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In this chapter the “communication compass” is introduced. It defines the key elements of communication and provides a language with which to communicate about communication in cancer care. The communication compass consists of two axes. One axis defines the associated perspectives of the clinician and the patient, the other axis the content of information and emotional experience.

Sometimes communication just flows. There are these special moments, as fleeting as they are intense. Often communication is stuck. It is as if we speak another language and never manage to understand one another. The lovers on the park bench need no words to express what they feel, neither do they need words to speak about communication. Where communication gets stuck, we need a suitable language to speak about communication.

Professional communication cannot be learned from a cookbook. Most of all it implies a readiness to communicate, which means openness to the other. The old adage that it is impossible not to communicate is only true if no criterion of quality is applied. As soon as some mutual understanding is implied in the definition of communication, the fact that it is at all possible to communicate becomes a miracle.

Since there is an important gap between theory and practice, we created a tool that aims to bridge that gap. We call it the communication compass. It does not propose a model of “ideal communication,” but provides a language with which to examine and analyze specific situations and to determine what the pitfalls and possibilities are. It is useful as a tool for identifying communicational difficulties in daily clinical practice and it can serve as a model for training basic communication skills (see Fig. 1).

Effective habit change usually requires a combination of psycho-educational, behavioural, and social learning strategies. Motivational interview and shared decision making are likely to be the most efficient approaches. Assessing the current motivation can be based on the transtheoretical model of change (TTM) with the goal to move from one behaviour to another healthier one. In a daily busy clinical practice, brief counselling interventions of one to three visits can substantially help patients change problematic behaviours, particularly in the areas of smoking cessation and exercise. The acronym FRAMES has been used to define the elements of an effective brief intervention which helps to trigger the patient motivation to change; giving Feedback based on a thorough assessment; helping the patient take Responsibility for changing; giving clear Advice on what behaviour must change; offering a Menu of options for making the change; expressing Empathy for the ambivalence and difficulty in making changes; enhancing Self-efficacy to foster commitment and confidence. This chapter reviews relevant aspects of clinician-patient communication with regard to cancer prevention, especially smoking cessation and exercise.

Cancer genetic counselling represents a very special situation of interaction between the geneticist and the counselee, marked by a number of specificities that account for its complexity. Cancer genetic counselling has multiple repercussions, such as identification of a deleterious genetic mutation associated with a high probability of developing breast and/or ovarian cancer, the implementation of preventive measures ranging from close surveillance to the decision to perform mutilating prophylactic surgical procedures, or the impact of the information on the other members of the counselee’s family also concerned by the genetic risk. This chapter is based on a review of the literature that has been rapidly growing over recent years and on our clinical expertise as psycho-oncologists and geneticists. We will first present the reasons that make the information so critical. These reasons are both objective (complexity of the genetic information per se, difficulties of understanding the concept of risk) and subjective (information given to people with an emotionally charged family history and a perception of risks closely linked to their representation of cancer). At the same time, the counsellees are charged with the transmission of this information to members of their own family. We will then discuss the various modalities of communication in this setting. While unidirectional transfer of information from the geneticist to the counselee has been the preferred method in cancer genetics for a long time, a model based on patient-centered communication is more adequate in predictive medicine and allows shared decision making. In all cases, the different professionals involved in the process have to learn how to work in a performing cohesion. We also present the main guidelines on the subject and the various underlying objectives with regard to information delivery and the subject’s personal experience. Although the psychological impact of genetic counselling consultations raises a number of questions, the results of preliminary studies are reassuring, demonstrating psychological benefits. However, a number of aspects concerning communication in predictive medicine remain to be investigated and improved.

This chapter focuses on four crucial situations representing important challenges for physician-patient communication: diagnosis, relapse, progression of disease and terminal illness. The psychological aspects of each situation are discussed and a framework for communication is provided. The aim of the chapter is to invite the oncology clinician to think about these different stages of disease and to support him or her in the communication with the patient.

Communication with cancer patients is a difficult task in clinical practice and it is especially challenging when informing about diagnosis and prognosis, when relapse occurs or when the disease is progressing. Physician-patient communication has undergone considerable changes and has become—compared to decades before, when medicine was based on a more paternalistic model of care—a central duty and challenge of the oncology clinician. The following chapter aims to discuss key elements of communication in the above-mentioned specific situations; it is based on our clinical experience as psycho-oncologists and teachers of communication skills training (Razavi and Stiefel 1994; Stiefel and Razavi 1994; Razavi et al. 2003; Berney and Stiefel 2004; Delvaux et al. 2005; Voelter et al. 2005; Bragard et al. 2006).

From the wealth of literature available it appears important to express a note of hope when communicating information, news or healthcare plans to patients with cancer, or in fact any serious illness. Whereas in previous years withholding information to protect patients, and the belief that this would not diminish hope, was common practice, more recently truth telling has become the norm. Healthcare staff who are able to empathise and care—as well as providing hope, trust, interest and commitment—are important to patients and their families. This implies that two dimensions of hope should be considered: (a) “patient/family orientations to hope”, which involves needing to believe in a miracle and living parallel realities—that is, hoping for a cure or remission whilst at the same time realising the terminal nature of the illness; and (b) “messages from the healthcare providers supporting hope” by using words and approaches that leave the door open, retain professional honesty and respect alternative paths. It is the duty of those health professionals concerned to do what they can to help maintain hope, to promote holistic care, and to maximise physical, social, psychological, and spiritual health, in the true nature of cancer care.

