Four Psychiatric Principles from the AMA that Can Help in Palliative Care
An article in the American Medical Association (AMA) Journal of Ethics talks about principles from the field of psychiatry that can be applied to the field of palliative care. Both fields have much in common, specifically relying very much on developing communication skills.
Commonalities between Psychiatry and palliative care
The article in the AMA journal was co-authored by Indrany Datta-Barua, MD, associate psychiatrist at Chicago Psychiatry Associates, and Joshua Hauser, MD, associate professor of medicine and director of the palliative medicine fellowship at Northwestern University Feinberg School of Medicine. They described four elements of psychiatry that are important for palliative care as well. They opine that both psychiatry and palliative care require clinical intimacy and strong communication skills to tackle complex and challenging conversations. These are the four skills identified:
Dealing with countertransference
Transference is the well-known practice of the patient transferring her feelings onto the clinician. Countertransference is when the clinician transfers his own feelings onto the patient. The doctor might have difficulty speaking to the patient about palliative care and end of life issues because he doesn’t want the patient to lose hope, or give over negativity, or for various other reasons that assume the feelings of the patient when in fact the doctor has no idea what the patient will feel. This is called countertransference, and needs to be addressed in palliative care.
Active listening and active reflection
Active reflection is the sle-monitoring of doctors in clinical psychiatric relationships. It’s being aware of countertransference, and also any behaviors that affect the doctor-patient relationship, and making changes if and as necessary. This is important in psychiatry because the doctor’s subjective thoughts and feelings affect his communication with his patients. It’s important in a palliative care setting because the physician is called upon to confront various personal challenges for patients that can easily trigger his own subjective biases. The doctor needs to ask himself, “Why do I want to have this conversation? Does it help the patient? Is it simply a construct of my own needs?” This goes hand in hand with active listening, which is listening with an open ear to what the patient is saying and why. “I hear the patient’s wishes, but why does he feel this way? Can I get to the root of the problem and explore the patient’s underlying needs and then address them?” He then reflects back to the patient what he hears, so the patient has the opportunity to confirm or change the doctor’s understanding of what he’s saying.
Staying silent and neutral
Part of the conversation between the clinician and the patient involves silence on the part of the clinician, allowing for free flow of thought of the patient. When the doctor is just listening without offering judgement, the patient may disclose more of her thoughts and feelings. This may broaden the overall picture of the patient’s wants and needs, and can allow the relationship to progress to a more understanding level.
Finally, after the doctor has listened and remained silent, he needs to name the feelings that the patient has expressed to confirm that he has understood them.
Teaching this to palliative care providers
Drs. Dratta-Barua and Houser offer a program to train doctors in palliative care in using these techniques.
The first part is to use role play, giving the trainees the opportunity to practice these skills in a real setting. The second part is to analyze the role play and make adjustments. As with anything else, practice makes perfect. By beyond the practicing, it’s the getting into the role and making a real effort to improve that will give the trainee the necessary empathy to help a palliative care patient.
At Hudson View Rehabilitation, we offer warm and caring palliative care options for patients going through challenging times.
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