Communication is the Foundation of Quality Palliative Care

Article by

S. Mirchandani

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.

 

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