Communication and Advance Care Planning
Essential communication with patients and families with ESKD Advance Healthcare Planning Essential communication with patients and families with ESKD Compassionate and effective communication is key to developing a working and trustful relationship between patients, families and healthcare professionals. It requires knowledge about what, with whom and when difficult conversations should be had. A
Essential communication with patients and families with ESKD
Essential communication with patients and families with ESKD
Compassionate and effective communication is key to developing a working and trustful relationship between patients, families and healthcare professionals. It requires knowledge about what, with whom and when difficult conversations should be had. A positive, non-judgmental attitude should be maintained. These skills can be taught and should be practised. Protocols such as SPIKES (breaking bad news) and the “Serious Illness Conversations” are examples of evidenced-based approaches to communication [36,37,39]. All breaking bad news conversations, especially around withholding or withdrawing dialysis, should be managed by a senior doctor on the team.
One of the most difficult challenges is the discussion with a patient in the public sector who cannot be offered dialysis. It is essential that everybody gives the same message when communicating with patients and families in order not to create false hope or distrust. All difficult conversations should be clearly documented in the patient notes. Such conversations should always be followed by reflection and, if necessary, debriefing. The moral distress of doctors involved in withdrawing or withholding dialysis requires collegial support from managers and other healthcare providers.
There are many barriers to having essential conversations with patients and families. Patient and/or family may misunderstand the diagnosis and prognosis, there may be cultural differences, clinician attitudes and beliefs around palliative care, lack of training and shortage of time available for difficult conversations. These conversations should aim to manage conflict, to acknowledge and address all emotions, to improve prognostic awareness and align care with expectations of patients and families.
The following are recommended essential conversations that should take place between healthcare professionals, patients and families:
a. Breaking Bad News [38] – must offer a hopeful, achievable alternative with a carefully considered palliative care plan.
b. Serious Illness Conversation [39].
Advance Healthcare Planning
Advance Healthcare Planning includes discussions with individuals about their preferences and wishes. They are best held when patients are relatively well, able to communicate effectively and have the mental capacity to make independent decisions. They should address values, goals and outcomes that are important to patients and families. The conversation should be ongoing and not a single event with the possibility of review if circumstances change. The plan will assist the healthcare team to make treatment recommendations that are aligned with specified values. This becomes increasingly important when the patient is no longer able to make or verbalise decisions independently. Research shows that patients expect clinicians to initiate these conversations, and when skilfully done it does not increase anxiety or hopelessness.
Examples of how to start the conversation:
- Routine visit: “It seems you are doing well but I like talking to all my patients about their preferences for care in case they get very sick.”
- Episode of acute illness: “To make sure we are working together while you are sick, I would like to talk about your goals of care.”
“I would like to talk to you about your current symptoms and how you would like us to manage it.” - Follow-up visit after an episode of acute illness: “What would be your goals of care if this happens again?”
Topics to discuss:
- Substitute decision makers or patient advocates: “Who would you like to speak for you if you are unable?”
- Understanding of current illness
- Current symptoms, fears and expectations
- How WE are going to address them
- What are you hoping for?
- Hope for the best but plan for the worst
- What have you learned from previous experiences about how you want to be cared for? (explore sources and clarify misconceptions)
- Support systems
- Make sure values, goals and care plan are communicated with decision makers and all decision makers are comfortable with the decisions.
- All communication should be clearly documented and included in the patient notes [38].
See Addendum 4 for the link to the Hospice Palliative Care Association of South Africa (HPCA) Advance Health Care Planning document.
Wearne, N., Krause, R., Davidson, B., and Brennan, F., 2020. Renal palliative and supportive care in South Africa – A consensus statement. African Journal of Nephrology, 23(1), pp.86-107.