1. Have You ever heard :..... ? ‘There is NOTHING to Do with this patient ’ ‘There is NOTHING to Do with this patient ’ ‘ Everybody dies ‘ ‘ Everybody dies ‘ ‘ You are young. You can have another child ’ ‘ You are young. You can have another child ’ MISTAKE ! MISTAKE !

2. Communication in palliative care Prof. Jacek Łuczak AM w Poznaniu

3. Quality of Life Psychological Psychological Physical Physical Spiritual Spiritual

4. Reactions for information about cancer disease (E. Kubler-Ross) denial, shock, numbness (trance) denial, shock, numbness (trance) anger, soreness, irritation, aggresion anger, soreness, irritation, aggresion chaffer with destiny - why me ? chaffer with destiny - why me ? depression depression acceptation acceptation

5. Emotions during cancer disease: Anxiety Anxiety Anger Anger Feeling quilty Feeling quilty Depression Depression Hope Hope

6. Emotions How are you ? I could not sleep… I could not sleep… Something worries me Something worries me I feel abandoned… I feel abandoned… I’m dying… I’m dying…

7. Defensive mechanisms ( adaptation in disease): Represive mechanisms Represive mechanisms Sensitive mechanisms ( subconscious) Sensitive mechanisms ( subconscious) Conscious mechanisms Conscious mechanisms

8. Is it a cancer, doctor ? DON`T PASS OVER IT IN SILENCE !!! DON`T PASS OVER IT IN SILENCE !!! No, but your disease is... No, but your disease is... I don`t know, because... I don`t know, because... Yes, but... Yes, but...

9. Know-how listenings: Active Active Reflective Reflective Empatic Empatic

10. Partnership with the patient Courtesy in behaviour Courtesy in behaviour Politeness in speech Politeness in speech Not patronizing, Being honest Not patronizing, Being honest Listening, Explaining Listening, Explaining Agreeing priorities and goals Agreeing priorities and goals Discussing treatment options Discussing treatment options Accepting treatment refusal Accepting treatment refusal

11. Hope and truth big small false big small false

12. General strategy What do you see ? What do you see ? What do you feel? What do you feel? What can you do ? What can you do ?

13. Detailed strategy: What does your patient need ? What does your patient need ? What does his family need ? What does his family need ? Some important issues from patient`s life.. Some important issues from patient`s life.. Let the patient give something... Let the patient give something...

14. Distancing Tactics Premature reassurance Premature reassurance False eassurance False eassurance Normalising Normalising Selective attention Selective attention Jollying along Jollying along Passing the buck Passing the buck “Turning a deaf ear” “Turning a deaf ear” Concentrating on a physical task Concentrating on a physical task Inappropriately introducing humour Inappropriately introducing humour Dissappearing from the stressful situation Dissappearing from the stressful situation

15. Breaking Bad News How to do it guidelines ( adapted from Mc Master technique ) Consider where to do it ! Consider where to do it ! Do NOT begin with an open question Do NOT begin with an open question Check patient’s current insight into his/her illness Check patient’s current insight into his/her illness Fire a warning shot ( eg. I’m afraid it looks more serious than we first thought’) Fire a warning shot ( eg. I’m afraid it looks more serious than we first thought’) Pause Take your ‘moving on’ cue from the patient. This may often be nonverbal. Some patients will not want to know more at this stage) Pause Take your ‘moving on’ cue from the patient. This may often be nonverbal. Some patients will not want to know more at this stage) Perhaps use hierarchy of euphemisms (again this may depend on the insight of the patient) Perhaps use hierarchy of euphemisms (again this may depend on the insight of the patient) Break the News. Do it clearly and without jargon, (so that the patient is not left with more uncertainties) Break the News. Do it clearly and without jargon, (so that the patient is not left with more uncertainties) Pause Pause Resist Reassurance Resist Reassurance Acknowledge any obvious feelings you witness in the patient ( eg. This is very upsetting for you) Acknowledge any obvious feelings you witness in the patient ( eg. This is very upsetting for you) Find out how the patient is feeling. It often helps to prefix what may seem an obvious statement with something like: ’ this may seem a silly question but I’m wondering how this has left you feeling right now?’ Find out how the patient is feeling. It often helps to prefix what may seem an obvious statement with something like: ’ this may seem a silly question but I’m wondering how this has left you feeling right now?’ Draw out any immediate concerns Draw out any immediate concerns Be realistic Be realistic Maintain Hope eg. ‘There are things that we can do’ Maintain Hope eg. ‘There are things that we can do’

16. SOME ADVICES one musn’t respond to all the problems during the first visit one musn’t respond to all the problems during the first visit use open questions use open questions be understandable be understandable respond to needs of the patient respond to needs of the patient predetermine time of talk predetermine time of talk be onest (synchronization of the words and body language) be onest (synchronization of the words and body language) use silence use silence repeat last words of the patient repeat last words of the patient use paralingvistic sounds …hmm… eh.. use paralingvistic sounds …hmm… eh.. don’t speak about yourself don’t speak about yourself avoid mentor’s position avoid mentor’s position be careful if you feel helpless. It is easy to make a mistake be careful if you feel helpless. It is easy to make a mistake first talk to the patient, secondary -to the family first talk to the patient, secondary -to the family talk to the family over open door talk to the family over open door Never say: Never say: Everybody dies Everybody dies You may have another child, (when the one died) You may have another child, (when the one died)

17. Communication with children: The evidence does suggest that those families who can express themselves openly benefit both during the child`s illness and after the death. / Spinetta et al. 1981 / The evidence does suggest that those families who can express themselves openly benefit both during the child`s illness and after the death. / Spinetta et al. 1981 / The consensus opinion in the literature has moved over the last 20 years from a protective approach to children towards honesty and openness / Chesler 1986 / The consensus opinion in the literature has moved over the last 20 years from a protective approach to children towards honesty and openness / Chesler 1986 / Many acquire considerable information about their disease, including the possibility of death, without being told specifically. This happened even to children who were cared for by staff and parents who were cared for by staff and parents who believed that the children would remain naive and protected if their disease was not discussed with them. / Bluebond-Langer 1978, Kendrick et al. 1987/ Many acquire considerable information about their disease, including the possibility of death, without being told specifically. This happened even to children who were cared for by staff and parents who were cared for by staff and parents who believed that the children would remain naive and protected if their disease was not discussed with them. / Bluebond-Langer 1978, Kendrick et al. 1987/ Even experienced staff who overtly expressed the wish to be open, have been observed to use distancing tactics regularly. / Maguire 1985/ Even experienced staff who overtly expressed the wish to be open, have been observed to use distancing tactics regularly. / Maguire 1985/