Transcript Making Difficult Decisions at the End of Life

END-OF-LIFE CARE:
Module 3
Communicating with Patients and Families
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Module #3
Identified Deficits in Physician
Communication Skills
• Talk too much
• Rarely explore patients’ values & attitudes
• Discuss uncertainty using vague language
Tulsky, et al., 1998
• Avoid patients’ affective concerns
Parle, et al., 1997
• Overemphasize cognitive communication
• Fail to assess patient understanding
Braddock, et al., 1999
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Learning Objectives
Recognize the importance of effective end-of-life
(EOL) communication
Increase your EOL communication skills in:
– Listening
– Sharing bad news
– Pronouncing death
Improve your ability to incorporate this content into
your clinical teaching
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Module #3
Outline of Module
Background
Three techniques critical to EOL communication
Skills training
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Listening
Sharing bad news
Death pronouncement
Diversity
Physician self-care strategies
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General Challenges to PatientPhysician Communication
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Time constraints
Language differences
Mismatch of agendas
Lack of teamwork
Discomfort with strong emotions
Quality of physician training
Resistance to change habits
Buckman (1984), Ford et al (1994), Buss (1998)
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Unique Challenges in
Communication at the end of life:
• Emotionally laden material
– For patient, for family, for providers
• Issues of uncertainty are common
– Prognosis
– What is it like to die?
– The meaning of death
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Three Techniques Critical to
End-of-Life Communication
• Distinguish between cognitive and affective
elements of communication, and respond
appropriately
• Clarify ambiguity
• Listen in balance with speaking
Suchman,1997
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Two Elements to Keep in Mind:
• Cognition = intellectual component
• Affect = emotional component
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Cognitive Response
• How might you respond to the cognitive
component of the patient or family member’s
communication?
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Affective Response
• Identify and explore the affect:
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“You seem angry (worried, upset) about this. Can
you help me understand what’s going on for you?”
• Acknowledge the probable source of affect and
connect it with its source
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“You’ve been through a lot. No wonder you’re
feeling like this.”
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Clarify Ambiguity
• Ambiguous statements:
– “I want you to take care of me when the time comes”
– “I want everything done for my father”
• What do you hear?
– “I want compassionate care”
– “I want assisted suicide”
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Listen in Balance with
Speaking
• Convey listening nonverbally
• Delay your response for a few moments
• Reflect the affective component
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Delay Exercise
A’s: Talk about a memorable experience with
dying, that you have had as a practitioner
B’s:
• Distinguish between cognitive and affective
components
• Listen for ambiguity
• Listen in balance with speaking
– Convey listening nonverbally
– Delay response for a few moments
– Reflect the affective component
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Module #3
Debrief
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Sharing Bad News
• Step 1: Prepare
• Step 2: Convey Information
• Step 3: Follow Up
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Step 1: Prepare
• Prepare yourself
• Prepare the recipients
• Prepare the environment
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Step 2: Convey Information
• Establish empathic connection
• Give an advance alert
• Convey realistic information in a clear manner
• Observe and respond to cognitive and affective
reactions
• Clarify ambiguity
• Restore and catalyze hope
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Step 3: Follow Up
• Set concrete goals
• Connect patient/family with support systems
• Arrange follow-up meetings
• Convey commitment and non-abandonment
• Communicate with treatment team
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Training Tape
Sharing Bad News in Two Different Ways
• Two scenarios from the End-of-Life Physician
Education Resource Center
http://www.eperc.mcw.edu
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Discussion
First scenario
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Discussion
Second scenario
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Skills Practice
Sharing Bad News:
• Step 1: Prepare
• Step 2: Convey Information
• Step 3: Follow Up
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Debrief
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Action Plan
Summarizing the Bad News Role Play
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Death Pronouncement
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Not just a medical event
Very important to family
Most physicians have not been trained to do this
A skill that requires practice
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Steps in Pronouncing Death
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Find out about the situation
Pronounce/say goodbye
Console the family
Silence
Follow-up paperwork and other business
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Role Play #1
• A patient died on the wards
• The nurse has just called you to “pronounce the
patient”
• The patient is alone in the room
• Model saying goodbye
• There is no ‘right’ or ‘wrong’ way to do this
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Module #3
Role Play #2
• A patient has died on the wards
• The nurse has just called you to “pronounce the
patient”
• Family member(s) present in the room
• Model the communication aspects of
pronouncing a person dead
• There is no ‘right’ or ‘wrong’ way to do this
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Debrief
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Summary
• Most of us have not been taught how to
pronounce death
• We may never have seen it done
• We are there as a guest in the room
• How does a doctor say goodbye to a human
being?
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Module #3
Death Notification by
Telephone
• Anticipate death where possible, and keep
family up-to-date beforehand
• Use skills of sharing bad news
• Allow time for immediate reaction
• Suggest they take their time coming in
• Provide contact person and explicit instructions
• Arrange follow-up
http://www.growthhouse.org/stanford
Module #3
Learning Objectives
Recognize the importance of effective end-of-life
communication
Increase your EOL communication skills in:
– Listening
– Sharing bad news
– Pronouncing death
Improve your ability to incorporate this content into
your clinical practice
http://www.growthhouse.org/stanford
Module #3