Communication and conflict in palliative care teams

¶ … life situation can create a lot of problems in terms of communication.

The natural thing is to want to heal the person so when that doesn't work, people feel stymied and angry. Communication in any such instance is difficult. For the palliative team that consists of different individuals teaming together to provide quality care for the patient this is all the more difficult. This is because the different members of the team - caseworkers, physicians, nurses, relatives, and friends -- have the same objective, to help the patient, but the stress and different ways of achieving that objective may merge into conflict. People who are close to the dying may feel this particularly so, and nurses who acts as intermediary between patient, physician, and family are often caught in the middle. The result are feelings that include guilt, low self-esteem, anger, misinterpretation and so forth all of which can exacerbate the situation and instead of the palliative team collaborating in making the patient feel most secure and comfortable, energy can become distracted into destructive conflict.

It is very important too that the nurse have all the information in order to provide quality care, but often times patients are confused, and anger and/or fuzzy miscommunication makes an already depressing situation even more negative and toxic. Micommunication or impediment of communciation can, at worst, worsen the patient's condition even resulting in critical issues occuring as a result.

It is to that end, that communication needs to be drastically worked on so that each member of the team is able to insert their best and most unique effort into efficiently and effectively communicating one with the other so that all can work together to the same end.

Tecomemndaitosn for nurse

Whether acute care nurse or hospice nurse both have to have excellent interpersonal skills with patience and ability to listen to the other. With the hospice nurse this is particularly important, since the brunt of her job depends more on listening to, being with, and making the patient feel good than actually treating the patient. She must also have the ability to remain calm and rational through extremely emotional situations and to assist others to deal with these situations in their best way.

As with the acute care nurse, the hospice RN has to be familiar with the ability to prescribe, diagnose, and treat her patient in all manners of ways, as well as monitoring that the nursing care is being provided as necessary.

The therapeutic relationship is different between the two professions by virtue of the fact that the former (acute care) is a short-term relationship and, therefore, emphasis is on physical treatment and monitoring of the patient with the intention of him (oftentimes, although not always) recuperating. The objective is towards the goal of effective recovery or, at least, helping him towards the motions of recovery. Hospice care, on the other hand, is a long-tem procedure, sometimes it may last for years, with the caregiver well-aware that the hospice serves as the patient's last home and is a substitute for medical care. The emphasis here is on therapy to domination of medical care, where the hospice nurse doubles over as counselor and confidante and where maximum value is placed on characteristics such as patience, empathy, communication, friendliness, and equanimity.

As Jaffe and Ehrlich (1997) demonstrate, hospice nursing differs entirely from other forms of nursing in that whilst other nurses attempt to preserve life, focusing on prevention and treatment, and, secondarily, on communications, the hospice nurse advocates, innovates, and educates. The chance for traditional methods of healing has passed. Now all the patient is left with is to live out the rest of her life in comfort, and whilst her medical system is maintained, the hospice nurse considers herself free to innovate in order to make that regimen as comfortable as possible for the patient. To this end, the hospice nurse summons a multidisciplinary spectrum of professionals -- such as chaplains, social workers, nutritionists, psychologists, and therapists -- to help her in her job.

As an aside, as with any nursing profession, in general, and with helping the dying person, in particulr, I realize that the practitioner / caregiver has to be mentally and physically healthy herself before she can help others. A licensed practical nurse, particularly if she is to help others make the most of their last dying moments, has to be aware of the preciousness of life and what it means to make the most out of it as well as to take care of herself and not allow herself to be depressed and frustrated by the challenging situation. By caring fior herslf, it will be easier to commucnaite with othrs and to be abel to negotiate stress better. This si paritucalry improatn sicn estress is an unavoidable nad regular compoentn of her life.

Tecomendations for people

Thirdly, being aware of Kubler's stages of death and relying this information to Mrs. Thomas and husband will be helpful. Elisabeth Kubler-Ross presented five distinct stages that a person goes through before he or she expired consisting of denial, anger, bargaining, depression, and acceptance. Each and every person goes through at least two of these stages although not all in the same order. Awareness of the ubiquity of these stages and their being experienced by both Mrs. Thomas as well as her immediate family will better help them deal with the situation. Hence, this is another strategy that I will employ to help Mrs. Thomas and her family move closer to the reality of her death. The five stages, in elaboration, are: Denial: The individual seeks to deny the reality of his or her situation feeling that this cannot be happening to her; Anger: Frustration, rage, and envy particularly so if the individual is young or relatively young as in the case of Mrs. Thomas; Bargaining -- The individual bargains with a higher power promising this higher power self-reformation or specific types of sacrifice in return for prolongation of life. It may also take the form of reliving past experiences, fantasizing how one may have strategized so that things would be different. In this instance, the Thomas family may be berating themselves over actions that they could have taken to prevent the cancer; Depression -- the individual (and others close to the individual)_ retreats within herself to mourn loss of her extension of life and to attempt to come to grips with that reality; Grief where the individual may refuse visitors, spend much of the time crying and grieving, and become silent; and finally acceptance where the individual is reconciled to the inevitability of her demise.

