Starting the Conversation
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Transcript Starting the Conversation
AOA Council on Palliatve Care
Goals of Care
Breaking Bad News
Unity Convention
October 24, 2010
Bruce Bates, D.O., FACOFP, CMD
Chair - Department of Geriatric Medicine
University of New England College of Osteopathic Medicine
Case
84 y/o W/F living independently, falls
at home suffering L femur Fx
Undergoes ORIF with post op
delerium, dysphagia, renal failure.
Aspirates, intubated difficult to wean
Attentive daughter
Case continued
Day #14 – many doctors talk to
daughter
Nephrologist: making more urine but
probably will need dialysis long term
Intensivist: able to turn O2 down to 50%
Gastroenterologist: plan for a PEG will
never eat regular
Internist – not doing well
Case manager – doctor ordered hospice
Daughter calls PCP to complain
Objectives . . .
Know why defining goals fo care is
important
Understand a 7-step protocol for
delivering bad news
Communicate uncertainty and conflict
Adjust care to changing goals
Importance of Goals of
Care
Most people want to Know if facing a
serious illness
Strengthens the physician- patient
relationship
Fosters collaboration
Establishes an appropriate allocation of
resources
Permits patients, families to plan, cope
Potential goals of care
Cure of disease
Relief of suffering
Avoidance of
premature death
Quality of life
Staying in control
A good death
Support for
families and loved
ones
Maintenance or
improvement in
function
Prolongation of life
Osteopathic Tenet
THE WHOLE PERSON
BODY
MIND
SPIRIT
Multiple goals of care
Multiple goals often apply
simultaneously
Goals are often contradictory
Certain goals may take priority over
others
Patient Centered Care
Goals of Patient - initial assessment
May Vary over time - ongoing
assessment
curative palliative
self family
physical spiritual
integrated focused
Goals may change
Osteopathic Principles make very clear
the distinction of caring for disease and
caring for the patient who has disease
Some goals take precedence over others
The shift in focus of care
Requires the patient (Guardian) to understand
is gradual
is an expected part of the continuum of
medical care
7-step protocol to
communicate bad news . . .
1. Create the right setting
2. Determine what the patient and
family know
3. What do they want to Know
. . . 7-step protocol to
negotiate goals of care
4. Sharing the information
5. Respond with empathy
6. Make a plan and follow-through
7. Review and revise periodically, as
appropriate
1. Create the Right
Setting
Quiet - private space
Allot enough open ended time
Determine that the right people are
present
FAMILY CLERGY GUARDIAN OTHER
2. What Does the Patient
Know
Establish Patients Knowledge and
Understanding
Asses ability to comprehend
Correct misunderstanding
Reschedule if unprepared or
unresolvable conflict of info
3. How Much Does the
Patient Want to Know
Recognize patient preferences
May decline voluntarily
May designate someone to
communicate on his/her behalf
Consider Power of Attorney or
advanced directive – 5 wishes
3. How much does the
patient want to know?
People handle information differently
Capacity
Race
Ethnicity
Religion
Education
Socio economic
Age and developmental level
Cultural differences
Who gets the information?
How to talk about information?
Who makes decisions?
Ask the patient
Consider a family meeting
4. Sharing the Information
Say it then STOP
Avoid monologue- promote dialogue
Avoid Jargon and Euphemisms
Pause frequently
Validate understanding
Use Silence and Body Language
Don’t minimize severity
Implications of “I’m Sorry”
Language with unintended
consequences -Negative
Do you want us to do everything
possible?
Will you agree to discontinue care?
It’s time we talk about pulling back
I think we should stop aggressive
therapy
I’m going to make it so he won’t suffer
Language to describe
the goals of care positive . .
I want to seek the most comfort and
dignity possible until the day you die
We will concentrate on improving the
quality of your child’s remaining life
Let’s discuss your needs and wants
5. Respond with Empathy
Affective response
Tears anger sadness love anxiety relief
Cognitive response
Denial blame guilt disbelief fear loss
shame
Basic psychophysiologic response
Fight – Flight
5. Respond with Empathy
Listen Listen Listen
Encourage descriptions of Feelings
Use Non Verbal communication
Physician: Acknowledge Yurself
6. Planning and followup
Explore what their hopes
expectations and Fears are
Plan for Next Steps
Added tests, treatment/non treatment,
Care vs cure, referrals
Sources of Support for patient/family
Medical, spiritual, emotional, social,
legal
7. Review and Revise
Give Contact info / next appointment
Assess Safety
Assess informal and formal support
Be Prepared to repeat info at next
visit – it was not all heard
Goals Change with time and
progression of condition
Reviewing goals,
treatment priorities
Goals guide care – whose?
Assess priorities to develop initial
plan of care
Review with any change in
health status
advancing illness
setting of care
treatment preferences
Communicating
prognosis
Providers markedly over-estimate
prognosis
Either way raises fears and stresses
Helps patient / family cope, plan
increase access to hospice, other
services
Offer a range or average for life
expectancy
Truth-telling and
maintaining hope
False hope may deflect from other
important issues
True clinical skill to help find hope
for realistic goals
When Family Says:
“Don’t Tell”
Ask Family
Why not? What are you afraid I will say?
What are previous experiences?
Personal,religious, or cultural context?
Patient knows something - why this
conspiracy? Will it feed mistrust?
Talk To patient together
Legal Obligation to obtain consent to
treat or not treat (assuming capacity)
Determine specific
priorities
Based on Patient values,
preferences, clinical circumstances
Influenced by information from
physician(s), team members, Patient
and family
Clinical Jazz
Summary
Begin the conversation Early
Keep seven steps in mind
Understand the Goal of Care
Patient centered values and preferences
Seek permission to involve family and
others
Give Permission to react/accept/reject
Revise and renew
IATP
IT’s ABOUT
THE PATIENT