Consultant in Palliative Medicine at Velindre Cancer Hospital and Bevan Exemplar
The recent months have changed many aspects of life. Covid-19 has brought with it a shift in how I, as a palliative care professional, communicate with my patients and their next-of-kin. Where possible, we now offer video and phone consultations to our patients, many of whom are self-isolating at home, and others are frightened of attending hospital and clinical settings.
My palliative care outpatient clinic has gone from 2% phone and 98% face-to-face consultations, to 98% video or phone consults in a very short space of time.
What I was not prepared for was the increase in bad news conversations, by phone and by video messaging. Some involve the topics of worsening disease that is no longer curable. Or even the concept of resuscitation and a person’s views on CPR if they became seriously unwell. Prompted by some challenging phone and video consultations, I have written down some pointers on how I prepare in this new medium. The bad news scenarios involve people with and without Covid-19, because all the other serious illnesses have of course not gone away.
Environment: Check the surrounding setting is okay, if you are in a setting that is noisy, or where there are other people who may be laughing, eating or talking loudly, then a bad news consult via video or phone could be misplaced here. Consider warning colleagues nearby that you are about to have a serious conversation.
Regarding the bad news, how much does the person suspect already?
Have a plan for what to do next. Further tests, any investigations, non-pharmacological and pharmacological options. Think about follow-up, is it needed quite soon to clarify questions?
If I’ve had multiple difficult phone or video conversations in a short time, do I need to take a break before going into the next one? It’s important to know your own limitations and take a rest, even if it’s just a few minutes. Take a comfort break, especially if it is likely that you are going into a long conversation.
I always fully introduce myself and my role and where I work, and double-check who is at the other end of the call.
Is it okay or even safe for them to talk right now? Are they alone or is there anyone around? Would it be better to call a bit later?
I nearly always preface that I have some difficult news. I might say something like: “I am sorry, but there is some news that is not good, and I wanted to let you know about this.” If someone asks me to stop there, I do so, and offer a further phone or video call. They are not ready yet, but will feel a need to speak later. They need time to prepare.
Give a summary of what you know. I do this with compassion, but also without too much prelude or hesitation. People want to know now, in my experience, so don’t make them wait with too many platitudes. I once heard a doctor talk about the weather before giving bad news. No. So if you have been given permission to proceed, don’t make small-talk. I sometimes intersperse this with questions checking what the person I am talking to already knows, or if they need a break, but then I try to align this with the newest news. I often find that people have already suspected and thought about the different bad news scenarios. “Yes, doctor, this is what I was fearing all long.”
I use non-medical words as much as possible. I also do this when I’m talking to a doctor-patient or a nurse-patient, in my experience they often prefer not to have too many acronyms and technical terms thrown at them at distressing times.
I try to bring them back into the now and the next few days. What will you do now? Shall we make a plan together? Are there people you need to tell? Who is there to support you? I often phone back sooner if there aren’t many people to support.
I also try to ask the person to summarise a bit about what we talked about. It allows them to ask questions. Sometimes, the white noise that breaks into our brains after a sentence like: “Your cancer has spread” or “Your husband has just died”, is so intense, that nothing beyond that is heard or understood. So I never assume that any other points I have tried to cover will be remembered, but a summary at the end can allow the person to come back with questions that are important to them and help clarify things.
I always write the conversation down. It helps me restart things next time I call, and we can focus on big themes during the first conversation. This is also helpful if I go off sick (a lot of my colleagues are off with Covid-19 and I am just waiting for when I get it) and someone else needs to pick up the conversation at follow-up. Some patients have even asked me whether they can record the consultation so that they can discuss it with those close to them, and I don’t have an issue with this at all.
In closing, I say good-bye, if needed I’ll state my name again and how to get in touch at the hospital, and what the follow-up will be. I try to find a way of expressing that we, as healthcare professionals, know how difficult this all is, and I make reference to the fact that I much prefer seeing people face-to-face. If needed, I will also highlight support agencies and charities, particularly local ones, that can provide a listening ear.
These sorts of conversations are never easy. On balance, patients appreciate the ability to have conversations, rather than none at all, and so I suspect video and audio consultations are here to stay. There will be gains, including the benefits for patients not to have to worry about hospital transport, long waits in crowded outpatient departments and the reassurance of being able to speak to experts from the comfort of the own home. There will be challenges and, perhaps video consultations will risk us missing the subtle nuances that make all the difference in a real life, face-to-face consultation. But the principles of good communication, some but certainly not all of which are alluded to in the above, still apply, no matter what the mode of communication.