besides it being a fundamentally ethical approach, speaking the truth preserves trust in the relationship. It has also been found that even if the truth is not easy to accept, people cope better than we expect them to, and in fact dealing with the facts and truth is far better than having to deal with uncertainty, for both the patient and the family members. Honest disclosure is the ﬁrst step towards helping the patient accept a situation, and arriving at strategies to deal with it.
The challenges of communication in the context of palliative care are several, and can sometimes appear over whelming even for the most seasoned professional. Yet, keeping in mind a few simple do’s and don’ts would go a long way in enhancing the quality of interaction and communication. It is important to identify one’s own barriers and preconceptions that can impede the process of communication. It is also vital to demonstrate consistency and openness at all times, and to refrain from being judgmental. Above all, we need to accept that as health care professionals we may not always be the best communicators, but if we approach our task with empathy, humility, and honesty, we set the context and environment for good communication to then automatically take place. Finally, eﬀective communication in the ﬁnal analysis is not an ‘add-on’ aspect of palliative care, but indeed the foundation upon which it rests.