The focus of this chapter is on how clinicians can understand and communicate with the families of patients suffering from cancer. Most doctors and nurses do not have training in this area and are uncomfortable when conducting interviews with whole families. The need to extend our skills in the family context reflects the changes in the way care is provided to patients with a serious illness. We recognise the part families play in providing care and the subsequent effects on family life. The influence of systemic thinking and social construction theories has led to the acknowledgement that we are all part of systems which interact with each other and it is no longer appropriate to see the patient in isolation. The chapter will look at ideas from family therapy which can help us assess and intervene when necessary.

The patient suffering from a life-threatening illness such as cancer looks to his family and friends for care and support. The management and course of the illness is affected by the involvement of the family and how they manage the stress and the effects of illness on a family member (Wright and Leahey 2000). Duhamel and Dupuis (2003) point out that there are three important factors in the management of the illness: the effects of family stress, the needs of the family as caregivers, and the effects of the role and how the family cope with the way the patient experiences his illness. This presents professionals working in the field with challenges they are often ill-equipped to deal with. Most healthcare workers have inadequate training in understanding family dynamics and even less knowledge about how to communicate effectively with whole families. Consequently, many healthcare professionals avoid couple and family interviews, feeling inadequate and helpless like the families themselves. I will address some of these issues in the chapter, firstly by examining what we now regard as the family and then by using ideas from systemic theory I will look at assessing families, the organisation of families and belief systems, concluding with communications which can bring about change in families needing our help.

Families are complex, they have histories and are influenced by the past. Relationships within families have different meanings and significance not understood unless questions that we ask bring access to them; moreover, their journeys through the illness of the family member is different from that of the patients. However, the need for support/information/valuing/respect is the same. If we are to help, we need to know how to approach families, how to asses their needs, and learn about interventions that help so that we can offer holistic care which will ease the practical, physical, emotional, social and spiritual pain and suffering of the people who will go on living with the significance of the death.

Some specific aspects of communication in pediatric oncology will be outlined in this chapter. These include openness about the disease, which has become increasingly important. Furthermore, the law of double protection, a self-protective strategy used by children, parents, and hospital staff, will be sketched out. It is very striking that protection is often achieved through protection of the other. Several examples of this strategy will be presented. Finally, attention will be paid to communication about death in the palliative phase.

After an introduction clarifying the notion of interdisciplinarity, this chapter focuses on the importance of specific roles and mutual respon-sibilities within the interdisciplinary team, as well as basic rules of communication respecting the values of the concerned partners and professionals, as well as patient and family. Finally, the communication structure for efficient teamwork, and the importance of building a common vision, sharing leadership and learning to work together will be discussed.

Cancer is increasing in incidence and prevalence worldwide, and the WHO has recently included cancer and its treatments as a health priority in developed and developing countries. The cultural diversity of oncology patients is bound to increase, and cultural sensitivity and competence are now required of all oncology professionals. A culturally competent cancer care leads to improved therapeutic outcome and it may decrease disparities in medical care. Cultural competence in medicine is a complex multilayered accomplishment, requiring knowledge, skills and attitudes whose acquisition is needed for effective cross-cultural negotiation in the clinical setting. Effective cultural competence is based on knowledge of the notion of culture; on awareness of possible biases and prejudices related to stereotyping, racism, classism, sexism; on nurturing appreciation for differences in health care values; and on fostering the attitudes of humility, empathy, curiosity, respect, sensitivity and awareness. Cultural competence in healthcare relates to individual professionals, but also to organizations and systems. A culturally competent healthcare system must consider in their separateness and yet in there reciprocal influences social, racial and cultural factors. By providing a framework of reference to interpret the external world and relate to it, culture affects patients’ perceptions of disease, disability and suffering; degrees and expressions of concern about them; their responses to treatments and their relationship to individual physicians and to the healthcare system. Culture also influences the interpretation of ethical norms and principles, and especially of individual autonomy, which can be perceived either as synonymous with freedom or with isolation depending on the cultural context. This, in turn, determines the variability of truth-telling attitudes and practices worldwide as well as the different roles of family in the information and decision-making process of the cancer patient. Finally, culture affects individual views of the patient-doctor relationship in different contexts.

Too many patients leave their consultations with insufficient understanding about their diagnosis, prognosis, the need for further diagnostic tests, the management plans, or the therapeutic intent of treatment. This situation is not entirely due to paternalism or a lack of awareness that patients worldwide desire more information, but rather a reflection of the dismal communication skills training that most healthcare professionals receive. There have been many developments aimed at rectifying this situation, but there are still too few publications available demonstrating efficacy. Nevertheless, evidence shows that communication skills can be taught and that if taught well then the impact endures into the clinic. This chapter looks at some of the history of good evidence- based interventions to improve communication and makes a plea for more research-based evidence for improved patient outcomes following training. Unless attention and resources are given to help healthcare professionals in this core clinical skill then we will never be able to help patients and their families take an informed and educated role in their own cancer care.