Transcript Difficult Decisions at the End-of

Difficult Decisions
at the End-of-Life talking
with patients and families
James Hallenbeck, MD
Medical Director,
VA Hospice Care Center
Objectives
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Be able to identify major difficult decisions at
arise at the end-of-life
Understand the importance of skilled
communication in addressing difficult decisions
Use the GOOD acronym in facilitating
communication
Understand the relation between High and Low
context communication in care of the dying
Background
Recent studies have demonstrated that
serious skill deficits in physician
communication
 Stanford Study Both Stanford caregivers and patient
families recognized that improvements in
communication are needed
 What were you taught about EOL care or
communication?
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Communication Barriers
Communication is natural- it just happens
 Language
 Time
 Cultural Barriers
 Taboo subject
 High Context Issues in a Low Context
Medical World
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Difficult Decisions
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MORE THAN JUST FULL CODE OR DNR
Resuscitation status
Overall goals of care
 Life-prolonging-comfort care
Specific treatments
 Chemotherapy
 Antibiotics
 Tube feeding
Where to live
 Home, Nursing Home
What makes these difficult
Care options- Hospice
decisions?
It’s Good to Discuss Patient
Preferences
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Goals
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Options
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Opinion
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Document
Goals
Identify stakeholders and their goals
 Future goals based on current understanding
 “What is your understanding of”
 “What did your doctor tell you”
 Identify ‘big picture’ goals first
 “Let’s look at the big picture, what is
most important to you?”
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Options
Identify relevant options and priorities
 Address benefits and burdens of options
 Do your homework
 Address probability of success
 Link options to identified goals
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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…
 Present data using neutral language:
 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
Who said what
 “Patient said he didn’t want tube feeding”
 What you did/will do with this information
 “Will cancel PEG tube insertion”
 Your assessment
 “This reasonable given …”
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Current and Advance Directive
‘Whopper no veggie’ – most common
preference
 Would like attempt at resuscitation, but if
it appears reasonable recovery unlikely,
would like transition to comfort care
 Document: current wishes, note who was
involved in discussion, broad goals and
specific, relevant issues and decisions
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Communication- more than the
words
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Words:
 I want you to do everything
 What did you give my father to knock him out?
 Isn’t there some new experimental therapy
available?
 Will you take care of me when the time comes?
 I want you to start an IV on my mother and I
want it NOW!
 Your killing my sister!
What do you hear?
Communication Hints
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Clarify ambiguous language
What is the ‘subtext’?
Identify cognitive and affective aspects of
communication
 Cognitive: the medical facts, data, meaning
 Affective: underlying emotions, hopes, fears…
Address both cognitive and affective aspects, as
appropriate
Look for ‘empathetic opportunities’
Listen more than you speak
High and Low Context
Communication
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Low Context Communication
 Communication embedded in verbal language
and written symbols
 Crosses cultures easily
 Example: science, computer code
 High Context Communication
 Non-verbal, situational, relational
• Examples: sex, death/dying
Dying
A High Context Event
In a Low- Context World
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Low-Context Medical/Scientific World Favors:
 Direct verbal discussion
 Efficiency (fast)
 Focus on issues/logic, not people
High Context Dying:
 Communication nonverbal, situational
 Relationships important:
 Who is trusted, Roles between people
Implications
Clinicians out of synch with patient/family
 Mutual frustration:
 Excessive frankness often offensive to
patients/families
 Providers frustrated with inability to ‘get
down to business’
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Getting Into Synch…
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Skills for translating high context into low context
communication
 GOOD Acronym
 Explanatory Models
 What, Why, Who
Skills for teaching low-context providers how to
relate in high context situations
 Slow down, establish trust, build relationship
In high context situations the shortest distance
between two points is a curve
SUMMARY
Good communication is everybody’s business
 Difficult decisions at the EOL require special
skills, simply because the decisions are
difficult
 Skill acquisition require practice
 Good communication requires:
 Being in synch
 Attention to thoughts and feelings
 Self-reflection
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