“Communication how people’s expressed wishes are met or


“Communication training is often a requirement forprofessionals working in settings where end-of-life care occurs.

Yet,communication towards the end of life is an area that policy-makers recommendcould be further improved. Discuss how communication impacts upon service users’experience of death and dying”. I will discuss about how the impact ofcommunication and how the setting has an impact on the experience of death anddying and also the different models of communication such as psychological andperson centered also biomedical approaches.

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I will explain about Harley’s modelusing case studies of the “the fat black Kid” and finally I will discuss howpeople’s expressed wishes are met or not within community setting and careproviders. I will also reflect on Evansand Payne approach to communication and Carl Rogers approach.   NICE guidelines (2004) make training a requirement for senior professionalsin cancer care. This requirement is fundamental in communication for the dyingperson and their family to have palliative care involved. Those involved with death and dying people predict knowingly orunknowingly how and when death will occur, this is the cause and shape of the terminalillness. Sociologists Barney Glaser and Anselm Strauss (1968) call thesepredictions ‘temporal predications or dying trajectories. They also observedthe influence between the dying person’s knowledge about their situation on theway the others communicate with them. In the UK at present the current trend istoward open awareness which is the dying person and the person knowing what iswrong to openly acknowledge it to it each.

This open awareness may not be whatthe dying person wants to know or other. The behavior or the dying and peopleinvolved my change once they have been given this diagnosis of a terminal, lifeending condition. Alison Langley Evans and Shelia Payne (1997) explained thatmost of the medical and nursing guidance is on communication focuses onbreaking bad news and counselling techniques to facilitate open awareness sothat all involved are aware of the terminal prognosis. In their study at a palliativeday Centre with a social setting the participates expressed how easy it was totalk to them about their cancer. Though this is not always the setting for talkingabout such conditions, some place’s is not as private as the dying person may wantas they maybe in a hospital ward or surrounded by doctors and family where theycould feel it is less private and person centered Going on to person centered communication if you put the dying person atthe forefront of the discussion listening to their wishes and feeling it relaysa positive approach.

With Carl Rogers (1957) an American psychologist and humanisticpsychology. Rogers drastically developed the person-centered way ofcommunication. He focused on the core conditions such as respectful openness tothe people empathy, genuineness these conditions are necessary in developingeffective communications in all relationships. Which promotes a strength oftrust between the professional and the dying person. In Activity 3.5 Noticingcommunication Skills. Its explained about a person being admitted to hospitaland the way the doctor involved did not connect with the patient.

Notexplaining as going through, making eye contact or using medical terms and notexplaining in terms the patient would understanf and the reasons for test. Thepatient explained that this still haunts them years on. This activity showsthat the patient was not at the center of the doctor, they were symptom focusednot patient focused. This goes into the biomedical approach to communication. Tomasz Okon (2006) challenges recommended models of communication, not onthe grounds of the communication or training he challenges the basis principlesof the biomedical model of which palliative medicine is a branch and also theunderlying principles of the humanistic/counselling model from which traditionalcommunication skills are derived. Okon talks about the heritage in biomedicine regardingunderstanding of and attitudes towards death, ok argues that is it the heritageof biomedicine that is history and that makes death unacceptable and alien. Hesays that palliative medicine functions on assumptions that are rarelyarticulated he also points out that in the national debate on death and dying,consideration of what the term “death” may signify is absent from the discussion.

Okon also challenges the structure that underlies the person-centered approachby juxtaposing dying people’s voices with the claims of the model. Thetripartite modal od empathy consists of cognitive, emotional and behavioralcomponents in which the listener lets the other person know that they understandthe message being conveyed, and “feel with the other” and the behavioral componentconsists of verbal and nonverbal ways the listener expresses the message back.With Okan notes a particular painful commentary on the experiences of dying forboth the dying person and those surrounding them. He also exposes the limits ofcommunication models and formulas. He takes a humanist view suggesting thatthere can be a profound human interconnectedness that uses an “analogical”middle voice that focus on the unknowable.

 The setting of where communication happens has an impact on the experienceof death and dying. With the setting of a, A&E department time may not beof the essence and that the vital communication may be lost. With the currenttrend of open awareness this may not always happen even with Evan and Langley’sapproach to open awareness and nursing guidance, when things happen suddenlythey cannot always have the time to have those discussion. Nigel Hartley in activity 4.4 ‘I did it my way’ he expressed the 3following steps to Hartley’s model 1- Personal, see people as primarily involvedwith themselves and the impact of situation on them as individuals. Hartleysuggests people at this level stop listening. Level 2 is Craft in this level peoplein the role of carer are fully engaged and doing their job and finally level 3is surprised Hartley claims at this level you are caught off guard a barriergoes up and you disengage. You go inside yourself to try to make sense of surprise.

Hartley explains that everyone is in and out of all three levels at everymoment during their life. He suggests to remedy the tendency to disconnect fromare immediate intense encounter with other people by focusing on yourself youneed to be able to focus on your own awareness. Hartley views on arts in communicationis that you do not need to know the ins and outs of someone but just to listenthrough music of the person as with Anita Rogers song ‘My Way’ the strength ifher voice and unwavering quality a testament to Hartley’s observations. In Activity 4.7 experimenting with three level awareness the video “fat blackkid’ it was extremely uncomfortable to watch or would zone out of what he wassaying but when I focused on his words and the way he was expressing them I felta connection that I understood him and where he was coming from. I applied the3 levels from the persons perspective, second from the perspective of craft ordetachment and third from the perspective of surprise. It was difficult but applyingthe 3 levels helped me to understand the complexity of what he was saying, howlong it could have taken him to create the speech, the use of words andexpressions.  Finally dying at home Gomes and Higginson’s (2008) identify six factorsof which can lead to the achievement of a home death and with that in order toattain a home death, the dying person must communicate a wish to die therethough this may change as a person’s illness progresses their wishes maychange.

The six factors are 1 low functional status, 2 an expressed preferenceto die at home, 3 the amount of professional care available, 4 the frequency ofprofessional care visits, 5 living with relatives and 6 being able to rely onextended family support. Though dying at home may not be available or may havelittle time to plan or obtain resources which could negatively impact the communitycare professionals and the dying person.   To summarize communication of end of life care can differ from setting orwhether the death is sudden or anticipated. Communication between the dyingperson and their family or friends plays a vital role also. As shown betweenthe discussions and arguments between Okan, Evan and Payne that differentapproaches and concepts of communication is key and putting the dying person atthe forefront of all discussion is paramount.

Whether this is exercised inpractice or not it seems vital that all should be included and wishes should berespected where possible. Discussion with the dying person about impendingdeath can have a positive or negative impact as they may change their behavior,attitude, denial or simply accept that its time. With the setting time, discussionand wishes may not be available. 

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