Download Aspects of Communication in Quality End of Life Care

Aspects of Communication
in Quality End-of Life Care
Presented by
Stephen Goldfine, MD
Chief Medical Officer
Samaritan Healthcare & Hospice
SamaritanNJ.org
Objectives
To know and understand:
• The importance of good communication
from diagnosis through end of life
• The types, purposes, and factors that influence
communication
• Ways to discuss hospice and palliative care
• The purpose of POLST & how it differs from DNR
• Strategies to understand and
resolve conflict related to patient
care and treatment goals
Definition
Sharing of information through utilization
of a set of common rules
• Types
– Verbal or nonverbal
• Body language, eye contact, gestures, tone of voice
• 80% of communication is nonverbal
– Oral or written
– Personal or impersonal
– Issue oriented or
relationship oriented
Benefits of Good Communication
• Improve accuracy of diagnosis and quality of
management
• Improve eliciting and imparting of information
• Improve patients’ understanding, retention of
information, compliance
• Reduce anxiety, uncertainty , and litigation
• Improve doctor and patient satisfaction
Dias et al. (2003). Breaking Bad News: A Patient’s Perspective, The Oncologist, 8:592.
Benefits of Good Communication
“Without clear, goal-directed communication,
care loses its purpose. When the purpose of
care (aggressive treatment or quality-of-life
preservation) becomes muddied or even lost in
an unfortunate battle of wills, distress is certain
to occur in patients, families, and caregivers.”
Marcus & Mott (2014). Difficult Conversations: From Diagnosis to
Death, The Ochsner Journal, 14:712
Communication in End-of-Life Care
• Fundamental aspect of palliative care
• Ethical obligation*
• Advanced or terminal illness
is a family experience
• Is a major area of need
• Requires interdisciplinary collaboration
* Lenherr, G., Meyer-Zehnder, B., Kressig, R., Reiter-Theil, S. (April 5, 2012). To speak,
or not to speak – do clinicians speak about dying and death with geriatric patients
at the end of life? Swiss Med Wkly, 142: w13563, p. 1
Communication in End-of-Life Care
(cont)
• Cannot share too much information
But individual preferences should be assessed; time may be needed to
accept new information*
• Is therapeutic
• Patients/families consider good
communication, including emotional and
spiritual aspects, key to a “good death”
• Providers must often initiate
the conversation
(Lenherr et al., p. 6)
(Lenherr et al., p. 6)
* Cherlin, E., et al. (2005). Communication between Physicians and Family Caregivers
about Care at End of Life, J. Palliat Med, 8(6) 1176-1185.
Factors Influencing Communication
• Patient/Family
– Family systems/culture
– Financial/educational
– Physical/cognitive limitations (Lenherr et al., p. 4)
– Coping/grief
Factors Influencing Communication
• Health care professionals
– Fear of own mortality
– Discomfort / lack of confidence to give bad news
(Lenherr et al., p.4)
– Inaccuracy of prognostication
– Fear of patient thinking doctor has “given up”
(Lenherr et al., p. 5)
Factors Influencing Communication
• Health care professionals (cont.)
– Lack of cultural understanding
– Fear of removing hope
– Lack of training
– Lack of time
– Gender differences
Other Barriers
• Lack of privacy
• Interruptions & distractions
• Palliative care stigma*
All contribute to stress.
Granek, L., Krzyzanowska, M., Tozer, R., Mazzotta, P. (July 2013). Oncologists’
Strategies and Barriers to Effective Communication About the End of Life,
jop.ascopubs.org, p. e132. Downloaded February 24, 2015.
Study: End-of-Life Communication
Yale study of 200 hospice patients and families:
• 21% of physicians did not tell family caregiver
patient’s illness could not be cured
• 32% never discussed using hospice
• First discussions of above often occurred within
one month of patient’s death
Cherlin, E., et al.
Study: End-of-Life Communication
(cont.)
• Communication about end-of-life care
is often limited
• Causes include physicians’ lack of discussion
and family caregivers’ difficulty hearing
the news
• A clear understanding of the illness and
treatment options is important
to patients and families
Cherlin et al.
Who are the “Dying?”:
Prognostic Accuracy in Terminally Ill Patients
• 343 physicians provided survival estimates
for 468 patients
• Median survival was 24 days
• 20% (92/468) predictions were accurate
• 63% were over-optimistic
• 17% were over-pessimistic
Christakis, N., & Lamont, E. (2000). Extent and determinants of error in doctors’
prognoses in terminally ill patients: Prospective Cohort Study, BMJ, 320, 469-473.
