Talking about dying and death: Essentials of communicating about approaching death from the perspective of major stakeholders.

OBJECTIVES Although caring for dying patients and their family caregivers (FC) is integral to patient care, training in communication about approaching death is almost inexistent in medical and nursing curricula. Consequently, many health professionals have insufficient knowledge about conducting these conversations. In order to gain a broader insight into essential aspects of this communication from different perspectives, we conducted focus groups with key stakeholders. METHODS Medical specialists, nurses, medical students, bereaved FC and patient representatives participated in five focus groups (n = 30). Following a focus group schedule, we elicited relevant aspects of communication about approaching death, associated emotions, and appropriate communication frameworks. We analyzed data thematically. RESULTS Four main themes were central to conversations about approaching death: (1) embracing care within medical expertise, (2) preparing the conversation while remaining open to the unexpected, (3) recognizing and reflecting on own emotions and reactions, and (4) establishing a meaningful connection with others. SIGNIFICANCE OF RESULTS Communicating about approaching death with dying patients and their FC can be complex and challenging at a professional and personal level. With the recognition of the dying phase, a process is initiated for which health professionals need solid clinical knowledge about but also effective communication skills, constant self-reflection and self-care strategies. Comprehensive training and supervision while dealing with the challenges of communicating approaching death to dying patients and their FC are key, particularly for trainees, less experienced physicians and nurses. The essential components identified in this study can help health professionals to master these conversations

Identifying the essentials of communicating about imminent death from key stakeholders’ perspectives

Background Caring for dying patients is an integral aspect of care, however medical and nursing students lack training and exposure to conversations with dying patients and their families. Thus, many health professionals lack the skills to communicate about imminent death causing a long-lasting impact to all involved. As a basis to develop an educational module, this study aimed at identifying aspects that are essential to conversations about imminent death from the perspective of key stakeholders. Methods Five focus groups were conducted with medical specialists, nurses, medical students, patient representatives, and bereaved relatives (n=30). Based on a semi-structured guide, relevant verbal and nonverbal aspects of conversations about imminent death, associated emotions, and appropriate frameworks for communication were elicited. All conversations were recorded and thematically analyzed. Findings Based on participants’ experiences four main themes were identified as essential to conversations about imminent death: (1) embracing care within medical expertise, (2) preparing the conversation while remaining open to the unexpected, (3) recognizing and reflecting on own emotions and reactions, and (4) establishing a meaningful connection with others. Discussion The findings indicate that communicating about imminent death with dying patients and their family members is a complex and challenging task for health professionals at a professional as well as personal level. Hence, comprehensive training is needed in order to impart clinical and interpersonal skills that support health professionals to recognize when and how to engage in these conversations. Furthermore, self-reflection processes and self-care practices are to be taught and encouraged to promote positive coping strategies in the long term. Guidance and supervision are also essential to support debriefing practices in order to revisit confronting experiences, as well as to consolidate and optimize what has been learned

Über’s Sterben sprechen: Das Wesentliche der Kommunikation über den nahenden Tod aus unterschiedlichen Perspektiven

Fragestellung: Obwohl die Betreuung von sterbenden Patientinnen und Patienten und ihren Angehörigen zum Alltag von Gesundheitsfachpersonen gehört, ist entsprechendes Training in Bezug auf die Kommunikation über den bevorstehenden Tod in der Ausbildung von medizinischen Fachkräften nahezu inexistent. Viele Fachpersonen fühlen sich in Folge unbehaglich und nicht kompetent genug, um solche Gespräche zu führen. In dieser Studie wurden Schlüsselelemente der Kommunikation über den bevorstehenden Tod aus Sicht der Hauptbeteiligten identifiziert, welche erfahrungsgemäß für solche Gespräche relevant sind. Methoden: Insgesamt wurden 5 Fokusgruppen mit Fachärztinnen und –ärzten, Pflegefachkräften, Medizinstudierenden, Mitglieder eines Spital-Patientenrates und trauernden Angehörigen durchgeführt (n=32). Basierend auf einem semistrukturierten Leitfaden wurden relevante verbale und nonverbale Aspekte eines Gesprächs über das Sterben, damit verbundene Emotionen und geeignete Rahmenbedingungen der Kommunikation eruiert. Alle Gespräche wurden aufgezeichnet und gemäß der thematischen Analyse1 ausgewertet. Ergebnisse: Basierend auf den Erfahrungen der Teilnehmenden, konnten sechs Hauptthemen bezüglich der Kommunikation über den bevorstehenden Tod identifiziert werden: 1. Professionelle und private Einstellung gegenüber Sterben und Tod sowie der familienzentrierten Betreuung, 2. Fachkompetenzen bezüglich dem Erkennen der Sterbephase, Wissen über den Sterbeprozess und die Notwendigkeit der Selbstreflexion, 3. Anerkennen der Einzigartigkeit jeder Situation inkl. Fokus auf individuelle Bedürfnisse und Ressourcen der Betroffenen, 4. Rahmenbedingungen und Inhalte des Gesprächs, 5. Aspekte der therapeutischen Beziehung wie Vertrauen und Authentizität, 6. Lernstrategien für diese Gespräche wie Training on the job, Rollenmodelle, Feedback. Diskussion: Die Ergebnisse zeigen die Vielschichtigkeit der Kommunikation über den bevorstehenden Tod mit sterbenden Patientinnen und Patienten und deren Angehörigen. Die Herausforderungen bei solchen Gesprächen sind fachlicher als auch persönlicher Natur. Mit dem Erkennen der Sterbephase wird ein Prozess eingeleitet, dem eine positive Grundhaltung gegenüber der familienzentrierten Betreuung und der Endlichkeit des Lebens förderlich ist. Dabei benötigen Fachpersonen solides Fachwissen aber auch mitmenschliche Fähigkeiten und nicht zuletzt stetige Selbstreflexion und wirksame Strategien der Selbstfürsorge, welche nur in der aktiven Auseinandersetzung mit solchen Gesprächen geübt und vertieft werden können. Take Home Messages: Dass Menschen sterben, gehört zum Leben. Darüber zu sprechen, ist jedoch (noch) nicht integraler Bestandteil der medizinischen Ausbildung. Eine frühzeitige, begleitete Auseinandersetzung mit den einzigartigen Herausforderungen in der Kommunikation mit sterbenden Patientinnen und Patienten und ihren Angehörigen ist ebenso erwünscht wie notwendig, um Menschen auch am Lebensende adäquat begleiten und betreuen zu können

