Transcript Talking the Talk: Having Those Difficult Discussions

Talking the Talk: Having
Those Difficult Discussions
With A Bit About Advance Directives
Paul Rousseau, MD
Medical University of South Carolina
• Poor communication skills are associated with
increased use of ineffectual treatments, higher rates of
conflict, less adherence, and increased risk of
malpractice
• There are many acronyms for appropriate physicianpatient communication, but one, CLASS, embodies the
basics:
– context
– listening skills
– acknowledgement of the patient’s and/or family’s
– strategy for clinical management
– summary
emotions
But delivering difficult news can be
challenging…
• when humans face danger, they are hardwired for a
“flight or fight” response
• in a physician’s office or hospital room, the “flight or
fight” response is to report hearing nothing after the
first few words of difficult or bad news (i.e., “The
biopsy showed cancer.”); patients and/or families
cannot cognitively take in any more news
Basic “rules…”
•
•
•
•
Start with big picture goals before getting specific
Give the patient your complete and undivided attention
Do not use medical jargon or ambiguous innuendos
Use compassionate honesty
Back A, Arnold R, Tulsky J. Mastering Communication with Seriously Ill
Patients, Cambridge University Press 2009
Basics of family meeting
communication…
• Family meetings challenge us because:
– 1) families bring the complexity of their own
relationships and interactions to the meeting
– 2) family members can each have their own interests
– 3) family members have individual emotional needs
– 4) family members may have different preferences for
information or decision making
– 5) family members may disagree about what the right
course of treatment/action is
• SPIKES
– get the setting right
– make sure you know the patient’s perspective
– Invite the patient to tell you how he/she wants to receive
information
– share the knowledge
– acknowledge the emotions and be empathic
– share the strategy for the next steps
Roadmap to conducting a family
conference…
• Prepare the people and the message for the meeting
– which family members should attend? all that want unless the
patient is or was able to request certain family members not
be involved in care decisions—do not marginalize anyone
– which health care providers should attend?
– health care providers should meet before the family meeting
to deliver a clear and consistent message (see next slide)
– one person should facilitate the meeting
Roadmap to conducting a family
conference…
• Prepare
– review the chart
– speak with attending physician(s) and consultants and unify
message
– know all family psychosocial information
– clarify goals for the meeting
– decide who from the medical team will be there
– establish proper setting (not in a hallway!)
– take a deep breath
• Introduce all participants and purpose of the meeting,
such as:
– “I want to tell you how your father is doing medically. I also
want to make sure that you understand what we are doing for
him. We also want to learn from you his values and goals so
we can make decisions that are ones he would make if he
could speak to us now. Are there any other things you want
to make sure we discuss?”
– identify the legal or family-appointed decision maker
• Obtain family understanding of medical condition
– “Tell me your understanding of your father’s current medical
condition.”
– encourage everyone present to speak
– for patients with a chronic condition, ask for a description of
changes during the past weeks/months
– if the patient is hospitalized, ask how things have changed
from admission
• Medical review
– fire a warning shot if family not aware (i.e., tumor found on
CT scan); you might say “The scan of your father’s abdomen
did not show what we expected.”
– summarize the big picture in a few sentences
– avoid medical jargon (i.e., ventilator, CBC, catheter, imaging,
MRI, CT, pulse ox, etc—use 8th grade language)
– offer to answer questions
– ask about the patient as a person (can do now or can also do
at beginning of meeting—might be best at beginning, would
help set goals later on)
• Allow silence
• Recognize and react to emotions
– use an empathic statement such as “This must be so hard for
you,” or “I can see this is very difficult for you.”
– if family members angry you can say “I can see that you’re
upset, this must be so difficult for you.”
• Present options and set goals
– prognosis
– present goal-oriented options (i.e., prolong life, improve
function, hospice, etc)
– stress comfort, no matter the goal
– make recommendations
– can ask “What is important in the time left?” or “What would
he want us to do if he could sit up and talk to us?”
• Translate goals into a plan of care
–
–
–
–
review plans for care
discuss DNR, DNI, tube feedings
summarize all decisions made/plans for care
offer again to answer questions
• Document in chart family meeting discussion
• Discuss with team members what transpired during
meeting (i.e., nurses, consultants)
• Debrief (what went wrong, how can we improve in the
future)
• Take a deep breath
• VALUE
– V=valuing and appreciating what the family says
• “I appreciate you coming to this meeting today and telling
us your father’s values and goals—this helps us develop
the best plan of care.”
– A=acknowledging the family’s emotions
• “I imagine this is not what you expected (wanted) to
hear—this must be so hard on all of you.”
– L=listening and understanding the family
– U= understanding the patient as a person
• “Tell me what your father enjoyed as a person before this
all happened.” and/or “What would you father think of
all of this?”
– E=eliciting questions
• “What concerns do you have? Are there any questions
that I might be able to answer?”
