Transcript GOOD Acronym for Nur..

Difficult Decisions
at the End-of-Life
talking with
patients and
families
James Hallenbeck, MD
Medical Director,
Stanford Hospice,
Va Hospice Care Center
Objectives
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
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
Not only a problem for doctors:
Ferrell Study: 2% of Nursing
textbook content on EOL care
What were you taught about
EOL care, communication?
The Nurse and
Communication at the
EOL
May be with patients/families
when they are more open to
talking
May be able to identify deeper,
emotional issues
Nursing identified with being
helpers and mediators
between the world of the
patient and world of the doctor
Nurse may be more aware
than physician of effects of
choices
Barriers to Skilled
Communication
Communication is natural- it
just happens
It is not my job
‘Let the doctor do it’
Good communication requires
a two-way street
Can be painful for caregiver as
well as patient/family
Lack of skill training
Difficult Decisions
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
Care options- Hospice
It’s Good to Discuss
Patient Preferences
Goals
Options
Opinion
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?”
Options
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
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 ask Dr. Smith to reevaluate decision to insert PEG
tube”
Your assessment
“Patient reconsidering his care
options”
Communication- more
than the words
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!
Communication
Hints
Clarify ambiguous language
“What do mean by ‘do
everything’
Identify cognitive and emotional
aspects of communication
Cognitive: the medical facts,
data
Emotional: underlying message,
tone of communication
Address both cognitive and
emotional aspects, as appropriate
Look for ‘empathetic opportunities’
Listen more than you speak
Role Play
60 yo man with a stroke for 1 year,
who tends to aspirate. Physicians
have been discussing PEG tube
feeding. You are helping the
patient eat, when the patient
brings up the issue. He says he
isn’t so sure he wants a PEG tube
and isn’t clear what is involved.
Using the GOOD Acronym,
begin discussion of patient’s
preferences.
SUMMARY
Good communication is
everybody’s business
Difficult decisions at the EOL
require special skills, simply
because the decisions are
difficult
Skills require practice
Difficult decisions should
involve input from relevant
stakeholders
The nurse’s role in this is
critical!