Transcript Consultation Models

Consultation Issues In
Palliative care and Advanced
Care Planning
Pete Nightingale
Macmillan GP
Why Bother?
I firmly believe that the skills we already
use on a daily basis work very effectively
in palliative care
These skills have been refined and well
taught in primary care and are in many
ways more advanced than in any other
speciality because we work in a time
constrained environment
The Disease - Illness Model
(1984)
Patient Presents Problem
Gathering Information
Parallel search of two frameworks
Illness framework
Disease framework
Understanding patients
experiences
Differential Diagnosis
Integration
Explanation & Planning
The Calgary -Cambridge
Approach to Communication
Skills Teaching (1996)
• Initiating the Session
• Gathering Information
• Building the Relationship
• Explanation and Planning
• Closing the Session
Gathering Information
Information is needed from 2 perspectives:1)The patients perspective-sometimes called the
illness agenda
2)The healthcare workers perspective-sometimes
called the disease agenda
It is often most effective to deal with the patient’s
agenda first
Understanding The Patients
Perspective
Why bother?
There is evidence for Morbidity reduction
(Headache study group etc)
There is an increase in patient satisfaction
and compliance (Stewart(1984))etc.
20% of diagnoses are aided by eliciting
patients ideas of causation
(Peppiatt(1992))
Two ways to discover Patients
perspective
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2.
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Picking up verbal and non verbal cues
Asking about:Ideas
Concerns
Expectations
Effects
Feelings
Ways to pick up verbal and nonverbal cues
• Repetition of cues
– ‘upset?’
– ‘something could be done?’
• Picking up and checking out verbal cues
– ‘you said you were worried it may be something
serious-what did you have in mind?’
• Picking up and checking out non-verbal cues
– ‘Am I right in thinking you are quite upset about the
explanation you have had in the past?’
IDEAS
‘ what you think may have started this
pain?’
‘is there anything you think that may
have made this problem worse?
Concerns
• Is there anything in particular
about this disease that is worrying
you?
• ‘Some people with cancer find
that they get worries about certain
things-has that happened to you?
Expectations
You’ve clearly given this some thought,
what were the most important things
you were hoping I may be able to do to
help you with these problems?’
‘How do you see things developing from
here?’
Effects
‘How are these symptoms
effecting your life at present?’
‘What do you find most helpful
to support you when you have
all this to deal with?’
Feelings
Of particular importance in serious illness
and palliative care:‘I sense you are upset/angry/tense, would
you like to talk about it?’
‘Some people with cancer get depressed,
or anxious-has that happened to you?’
‘Do you find there is anything you can
still look forward to?’
How to stop a downward spiral
‘I think I understand a little
more of what you have been
feeling. Let’s look at the
practical things we can do to
help?’
