END OF LIFE CONVERSATIONS The Social Worker Modeling Patient and Family Communication within the Interdisciplinary Team

Transcription

1 Workshop Presenters END OF LIFE CONVERSATIONS The Social Worker Modeling Patient and Family Communication within the Interdisciplinary Team Bob Davidson, LCSW, ACHP, MDiv Rebecca Lefebvre RN, BSN, BSW, CCM Kelly Krieger, DNP, FNP BC Objectives 1. Become familiar with End of Life conversation strategies (Conversation Project, Respecting Choices, Prepare) 2. Identify best practices for conversations at end of life and provide models of how the social worker and the Interdisciplinary Team function most effectively with patients and families 3. Through creative interaction with participants role play conversations between social worker and medical provider within the Interdisciplinary Team 1

2 Resources for EOL conversations Free resources to facilitate social worker/family interaction 1. kits

3 Healthcare team structure Multidisciplinary Interdisciplinary Transdisciplinary Who s Leading the IDT Spiritual Care IDT Members Medical Providers Unique perspectives Collaboration essential Social Work Facing challenges together 3

4 Role of Social Work in IDT Benefits of IDT to the team Psychosocial assessment Exploration of psychosocial aspects of patient suffering and patient care Offers a support system in coping and grieving for patient and family Connect with community resources Engaging in difficult conversations Support from diverse colleagues Wisdom from diverse colleagues Improves group performance Qualities of an effective IDT What makes IDT work? Respect and trust Flexibility Role overlap/ Synergy Collective ownership of goals Interdependence Reflection on process Mission Does it have meaning? Communication Do people feel comfortable handling tension? Time informal conversations, time to check in Structure are people heard and understood, opportunity to voice opinions 4

5 END OF LIFE CONVERSATIONS Social Worker Modeling Patient and Family Communication with the Interdisciplinary Team Atul Gawande, M.D., MPH. Being Mortal: Medicine and What Matters in the End End of Life Conversation Starters What s your understanding of where you are with your health at this time? What are your fears and worries for the future? What are your goals and priorities if your health worsens? What are you willing to go through or not for more possible time? SW modeling end of life conversations with IDT While IDT colleagues have many shared skills, social workers are specifically trained in: Verbal and non verbal communication Role modeling Shared decision making Joint learning Group Therapy Facilitation Relational Dynamics Family Systems Therapy teams are families 5

6 Case Scenario Halcyon Hospice/Palliative Care Interdisciplinary Model: LCSW/NP Joint Visits/Shared Assessments Lead with Psychosocial or Medical? Family/MDPOA Conference Patient Demographics Age 60 female Spiritual (not religious) Children that are not present in her life, single mother all of her life, Sister is closest relative who lives out of town Poor socioeconomic status, lives alone Goals/Values Enjoys her neighbors Claims to be a fighter due to past life experiences Wants to have as much fun as possible with the days she has left Enjoys the truth and prefers to have communication be direct and straight forward Medical History Lung Cancer with possible metastasis to the bone however the last scan was not conclusive. Due to increasing pain radiation was recommended and due to continued effects of radiation another scan is planned 30 days from radiation COPD: 4L oxygen continuous smoker Hepatitis C: was considering treatment but deemed not a candidate by GI Failure to thrive: Low BMI, no current appetite, loosing weight rapidly Cognition: very overwhelmed, very forgetful,. Brain metastasis questionable Debility: PPS 50%, increasing falls, SOB at rest, increasing weakness but continues to walk without assistive devices. Severe pain on high dose Fentanyl transdermal and Dilaudid for BT every 4 hours around the clock. Intermittent nausea and vomiting. Severe anxiety and anger, obvious poor coping. Excessive secretions likely radiation induced 6

7 INITIAL NP VISIT Obvious symptom burden: malignant pain, dyspnea with copious secretions, severe anxiety. Providers not willing to provide pain medication. Patient begins to discuss her concerns with her prognosis and states she wishes the doctor would tell her if she is going to die. She says If I only have months to live I want to have fun, I don t want to do chemotherapy and make myself sick. I am already sick enough. Patient expresses her wishes to not pursue chemotherapy if it will only extend her prognosis by months. MDPOA is completed and MOST form indicating DNR status and comfort measures. However her MDPOA lives in a different state and she has not spoken with her children in years. NP collaborates with oncology expressing concerns for a potential prognosis of weeks to months and goals aligning with hospice. Oncology feels they need to wait to stage the cancer and consider immunotherapy. They will not discuss prognosis. INITIAL LCSW VISIT Psychosocial Isolation and lack of support system with family out of town Feeling of abandonment with children not involved in her life Increasing anxiety due to disease progression Anger at care team for unwillingness to be truthful Goals of Care Support: Helping patient find her voice Focusing on truth telling with care team Defining short term and End of Life goals Resource Needs: Need for LTC Medicaid and HCBS services Need for recertification for food stamps Need for a private caregiver to provide temporary housekeeping until home health care begins Palliative Team strategies for addressing complexity of patient care Severe and life shortening symptom burden Intervention: Explore existential sources of pain/anxiety/sadness, provide ongoing LCSW support to assist in moving through experiences Outcomes: likely decreased or stable symptom burden, possibly more effective pain management regimen Anger at physicians Interventions: diffuse anger, explore sense of health realities Outcome: reduce shock of altered functioning, coping realistically with prognosis High risk for Dying alone Interventions: Ethics consult to discuss risk of dying without support Outcome: Moral distress reduced for team members and family involved Allgning with Physician around prognosis and hospice eligibility Interventions: facilitate ethics consult, continued and regular collaboration with providers, consensus on prognosis, identifying high risk concerns Outcome: Physician agreeing on medically indicated plan of care, facilitating healthcare education and quicker referrals to higher levels of care, building provider relationships Palliative Team strategies for addressing complexity of patient care Patient self advocacy Interventions: role play with patient her conversation with oncology either on the phone or in person Outcome: Values and choices respected Complicated grief with estranged children Interventions: Explore integration of sense of guilt and loss, validate sense of sadness Outcome: Dialogue of impending loss Advance Directives/Comfort vs. treatment Interventions: explore meaning, facilitate consensus of prognosis, emphasize symptom burden and decreased quality of life Outcome: Desired quality of life respected 7

8 Role Play Debrief REFERENCES Abramson, J. S. and Mizrahi, T When social workers and physicians collaborate: Positive and negative interdisciplinary experiences. Social Work, 41: Back, A Communication between professions: Doctors are from Mars, social workers are from Venus. Journal of Palliative Medicine, 3(2): Connor, S. R., Egan, K. A., Kwilosz, D. M., Larson, D. G. and Reese, D. J Interdisciplinary approaches to assisting with end of life care and decision making.american Behavioral Scientist, 46: Stark, D. Teamwork in Palliative Care: An Integrative Approach. Oxford Textbook of Palliative Social Work. NY, Pg Contact Information (303) Experienced Compassionate Innovative Bob Davidson, Rebecca Lefebvre, Kelly Krieger, 8