Fostering Effective Communication Skills for Addressing Serious Illness

Chronic kidney disease (CKD) and end-stage renal disease (ESRD) frequently occur in conjunction with serious conditions such as cancer, cerebrovascular disease, diabetes, heart disease, and liver failure. Although dialysis can improve CKD symptoms such as uremia and fluid overload, the increasing age of patients initiating renal replacement therapy means that many also have comorbidities such as dementia and frailty that are difficult to treat and compromise their quality of life. 

Amar D. Bansal, MD, FASN, assistant professor of medicine in the Renal-Electrolyte Division and Section of Palliative Care and Medical Ethics at the University of Pittsburgh School of Medicine, and associate program director of the Nephrology Training Program, is working at the intersection of nephrology and palliative care to assist his fellow physicians in developing the necessary communication skills to have effective conversations with their peers and with patients and families about just such challenging clinical scenarios. Dr. Bansal’s research interests are in communication strategies, directed interventions, and the epidemiology of patients with advanced CKD who opt for renal supportive care. 

Dr. Bansal graduated from the New York University School of Medicine in 2010. He completed his residency in internal medicine and fellowships in nephrology and palliative care at the Hospital of the University of Pennsylvania. He joined the University of Pittsburgh School of Medicine in 2017 as an assistant professor of medicine with subspecialties in nephrology and palliative care.

Talking About Prognosis and Advance Care Planning

Dr. Bansal has developed a new curriculum, with mentorship from colleagues Julie Childers, MD, and Rene Claxton, MD, GI Talk, to teach gastroenterology fellows how to have conversations about goals of care and other clinical scenarios relevant to their practice. In April 2019, he and his colleagues hosted the first one-day communication workshop on this topic. 

“Many gastroenterology patients have a heavy symptom burden and are not able to obtain effective treatments, such as liver transplants, whether because of comorbidities or the general shortage of donor organs,” says Dr. Bansal. “The goal of this curriculum is to help their physicians become comfortable having difficult conversations with patients and their families about topics such as prognosis, advance care planning, and the end of life.”

Dr. Bansal’s GI Talk curriculum is based on VitalTalk, an evidence-based teaching method that equips clinicians to navigate difficult conversations with patients. “Whether it’s serious illness, end-of-life care, or other challenging decision-making, our mission is to teach doctors how to have those conversations effectively,” says Dr. Bansal.

Teaching Relevant Clinical Cases

Dr. Bansal and his colleagues worked for several months to compile clinical cases that were relevant for GI fellows. The cases were reviewed by gastroenterology faculty to ensure that the content reflected scenarios that gastroenterologists commonly face. To protect patient privacy, professional actors played the roles of standardized patients, and workshop participants took part in encounters with them.

The first case concerned a patient with end-stage liver disease who was no longer a transplant candidate and was dealing with the emotions that this created for his family. 

VitalTalk was co-developed by Robert M. Arnold, MD, FAAHPM, Distinguished Service Professor of Medicine, chief of the Section of Palliative Care and Medical Ethics at the University of Pittsburgh School of Medicine, and medical director of the UPMC Palliative and Supportive Institute.

“We emphasized engaging the patient and family in a meaningful way so that family members didn’t feel abandoned or guilty because of the knowledge that their loved one had a short time to live,” says Dr. Bansal. 

The second case involved an elderly woman with dementia that limited her quality of life and focused on helping the fellows have a conversation with the woman’s daughter about whether or not to proceed with the insertion of a feeding tube.  

A Framework for Goals-of-Care Conversations

Workshop participants were introduced to REMAP, a framework for goals-of-care conversations that was developed by University of Pittsburgh palliative care physicians. Two presentations explored using the framework to enable these conversations with patients and families. 

REMAP

• Reframe why the status quo isn’t working.
• Expect emotion, respond with empathy.
• Map out what’s important.
• Align with patient values.
• Plan to match values.

In a pre- and post-survey, participants described the workshop as a positive experience. They said that after completing it they felt more confident in carrying out a variety of conversations on specific topics that they are likely to encounter in clinical practice. All seven participating fellows said that they would recommend the training to others and reported feeling strongly that it should be a required part of fellowship training. 

Dr. Bansal is optimistic that the GI Talk workshop will become an annual event. An abstract he submitted on the overall curriculum design and results of the initial workshop was accepted for presentation at the American Academy of Hospice and Palliative Medicine Annual Assembly in March 2020. He and his colleagues also hope to collaborate on this education model with other institutions. 

“I have spoken with potential partners from Massachusetts General Hospital in Boston and the University of Texas Southwestern in Dallas,” says Dr. Bansal. “There is national interest in moving the needle on this topic.”

One Fellow’s Experience: “Fluency in Goals-of-Care Conversations Requires Practice”

“Overall I would say it was a positive experience,” says Weston Bettner, MD, a third-year gastroenterology fellow in the Division of Gastroenterology, Hepatology and Nutrition at the University of Pittsburgh School of Medicine and one of the seven fellows who participated in the first GI Talk workshop. 

Dr. Bettner says that he would recommend this training to his colleagues and peers. Role playing in front of one’s peers does inherently feel awkward.

“But, as with any skill set, fluency in goals-of-care conversations requires practice. End-of-life discussions can be particularly challenging. Practicing in a ‘safe’ environment — where ‘failure’ simply means restarting the simulated scenario — is ideal before having to do it in the real world, where there are no ‘do overs,’” says Dr. Bettner.  

Prior to attending the GI Talk workshop, Dr. Bettner’s formal training in palliative care in medical school and residency was limited. 

“In medical school, we had standardized patient interactions, and one session focused on breaking bad news, which involved informing a patient about a new cancer diagnosis,” says Dr. Bettner. “In residency, palliative care training was essentially on-the-job training.”  

Dr. Bettner indicates he learned that while each palliative care discussion is unique, these conversations can be framed in a systematic way, with the aid of tools such as the NURSE statements for articulating empathy (Naming, Understanding, Respecting, Supporting, Exploring). 

“I found it helpful almost immediately in my clinical practice to apply the tools and teaching learned in the workshop in conversations with my patients and their family members,” says Dr. Bettner.

Further Reading

About VitalTalk.

Arnold RM, Back AL, Baile WF, Edward KA, Tulsky JA. The Oncotalk/Vitaltalk Model. In Kissane DW, Bultz BD, Butow PN, Bylund CL, Noble S, Wilkinson S, eds. Oxford Textbook of Communication in Oncology and Palliative Care, 2nd ed. 2017. Oxford, UK: Oxford University Press. 

Bansal AD, Leonberg-Yoo A, Schell JO, Scherer JS, Jones CA. Ten Tips Nephrologists Wish the Palliative Care Team Knew About Caring for Patients With Kidney Disease. J Palliat Med. 2018 Apr; 21(4): 546-551. doi: 10.1089/jpm.2018.0087.

Childers JW, Back AL, Tulsky JA, Arnold RM. REMAP: A Framework for Goals of Care Conversations. J Oncol Pract. 2017 Oct; 13(10): e844-e850. doi: 10.1200/JOP.2016.018796. 

Responding to Emotion: Articulating Empathy Using NURSE Statements. 2019. VitalTalk. https://www.vitaltalk.org/guides/responding-to-emotion-respecting/.