Download Interdisciplinary….

End-of-Life Communication
from
Interdisciplinary Perspectives
Learning to Care for the
Patient’s Lived Body
Speakers
Sandra Sanchez-Reilly, MD
University of Texas Health Science Center and the South Texas Veterans Health
Care System, San Antonio, TX
Elaine Wittenberg-Lyles, PhD
University of North Texas
Michele Saunders, MD
University of Texas Health Science Center and the South Texas Veterans Health
Care System, San Antonio, TX
Objectives
• To present an overview of several innovative
educational methods currently used in end-of-life care
communication training (Education and
Communication)
• To acknowledge the importance of interdisciplinary
team approach in end-of-life care and training
(Interdisciplinary and Communication)
General Definitions
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•
•
•
Palliative Care
End-of-Life
Interdisciplinary
Lived Body
General Definitions
•
•
•
•
Palliative Care
End-of-Life
Interdisciplinary
Lived Body
The Cure - Care Model:
The Old System
D
Life
Prolonging
Care
Palliative/ E
Hospice
Care
Disease Progression
A
T
H
Palliative Care’s Place in the Course of Illness
Life Prolonging Therapy
Death
Diagnosis of
serious
illness
Palliative Care
Medicare Hospice
Benefit
Palliative Care
“Modern
Medicine”
End-ofLife
General Definitions
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•
•
•
Palliative Care
End-of-Life
Interdisciplinary
Lived Body
Interdisciplinary Teams
• Consist of a medical director, the patient’s
physician, a nurse who functions as the case
manager, social worker, pastoral care, and
certified nurse assistant.
• Team members who work from different
orientations while at the same time engaging in
joint work.
• Care plans that have been assessed by experts in
different disciplines
Hoyer T: A history of the Medicare Hospice Benefit. The Hospice Journal 1998;13:61-69.
Dyeson TB: The home health care team: What can we learn from the hospice experience? Home
Health Care Management & Practice 2005;17:125-127.
The patient’s lived body
• Communication about the psychological
and social aspects of dying.
– includes good health care professional and
patient communication
– team attention to psychosocial issues such as
depression
– efficient interdisciplinary staff
communication
EDUCATION IN
END-OF-LIFE
COMMUNICATION
Where are we?
Goals of Education
• Increase knowledge/expertise
• Communication skills
• Interdisciplinary team awareness
Goals of Education
• Increase knowledge/expertise
• Communication skills
• Interdisciplinary team awareness
Deficiencies in Medical Education
• 74% of residencies in U.S. offer no training in end
of life care.
• 83% of residencies offer no hospice rotation.
• 41% of medical students never witnessed an
attending talking with a dying person or his family,
and 35% never discussed the care of a dying patient
with a teaching attending.
Billings & Block JAMA 1997;278:733.
The Good News:
Palliative Care Education Is Improving
• Medical school LCME requirement:
“Clinical instruction must include important aspects of … end of life care.”
2000
• Residency ACGME requirements for internal
medicine and internal medicine subspecialties:
“Each resident should receive instruction in the principles of palliative
care…it is desirable that residents participate in hospice and home
care…The program must evaluate residents’ technical
proficiency,…communication, humanistic qualities, and professional
attitudes and behavior…” 2000
Palliative Care Education in Medical Schools
Is Improving
• Annual medical school exit questionnaire 20022003
• 126 LCME accredited medical schools
• 110 (87%) require instructional hours in
palliative care
• Average # of hours required: 12, but highly
variable (4-14)
Barzansky B, Etzel SI. JAMA 2003; 290:1190-6
Dickinson GE. Am J Hosp Palliat Care. 2006
23(3): 197-204
Current State of Nursing Education
in Palliative Care
• Only 3% of nursing programs in the United States
reported having a course dedicated to end-of-life issues
in 2002.
• 40% focus groups felt a need to increase this content in
their curricula.
• Nursing textbooks offer little in the way of end-of-life
care
• Nurses report wishing they had learned more about
caring for the dying while in their undergraduate and
graduate nursing programs.
