We'll now review some of our basic concepts on communication. If you remember from our course, we spent a little bit of time talking about active listening. We know that active listening really helps us to build rapport, and to better understand our patients and their goals. Now, what does active listening really mean? It means giving our undivided attention, putting aside our own emotions, and asking open-ended questions. In many ways, patients feel listened to if you can summarize or restate what the patient says. For example, tell me a little bit about your pain. Well, I noticed my pain is in my belly and gets worse with eating. I see, so what I'm hearing you say is, so that dialogue of using an open ended question, and then summarizing what the patient is saying, really allows for the patient to feel heard. And then of course, always remembering to clarify any questions that may come up as you're going through that dialogue with patients and their loved ones. We also know that in addition to verbal communication, nonverbal communication is really important. It's as important as the words that we choose. So, if you remember we had a mnemonic in our course where we talked a little bit about what does it take, in terms of your body language, to exhibit good nonverbal communication that allows for trust and sharing. One is that we believe that you should sit squarely and have an open body posture. Try not to cross your arms or legs, show that you're open and approachable. Lean in, allow patients to feel like you're connecting. Make eye contact. And use a relaxed overall posture. We call that mnemonic SOLER. S for sitting squarely. O for open body posture. L for leaning in. E for eye contact. And R for being relaxed. We also spent a little bit of time talking about how we can respond to a patient's emotional cue in a compassionate manner. We use the mnemonic NURSE, and we're going to review that today. In this particular scene, we see the physician speaking to the patient. And we can tell that she looks upset, and she states, the physician states, I can see this is upsetting. In the NURSE mnemonic, this is the N, it's simply naming the emotion. Her next response is really to let the patient know that it's okay to feel this way. She says, many of my patients have had similar feelings. What does that mean? it normalizes the fact that hearing this difficult news is upsetting, and it's showing that you understand. So the U in NURSE is understand. Showing emotion takes an enormous amount of courage, and to show emotion in a medical setting where you can often feel disenfranchised, or like you have no power is very difficult. And so, exhibiting respect for the patients a willingness to show emotion is so important. And this doctor says very nicely, you've been so positive during these treatments, conveying respect for both the hard periods, but also the periods of strength that this patient has shown. The S is support. We know that going through treatment for illness is difficult, but when your doctor says I will support you, I will be here with you, it goes a long way for patients who are going through a difficult time. And then the E is allowing for that patient to really take that emotion and explore it with you. So, if someone says that they're nervous, ask them why. Tell me more about what makes you nervous. Or if they're sad, why do you feel sad? Patients feel supported if you give them an opportunity to provide more data on their emotional cue. We also had a chance to review a really terrific mnemonic on how to break difficult news to patients and their families. That mnemonic is called SPIKES, and we're going to review that together today. The S in SPIKES is pretty basic, but sometimes something we forgot, it's setting. It's allowing for the patient and the family to be with you in a space that feels comfortable, and it's quiet, and allows them to feel like they have your undivided attention. The P is perception. So, one of the things that's most important with talking through difficult news, in breaking bad news, is allowing for the patient to first tell us what they know. This allows you to understand the stage where the patient's spin all of the data that they've already received, so that you can start at the right place, and provide the right information. So ask an open ended question about their perception such as, can you tell me what you understand about your illness? The eye in SPIKES is again a way to show respect, and that's really to allow patients and families to tell you how much information they are ready to hear. Bad news is hard, it's really hard, and for people who have a chronic illness, sometimes it feels like they're getting a lot of difficult news. So it goes a long way for you to ask for an invitation to move forward in the conversation. Something as simple as, would it be okay for me to discuss your latest results? Or is this a good time to talk about next steps? It allows for the patient to say, yes, I'm ready, or no, I've gone through a lot today, it would be great for us to do this when I have my son present, or maybe next week when I'm feeling better. So invitation is a crucial part of allowing for the patient to have some control. The K is knowledge. This is often what we spend a lot of time on as physicians where we kind of just provide a lot of data. In SPIKES of course we acknowledge the fact that data is important, and we definitely do need to provide that data. And so this is that data part, which is, let me tell you a little bit of information about what's happening with your illness based on everything that we've talked about. And usually with bad news, we recommend that you provide that information in small, honest chunks, and avoid jargon, and avoid editorializing the information. The E is acknowledging the fact that when you provide difficult news, you do need to have an empathic response, and to normalize that. So if you're breaking bad news, it's okay to say something that says it's common for many of my patients to feel anxious when they hear about a new diagnosis, is that how you feel? Or it's normal to need support when you're going through something like this, and I would love to understand how you're feeling right now, and how we can help you. And then finally the S in SPIKES is summarize or strategize, which is don't leave the patient hanging. You've just given them some hard news, the next step is really to make sure that they're not at the edge of a cliff without any support. So make a plan, make sure that the patient understands what that plan is and how it fits in to their overall goals. After you've made a plan, ask them what their thoughts are with some open ended questions. When you've given patients data or knowledge or bad news, it's always important to assess understanding. And a big component of palliative care communication is really assessing patient understanding, so you are at the right starting place to move forward. A great tool that we use for that is something called Ask-Tell-Ask. When a patient is receiving new information, the first ask is to determine what the patient understands. So, what have you been told about your illness before this visit? The second question is tell. Again, this is the data part, so let's say some of the information is right and some of the information is wrong. You can say thank you so much for telling me what you know about your illness so far, you are correct, X, Y and Z. However, I would want to add, and then tell them the data that you may think they need to know and may have been missing from their initial assessment. And then sometimes the hardest part about this is really knowing, did that patient take everything away that you had told them. And so this third ask is so important which is basically seeing if the patient understood. And a very nice way to do this is to say, we've covered a lot of ground today, sometimes my explanations are not as always clear as I would like them to be. Would you mind telling me your understanding of what we've spoken about? And we know that throughout the interaction, even though we've given you some great tools, SPIKES, NURSE, Ask-Tell-Ask, there's some really basic communication pearls that we hope that you take away for every interaction. For example, we would want to make sure that you give the patient the opportunity to participate in the agenda setting. You have a list of things you need to cover as the physician or clinician, what are the things that the patient really wants to cover? Set that mutual agenda at the beginning of the visit. Involve the family and caregiver. Make sure that every time you ask a question or get data, you turn to the loved one and ask them what their thoughts are. Have them be an active participant in the dialogue in the room because you know that they are an active participant at home. And if you don't involve them in the clinic visit, you may be only getting half the story. Pause for questions. Patients are processing so much information, and if you don't give them a chance to take a moment and breath, they're going to forget their question, they may not know how to get you to stop so that they can ask it. So build those pauses in and ask people if they have questions. When you do have questions for the patient, don't make it a run on of questions. Patients are processing a lot, so ask the patient only one question at a time. Instead of saying something, tell me about the severity of your pain, where it happens, how often it occurs and what aggravates it. You may say something like, do you have pain? Where is it? And pause between each of those questions to get the responses. Don't be afraid to go the old fashioned way. Take some notes, draw some pictures, goes a long way because often patients don't remember everything and they really rely fully on your clinician scratch. Where they appreciate your depiction of the clinical scenario, and then take that home and use that to help talk to their family about things. Avoid jargon, remember this is the twilight zone for patients and families, we can make it better by using simple language and doing it in digestible chunks. And whenever you can, if you have good educational content, make sure that you provide it. And if you're stuck and you need help, don't be afraid to ask. Palliative care specialists are there to help you, social workers are there, sometimes it's just help for the patient from the community. If you've reached the end of your rope in terms of figuring out how to support them, thinking about school counselors, clergy, folks, anyone who you think that that patient would trust to get some support and help.