In aparitucalry moving story, Jaffe and Ehrlich (1997) talk about a dying preacher who was trying to reconcile his family to his approaching death and the RN nurse's advice was particularly thought provoking in that she urged him not to fight the pain but to recognize it and to focus on life despite it. This would be my message -- not only for myself in turns of enabling me to go through the emotional circumstances but also to help my patient and those related to my patient (whether Mr. Thomas in this case or the extended family) deal with the pain and focus on making the most of the remaining moments. My recommendation would be to recognize the pain but to continue despite it so that all individuals in this scenario -- Mrs. Thomas as well as Mr. Thomas and their children can make the most of the remainder of Mrs. Thomas' life.

Listneing

Jaffe and Ehrlich's book, All kinds of love: Experiencing hospice, rells a story that shows better thatn anything else how I mproatn open commucnaiton, acceptance and lsuitenign is to te h moraltly ill. Sandy was gay and revealed this fact to his parents when he was 23 who, shocked by the news, rejected him. Shortly after, Sandy was diagnosed with a terminal illness and was hospitalized demoralized and depressed. Janice, the hospice nurse was summoned by his boyfriend to the scene and she was followed by Sandy's grandmother, who arranged to help Sandy through the illness. Existentialist questions on Sandy's part gave Janice the original idea of adding a chaplain to their team. Chaplain Frank suggested that the patient's parents be contacted. Sandy's mother soon came and, in the hospital environment, the two female family members acknowledged Sandy's lover as part of their family. After a ten-day interval of Sandy finding respite, the chaplain prepared the family for the end, and Janice instructed the grandmother and Joe regarding symptoms of death and how they should deal with it. Janice's innovation was bringing the chaplain into the case. Doing so resulted in ramifications that helped Sandy achieve closure and, accordingly, die in peace.

What communcaiton is

Communcaiton entails the give and take so that each side understands, is open with, and directly communcaites their perspective and sittuion to the other so that potential conflict is broken theorugh and a stae oof peaceful transparency exists.

How to best do this is illustrated by the follwoign stoy:

Jon the dying preacher is an example of where dying in peace and comfort is the most important aspect that a hospice nurse can gift a patient. Both Rose and Jon had adjusted to Jon's imminent death and attempted to encourage their daughters, Susan and Joan to show Jon that they could easily communicate and come to grips with his transition to death. Joan was the least able, but realizing that Jon wanted to make the most of his last moments on earth and that he, as terminally-ill patient wanted to live each and every one of those moments to the fullest without remorse and pain, Janice, the hospice nurse, enabled the daughters to express their feelings, to be mutually open with their feelings, and, letting themselves feel the pain, to savor each moment to the fullest.

Communication is a process between sender and recipient. It is meant to be effective so that the process is as smooth as possible with both recipient and sender, regardless of different context, background and experience, sending and receiving the message in a way that each intends the message to be deciphered. The goal of the communication process is to accomplish a certain bond of shared meaning and understanding to transpire between sender and recipient for message, and that this message come across intact and be rebounded time and again intact, without any breaks and conflict; at least until the end of the session.

Active or emphatic listening, on the other hand, involves a state of mind where the recipient fully engages himself to tuning it to the other's words and gestures, and accords the message and messenger his/her fullest attention.

Skills of listening are achieved by paraphrasing, reflecting, and summarizing the other's words in order to ascertain that one understands and that one has been understood as intended; to intermittently investigate by asking whether the other has understood the content of one's words and agrees with the content and structure; to openly state that one feels misunderstood (if one feels so) and request feedback; to absorb gestures and emotions of the other as one is listening; to lean forward in order to convey interest and so forth. In short, active listening requires the ability to attend which means focusing in on the message and screening out distracting elements.

Spielberg compared the listening brain to a sponge -- soaking it all up. That is a very powerful image.

Usually, stories can teach us better than straightforward prescription how to behcae in ceritn way.