Who are the “Dying?”:
Prognostic Accuracy in Terminally Ill Patients
Prognosis

Christakis et al. (BMJ 2000) found that only 20% of predictions were
accurate, overestimated survival by a factor of 5.3%, and as the
duration of physician patient relationship increased, prognostic
accuracy decreased.

Christakis el al.* found that physicians disdained prognostication:
– 60.4% find it “stressful”;
– 58.7% find it difficult;
– 43.7% wait to be asked by patients
before offering predictions.
*Christakis, Nicholas A., MD, PhD, MPH, Iwashyna, Theodore J., “Attitude and Selfreported Practice Regarding Prognostication in a National Sample of Internists, Arch
Intern Med/ Vol. 158, Nov 23 1998, 2390-93
Communication process
• Seven key elements
–
–
–
–
–
–
–
Medium
Message
Speaker
Listener
Feedback
Interference
Context
Communication Process
• The Message
– Most difficult aspect in end-of-life discussions
• Doctors are poor prognosticators and tend to avoid this
subject
• Influenced by culture
• The Speaker
– Clear, sensitive, and have proper vocabulary
•
•
•
•
Be direct, but not excessively blunt
Balance honesty/realism with sensitivity/support
Give realistic hope (for comfort if not cure)
Convey that patient/family will not
be abandoned (Dias et al.)
Communication Process (cont.)
• The Listener
– Actively involved in the conversation
– Nonverbal communication
– Must be present
– Occurs at 5 levels
• Hearing, understanding, retaining,
analyzing, and active empathizing
– Offers feedback
Communication Process (cont.)
• Interference
– Internal
– External
• Context
– Time
– Place
Communications Strategies
and Techniques
• Oncotalk
• SPIKES model
• Motivational Interviewing (MI)
- Avoid closed-ended questions
- Ask for the “story” in patient’s words
• Solution-Focused Brief Therapy (SFBT)
- Miracle question
• Cognitive Behavioral Therapy (CBT)
• MI and CBT help patients
acknowledge difficult truths
Marcus & Mott, p 714
Broaching the Topic of Hospice
and Palliative Care
• Initiate conversation early in disease course,
when patient is still feeling well *
• Ask what the patient/family already know
• Ask how much they want to know
Advanced age, level of depression etc. may limit
what patient wants to know (Dias et al.)
• Use language they
understand
*Ngo-Metzler, Q., August, K., Srinivasan, M., Liao, S., Meyskens, F.
(January 15, 2008). End-of-Life Care: Guidelines for
Patient-Centered Communication, American Family Physician, 77(2): 168.
Downloaded February 24, 2015.
Common Statements to Avoid
• “There’s nothing we can do for you.”
• “It’s time to think about withdrawal of care.”
• “You’ve failed the treatment.”
• “I think you should consider hospice.”
Ngo-Metzger et al., p. 172
Alternatives: Statements to Use
• “We can offer many options to control your
symptoms and make you feel better.”
• “Do you think it’s time to consider a different type of
treatment, which focuses on your symptoms? I’ll be
here with you no matter what you decide.”
• “I want to provide intense, coordinated care with a
team of professionals who will treat your symptoms
and help you stay comfortable.”
Ngo-Metzger et al., p. 172
General Tips:
Discussing Difficult Topics:
• Prioritize 2 - 4 key points patient should retain
• Coordinate key prognosis points with all
providers, for consistent messages
• Multiple visits may be needed
• Continually probe patient’s understanding
• Ask patient how he/she feels
• Leave time for questions
(Ngo-Metzger et al.)
(Dias et al.)
Broaching the Topic
of Hospice and Palliative Care
Studies indicate:
• Patients and families value being able to prepare
for death
• Delays in discussions often lead to later hospice
admission and fewer opportunities to say goodbye,
complete personal and financial arrangements, and
plan for last phase of patient’s life.
Cherlin et al.
Broaching the Topic
of Hospice and Palliative Care
• Review the goals of palliative care
– Symptom management
– Achieve the best quality of life for the patient and
his or her family
– Address all needs: physical, emotional, spiritual
DNR and POLST
•
•
•
•
•
Need for these documents
DNR vs. POLST
Advance directives extend the patient’s autonomy *
Lack of DNR/POLST can signal lack of communication
Only 20-30% of patients with metastatic cancer have
a documented code status on their outpatient
charts.
