COMMUNICATION IN

PALLIATIVE CARE
BY PALLIATIVE TEAM WD 23

SSN Anitha
ANC Joy
SSN Sok Fun
SN Agnes
OBJECTIVES
1) Understand the principle and goals of palliative care .

2) Be comfortable to have open conversations about death and

dying.
3) Identify factors influencing the integration of palliative
approach.
4) Recognise signs and symptoms of 5 stages of grief.

5) Adapt and apply skills and approaches for end-of-life

conversations
 PALLIATIVE CARE
World Health Organization Definition of Palliative Care :

Palliative care is an approach that improves the quality of life of patients and their
families facing the problem associated with life-threatening illness, through the
prevention and relief of suffering by means of early identification and impeccable
assessment and treatment of pain and other problems, physical, psychosocial and
spiritual.
MYTHS about Palliative Care
MYTHS and FACTS 1
Having palliative care means you will die soon.

● Palliative care is not just for the end of life

● It is a holistic approach that includes caregiver support,

spiritual care, bereavement and much more.

● Recent studies show that many patients who receive

palliative care may live longer than those receiving
standard care based on a more curative model.
MYTHS and FACTS 2
Palliative care is just for people with cancer.

● All those who are diagnosed with a chronic life-limiting

illness can benefit from hospice and palliative care.

● These conditions include heart, lung, liver, kidney, brain

and motor neuron diseases as well as very frail elders.
MYTHS and FACTS 3
Palliative care manages pain through the use of
addictive narcotics.
● Palliative care is whole person care that provides
psychosocial and spiritual care along with pain management.

● Pain relievers like morphine are essential to good palliative

care to relieve pain and other symptoms.

● Other measures are also needed to address pain including

counseling and social support.
MYTHS and FACTS 4
Palliative care is generally just for old people.

● Palliative care is for people of all ages.

MYTHS and FACTS 5
Palliative care means the patient’s doctor has given
up and there is no hope.

● Palliative care help people achieve their best quality of life for
the rest of their life .

● Hope changes from curing the disease, to living life as fully as

possible
Let’s do a little Role Play !
SCENARIO 1
Your patient Mr Ng is DDIL, team instructed to stop milk
feeding and IV infusion as patient is clinically deteriorating
and getting more drowsy. However patient’s daughter
approached you and said,

“ I think my father is not waking up because

he has no energy. He must be so hungry
now. Can we start back the milk feeding or
give him some water? I don’t want him to die
of hunger …”
What will you say ???
Guidance about oral nutrition at the end of life
- Hunger and thirst are usually absent as death nears . If there is no hunger or
desire for food, then forcing intake might risk making the patient nauseated or
bloated.

- If patient requested for his desires food, family can provide

small amount of his favourite food, often just a mouthful or
sip is enough, but they have to understand and accept the
risk of aspiration.

- Nutrition is almost always compromised in the final phase of

progressive terminal illness. providing calories cannot
change that because the body is not able to use them for
energy or to build muscle, fat and so on.

- Feed for comfort.

 Next time maybe we can say :
“It must be distressing for you seeing him getting more
tired and not eating. His body is getting weaker and may
not feel hungry & thirsty anymore. If we are going to feed
him, his organs are unable to function to digest the food
and may cause him to choke and lead to more
complications that cause more sufferings to him, and i’m
sure you don’t want that to happen , am I right? ”
SCENARIO 2
Mdm Lim with stage 4 ovarian cancer mets to the lungs had started S/C
morphine infusion for pain control and symptom management. She was in
bad pain and required a few doses of breakthrough during your shift. Her
son approached you and raised his concern :

“ I noticed my mother required more

breakthrough doses compared to yesterday
and is getting more sleepy. Is she getting
addicted to morphine and will the pain killer
make death come sooner ? ’’
How will you answer him ???
Does End of Life Pain medicines speed up dying
process?
- There is no evidence that opioids such as morphine hasten the dying process.

- Opioid helps maintain the person’s comfort throughout the illness

and up to the time of death. The person declines because of
the illness with or without the morphine.

- It would take a large dose increase over a short time to harm

someone. Morphine doses are increased gradually and only as
needed to maintain comfort.

