The Use of Skype in a Community Hospital Inpatient Palliative Medicine Consultation Service

Introduction

Skype™ is a software application (Microsoft Corp., Redmond, WA) that allows its users to make voice and video calls over the Internet. It was created in 2003 and has more than 600 million registered users as of 2010. ¹ Although telemedicine has been employed in health care, its role in palliative medicine has not been fully explored or reported. Whereas lay literature highlights numerous scenarios documenting the potential uses of Skype,^2,3 there is little in the medical literature discussing the value of Skype for patient-to-family communication. Extensive literature reviews have revealed the value of this technology in rural health settings, obstetrics, and, especially, in psychiatry. It has often been employed in oncology and neurology. An inpatient Palliative Medicine Consultation Service, whose focus is often on symptom management and patient goals of care, can successfully employ Skype in enhancing communication. Although much of palliative care is not necessarily end-of-life care, many times the poor functional status of patients precludes their involvement with their families and providers face to face. Sometimes, the issues relate to financial or physical concerns not of the patient, but of his or her loved ones. To make better use of available technology, we have employed the use of Skype to help overcome these barriers. Speakerphones have been employed frequently, but allowing the patient and family member to see one another often provides nonverbal communication and allows the family member to get a sense of how the patient currently looks. This may be especially valuable for family members who may not have seen “Mom” since last year, allowing them to gain needed insight from many miles away on the quality of life and clinical condition of their loved one. Often such communication provides relief from emotional and spiritual suffering for both patient and family, and it also offers a great example of patient/family-centered care. Utilizing Skype and related technologies can potentially enhance the quality of our patients' lives and also improve the range of services offered at hospitals or inpatient hospice units.

We provide four clinical examples in which patients seen on our inpatient Palliative Medicine Consultation Service were able to enhance the quality of their lives or achieve personal goals via the use of Skype.

Case Descriptions

Equipment Needed

Skype is a communication tool allowing its users to make computer-to-computer calls with audio and video capability. Fortunately, the equipment needed is basic and relatively inexpensive, consisting of a PC or MAC computer with broadband Internet connection, speakers, a microphone (often built in), and a webcam (usually built in but can be added). Additionally, Skype is now available on many personal communication devices, which will allow more people to avail themselves of it.^4–6

Legal Issues

Skype uses a complex method of encrypting both voice and imaging and is basically a “peer-to-peer” connection. As such, it is generally considered a secure site, similar to any other voice transmission with the same Internet protocol. ⁷ The 256-BIT AES (advance encryption standard) would most likely meet HIPAA (Health Insurance Portability and Accountability Act) standards. Our Palliative Medicine Consultation Service reviewed our recommendations with our hospital's legal team, and we suggest consideration of a registration form or simple consent. At our institution, this is required if any staff member were to be in the picture, although that is not our intent. It is our recommendation that a Skype program be evaluated and approved by Legal Services. To date, this has not been an issue at our institution.

Discussion

These cases highlight the important role telemedicine, and Skype specifically, can play in palliative care. A PubMed search of the literature using MeSH keywords “palliative care,” “video-conferencing,” “social isolation,” and “communication” did not reveal any literature specific to Skype being used in an inpatient hospital setting as a means for palliative care patients to communicate with their families. However, there is literature addressing the use of this type of technology for physician-to-patient communication in various settings,^8–11 as well as for patient-to-family communication in long-term care facilities and rural health settings.^12–15 There are also studies validating the use of a variety of modalities in relieving social isolation, such as the use of poetry, pet therapy, and music therapy.^16–18

Before Skype, advocation for alternative communication systems in medical diagnosis, patient and family communication and decision making had been present in the literature. These systems have been used to help patients and families in multiple medical situations,^19,20 including the use of telemedicine in hospice care, as well as in long-term care.^21,22 Additionally, values of telemedicine have been demonstrated in psychiatry and oncology, and in rural areas with limited physical access to specialized medical care.^23,24 The key benefits of the use of telemedicine in these situations were a sense of closeness, reduced feelings of guilt, and minimized social isolation.

The majority of inpatient palliative medicine consults seen in the community hospital setting are to help “establish goals of care.” Relief of physical, psychological, and social suffering are the other reasons for consultation. Although symptom management is important to them, patients and their families often consider enhancing patient-family communication to be of critical importance. Many of our patients are so weak or debilitated by their disease that providing them with a resource with which they can see and speak with distant family members and/or friends enhances the quality of their lives. The emphasis on relief of physical symptoms, a common request of our referral providers, often overlooks the emotional support our palliative care patients need. Skyping between patient and family can help relieve burdens and strengthen relationships with loved ones. In a qualitative study regarding a patient's perspective on quality end-of-life care, Singer and colleagues ²⁵ state that “although most commentators focus on end-of-life relationships between physicians and patients, these results suggest that communication between dying people and their loved ones is crucial.” The study describes five domains that are important from a patient perspective, with two of them being relieving burden on loved ones and strengthening relationships with loved ones. ²⁵ Our experience with Skype reveals that technology can facilitate this aspect of quality of life for our palliative care patients, especially for those at the end of life. We have found, as previous studies have, that for the dying experience to be most meaningful, participants desired involvement of family and loved ones, regardless of their physical presence. Additionally, our team chaplain and social worker have reported less symptom burden in spiritual pain and social isolation.

Most hospitals today have the ability to facilitate the use of Skype between patients and their families. More often than not, the family or the hospital is able to provide the communication equipment (laptop, tablet, mobile phone, or other WiFi enabled portable device), and the actual cost to use the Skype service is free. Facilitating communication using Skype for patients at the end of life, or for those whose functional status precludes an opportunity for direct communication, is a valuable tool, which can be employed with relative ease. It also allows family members, who for many reasons may not be able to be physically present, to interact with their loved ones. As telemedicine continues to play an ever-increasing role in palliative medicine, it is our hope that recognition of the value of Skype in direct patient-to-family communication will grow and its use will expand.