This is the sotry of Janice a hospice nursebrough down by th e heroine herself, who shwoed how she best communcaited with the family when they had difficutly caring for Minnie, their elderly moteher hwo was dying. Minnie, a widow in her early 60s had spent the last few years struggling to defeat her breast cancer. Succumbing, she moved in with her daughter Jane and her lover, Howard, together with Jane's two adolescent daughters Amy and Beth. Each member of the family (Minnie included) experienced frustration and difficulty with the arrangement, hence Janice arranged that a volunteer visit the family on a frequent basis, and both Janice and the volunteer (Elaine) served as mediator (and sometimes arbitrator) between Minnie and the various family members. For instance, when Minnie was aggravated by Jane and Howard's unmarried status, Janice encouraged Minnie to speak to Jane, which was accomplished with satisfactory results. In a similar way, Elaine empathetically helped Amy understand why her grandmother 'usurped' her bedroom and that this 'living-in'; arrangement would be only temporary. Educating the family regarding the contingencies of death and how to best deal with the challenges of the situation, Elaine and Janice helped Minnie receive the loving care that she most needed. After her death, both case worker and assistant continued helping the family.

A particaulry varlauebl tool for commucniton amongst nurses and family of the patient is the SBAR tool.

The SBAR (Situation, Background, Assessment, Recommendation) tool has beenr ecnelty populatrized as a valuable instruemtn for communcaigton-onprevetn in any hostpical-type setting, and tis use can be aprorpatied to any tesne medical situation where nurses and toerhs conjoin in caring for an ill patient. The SBAR is deliebralty devised so as to prevent, reduce, and hopefully eliminate conflicte from occurring. NHS. Quality and Service Improvement Tool.; web).

SBAR helps present critical recommendations to the clinician and encourages the nurse to articulate recommendations. Most importantly, it helps develop an atmosphere of teamwork, thereby, augmenting patient safety by ensuring that communication between staff is focused, effective, and consistent and that repletion or need for repetition is abrogated. Information is provided with the right level of detail and the results of the SBAR can be disseminated throughout the medical institution from patient's entry, to communication between consultant and colleagues, to eventual discharge.

To elaborate, the acronym of the SBAR process consists of the following:

Situation entails identifying the site / unit that I am calling from; providing the name of the patient; succinctly stating my concern. Here, I describe the patient's situation whilst including the patient's name, consultant, patient location, code status, and vital signs.

Background: I provide the patient's reason for admission; provide appropriate medical history; and having collected all the patient's records, provide consultant with admitting diagnosis, date of admission, prior procedures, current medications, allergies, pertinent laboratory results and other relevant diagnostic results.

Assessment: this includes taking vital signs; recording clinical impressions or concerns; and contraction patterns. Critical assessment is important here.

Recommendation: succinctly clarify your needs; succinctly state your expectations from treatment as well as recommendations.

SBAR has been a consistently proven tool and is valuable for any organization. However simple it may sound, however, implementation may take a while and it necessitates that all involved members of the organization be motivated to improve their communication and that they be willing to be trained in and to implement the SBAR process.

SBAR, in short, makes communication decisive, effective, and direct between all members of the medical organization and prevents innuendoes or misinterpretations as well as need for repetition of certain directives all of which can ruin the hospital's reputation as well as endangering the patient's safety.

Summary

Nurses and family caring for eteh end-of-life patient have enpormous challenges in withstanding stress and maintiangin therioe foces onteh pateitn. Disagreemtns and conflict would eb a ntuarl part of such a tense atmosphere, and nurses working in such an enviroentmn wodul have to wrok [partioualy hard and gain some valuable tools in descaltaign such conflict.

Keeping the other in mind, his background, level of understanding, ways that he may possibly interpret message, the best ways of reaching him are different strategies by which one can enable one's message to get across. The best metaphor that I have once read of communication is to imagine it as a ball that one wants the other to precisely catch. In order to do so, one has to stand back and assess distance between oneself and the other and the most effective techniques that can help that 'ball' most directly reach the other. The aims and goals of each channel of communication -- both formal and informal -- should be understood, and the officer should meet these aims and goals precisely. Communication, in all instances, should be open and honest; the question and intent of statement / questions / message should be understood and, if not fully comprehended, should be stated. Careful time and thought should be given to answering questions and to transmitting one's response, particularly when one is in doubt. Courteousness is a given. Most of these requirements apply to both formal and informal mediums of communication. In essence, two cardinal results or strategies for communication may be presented: firstly to treat the other as one would oneself want to be treated; secondly to treat the other with respect, honesty, and dignity. The second strategy can be subsumed in the first.

Sources

Berne, D. Games People Play. Grove Press, Inc., 1954

Couric, K. (2011) The best advice I ever got: Lessons from extraordinary lives. NY: Random House

Goulston, M. (2010). Just listen USA: AMACOM

Jaffe, C. & Ehrlich, C.H. (1997). All kinds of love: Experiencing hospice. New York,

NY: Baywood Publishing Co.

McClain, C.S. & Rosenfeld, B. (2003). Effect of spiritual well-being on end-of-life despair, The Lancet, 36, 1603-1607.

NHS. Quality and Service Improvement Tool. SBAR.