- Keeping people comfortable often requires increased doses of

pain medication as the body gets used to the medication. It is not
addiction.
 Next time maybe we can say :
I do agree that she sleeps more nowadays but do
you realised that she is no longer grimacing in pain
and appeared much calm and comfortable now?
Morphine is given safely and appropriately to ease
her breathlessness and control her pain. We might
need to increase the dose sequentially day by day
due to her disease progression, I am sure we are
working on the same page to keep her as
comfortable and as pain free as possible.
Why don’t we talk about death,
dying and grief ?
How does death looks like through the lens of someone
actively dying?
Tell me how would you spend your last days of life ?
What matters the most to me
Thanks to my mom
who always there for
me when I need her.
Thanks to my
brother who 24/7
there for me and
he’s my good listener
. Thanks to hubby
help to take care my
kids n my home when
I’m abroad . Love
them so much .
To be surrounded by the people I love
My support and pillar

I really
appreciate the
effort my
husband does
when I am at
work. I am very
proud to have a
supportive
husband.
Factors influencing the integration
of palliative approach
“ How can we better promote palliative care ? ”
CULTURE AND PALLIATIVE CARE
● Cultural beliefs and practices are particularly salient
within patient and family members’ experiences and
suffering.
● Lack of sufficient knowledge about how patient’s
cultural beliefs and practices may contribute to
disparities in palliative care.
● How culture matters in the provision of high quality
palliative care in four areas:
● 1) Preferences for care
2) Communication patterns
3) Meanings of sufferings
4) Decision-making processes
 PREFERENCES FOR CARE
Individuals’ preferences for care affect both processes and outcomes of
care.
Processes include :
1) The use of analgesics

2) Types of interventions tried

3) Level of family involvement in in care decisions

4) Economic conditions

5) Insurance status

6) Knowledge
Factors affecting communication pattern
● Age

● Education

● Language

● Directness of communication regarding death

○ Some patients may want to know the full details
○ Whereas others prefer to not know

● Usage of terms such as- death, cancer

● Non verbal cues

 MEANINGS OF SUFFERINGS
- Our upbringing and social values influence how we
express pain .
- Some cultures encourage the expression of pain
but some suppress it.
- Education of pain management is important .
 DECISION MAKING PROCESS
Patient autonomy is important in the decision making process.
However we need to balance patient autonomy .

Balancing between:
- patient autonomy
- opinion of family members
- medical team
CASE STUDY
Mr Dave, 85 y/o with stage 4 prostate cancer metastasized to bones had failed his
chemotherapy , radiation and hormonal treatments. However his family has remained
optimistic and fully expected him to pursue aggressive treatment. In the other hand, the
medical teams now want to transition his care and incorporate hospice and palliative
approaches to managing his illness.

At first he insisted on pursuing aggressive acute care for his prostate cancer but he also
seemed exhausted.

After a long discussion, he slowly confessessed that it isn’t what he wants , aggressive acute
care seems to be excessive and futile at this point but he doesn’t want to let his family down
by not “fighting”.

He fears that his family thinks of hospice and palliative care as capitulating and “giving up” .

What should you do and what would you say?

TAKE HOME MESSAGE
- We have to respect patients’ autonomy by giving them the information
needed to understand the risks and benefits of a proposed
interventions.
- In this case, we can remind Dave that his family might be more open to
his desired treatment options that he thinks.
- We can demonstrate our support to Dave by continuing to advocate for
his personal wishes and encourage him to have open discussion with
his family with the presence of medical team. Even if they do not agree,
they might have a better understanding of each other’s perspectives.
- However do bear in mind that respecting patient autonomy includes
respecting how patients wish to make a decision, even if the decision is
to allow their family’s desires to supersede their own.
HOW TO COMMUNICATE WITH LOVED
ONES ABOUT PALLIATIVE CARE
Your loved one may say You may be tempted to reply like Try this instead…
something like this… this…

“ I dont think im going to make it,” “ Dont worry, you’ll be just fine. “ “ It must be hard to come to terms
with how things are going..”

“ When I go, can you…” “ Choy! You are not going to die. “ What about this that worries you
You must fight this !” or what I can do to help?”

“ The treatment is not working.” “There must be something else “ I will be with you even when we
we can do.” have done all we can possibly can
to treat you”

“I dont think I can do this” “Dont give up!” “It is tough enough.What would
give you some comfort and
strength at this time?”
5 STAGES OF GRIEF
DENIAL

“You must be wrong.

This cannot be
happening to me.”
ANGER
“ Just because I am sick
does not mean I cannot do
the things I used to do
anymore. Do not patronize
me, and I know how to
handle myself, don’t come
near me ! ’’
BARGAINING
“I would give everything
I own if I become
healthy and free of this
sickness.”
DEPRESSION
“I would rather stay in my room
than go out. I do not feel like
doing anything all day.”

“ Nothing can be done for me

anymore. I cannot be cured of
this disease; I might as well lie
here and fade away. I would still
die soon; all hope is lost for me”
ACCEPTANCE
“I am fully aware that I
would have this disease
for a long time. I would
just let God handle my
fate, and I would spend
more of my time with my
loved ones from now
on.”
Resources of palliative care in Intranet
What’s your take home message today ?
Thank you for your attention !
We need your feedback ;)

https://docs.google.com/forms/d/e/1FAIpQ
LSc0jaakqc565neOrEC6lE6cj1-2rN0PNm
KSG3vw4hCl6bd0pA/viewform?usp=sf_lin
k
Your Event ID is:
SNB20220901-I-0024.