Client support and communication
Good communication skills are a key component of a successful practice.39 Oncology cases raise the bar by placing a premium on the clinician’s ability to engage and empathize with the owner of a cancer patient. Cancer is an upsetting diagnosis associated with emotionally charged situations. The goal of the initial discussion is to present detailed information about the diagnosis, testing and treatment options, and prognosis while at the same time assessing the client’s goals and limitations, all done in an empathetic and supportive manner. Understanding costs, risks, benefits, and potential outcomes is crucial for owners of pets with cancer, as is feeling part of a caring team battling the disease. Multiple studies in human oncology confirm that effective communication skills are a critical source of satisfactory case outcome for both the patient and clinician.40–42
A large part of communication between individuals is nonverbal and often unintentional. Unspoken information that cannot be hidden is still being exchanged at all times. The nonverbal aspects of communication can give away what a client may be thinking or feeling, possibly contrary to what they say. Hesitantly saying, “yes” and looking downwhen asked, “Do you understand?” is a non-verbal “no” fromthe client. Frankly addressing issues when nonverbal cues indicate lack of understanding or acceptance will save future misunderstanding and upset. Practitioners should be mindful of their own nonverbal “body language” as well as that projected by their clients.
Empathy is the ability to imagine what a client is experiencing and to reflect that understanding. Stated another way, empathy can be thought of as having a client know that he or she is being seen, heard, and accepted. ‘You seem worried” or ‘you look like you have some questions” are statements that show clients that they are recognized as individuals with feelings and emotions, and not just as a customer. While statements like these might seem awkward or unnatural at first, the ability to express empathy improves with practice. A common concern is that acknowledging a client’s concerns or state of mind will escalate that person’s emotions. Experts agree that the opposite usually occurs. Acknowledging their distress, discomfort, or doubts helps clients know that their feelings are seen and accepted. This usually helps the client focus on the medical discussion and treatment issues. Examples of nonverbal displays of empathy include varying your speaking tone and rate, adopting a sympathetic posture, or simply handing a box of tissues to a crying client.
To clients, knowing that they are being heard is as powerful as knowing they are seen and recognized. Telling clients that you recognize their concerns uses a core communication skill: reflective listening (discussed in more detail later). This type of acceptance will help the owner of a cancer patient to be open and express difficult or even embarrassing issues and questions. Statements like ‘I can see that this is difficult to discuss” or ‘it is common for these masses to be overlooked until they become large” can be reassuring to the client and open lines of discussion.
Open-end versus closed-end questions
Posing open-end questions is a simple but particularly useful technique for obtaining an accurate patient history and having fruitful discussions about diagnostic results and treatment choices. Open-end questions tend to strengthen the client–veterinarian relationship by allowing pet owners to tell their story. When that occurs, clients feel that their comments and opinions are valued and are contributing to the veterinarian’s understanding of the situation.
Open-end questions often begin with the words “what” or “how” and allow the client to talk using their own vocabulary. An open-end question is a good way to begin an interview, such as, “What has been going on?” Open-end questions are also useful as the case progresses because they encourage the client to make difficult but unavoidable decisions. The skill and sensitivity with which these questions are posed is important. For example, asking a client “Are you thinking about euthanasia?” risks an emotional response. A better approach would be to ask, “What are your thoughts about the options we have discussed?” A good guideline is to ask first and then tell. When a new diagnosis has been made, asking a client what they know about the disease rather than offering a description of the problem can save time and show the client that they, and their knowledge, are valued.
Reflective listening involves repeating or paraphrasing what another person has said or implied. This technique is a good way of showing empathy and is an excellent tool for ensuring that you understand the client’s viewpoint. Reflective statements not only tell clients they are being heard but also allow them to correct misconceptions. In that sense, reflective-listening comments operate as a kind of check step in how you perceive the case and the client’s point of view. The classic reflective listening response begins with the phrase, “What I hear you saying is …” Other phrases that may feel more natural or less clichéd are “so, you are saying” or “it sounds like …” For example, a comment like “It sounds like you may be concerned about the cost” may elicit a response like, “Yes, it seems expensive” or “No, cost isn’t the problem, it’s the time involved.” When the reflective-listening approach to dialogue is used, a client’s true feelings and opinions often emerge because you are asking them to confirm or modify your understanding of what they have said.
Breaking the news
Clients need time to adjust to the idea that their pet may have cancer, particularly if the prognosis is poor. Being empathetic and candid in discussing a suspected or confirmed cancer diagnosis often helps the pet owner accept the situation and make treatment decisions in coherent, proactive manner. It is a good idea to announce a cancer diagnosis with a “warning shot” phrase, such as, “I’m afraid the news is not good.” Using short phrases and waiting for the client’s response is a good approach to discussing a cancer case. An example would be, “I’m so sorry about this upsetting diagnosis. Lymphoma is a common cancer in dogs. Unfortunately, it’s not curable but the good news is that it is treatable.” Then pause and ask, “Would you like to discuss further testing and treatment now, or would you prefer to talk later?”
Most clients will have a negative response to the words “cancer” and “chemotherapy.” Their initial reaction to a cancer diagnosis often changes as they process and accept the difficult news and listen to the options on how to proceed. It is not uncommon for an initial refusal to consider more testing or treatment to change with further discussion about how well most pets do with their therapy. The likelihood of that change of heart occurring often depends on the extent to which the veterinarian applies the core communication skills of nonverbal communication, empathy, open-end questioning, and reflective listening. A practitioner who takes that approach almost always helps the pet owner transition from shock and sadness over a cancer diagnosis to taking an active role in managing their pet’s disease.
When discussing a cancer diagnosis or treatment plan with a pet owner, it is important to use lay terminology or medical vocabulary accompanied by a clear explanation. Using clinical terminology that clients are unfamiliar with will only create confusion or embarrassment and add to the owner’s sense of being overwhelmed. When presenting treatment options, it is important to avoid overwhelming the owner with choices and unnecessary detail. First assessing the client’s goals and limitations is an integral part of presenting options. When suggesting that the patient’s prognosis is poor, keep in mind that only the pet owner can determine the value of the additional time treatment may provide. Clients should be advised that median survival time does not predict what the outcome will be for an individual patient. Balancing realism with optimism is critical for veterinarians treating cancer.
Applying the core communication skills discussed here will help a client to view the veterinarian as a partner-in-care when facing a pet’s cancer diagnosis. Together, the healthcare team can make decisions and implement a treatment plan that proves satisfactory for all concerned.
Click to access the 2016 AAHA/IAAHPC End-of-Life Care Guidelines.
One of the options that veterinary medicine has to offer in order to alleviate pain and suffering is euthanasia. Many cancer cases will conclude with a discussion and an end-of-life decision involving the owner and a member of the healthcare team. Understandably, these discussions can be difficult. Practitioners should be prepared to help the pet owner realize that euthanasia is a humane alternative and a viable option to end a pet’s suffering or an unacceptably poor quality of life. Veterinarians should advise clients to consider euthanasia when the clinician can no longer prevent suffering, preserve the pet’s quality of life, or otherwise ensure the quality of its death. In cases where euthanasia is advisable, the veterinarian should consider offering the owner the option of being present during the procedure and spending as much time as they wish with the pet immediately prior to euthanasia. Many practices now have a designated room that provides privacy and a non-clinical, stress-free atmosphere for the euthanasia procedure. A bereavement counselor and support groups can be great resources for the client at any point before or after a pet’s passing.