Page 338 - Withrow and MacEwen's Small Animal Clinical Oncology, 6th Edition

316 PART III Therapeutic Modalities for the Cancer Patient

5. Defusing clients’ emotions (e.g., frustration, sadness, anxiety) can preferences to tailor your discussion to the individual client’s needs
be accomplished by building rapport; expressing empathy; cre- (“Some clients like to know all the details about their pet’s cancer, and
ating a safe, nonjudgmental space and providing opportunities
others prefer the basic facts. What would you prefer?”).
VetBooks.ir to be heard; and posing questions. This puts clients at ease and that may be difficult to hear (“Unfortunately, we do not have good
Provide a warning shot to forewarn the client of information
enhances their ability to process, understand, and recall infor-
mation; it also prepares them to make decisions. 421,447 options for treating this cancer.”). Then deliver the bad news in
stages, giving information in small, easily understandable pieces
Approaches to Cancer Conversations and checking for the client’s understanding before moving on
(“This is going to be difficult to hear. The cancer has spread to Mandy’s
As presented in the introduction, cancer communication is a series lungs, making it hard for her to breathe. What concerns would you
of conversations over time, starting with delivering the diagnosis like to discuss at this point?”). To pace the conversation with your
(i.e., delivering bad news); discussing the prognosis; making deci- client, ask permission to proceed to the next step in the conversa-
sions about treatment options; assessing the patient’s QOL; transi- tion (“Would it be alright if I went over Mandy’s prognosis?” or “Is it
tioning to palliative, supportive, or hospice care; and ending with alright if we talk about what this will mean for Mandy?”). Avoid use
preparing families for euthanasia, dying, or natural death. These of technical jargon and define medical terms. Use supplemental
difficult conversations are spread throughout multiple visits. This educational tools, such as written materials (e.g., client handouts,
step-by-step approach is guided by the veterinarian’s expertise, information sheets, or discharge statements), website resources,
the client’s agenda and perspective, and the patient’s condition, whiteboard notes, or audiotape recordings, so clients can review
response to treatment, and QOL. the information at a later date.
Conduct these conversations in an appropriate setting to ensure Empathize throughout the conversation to acknowledge, vali-
privacy, client and patient comfort, lack of distractions, ability to date, and normalize the client’s emotional responses (“This is not
sit down together, and place to include multiple individuals (e.g., what you were hoping to hear.”; “This is overwhelming.”; or “I can
examination, consultation, or comfort room). Start by creating feel your sadness.”). Allow for silence and display compassionate
a safe space for clients by taking time to establish initial rapport, and caring nonverbal cues (e.g., sit close to the client; mirror facial
checking in on their well-being, and demonstrating interest in the expressions; use a gentle, calm, and caring tone of voice; use a slow
client. (“How are you doing? Thank you for bringing Mandy in so pace of speech; lean forward; reach out with touch if appropriate)
that we could address this problem. Sounds like it’s a stressful time for (“I’m here for you. Take your time.”). Offer partnership so the cli-
you all.”) Identify the client’s support system and extend an invita- ent does not feel alone in processing the information and making
tion for key decision makers, family members, and friends to track decisions (“I will talk you through this, and we will make decisions
information and provide emotional support (“I am wondering who for Mandy together.”). Summarize what was discussed, negotiate a
makes decisions regarding Mandy’s care” or “Who else may want to plan for treatment, palliative or hospice care, and a timeline for
participate in this discussion?”) Because these are emotionally laden follow-up (“Today, we talked about the cancer spreading to Mandy’s
discussions loaded with complex information and associated with lungs. Unfortunately, it will be more and more difficult for Mandy
decision making, compose and center yourself beforehand, pace to breathe. We discussed ways to monitor Mandy’s quality of life. I
yourself with your client, and offer some time for reflection. Allow am going to talk to your veterinarian about Mandy’s supportive care.
for silence or offer a break to create space for clients and yourself to What questions do you have?”).
work through emotions and process the information exchanged.
Discussing the Prognosis
Delivering Bad News
Three different approaches have been described in the medical
Bad news is defined as any news that drastically and negatively communication literature for presenting prognostic informa-
alters the person’s views of her or his future with their pet, such tion—realism, optimism, and avoidance. 404 The challenge with
as a cancer diagnosis. 402 Clients interpret bad news on an indi- realism in human medicine is that approximately 20% of patients
vidual basis, and their response is related to their relationship with do not want full information about their prognosis. 448–451 In vet-
their companion animal, the severity of the diagnosis, past experi- erinary medicine, clients wanted the truth and information about
ences, other stressors in their lives, and their support system. Grief all aspects of their pet’s cancer and its treatment. 443 The draw-
often accompanies change, and clients may express a wide range back of optimism is that clients may lose opportunities to fulfill
of emotions that are largely unpredictable. One useful model for last wishes, prepare themselves and their family, and spend qual-
delivering bad news is the SPIKES six-step model developed by ity time with their pet. Finally, the shortcoming of avoidance is
Buckman 402 and used in many medical school curricula. The appearing evasive or dishonest, risking the trust that has been built
SPIKES model 402 (i.e., setting, perception, invitation, knowledge, between the veterinarian and client and potentially compromising
empathize, and summarize) provides guidelines on how to present the pet’s care.
information, structure the conversation, and create a supportive Based on recommendations in human 404,415,416 and veterinary
environment. 447, 479 medicine, 443 information should be tailored to the client’s back-
Explore clients’ perspectives by asking open-ended questions ground, previous experiences, and information preferences (“How
about their concerns, ideas, thoughts, beliefs, previous experi- much would you like to know about the course of Mandy’s cancer?”
ences, and the effect of the pet’s illness on their lives (“What wor- or “Some clients would like all the details and others would like the
ries you most about Mandy’s cancer?” or “What types of treatment did big picture. What works best for you?”). Provide a warning shot, so
you have in mind?”). Assess what the client knows about the pet’s the client can prepare to hear the information (“Unfortunately, the
cancer or cancer in general (“Tell me what you understand about prognosis is serious for Mandy.” or “This is the next difficult step in
Mandy’s cancer?” or “Share with me your experiences with cancer or our conversation.”) Break the information into small pieces (i.e.,
those of others in your life.”). Determine the client’s information chunks) and then check for client understanding and how the