Intended Near-Total Removal of Koos Grade IV Vestibular Schwannomas: Reconsidering the Treatment Paradigm.

BACKGROUND The goals of treating Koos grade IV vestibular schwannomas are to relieve brainstem compression, preserve or restore neurological function, and achieve long-term tumor control while minimizing tumor- and treatment-related morbidity. OBJECTIVE To propose a treatment paradigm involving the intentional near-total removal of Koos grade IV vestibular schwannomas, in which a small amount of residual tumor is not dissected off the cisternal portion of the facial nerve. Patients are then followed by a wait-and-scan approach. Any subsequent volumetric progression of the residual tumor is treated with radiosurgery. METHODS This is a case series of 44 consecutive unselected patients who underwent intended near-total resection of a Koos grade IV vestibular schwannoma through a retrosigmoid approach from January 2009 to December 2015. Pre- and postoperative volumetric analyses were performed on routine magnetic resonance imaging sequences (constructive interference in steady state and gadolinium-enhanced T1-weighted sequence). RESULTS The mean preoperative tumor volume was 10.9 cm 3 . The mean extent of resection was 89%. At the last clinical follow-up, facial nerve function was good [House and Brackmann (HB) I-II] in 89%, fair (HB III) in 9%, and poor (HB IV-VI) in 2% of the patients. At the last radiological follow-up, the residual tumor had become smaller or remained the same size in 84% of patients. Volumetric progression was negatively correlated with the original extent of resection and positively correlated with postoperative residual tumor volume ( P = .01, P < .001, respectively). CONCLUSION Intended near-total removal results in excellent preservation of facial nerve function and has a low recurrence rate. Any progressive residual tumor may be treated by radiosurgery

Identifying the essentials of communicating about imminent death from key stakeholders' perspectives

Background Caring for dying patients is an integral aspect of care, however medical and nursing students lack training and exposure to conversations with dying patients and their families. Thus, many health professionals lack the skills to communicate about imminent death causing a long-lasting impact to all involved. As a basis to develop an educational module, this study aimed at identifying aspects that are essential to conversations about imminent death from the perspective of key stakeholders. Methods Five focus groups were conducted with medical specialists, nurses, medical students, patient representatives, and bereaved relatives (n=30). Based on a semi-structured guide, relevant verbal and nonverbal aspects of conversations about imminent death, associated emotions, and appropriate frameworks for communication were elicited. All conversations were recorded and thematically analyzed. Findings Based on participants’ experiences four main themes were identified as essential to conversations about imminent death: (1) embracing care within medical expertise, (2) preparing the conversation while remaining open to the unexpected, (3) recognizing and reflecting on own emotions and reactions, and (4) establishing a meaningful connection with others. Discussion The Findings: indicate that communicating about imminent death with dying patients and their family members is a complex and challenging task for health professionals at a professional as well as personal level. Hence, comprehensive training is needed in order to impart clinical and interpersonal skills that support health professionals to recognize when and how to engage in these conversations. Furthermore, self-reflection processes and self-care practices are to be taught and encouraged to promote positive coping strategies in the long term. Guidance and supervision are also essential to support debriefing practices in order to revisit confronting experiences, as well as to consolidate and optimize what has been learned