When there is conflict…
• Remain neutral
– do not take sides—this will be hard, as the disagreeing family
member may agree with what you think
– if everyone starts fighting and disagreeing, you might
consider saying “I can see that you all have some
disagreements—I wonder if we could put these
disagreements aside so we can focus on what’s going on with
your father.”
– but let other family members care for each other before you
jump in—take a secondary role
– if a family member displays empathy, reward them by
commenting about their empathy
– if the family continues arguing or disagreeing, step in with
empathy—this will have value to family members in how you
model empathy
– above all, remember you are primarily a facilitator, as well as
the medical expect
•
•
•
•
Name the disagreement/conflict
Acknowledge the emotion in the room
Respect everyone’s opinion
Determine source of disagreement/conflict
–
–
–
–
–
grief
guilt
family dysfunction
distrust in medical team
culture
• Clarify any misperceptions
• Negotiate for time limited goals
And now advance directives…
• A 1991 federal law, the Patient Self-Determination Act,
requires that patients are informed about their right to
participate in health care decisions, including their right
to have an advance directive. Advance directives fall
into two broad categories: instructive and proxy.
Instructive directives allow for preferences regarding
the provision of particular therapies or classes of
therapies. Living wills are the most common
examples of instructive directives
• The proxy directive, generally a Durable Power of
Attorney for Health Care (DPAHC), allows for the
designation of a surrogate medical decision maker
of the patient's choosing. This surrogate decision
maker makes medical care decisions for the patient in
the event he/she is incapacitated
• Each state has its own laws or regulations regarding
advance directives, but when a patient from out of state
is treated at MUSC, we honor their advance directive
from their home state
Life Expectancy
Four-Year Mortality Index for Older Adults http://www.soapnote.org/elder-care/4-year-prognostic-index/
Age
60-64
1
65-69
2
70-74
3
75-79
4
80-84
5
≥85
7
Male
2
Female
0
<25
1
Diabetes
Yes
1
Cancer or malignant tumor, exc. minor skin cancers
Yes
2
Chronic Lung Disease that limits usual activities or makes you need 02 at home
Yes
2
CHF
Yes
2
Yes
2
Managing your money such as paying your bills and keeping track of expenses?
Yes
2
Walking several blocks?
Yes
2
Pulling or pushing large objects like a living room chair?
Yes
1
Sex
BMI
Has a doctor ever told you that you have:
Have you smoked cigarettes in past week?
Because of health or memory problems, difficulty with:
Risk of 4 Year Mortality: 0-5 3% risk; 6-9 15% risk; 10-13 40% risk and 14+ 67% risk
Reference: Lee SJ, Lindquist K, Segal MR, and Covinsky AE. (2006) Development and
Evaluation of a Prognostic Index of
4-Year Mortality in Older Adults. JAMA 295(7):801-808.
Total Points:
Risk %
Conclusions
• Mammography use inversely associated with 4-yr
mortality risk after adjusting for confounders
– Prognosis seems to be a factor in decision to receive
mammography in older female Medicare beneficiaries
Again…
• Healthcare Power of Attorney
– a written, legal document that states who the patient has
chosen to make health care decisions for them if they become
unable to make medical decisions
– document does not have to be notarized
• Living Will (Declaration of a Desire for Natural Death)
– a written, legal document that describes the kind of medical
treatments or life-sustaining treatments a patient would want
if they were seriously or terminally ill
– document must be notarized
• At MUSC, Chaplin Service is designated to help
patients complete advance directives
• The Declaration of a Desire for Natural Death (Living
Will) for South Carolina states:
– “In the absence of my ability to give directions regarding the
use of life-sustaining procedures, it is my intention that this
Declaration be honored by my family and physicians and any
health facility in which I may be a patient as the final
expression of my legal right to refuse medical or surgical
treatment, and I accept the consequences from the refusal.”
– “I am aware that this Declaration authorizes a physician to
withhold or withdraw life-sustaining procedures. I am
emotionally and mentally competent to make this
Declaration.”
• It specifically addresses artificial nutrition and hydration
in a terminal condition and a persistent vegetative state,
stating that both either be provided or not provided
(separate individual statements)
• However, the Healthcare Power of Attorney in South
Carolina also addresses withholding and withdrawing
treatments, as well as tube feedings
• It specifically allows 1 of 3 selections for all treatments
other than tube feedings:
– grants discretion to the agent
– directs to withhold or withdraw treatment
– directs maximum treatment
• And for tube feedings, it allows 1 of 3 choices:
– grants discretion to the agent
– directs to withhold or withdraw
– allows provision of tube feedings within the standards of
accepted medical practice, without regard to medical
condition, without regard to whether other forms of lifesustaining therapy are being withheld or withdrawn,
without regard to whether recovery is expected or not,
and without regard for the cost of the procedure