Covid-19 communication aidsBMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2255 (Published 11 June 2020) Cite this as: BMJ 2020;369:m2255
All rapid responses
We thank Professors Gray and Black for this helpful article. COVID-19 has brought communication between clinicians, patients and families to the fore and we have used the vital talk guide to help clinicians in our hospital during the COVID-19 pandemic. We already know that communication about uncertainty and possibility of dying, and how clinicians undertake these skills, impacts the patient and the family (Krawcsyk 2018; Anderson 2019), and the clinician (Chang 2018) and we particularly welcome the section on the possible impact for clinicians of communicating with patients and families in the context of COVID-19.
You highlight that your guide is a starting place for improving conversations and we want to build on that and to share with you what we have learn during COVID-19. These conversations between clinicians, patients and families have been scaled up in number by the volume of illness and deaths and complicated by the use of personal protective equipment, which hides lip movement, masks speech, and obscures non-verbal facial expression. A recent BMJ article highlighted the challenges of using masks for professionals and patients who are deaf https://www.bmj.com/content/369/bmj.m2372.full.pdf. Similar challenges apply to patients or families with other sensory impairments, dementia or learning disability.
There has been restricted visiting in UK hospitals and care homes, https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/... This is a complete turn around from previous guidance e.g. John’s campaign https://johnscampaign.org.uk/#/ where family, friends and carers were encouraged to be present to benefit the patient and the visitor. It should be noted that whilst NHS guidance permitted visitors to those with a mental health issue e.g. dementia, a learning disability or autism, many who were offered the opportunity to visit declined (anecdotally about 80%) because they themselves were elderly and instructed to shield. In people’s own home there has been restricted visiting by clinicians.
There has thus been a turn towards telephone and video consultations https://www.bmj.com/content/bmj/suppl/2020/03/24/bmj.m1182.DC1/gret05591... We have learnt that this is not simple work and additional skills and awareness is required especially when phoning patients who are experiencing domestic abuse https://www.lambeth.gov.uk/sites/default/files/IRIS-COVID-19-Guidance-fo... or when there are child safeguarding concerns.
The expedience for developing local clinical guidelines and resources for clinicians to communicate with patients and families must not be at the expense of patient’s and families own social interaction needs. In our own acute trust we have focused on ensuring patients and families can communicate between themselves as well as with clinicians. We suggest there are at least eight different priorities for communication and we need to ensure:
• Patients who have mental capacity and their key contacts can communicate independently and
• Patients who do not have mental capacity or are confused or have communication challenges can communicate at least once a day with their key contacts to ensure social stimulation and reassurance.
Both these above scenarios would normally be by their own devices, but trust devices and support may need to be provided for those with learning disabilities and communication challenges or who do not have access to their own device. Volunteers, chaplaincy and clinical teams can provide this support.
• The ward team updates the key contact daily (with the patient’s consent). This contact may include the patient on the phone or video call depending on the patient preference, and clinical condition.
• The doctor calls the key contact if there is a significant change in medical treatment. This is usually on the phone and advance consent is sought from patients for this eventuality. Where the patient does not have capacity throughout admission, a best interests decision is made regarding such communication.
• A family meeting is arranged, with use of technology, for such things as best interests decision making, complex discharge planning. These meetings could be by a conference call, or a video call. They need to include the patient when possible, and multiple members of the MDT and family, and need to pay attention to the communication needs of all the parties.
• There is supported virtual visiting of the dying patient by video call
• There are regular updates regarding those who are dying from the clinicians to key contacts
• There is the facility for supported virtual visiting of the deceased (if required) if the patient has given consent, or there is a best interests decision
Any and all of these may require interpreter, signing expert or specialised technology. Thinking about these categories of communication enables clinicians to think carefully about communication, and to prompt and action the most appropriate mode of communication, the time needed for the communication, where the call can take place and such things as who else needs to be on the call.
We suggest that alongside the vital talk guide, organisations need to consider:
• the detail of communication of phone work and videoconference work
• how we educate staff to utilise these forms of communication and support families and key contacts to do so
• support for patients and key contacts who are children or who have learning difficulties
• how we manage potentially challenging situations e.g. very distressed relatives, family disagreements and dynamics
• potential risks and the need to generate guidelines to cover consent for filming, transmission and storage of images and video.
Krawczyk M, Gallagher R. Communicating prognostic uncertainty in potential end-of-life contexts: experiences of family members. BMC Palliat Care. BioMed Central; 2016 Jul 12;15(1):59.
Anderson RJ, Bloch S, Palliative MA, 2019. Communication between healthcare professionals and relatives of patients approaching the end-of-life: A systematic review of qualitative evidence. journalssagepubcom.
Chang BP, Carter E, Ng N, Flynn C, Tan T. Association of clinician burnout and perceived clinician-patient communication. The American Journal of Emergency Medicine. 2018 Jan;36(1):156–8.
Competing interests: No competing interests
I thank Professors Gray and Back for their contribution to help clinicians communicate with people in these uncertain times.
While I wish I knew of this earlier (considering the authors suggest it was available since March), nevertheless I appreciate this news even at this time, as I suspect we haven’t really seen the worst of the pandemic yet.
I acknowledge some readers may think the suggestions and tips given by these authors may be obvious and part of the expected training, particularly for those dealing in emergencies and/or serious conditions including cancers; but during thes stressful and uncertain times, many of us do need help reminding that how we communicate matters as much as the outcome.
Frankly the pictorial nature of these aids makes them more approachable than a cold black and white printout of words of the same content easily fitting onto an A4 sheet of paper.
Please keep them coming.
Competing interests: No competing interests