Medical Simulation improving patient communication: Jon Gatward
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We regularly have difficult conversations in critical care. We deal with sick and complex patients who may be at the end of life. The families we talk to may be in a state of shock and acute grief, unable to think clearly and make important decisions. Moreover, patient safety incidents and other challenging issues such as organ and tissue donation may further complicate the patient journey. In this talk by Jon Gatward, we follow the story of Leah and the difficult conversations that were needed in caring for her and her family. Jon examines some of the key elements that can contribute to successful communication in difficult circumstances such as: • Having a plan and a structure before embarking on these difficult conversations. • Working towards a common agenda and ensuring that everyone feels safe and able to ask questions. • Showing empathy and using silence well, allowing people the space and time to process information. • Giving people the benefit of the doubt, after all, these are their family members that we are talking about. As clinicians, our training in this type of communication may be limited to observing our mentors, and we may feel inadequately prepared. We will investigate how simulation training can be used to improve the quality of communication, increase our skill and comfort level so that we can guide patients and families through complex and challenging situations. We will also investigate how lessons learnt from simulation debriefing can be transferred to the conduct of difficult conversations in real life. Most importantly – we need to ensure that we look out for ourselves and for our colleagues. These conversations are draining and difficult. Tune in to a DAS SMACC talk by Jon Gatward on Critical Moments in the Intensive Care Unit. For more like this, head to our podcast page. #CodaPodcast
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Medical Simulation improving patient communication: Jon Gatward
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Notes de l'éditeur
- We have difficult conversations in Critical Care. Hi. I’m Jon What you have just seen was a selection of clips from some of the difficult conversations that took place in the Intensive Care Unit during the care of Leah, who we have been following this week.
- The first conversation was an open disclosure conversation, where the Intensive Care Specialist Lucy explained to the family that Dr Hicks had made an error when he allowed Leah to leave the emergency department without proper assessment or imaging.
- In the second conversation, Leah’s family were told that her condition had worsened and she was dying.
- The third conversation was a family donation discussion in which Leah’s family decided to follow her wishes and proceed with organ and tissue donation.
- Sorry. They don’t call this the graveyard shift for nothing! These types of conversations are amongst the most challenging that we have in critical care. I want you to think back to the most challenging conversation you have been involved in.
- If you are like me, you will be thinking, I was out of my depth, uncomfortable or poorly prepared. I could have done better. The family deserved better..
- We know that good communication skills improve family outcomes, by decreasing anxiety, depression and post traumatic stress disorder, and improving satisfaction and decision making Training in leading the family donation conversation has been shown repeatedly to increase consent rates, but more importantly, to increase the proportion of durable decisions, which the family is still comfortable with 6 months down the track. So we need to get it right. Unfortunately, many studies show that we often fall short, with up to 30% of families reporting dissatisfaction, and several studies that show that families remember less than half of what we tell them.
- I’m passionate and curious about how I can improve the conversations I lead, and how we can teach others to lead them. Over the next few minutes I’m going to give you some insights from my career as a healthcare communicator and simulation trainer and show you how simulation can help us become more comfortable with these conversations.
- This is me during my early days as a sim educator. About this time, I started to be let loose with family discussions in the ICU. I wasn’t very good at it. I was awkward, and I talked too much. We didn’t deal with organ donation well then either. It would be tacked on to the end of life discussion, like this... Turn “Oh, there’s one more thing. Sorry, I have to ask you this. Did Bob ever talk to you about organ donation? No? OK. Sorry for asking.” I was also a terrible debriefer. I talked too much and told the learners what I wanted them to hear. I was instructor, rather than learner centred.
- Over the years I have done more and more simulation debriefing and a couple of debriefing courses, and I now work with DonateLife in Australia, training donation specialists to lead donation conversations using workshops and simulation. In this program, we trained over 100 organ donation Specialists using real, anonymised cases, professional actors, and a three stage debriefing process – with the family in character, then out of character, then using video feedback. Participants especially liked the realism of the scenarios and being debriefed by the family in character, and almost everyone felt more confident afterwards FOR ME – I learnt a lot about communication and debriefing. And this is where I had a bit of an epiphany.
- I began to realise that leading a difficult conversation is a lot like leading a simulation debrief. There are many transferable skills between the two. I’d lie to go through a few of these skills that I think can help us with family conversations and debriefing.
- Ideally, we should have a quick planning meeting. For family discussions, to share information about the family and plan what we are going to cover, in simulation debriefing, to decide on the issues we would like to discuss.
- We may decide to use a structure, which depends on the conversation we are having. If we are delivering catastrophic news like a death, we should tell the family very early in the conversation. In other circumstances, we might establish what the family know first, before updating them. For debriefing, I use Andrew Cheng and Walter Eppich’s PEARLS framework, starting with the Reactions phase, we ask participants how they are feeling, then a description of the case, then an Analysis phase where we discuss issues important to us and the learners, then a Summary with Take-home messages. If you use a structure, always be prepared to be flexible and change your approach if necessary.
- We need to find a common agenda with the people in the room. A good way to find out what they want to talk about is to ask. There’s good evidence that if you give families a written list of questions they might want to ask, they remember to ask the difficult questions, and have better recall of the whole conversation. We can find a common agenda with learners by asking for their reactions at the beginning of debrief, or by using a simple construct like Plus/Delta – What did you do well? What could you improve on? This is learner centred debriefing – where the participants identify their own learning needs.
- We need to make sure people feel safe, so they can speak up and ask questions. In simulation we create a safe container for learning. Much of this is accomplished in the pre-brief, where we clarify expectations and commit to confidentiality and respecting learners and their psychological safety. We need to be honest and open. Families need clear, unambiguous information and an honest opinion about their loved one’s prognosis Learners deserve the same - if there is a performance gap, we name it, and are then curious and find out why it happened. We don’t make the participants try to guess what we are thinking.
- If we upset somebody, we have to acknowledge it and show empathy. We need to have a heart moment rather than a head moment. I want to give you an example of when thinking about heart moments could have helped me. During a family donation discussion about a brain dead patient, her sister said “I don’t want her to suffer any more”. I followed my head and explained to her again that her sister could not possibly suffer any more, because she was brain dead. I thought I was doing the right thing, but in retrospect, what she was saying was that she couldn’t bear the thought of her sister having another operation. I should have said, “I’m so sorry, this is you sister we are talking about, it must be so difficult for you..….”
- If I could give you one take home message today, it’s this: Use silence well. Families and learners need time to process information, discuss things amongst themselves, vent their frustration. They can’t do this if you talk all the time. You should also use silence if you have dropped a hand grenade. If you say, ‘I’m sorry, Bob has died’ , whatever you say in the next minute will not be heard or understood.
- Finally, something I ‘ve taken from simulation back into the family conversation. It’s the concept of the basic assumption. In simulation, we assume that participants are capable, doing their best, and want to improve. When a family member is unreasonable, cut them some slack. Assume they just want the best for their loved one and are in distress.
- So, if you want to become more comfortable with difficult conversations, I recommend going on a communication course, especially if they are using professional actors, and even better, if they debrief you in character. It’s tremendously powerful. Alternatively, or in addition, become a simulation instructor, read about and practice debriefing. You will become a better communicator.
- As for me – I’m still on the journey. After debriefs and difficult conversations, I get feedback from my colleagues, trying to improve all the time.
- One final thought. These conversations are emotionally draining, so look out for your colleagues. We can’t always be the bear.