Transcript Al Jonsen Presentati..

CASE PRESENTATION
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80 Man with respiratory failure
admitted to ICU and found to
have metastatic cancer…
Patient deemed“un-weanable”
ICU care perceived as “futile”
Patient has capacity, no
surrogate
When asked for permission to
discontinue life-support, patient
asked for “everything to be
done.”
Ethics and Palliative Care
consults were obtained
Session Goals
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Discuss this case relative to:
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General issues in physicianpatient communication
How to communicate
regarding difficult decisions
How to incorporate patient
preferences into decisions
Ethical issues involved
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Focus on the concept of medical
futility
Communication
Premises
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Most people interpret and
construct their lives based on
stories
Problems often occur when
personal storylines have been
disrupted
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Patient/family stories conflict with
medical stories
Problem resolution is enhanced
by effective communication and
mutual construction of a new
storyline
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Which requires patient/family and
provider to be “in-synch”
ICU Clinician Story
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Continued care is medically
futile
Patient does not get how sick
he is - ? “in denial”
Running out of time before
patient becomes confused
With no surrogate decision
maker, will they be forced to
continue to “do everything,”
even it such care is useless
and harmful?
The Patient’s Story …
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In the process of writing a
book – wants a year to finish
Was unaware that he was
this ill – acute illness took
him by surprise
Trying to come to grips with
prognosis – all happening
too fast
Question:“What can we
do for you?”
Answer: “Give me TIME
Communication –
specific skills required
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General
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Active Listening
Verbal and Non-Verbal
Addressing emotional as well
as cognitive components of
communication
Recognition of barriers
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Language, Hearing, Speaking
Above presumes a connection between
participants that may not in fact be present
Entrainment as a
Communication Skill
Like gears must touch, but not
crowd
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Gears must be synchronized
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Spacing
Aligned temporally
Work toward a common
purpose
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Shared narrative construction
Space as an Aspect of
Communication
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Culturally defined, out of
general consciousness
Varies with roles and
relationships
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Formal Space
Friendly Space
Intimate Space
Time as an Aspect of
Communication
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With age time experienced
more slowly
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Perception of time correlates
with the inverse of the square
root of chronological age
Elders perceive the young to
move too quickly
The young perceive elders to
move too slowly
Young and Old out of Synch:
Working toward a
Common Purpose
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Demonstration of respect for the
person
Inquire regarding current
understanding of illness
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Explanatory Model
Explaining one’s own explanatory
model (and story)
Inquire regarding goals (where is
story headed)
Look for opportunities to come
into synch with these goals
So What Happened?
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How to establish
synchronicity between
patient and ICU staff?
Shifting goals of care
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For Patient
For Staff
Bringing stories into
alignment
Negotiating a mutually
satisfactory story ending
The Good Acronym
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Goals
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Options
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Opinion
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Document
Goals
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Identify stakeholders and
their goals
Future goals based on
current understanding
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“What is your understanding
of”
“What did your doctor tell you”
Identify ‘big picture’ goals
first
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“Let’s look at the big picture,
what is most important to
you?”
Options
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Identify relevant options and
priorities
Address benefits and burdens of
options
 Do your homework
Address probability of success
Link options to identified goals
Pearl: Too often clinicians get bogged
down in discussions over specific
options without understanding how
options relate to overall goals.
Opinion
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In offering your opinion…
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Present data using neutral
language:
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Crush the chest
Massage the heart
Press on the chest
Be clear what is data and what
opinion
Incorporate goals,
benefits/burdens and values into
your opinion
Listen to other’s opinions
Document
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Who said what
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What you did/will do with
this information
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“Patient said he didn’t want
tube feeding”
“Will cancel PEG tube
insertion”
Your assessment
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“This reasonable given …”
SUMMARY
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Good communication manifests
in real relationships between real
people and facilitates problem
solving
Establishing such relationships
requires:
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Entrainment
Trust
Sharing of stories
Negotiation
Mutual construction of a new story