Talking to Your Oncologist & Living with Cancer

Transcription

1 Talking to Your Oncologist & Living with Cancer Anthony Back, M.D. University of Washington Fred Hutchinson Cancer Research Center Seattle Cancer Care Alliance

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3 Highlights?

4 The old way doctors talked

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8 What research says: The old way doesn t work.

9 Physician self-assessment: Imperfect Patient-rated competence Doctor self-rated competence

10 Most patients want more information.

11 Just after a conversation, patients overestimate prognosis. How do you rate your chance of being cured? % Underestimate Overestimate

12 But physicians think the patient got it. How would you rate the patient s understanding? 16 84% fair good, very good, excellent

13 Shouldn t telling the number improve understanding? 40 physicians, 236 patients with hematologic malignancies 88% of patients wanted quantitative information 64% of these visits involved physician giving quantitative information about prognosis Yet giving numerical information not associated with concordance

14 Emotion can flood cognition. Excerpt from consult: So if you had 100 people, the survival curve drops down because people die of one thing or another, including relapse. That tends to level off at about 2.5 years after transplant and stays level after that. It s about 30% in your situation 30 Patient s pre-visit estimate of cure: % Patient s post-visit estimate of cure: %

15 Prognosis is emotionally loaded. After he said the 30%, he just kept dinging along in his facts, and I was stunned. Literally, my notetaking was completely done. All I wrote was 30% the rest of the time all over my paper. And I mean, I just couldn t get past that point. I don t know how to describe it.

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17 Most patients want to share decisions.

18 Most patients dread bad news.

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20 Where doctors & patients agree: Better communication is needed.

21 Do big picture conversations matter? 332 patients identified, prospectively Asked: Have you and your doctor discussed any particular wishes about the care you would want to receive if you were dying? Yes/no: Compared re Distress/Depression p=ns Accepts illness as terminal OR 2.19 Wants to know life expectancy OR 2.40 JAMA 300:1665, 2008

22 Outcomes correlated with a transition conversation Medical care in last week of life ICU admission OR 0.35 Ventilator use 0.26 Resuscitation attempt 0.16 Outpt hospice >1 wk 1.58 Caregiver bereavement Better QOL Felt prepared for death Regret p=0.001 p=0.001 p>0.001 JAMA 300:1665, 2008

23 Temel et al, New Engl J Med 2010

24 What oncologists do is changing.

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27 The new way: A dialogue about choices & living

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29 What would better look like?

30 Default communication behavior: broadcasting Qualitative study drawn from 236 hematologic malignancy consults Dr: The results looked very encouraging so they did another study... Dr s estimate of cure: 10-19% He did most of the talking. He started running it down to us. There was some material in there that was quite shocking. Patient s estimate of cure: 50-59%

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33 Communication is a learned expertise.

34 When it s your turn: 1. Select a skill 2. Try it out 3. Self-assess 4. Brainstorm alternatives

35 Recognizing and responding to emotion improves trust. 48 oncologists, 264 patients Oncologists randomized to CD-ROM based intervention If received intervention, oncologists made more empathic statements (OR 1.9), responded to more empathic cues (OR 2.1) Patients of intervention oncologists reported greater trust (p=.036) Annals Int Med 2011:155;593

36 Improving how residents verbalize empathy 145 internal medicine residents Randomized to communication clinic block Pre-post standardized encounters 1 m apart» p value Assess understanding.001 >10s silence after news.002 Explored emotion.001 Respect or praise.001

37 Doctors who know how to communicate

38 ...what it means to make smart choices, live fully, take charge

39 QuickTime and a Apple ProRes 422 decompressor are needed to see this picture.

40 A team to focus on quality of life

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42 An easy way to prepare before your visit

43 The Jumpstart study: Fill out a questionnaire Get a reminder Take it to your visit

44 What you can do now

45 Set your sights on what s important for you.

46 Try a first draft conversation.

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