Robinson R. End-of-life education in undergraduate nursing
curricula. Dimens Crit Care Nurs. 2004 Mar-Apr;23(2):89-92
Special Initiatives
• Objective Structured Clinical Examination (OSCE)
with Standardized Patients
• End of Life Nursing Education Curriculum (ELNEC)
• Education on Palliative and End-of-life-care (EPEC)
• Education on Palliative and End-of-life-care for
Oncologists (EPEC-O)
• Palliative Care Education and Practice (PCEP)
• Center for Advanced Palliative Care (CAPC)
GERIATRICS AND
PALLIATIVE CARE
FACTS
GERIATRICS
PALLIATIVE
CARE
POPULATION
OLDER
EVERYONE: MANY
OLDER ADULTS
QUALITY OF LIFE
VERY IMPORTANT
VERY IMPORTANT
GERIATRIC
SYNDROMES
MENTAL STATUS
CHANGES, PAIN,
FALLS, WEAKNESS
MANY SYMPTOMS
FAMILY
VERY IMPORTANT
VERY IMPORTANT
SUB-SPECIALTY
YES
YES
FUNCTIONAL
STATUS
VERY IMPORTANT
COMFORT AND
QUALITY OF LIFE
University of Texas Health Science Center at San
Antonio and The South Texas Veterans Health Care
System
Geriatric
Palliative Care
Program:
Fellowship
Consultation
Service
Inpatient Hospice
Unit
Community Home
Hospices
Clinics
Pediatric
Palliative Care
Palliative Care:
Educational Programs
• Interprofessional Palliative Care Fellowship
• Community Hospice Settings
• Medical Students
Models of Care:
A Geriatric Palliative Care Team
NURSES
COMM.
EXPERTS
PSYCHOLOGIST
PHYSICIANS
PATIENT
AND
FAMILY
IDT.
TRAINEES
RESEARCH
STAFF
CHAPLAINS
SOCIAL WORK
Goals of Education
• Increase knowledge/expertise
• Communication skills
• Interdisciplinary team awareness
End-of-Life Communication
• Clinical Barriers
– Uncertainty
– anxiety (patient & doctor)
– feelings of failure
– expressed emotion
– lack of training
– Time
End-of-Life Communication
• Educational Barriers
One-way communication
End-of-Life Communication
• Team Barriers
– Working together as a team
– Different disciplines
• Psychologist
Potential Solutions
• Clinical Barriers: EDUCATION
• Team Barriers:
– INTERDISCIPLINARY TEAM MEETINGS
– SELF CARE: “SPIRITUAL ROUNDS”
• Educational Barriers:
– FAMILY MEETINGS
Potential Solutions
• Family meetings
–
–
–
–
Provides for team environment
Includes patient and family
Based on communication
Necessary for treating the patient’s lived body
Family Meetings: Background
• The importance of involving patients and family
members in healthcare teams is well
documented*
• Family meetings improve satisfaction,
coordination of care, and communication**
*(Saltz & Schaefer, 1996; McDonald et al., 2002; Fischer, Schulz, &
Ogletree, 1999; Andrews et al., 1998)
** (Andrews et al, 1998; Axford, Askill, & Jones, 2002)
What Do Family Members Want?
Study of 475 family members 1-2 years after bereavement
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Loved one’s wishes honored
Inclusion in decision processes
Support/assistance at home
Practical help (transportation, medicines, equipment)
Personal care needs (bathing, feeding, toileting)
Honest information
24/7 access
To be listened to
Privacy
To be remembered and contacted after the death
Tolle et al. Oregon report card.1999 www.ohsu.edu/ethics
Family Meetings
• Challenges
– Difficulty listening – Physician Perspective
– Difficulty making decisions – Social Worker
Perspective
– Difficult family dynamics
Family Meetings: A Framework
PRE-MEETING
“BRING THE
PATIENT INTO
THE ROOM”
“SPIKES” MODEL
THE S.P.I.K.E.S. MODEL
• S: Setting. Pick a private location.
