The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 21: Patient-Clinician CommunicationMaking Preparations Before the DiscussionA common mistake that some clinicians make is to embark on a discussion about palliativecare with26 picasa patient or significant others without having made the necessary preparations for thediscussion. Clinicians should review what is known about the patient’s disease process includingthe diagnosis, prognosis, treatment options, and likely outcomes with different treatments.Clinicians should identify gaps in their knowledge by systematically reviewing this informationand seek out the information they need before they find themselves in a discussion with patientsor their significant others. Clinicians should also be aware of the communication that hasoccurred with other team members and of the plans for care established or agreed upon by anyother care provider responsible for the patient’s care.It is also important for clinicians to review what they know about the patient and their familyand social support network including their relationships with one another, their attitudes towardillness, treatment, and death, and their prior reactions to information about illness and death.If, for example, there are significant others who have had strong emotional reactions to badnews, it may be helpful to mobilize the aid of a family member, friend, or staff member, such asa social worker or chaplain, who can support them through and after the discussion with theclinician.Finally, it is useful for clinicians to consider their own feelings of grief, anxiety, or guilt beforeholding a discussion about palliative care with patients or significant others. This may beespecially important when the clinician has known the patient or significant others for a longtime, when the clinician and patient or significant other have been through a lot together, orwhen the clinician has some feelings of inadequacy about the patient’s condition or treatment.Acknowledging these feelings explicitly can help the clinician avoid projecting his or her ownfeelings or biases onto the patient or the significant others. In addition, the clinician’s ownfeelings of guilt or inadequacy can lead him or her to avoid the patient or significant others or toavoid talking with them about death. Reviewing these feelings by oneself or with another cliniciancan be the first step to becoming more comfortable discussing dying and death with a patient or60, 61significant other.An additional step in preparing for an end-of-life discussion is to plan where the discussion willtake place and who will be there. Ideally, these discussions should take place in a quiet andprivate room where there is some assurance that people, phones, or pagers will not interrupt thediscussion. It should be a room that is comfortable for all the participants without a lot ofmedical machinery or other distractions such as medical diagrams. All parties should be sittingat the same level around a table or chairs in a circle. It is best to avoid having a clinician sittingbehind a desk with the patient and significant others in front of the desk. If the patient canparticipate in the discussion but is too ill to leave their hospital bed, efforts should be made tomake the room comfortable for everyone present.Before the scheduled conference about palliative care, the clinician, patient, and significantothers should discuss who should be present for the conference. In addition, the clinician shouldmake certain that all appropriate members of the staff are consulted about whether they shouldbe present, including the medical staff, nursing staff, chaplains, and trainees who have beeninvolved with the patient or significant others. Ideally, someone should take responsibility forscheduling the conference at a time when as many as possible can be present. It may be helpfulto suggest that patients and their significant others write down any questions they havebeforehand to be sure their questions are answered.438U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau