How can We Improve the Communication Skills between Doctors and the Relatives of Postarrest Patients Receiving Home Palliative Care Services?

Objective: It is more complicated to include the relatives of the patients in this process of the patients who are discharged home after cardio pulmonary resuscitation (CPR), especially those who are dependent on household mechanical ventilator and with the lack of communication skills to describe and express their own conditions. The aim of this study is to evaluate the communication between the doctors and the relatives of the postarrest patients who are followed at home, to contribute to the improvement of communication skills identifying the barriers for communication and facilitating factors. Methods: This descriptive study was carried out with 76 relatives of 44 palliative patients who survived after cardiopulmonary arrest and were discharged from hospital between June 2016-2018. Of the patients who survived at the end of the first year; A total of 76 relatives who were over 18 years of age and were able to read/write Turkish and consented to participate were included in the study. All patient relatives consisted of family members. Results: A communication attitude scale with a 5-point Likert scale was applied to 76 patients' relatives of total 44 palliative patients who were included in the study. There was statistically significant difference in the confidence sub dimension between the genders of the patients’ relatives. There were statistical differences in the information, empathy and confidence sub dimensions of the relatives of the patients. Statistically significant difference occurred between the frequency of visits by the relatives of the patients who received homecare and empathy and trust sub dimensions. There was statistical difference between the chats of the relatives of the patients with the physicians in the sub-dimension of empathy. In terms of the characteristics of the doctors that are important for the relatives of the patients, “giving good news” group was statistically different in the informative and empathy sub-dimensions and ” giving correct information “group was statistically different in informative, empathy and confidence sub- dimensions and “having a sympathetic attitude”group was statistically different in the information and confidence sub dimensions. Conclusions: Patient-doctor communication is basically a communication between two people and requires mutual information support, respect and trust. Doctors may not be born with good communication skills, but since a doctor is expected to be the professional side in this communication, a doctor should be one to direct the communication and to solve the problems. We believe that communication between the patient's relatives and the doctor can be increased improving the existing communication skills of the doctors through various training programs and good samples of communication scenarios.


INTRODUCTION
The attitudes of the patients' relatives towards communication were evaluated with 23 questions based on the 5-point Likert communication attitude scale (5 = always, 4 = usually, 3 = occasionally, 2 = rarely, 1 = never). In calculating the total score in the communication scale; answers according to whether the statement is positive/negative; it ranks from 1to 5 or from 5 to 1. Factor analysis is performed to select the most distinctive items. In item analysis, items that show high correlation with all scale scores are kept, others are discarded. Information, empathy and trust sub dimensions were evaluated with these questions. The score of each dimension was calculated by averaging the scores given to the questions of that dimension. However, before the scores of the language and communication size of the physician were calculated, the scores of 2 nd , 18 th and 22 nd questions were reversed (inverse Likert) since the statements in the scores of these questions were configured negatively compared to the statements in the other questions. The questionnaire is available online (7).

Ethical approval
Ethics approval was obtained from the Ethics Committee of OOOOOO University of Medical Sciences (NMRR-2019/13).

Statistical analysis
Statistical Package for Social Science (SPSS, 21.0 SPSS FW, SPSS Inc., Chicago, IL., USA) were used for statistical analysis of the data. Frequency (n) and percentages (%) were obtained for descriptive data. One-way analysis of variance (One Way ANOVA F test) and significance test (Student's t test) of the difference between the two means were used for the normally distributed numerical data of patients' relatives. Kruskal-Wallis variance analysis and Mann Whitney U test were used for numerical data that did not conform to normal distribution. When the difference between the groups was found as a result of the variance analysis, Fisher's LSD (Least Significant Differences) test was used to determine which group or groups the difference was caused by. This LSD test was chosen because even smaller mean differences are likely to be significant. The significance level was taken as 0.05.

RESULTS
A communication attitude scale with a 5-point Likert scale was applied to 76 patients' relatives of total 44 palliative patients who were included in the study. The scores of the responses of the relatives of the patients about the informing, empathy and trust subscales in the 5-point Likert-type communication attitude scale is shown in Table 1. There was statistically significant difference in the confidence sub dimension between the genders of the patients' relatives. There were statistical differences in the information, empathy and confidence sub dimensions of the relatives of the patients (p=0.004, p=0.019 and p=0.001, respectively). According to the description of the physicians by the patients' relatives, there was statistical difference in information and empathy sub dimensions (p=0.041 and p=0.039, respectively), as well as information and empathy sub dimensions between the age groups of the patients' relatives (p<0.001). There was statistical difference in the confidence sub dimension (p=0.040) according to being close relatives of the patients. In addition, there was statistically significant difference between the frequency of seeing the relatives before the patients began to receive homecare service and empathy and trust sub dimensions (p=0.005, p=0.001 and p=0.008, respectively). Statistically significant difference occurred (p<0.001) between the frequency of visits by the relatives of the patients who received homecare and empathy and trust sub dimensions. There was statistical difference between the chats of the relatives of the patients with the physicians in the sub-dimension of empathy (p<0.001). Regarding the conditions that relieved the stresses of the relatives of the patients, ''talking with the doctor " showed a statistically significant difference in the empathy and confidence sub dimensions (p=0.001 and p<0.001); "Being with the patient " was a statistically significantly different in the informative and empathy sub-dimension (p=<0.001 and p<0.001) and "praying" in the informative sub-dimension (p = 0.001). In terms of the characteristics of the doctors that are important for the relatives of the patients, "giving good news" group was statistically different in the informative and empathy subdimensions (p=<0.001 and p= <0.001), and " giving correct information "group was statistically different in informative, empathy and confidence subdimensions ( p=0.037, p=<0.001 and p=0.005 respectively), and "having a sympathetic attitude"group was statistically different in the information and confidence sub dimensions (p=0.018 and p=0.001) ( Table 2).

DISCUSSION
Communication skill is one of the most important factors in the relationship between the patient and the doctor. Patient's relative-doctor communication is not only the process of getting information about the epicrisis from the patient's relative, but also a relation / communication between two people. Credibility, context, content, clarity, continuity and consistency, channels and capability of audience are the basic elements that make up this communication (10). In this study, it is seen that male relatives of the patients trust the doctors more. This result was not surprising given that female relatives of the patients were more emotional in this process.
Nowadays because of the easy access to information by means of internet etc., the number of university graduates and relatives who read and understand the disease and treatment methods in detail, make many additional requests, dislike the treatments applied and criticizes increasing gradually (11). In our study, it was observed that the relatives of the patients thought that they were less informed as their education levels increased. Similarly, the empathy and trust relation between the doctor and relatives decreased as the level of education increased.
In the relationship model where the patient is passive and the doctor is active, there should be always a doctor figure like a 'father' acting on behalf of the patient. However, with the 20th century, changes in health and disease concepts, differences in physician identity, the concept of right to health and medicine being a discipline that increasingly uses intensive technology, the patient's autonomy in medical decisions and health have caused the conflict between the patient's values and the physician's values (12). However, the relatives of the patients still regard the doctors as a ''life-saver". In this study, it was found that the relatives of the patients who defined the doctors as a life-saver received more information from the doctors and had better empathy.
Literature mostly focuses on the communication of younger patients with doctors (13,14). It was determined in this study that the relatives of the young patients, the relatives of the patients below the age of 35, were less informed by the doctor and had less empathy.
There is no literature regarding the effects of the visiting frequency of the patients by the relatives of the patients on the communication with doctors. In this study, while there was a lack of being informed and confidence in the relatives who met more frequently with the patient before admitted to hospital, these relatives had more empathy with doctors.
Communication with the patient's relatives is often a short-term interview on a daily basis. To reach information about the patient's medical condition and to have a high quality relationship with health care practitioners is a priority for the relatives. Although the length of interview between the relatives of the patients and their doctor is generally quite short, it is regarded as the most important moments for them. In this short period, relatives often state that doctors do not give enough information about their patients, their interview is frequently interrupted and they can not ask several things they want to ask (8,15,16). In another study, ''good''ranged first with 42.1% among the opinions about the time health care professionals devoted to the patients. The reason for this was attributed to the fact that the service provided in the patient's place prevented unnecessary distraction and thus, good service was given in sufficient time (17). In this study, it was observed that the daily communication of the relatives of the patients with the physicians for 10 minutes and over improved the empathy ability. Socio-economic conditions, level of education, religion, moral attitudes, ethnic and cultural background, previous experiences, doctor perception and expectations determine the results of the relationship between doctor-patient in the health system (18). In the study of Hunsucker et al. (19) the sense of trust and being informed were determined as the most important requirements of the families and these were followed by being close to the patient, comfort and support requirements. In this study, the relatives of the patients who relieved after the interview with the doctor had better empathy with the doctor and they trusted in the doctor more. In addition, the patient's relatives who cared about the good news by the doctor thought they were better informed and had better empathy with the doctor. However, the relatives, who were relieved when they were with their patients, thought they were not well informed and had a worse empathy with the doctor. The relatives of the patients, who were relieved praying in addition, thought that the doctors informed them worse.
The relatively low frequency of visits in the home palliative care services and the fact that they think that there is not enough time to talk with the relatives may cause many problems in the minds of the relatives.
Home palliative care services are mostly used by non-cooperating patients who receive household mechanical ventilator therapy. Therefore, the families of ICU patients experience high levels of emotional stress (5). It is frequently needed to use communication skills to obtain adequate/appropriate information about the disease of the patient and to inform the relatives of the patient about the treatment management. Earlier studies in the West reported that the most urgent need of relatives of the patients in the intensive care unit was to obtain clear, straightforward and honest information about the patient's condition, but only half of the relatives of the patients were able to obtain full information from the doctors about the diagnosis, treatment and prognosis of the patient. In other studies, while the relatives of the patients emphasized the importance of the purpose of communication, they reported that the information given about the patient was more than the emotional support exhibited (20,21). Yeşiltaş et al. (17) reported in a study conducted with the relatives of the patients that the relatives of the patients' expressed the courtesy levels to be very high at the point of applying for home care services and providing service to the patient and his relatives, and this demonstrated that the health staff who provided home care services were sufficient in communication. In this study, the relatives of the patients who care about being given the correct information, stated that they were better informed, they had better empathy and they felt more trust in doctors. The relatives of the patients who care about the sympathetic attitude of the doctors have more confidence in doctors. Chenoweth et al. (22) emphasized the importance of communication between nurse-patient and nurse-patients' relatives in a review. In order to determine the factors that affect nurses' recruitment and employment, many studies have been evaluated and the nurses' care about their patients and their relatives, and the presence of the relatives of the patients, who appreciate their nursing duties, ensure nurses to be kept in elderly care.
In Norway, an electronic messaging system, which is a standard communication network, is used in primary health care. This system is also adapted to home health care systems used in the offices of family physicians working in Norway. In this system, a dialogue messaging system is designed for all health information of the patients, their requests for special care needs, the drugs they use, the types of health services provided to the patients (23). The establishment of such a system network in our country can solve the existing problems between the health staff working for home health services and the patients and their relatives by improving communication.
There have been some limitations in this study. First, the number of doctors providing home palliative care services being few and fixed has limited our ability to apply this survey to doctors, the other side of the communication. Secondly, this study was performed in the first year of the patients who were discharged home after postarrest. In the following years, information, empathy and trust attitudes could be re-evaluated through re-applying the sub-dimension of the communication to the relatives of the ex-patients followed-up.

CONCLUSIONS
Patient-doctor communication is basically a communication between two people and requires mutual information support, respect and trust. Doctors may not be born with good communication skills, but since a doctor is expected to be the professional side in this communication, a doctor should be one to direct the communication and to solve the problems. We believe that communication between the patient's relatives and the doctor can be increased improving the existing communication skills of the doctors through various training programs and good samples of communication scenarios.
Suggestions developed by the authors according to the findings obtained from the study 1. Patients' relatives have better empathy with female doctors, but rely more on male doctors. Therefore, interviews with female and male physicians with the relatives of the patients can compensate the communication deficiencies. 2. Satisfactory level of information can be provided according to the education level of the people in order to eliminate the lack of empathy and confidence in doctors caused by the increase according to the level of education of patients relatives.
3. It is an advantage that the relatives of the patients still regard doctors as lifesavers, and this can be used in a positive way without impairing the social and emotional status of their relatives. 4. As the relatives of patients under thirty-five are less empathetic, cooperation with young colleagues can be established and communication scenarios can be determined to develop a communication language for this age group. 5. Further information may be provided to maintain information and confidence between the relatives,who visited the patient more often when the patient was alive, and doctors. 6.Mutual empathy can be improved if doctors and the relatives of a patient have a minimum of 10-minute interview. 7. A good communication dimension can be provided if home palliative care doctors give accurate information and good news, adopt sympathetic behaviors and mind providing their relatives with medical information support. 8. Developing professional guidance application protocols for home palliative care services and monitoring and controlling home palliative care services by health authorities can eliminate the existing problems. In addition, it can provide a good communication skill between doctor and patient, doctor and patients' relatives, other staff employed in home palliative care services and patients and the relatives of patients. 9. Implementation of continuous training programs with certain periods in order to improve the communication skills of home palliative care personnel can be effective in solving the existing problems. 10. Developing a common communication network between all institutions providing home health care services, developing guidelines in a certain standard and establishing follow-up mechanisms and introducing certain standards for home palliative care services can be a very effective method for solving the existing problems. This study, which was conducted to evaluate the communication between the doctors working in home palliative care and the relatives of postarrest patients, is thought to be the first study according to the English literature. It is thought that studies to be conducted in larger sample groups in order to get healthier information in this field will contribute more to the literature and will be useful to develop home palliative care services.