• P: Perception. Find out how the patient views the
medical situation.
• I: Invitation. Ask whether the patient wants to know.
• K: Knowledge. Warn before dropping bad news.
• E: Empathy. Respond to the patient’s emotions.
• S: Strategy/Summary. Once they know, include patients
in treatment decisions.
Walter F. Bailea, Robert Buckman. The Oncologist, Vol. 5,
No. 4, 302-311, August 2000
Family Meetings: A Framework
PRE-MEETING
“BRING THE
PATIENT INTO
THE ROOM”
“SPIKES” MODEL
COMFORT AND
REFRAME
Family Meetings: ROLE PLAY
• 85 YEAR-OLD MAN WITH PAST
MEDICAL HISTORY OF DIABETES,
HYPERTENSION, AND RECENTLY
DIAGNOSED METASTASIC LUNG
CANCER. PT IS IN THE HOSPITAL WITH
EXCRUTIATING PAIN, BUT ALERT,
WITH HIS WIFE AND DAUGHTER AT
BEDSIDE. THEY ARE HOPING FOR A
CURE…
Family Meetings: ROLE PLAY
• DR. R., HIS PRIMARY PHYSICIAN AND A
MEDICINE RESIDENT, IS NOT VERY
COMFORTABLE WITH DELIVERING
BAD NEWS, HE WAS NEVER PROPERLY
TRAINED…
• HIS ATTENDING PHYSICIAN IS NOT
WILLING TO DO IT EITHER: “THE
FAMILY SHOULD KNOW BY NOW”
Family Meetings: ROLE PLAY
• PT LIVES WITH HIS WIFE, AND HIS
PENSION IS THEIR ONLY SOURCE OF
INCOME
• HIS DAUGHTER HAS NOT BEEN
INVOLVED IN THEIR LIVES SINCE HE
RE-MARRIED
• THE PALLIATIVE CARE TEAM IS
CALLED TO “PROVIDE HOSPICE
CARE”…
Family Meetings: A GOOD SKILL
TO MASTER
• Rewards/Learning about communication
– Family understanding
• Understanding your role
– Facilitating difficult conversations
• Understanding the context
Goals of Education
• Increase knowledge/expertise
• Communication skills
• Interdisciplinary team awareness
End-of-Life Communication
is team based!
Geriatrics Interdisciplinary
Advisory Group, 2006
Interdisciplinary care:
• Improves healthcare processes
• Benefits the healthcare system and caregivers,
• Adequately prepares healthcare providers for
better care of older adults
Interdisciplinary Collaboration
• Interdependence and flexibility
– Deviation from specific discipline specific
boundaries; flexibility of job responsibilities
Bronstein LR: Index of interdisciplinary collaboration. Social Work Research 2002;26:113-126.
Bronstein LR: A model for interdisciplinary collaboration. Social Work 2003;48: 297-306.
Interdisciplinary Collaboration
• Newly created professional activities
– Expansion of an individual’s specific job
responsibilities
– New activities that evolve through interdisciplinary
collaboration include: (1) information sharing to
educate others; and (2) additional tasks.
Interdisciplinary Collaboration
• Collective ownership of goals
– Individuals share responsibilities for all aspects
of decision-making and implement decision
together
– The discussion of “special cases” illustrated a
collective ownership of goals. Such cases
warrant additional information sharing.
Interdisciplinary Collaboration
• Reflective process
– Team evaluation of team’s outcomes
– Includes information about (1) procedural issues, (2)
reviews of deaths, and (3) the sharing of workplace
stress.
Interdisciplinary Perspectives
• Team member collaboration provides for
holistic care of the patient’s lived body
Example: Treatment of all pain
• Physical
• Spiritual
• Emotional
• Psychological
Thank you
Sandra Sanchez-Reilly
[email protected]
210-617-5237
Elaine Wittenberg-Lyles
[email protected]
940-565-4450