Disease Agenda:- 4 main symptom
areas to remember
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Pain
Nausea/vomiting
Breathing
Agitation/Confusion
But please don’t forget other areas for
people not in the dying phase of their
illness
Disease Agenda
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Pain
Nausea / vomiting
Appetite
Breathing/cough
Bowels
Bladder
Mouth
Swallowing
Mobility
Oedema
Sensation in Legs
Pressure areas
Sleep
Confusion
Use of a Summary
 One of the most important information gathering
skills
 It is the key method of ensuring accuracy
because:1)It demonstrates you are interested and
have listened
2) It invites the patient to confirm or correct
your interpretation
3)We can pause and formulate our thinking
in both disease and illness frameworks
Gathering Information
Summary
1. Check out I.C.E. with Effects and
Feelings
2. Have a ‘palliative care sieve’ of disease
specific questions to ensure nothing
important is missed
3. Summarise with the patient
Building The Relationship
with palliative care patients
Developing Rapport
• Again only 3 main skills to consider
• ACCEPTANCE
• EMPATHY
• SUPPORT
Developing Rapport
• Acceptance
– Acknowledge legitimacy of patients view
– Non-judgementally accept view
– Value contribution
• ‘Yes, but….’ can negate acceptance-try using
silence
• Acceptance is NOT agreement
EMPATHY
• Empathy can be learned
• It overcomes the patients isolation in their
illness
• It is therapeutic in its own right
• Communicated by linking the ‘I’ and the
‘you’
– ‘I can see how difficult this pain is for you’
Sympathy and Empathy
• Empathy is seeing the
problem from the patient’s
position
• Sympathy is a feeling of pity
or concern from outside the
patients position
Supportive approaches
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Concern
Understanding
Willingness to help
Partnership
Acknowledge coping efforts and self care
Sensitivity
Summary-Building the
relationship
• Non verbal communication
– Demonstrates appropriate non verbal behaviour
– Use of notes
– Picks up Cues
• Developing Rapport
– Acceptance
– Empathy and support
– Sensitivity
• Involving the Patient
– Sharing thoughts
– Provide rationale
– Examination
Breaking Bad News
Basically involves finding out what the
patient knows already and what else they
want to know
10 Step model (Based on the work
of Peter Kay)
1. Preparation
Know all the facts before
the meeting, find out
who the patient wants
present and ensure
privacy
2. What does the patient know?
Ask for a narrative of
events by the patient (eg
‘What has happened
since we last met?’ or
‘what did they tell you
after the endoscopy?’)
3. Is more information wanted?
Test the waters, but be
aware that it can be very
frightening to ask for
more information (e.g.
'Would you like me to
explain a bit more?')
4. Give a warning shot
e.g. 'I'm afraid it looks
rather serious', then
allow a pause for the
patient to respond.
5. Allow denial
Denial is a defence,
and a way of coping.
Allow the patient to
control the amount of
information.
6. Explain (if requested)
Narrow the information
gap, step by step. Detail
will not be remembered,
but the way you explain
will be.
7. Listen to concerns
• Ask, 'What are your main
concerns about this that
we need to deal with?'
and then allow space for
expressions of feelings.
8. Encourage ventilation of feelings
• ‘I am very sorry about this
news, this must be very hard
for you, how are you feeling?’
• This is the KEY phase in terms
of patient satisfaction with the
interview, because it conveys
empathy.
9. Summarise and plan
Summarise concerns,
plan treatment
together, foster hope.
10. Offer availability
Most patients need
further explanation
(the details will not
have been
remembered)
Are we in effect delivering Spiritual
Care?
• Service given to others has
been described as "love in
action".
• As such all health care
workers could be regarded as
providing spiritual care.
Helping with Love/Positive
Regard
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Being genuine
Respecting the patients individuality
Deep listening
Attentive silence,
To listen with the whole of our being.
We should avoid giving "answers"
Expressing empathy, warmth and
positive regard.
Helping with finding Meaning
"He who has a why to live for can bear almost any
how" (Nietzsche).
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4.
A useful working framework is The "4
R's", described in "A Handbook for
Mortals"by Dr Joanne Lynn and Dr. Joan
Harrold .
Remembering
Reassessing
Reconciling
Reuniting
To die healed
We need to be allowed to express
• I love you
• Forgive me
• I forgive you
• Thank you
• Goodbye
Overall Summary
• You already use all the skills needed in
palliative care
• I hope we have refined some of these
skills that can be particularly helpful in this
setting.
• Remember ICEEF, ‘palliative sieve’ and
collaborative approach to problem solving
with the patient.
GSF-Going for Gold
2012 is an important milestone in the UK
as we become host nation for the next
Olympics Games, that symbol of lifeaffirming health. 2012 also marks a
demographic milestone as the number of
deaths in the UK is predicted to soar by
over 17% for then next 20 years, until
deaths outnumber births in about 2032
1.ACP- why is it important -1?
• Not yet getting it right with care towards the end
of life.