*Daher, M., Ethical issues in the geriatric patient with advanced cancer ‘living to the
end’ Ann Oncol (2013) 24 (suppl 7): vii55-vii58 doi:10.1093/annonc/mdt262, p. vii56
Working with Emotions
• Sadness and anger are appropriate reactions
to bad news
• Attentive listening
• Be silent—allow time to process
• Acknowledge your own feelings
– “I’m so sorry”
– “I feel so bad for you.
How can I help you?”
Working with Emotions
• Reflect thoughts, emotions or behavior
– “I can see how upset you are.”
– “This is so hard.”
• Affirmation and respect
– “Please tell me more about
how you are feeling.”
– “Thank you for sharing your
thoughts and feelings with me.”
Working with Emotions
• Summarize/paraphrase
“We’ve been talking for awhile about how things are going
for you. Let me see if I can summarize and you can let me
know if I’m on track.”
• Make a plan
“How can we help? We are here to answer any questions
you or your family may have.”
• Encourage reminiscing
Conflict
• Occurs in any situation in which the wants and
needs of one party are incompatible with
another’s wants and needs
• Prolonged conflict will destroy relationships.
• Conflict resolution strategies
Areas of Potential Conflict
• What if you do not agree with patient goals
and treatment choices?
• What if family is pushing for treatment
considered to be futile, especially if the
patient has expressed other wishes?
• Continuing futile treatment, or not pursuing
treatment perceived as
beneficial, is a source of
moral distress.
Resolving Conflict
•
•
•
•
•
•
•
Try to take a step back.
Identify your own emotions.
Define the conflict.
Are your own values getting in the way?
Obtain agreement on the conflict.
Is this an ethical issue? Resources?
Find a colleague and talk about it.
Prognostic Accuracy of Doctors?
1.
2.
3.
4.
10%
20%
40%
60%
Palliative Care Goals
1. Aggressive symptom management
2. To achieve best quality of life
for patients and their families
3. To address physical, spiritual, and emotional
needs of patients and their families
4. All of the above
References:
•
•
•
•
•
•
•
•
•
•
Dias, L., Chabner, B., Lynch, T., Penson, R. (2003). Breaking Bad News: A Patient’s Perspective, The Oncologist,
8:592, 595.
Daher, M., Ethical issues in the geriatric patient with advanced cancer ‘living to the end’ Ann Oncol (2013) 24
(suppl 7): vii55-vii58 doi:10.1093/annonc/mdt262
Marcus, J., & Mott, E. (2014). Difficult Conversations: From Diagnosis to Death, The Ochsner Journal, 14: 712
Lenherr, G., Meyer-Zehnder, B., Kressig, R., Reiter-Theil, S. (April 5, 2012). To speak, or not to speak – do
clinicians speak about dying and death with geriatric patients at the end of life? Swiss Med Wkly, 142: w13563,
p. 1
Cherlin, E., Fried, T., Prigerson, H., Schulman-Green, D., Johnson-Hurzeler, R., Bradley, E. (December 2005).
Communication between Physicians and Family Caregivers about Care at the End of Life: When Do Discussions
Occur and What is Said, J. Palliat Med, 8(6): 1176-1185
Christakis, N., & Lamont, E. (2000). Extent and determinants of error in doctors’ prognoses in terminally ill
patients: Prospective Cohort Study, BMJ, 320, 469-473.
Christakis, Nicholas A., MD, PhD, MPH, Iwashyna, Theodore J., “Attitude and Self-reported Practice Regarding
Prognostication in a National Sample of Internists, Arch Intern Med/ Vol. 158, Nov 23 1998, 2390-93
Granek, L., Krzyzanowska, M., Tozer, R., Mazzotta, P. (July 2013). Oncologists’ Strategies and Barriers to Effective
Communication About the End of Life, jop.ascopubs.org, p. e132. Downloaded February 24, 2015.
Ngo-Metzler, Q., August, K., Srinivasan, M., Liao, S., Meyskens, F. (January 15, 2008). End-of-Life Care: Guidelines
for Patient-Centered Communication, American Family Physician, 77(2): 168. Downloaded February 24, 2015.
Center to Advance Palliative Care. For Policymakers: Overview. https://www.capc.org/policymakers/overview/ ,
Downloaded March 18, 2015.