“Communication is the dying person and the person

“Communication training is often a requirement for
professionals working in settings where end-of-life care occurs. Yet,
communication towards the end of life is an area that policy-makers recommend
could be further improved. Discuss how communication impacts upon service users’
experience of death and dying”. I will discuss about how the impact of
communication and how the setting has an impact on the experience of death and
dying and also the different models of communication such as psychological and
person centered also biomedical approaches. I will explain about Harley’s model
using case studies of the “the fat black Kid” and finally I will discuss how
people’s expressed wishes are met or not within community setting and care
providers. I will also reflect on Evans
and Payne approach to communication and Carl Rogers approach.



NICE guidelines (2004) make training a requirement for senior professionals
in cancer care. This requirement is fundamental in communication for the dying
person and their family to have palliative care involved.

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Those involved with death and dying people predict knowingly or
unknowingly how and when death will occur, this is the cause and shape of the terminal
illness. Sociologists Barney Glaser and Anselm Strauss (1968) call these
predictions ‘temporal predications or dying trajectories. They also observed
the influence between the dying person’s knowledge about their situation on the
way the others communicate with them. In the UK at present the current trend is
toward open awareness which is the dying person and the person knowing what is
wrong to openly acknowledge it to it each. This open awareness may not be what
the dying person wants to know or other. The behavior or the dying and people
involved my change once they have been given this diagnosis of a terminal, life
ending condition. Alison Langley Evans and Shelia Payne (1997) explained that
most of the medical and nursing guidance is on communication focuses on
breaking bad news and counselling techniques to facilitate open awareness so
that all involved are aware of the terminal prognosis. In their study at a palliative
day Centre with a social setting the participates expressed how easy it was to
talk to them about their cancer. Though this is not always the setting for talking
about such conditions, some place’s is not as private as the dying person may want
as they maybe in a hospital ward or surrounded by doctors and family where they
could feel it is less private and person centered


Going on to person centered communication if you put the dying person at
the forefront of the discussion listening to their wishes and feeling it relays
a positive approach. With Carl Rogers (1957) an American psychologist and humanistic
psychology. Rogers drastically developed the person-centered way of
communication. He focused on the core conditions such as respectful openness to
the people empathy, genuineness these conditions are necessary in developing
effective communications in all relationships. Which promotes a strength of
trust between the professional and the dying person. In Activity 3.5 Noticing
communication Skills. Its explained about a person being admitted to hospital
and the way the doctor involved did not connect with the patient. Not
explaining as going through, making eye contact or using medical terms and not
explaining in terms the patient would understanf and the reasons for test. The
patient explained that this still haunts them years on. This activity shows
that the patient was not at the center of the doctor, they were symptom focused
not patient focused. This goes into the biomedical approach to communication.

Tomasz Okon (2006) challenges recommended models of communication, not on
the grounds of the communication or training he challenges the basis principles
of the biomedical model of which palliative medicine is a branch and also the
underlying principles of the humanistic/counselling model from which traditional
communication skills are derived. Okon talks about the heritage in biomedicine regarding
understanding of and attitudes towards death, ok argues that is it the heritage
of biomedicine that is history and that makes death unacceptable and alien. He
says that palliative medicine functions on assumptions that are rarely
articulated 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 approach
by juxtaposing dying people’s voices with the claims of the model. The
tripartite modal od empathy consists of cognitive, emotional and behavioral
components in which the listener lets the other person know that they understand
the message being conveyed, and “feel with the other” and the behavioral component
consists of verbal and nonverbal ways the listener expresses the message back.
With Okan notes a particular painful commentary on the experiences of dying for
both the dying person and those surrounding them. He also exposes the limits of
communication models and formulas. He takes a humanist view suggesting that
there 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 experience
of death and dying. With the setting of a, A&E department time may not be
of the essence and that the vital communication may be lost. With the current
trend of open awareness this may not always happen even with Evan and Langley’s
approach to open awareness and nursing guidance, when things happen suddenly
they cannot always have the time to have those discussion.

Nigel Hartley in activity 4.4 ‘I did it my way’ he expressed the 3
following steps to Hartley’s model 1- Personal, see people as primarily involved
with themselves and the impact of situation on them as individuals. Hartley
suggests people at this level stop listening. Level 2 is Craft in this level people
in the role of carer are fully engaged and doing their job and finally level 3
is surprised Hartley claims at this level you are caught off guard a barrier
goes 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 every
moment during their life. He suggests to remedy the tendency to disconnect from
are immediate intense encounter with other people by focusing on yourself you
need to be able to focus on your own awareness. Hartley views on arts in communication
is that you do not need to know the ins and outs of someone but just to listen
through music of the person as with Anita Rogers song ‘My Way’ the strength if
her voice and unwavering quality a testament to Hartley’s observations.

In Activity 4.7 experimenting with three level awareness the video “fat black
kid’ it was extremely uncomfortable to watch or would zone out of what he was
saying but when I focused on his words and the way he was expressing them I felt
a connection that I understood him and where he was coming from. I applied the
3 levels from the persons perspective, second from the perspective of craft or
detachment and third from the perspective of surprise. It was difficult but applying
the 3 levels helped me to understand the complexity of what he was saying, how
long it could have taken him to create the speech, the use of words and


Finally dying at home Gomes and Higginson’s (2008) identify six factors
of which can lead to the achievement of a home death and with that in order to
attain a home death, the dying person must communicate a wish to die there
though this may change as a person’s illness progresses their wishes may
change. The six factors are 1 low functional status, 2 an expressed preference
to die at home, 3 the amount of professional care available, 4 the frequency of
professional care visits, 5 living with relatives and 6 being able to rely on
extended family support. Though dying at home may not be available or may have
little time to plan or obtain resources which could negatively impact the community
care professionals and the dying person.



To summarize communication of end of life care can differ from setting or
whether the death is sudden or anticipated. Communication between the dying
person and their family or friends plays a vital role also. As shown between
the discussions and arguments between Okan, Evan and Payne that different
approaches and concepts of communication is key and putting the dying person at
the forefront of all discussion is paramount. Whether this is exercised in
practice or not it seems vital that all should be included and wishes should be
respected where possible. Discussion with the dying person about impending
death 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, discussion
and wishes may not be available. 


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