• Pre-planning of care a means to improve this
• Close relation to implementation of Mental
Capacity Act
• Research evidence that it is of benefit to
patients, (with some caveats )
ACP- Why is it important 2
• Used extensively across the world
• Encourages pre-planning of care
• Enables better provision of service, related to pt
needs
• Empowers and enables pt and family
• Some find increases ‘realistic hope’ and
resilience
• Encourages deeper conversations at an
important time
Hope and ACP
Davison Simpson BMJ
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ACP can enhance hope not diminish it
Hope helps determine future goals and provide insight
Information leads to less fear and more control
Helps maintain relationships, preserve normality, reduce
feeling of being a burden, encouraging sense of being in
control,
• Empowering and enabling
• Current practice is ethically and psychologically
inadequate
But…barriers
• Left to HCP to initiate discussion
• Busying over routine clinical issues
Open questioning
• Could you tell me what the most important things are
to you at the moment?
• Can you tell me about your current illness and how
you are feeling?
• Who is the most significant person in your life?
• What fears or worries, if any do you have about the
future?
• In thinking about the future, have you thought about
where you would prefer to be cared for as your illness
gets worse?
• What would give you the most comfort when your life
draws to a close?
Horne, G., Seymour J.E. and Shepherd, K. (2006) International Journal of Palliative
Nursing.12(4): 172-178.
Research evidence 1
• Associated with death in place of choice and
with use of palliative care1-3
• May increase a sense of control 4
• May increase congruence between
preferences and treatment 5,6
• Narrow interventions focusing on AD
completion not as successful as complex,
multiple interventions.
1.Ratner E, et al J of the American Geriatrics Society 2001;49:778-78.
2.Degenholtz HB et al Annals Of Internal Medicine 2004;141: 113-117.
3. Caplan GA et al. Age and Ageing 2006; 35: 581-585.
4.Morrison RS et al J of the American Geriatrics Society 2005;53(2):290-294.
5. Hammes B, Rooney B. Archives of Internal Medicine 1998;158:383-390.
6. Molloy DW et al et al. JAMA 2000; 283(102):1437-1444.
Research evidence 2
ACP may improve patients’ quality of life by
contributing to:
• Mutual understanding
• Enhancing openess
• Enabling discussion of concerns
• Enhancing hope
• Relieving fears about the ‘burden’ of decision
making
• Strengthening family ties
But…Cultural and Psychological
Challenges
•Sensitive to cultural interpretations
•Changing views over time
•Clash of viewpoints
•The impact of a ‘bad news’ interview
• A desire to ‘live for the moment’ or ‘take
one day at a time’
Timing: possible trigger points
• life changing event e.g. death of spouse
• following a new diagnosis of life limiting
condition
• assessment of a person’s need
• in conjunction with prognostic indicators
• multiple hospital admissions
• admission to a care home
3.What is ACP in the UK ?
Confusion about language
Advance care planning
• ACP is a process of
discussion between
an individual and their
care provider, and this
may or may not also
include family and
friends.
Advance Statement
• A requesting statement reflecting an
individual’s preferences and
aspirations.
• This can help health professions
identify how the person would like to
be treated
• Not legally binding
• Past and present and future wishes
Advance Decision
• An advance decision must relate
to a specific treatment and specific
circumstances
• It will only come into effect when
the individual has lost capacity to
give or refuse consent.
• Used to be called Advance
Directive/ Living will
. Difficulties
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Prognostication
Difficult discussions
‘Death Anxiety’ of staff
Making time
Sensitivities and sadness
May require extra communication skills
1. ACP is a key part of the solution to improving end of life
care
2. ACP in is well used and has been found to be of value
abroad
3. Need to align activities and care with patients wishes.
4. ACP is now part of the NHS End of Life Care Strategy.
Good experience of using it eg GSF, PPC. Needs to be
offered routinely
5. The process of ACP is important- various tools.
6. Sensitive area- counterintuitive but also constructive
Death teaches us about life
Dying teaches about living