Biography Laura J. Morrison, MD, FAAHPM Medical school training Case Western Reserve Internal Medicine Residency Cleveland Metro Geriatrics and Palliative Care Fellowship training - Baylor College of Medicine 9 years on Baylor faculty where increased local palliative care curricula and clinical program support Leadership on Hospice and Palliative Medicine Fellowship standards including competencies and entrustable professional activities S L I D E 1
Serious Illness Conversations : The Tools and Science Informing Best Practice Laura J. Morrison, MD, FAAHPM Associate Professor of Medicine (Geriatrics) Director of Palliative Medicine Education Director, Hospice and Palliative Medicine Fellowship Program S L I D E 2
Disclosures None S L I D E 3
Summer 2017 S L I D E 4
I want to know what happens Can we stop doing this? if I decide against more cancer I want to know what happens if I decide against more cancer treatment. treatment. S L I D E 5
I I want want to to know know what what happens if I want to know what happens if I decide against more cancer I if decide I decide against treatment. against more more cancer treatment. S L I D E 6
Our Agenda Responding to the Question The Science The Tools REMAP demonstration Yale Curricular Initiatives S L I D E 7
I I want want to to know know what what happens if I want to know what happens if I decide against more cancer I if decide I decide against treatment. against more more cancer treatment. S L I D E 8
A Framework of Awareness 1) Presence and Active Listening 2) Planning for My Next Response 3) Scanning for Emotion Mindfulness Navigation Emotion S L I D E 9
What Was I Thinking? Wow, she has courage! I have information to give her hold on this How did she get to this statement? S L I D E 10
Communication Skills Continuum Less Skilled Highly Skilled Goal and task focused More comfortable in providing information Doesn t notice or follow emotional cues Speaks more Accepts the process Flexible, able to pivot between approaches Looks for and explores emotional cues Listens more S L I D E 11
Silence Provide Information Explore Divert or Resist S L I D E 12
Our Agenda Responding to the Question The Science The Tools REMAP demonstration Yale Curricular Initiatives S L I D E 13
Questions: 1) Who should be having these conversations? 2) Do patients want to have these conversations? 3) Do these conversations help or harm patients and families? 4) Are we trained to have these conversations? 5) How do we teach these skills? S L I D E 14
Who should be having these conversations? S L I D E 15
IOM Report September 2014 call for universal health professional and clinician (physician, nurses, social workers, others) education and training in the core principles and practices of palliative care: skilled communication about what matters most to patients and their families and how the health care system can help achieve those goals. Meier, Health Affairs Blog, 2014 S L I D E 16
Schaefer et al, Acad Med, 2014 S L I D E 17
Do patients want to have these conversations? S L I D E 18
Mostly Yes 80% if seriously ill, would want to talk to doctor about end-of-life care California HealthCare Foundation, 2012 Most patients/family members want communication about the illness and its progression Lamas et al, J Pall Med, 2017 Fakhri et al, J Pain Symp Manage, 2016 Davison, Clin J Am Soc Nephrol, 2010 Kirk et al, BMJ, 2004 S L I D E 19
Do these conversations help or harm patients and families? S L I D E 20
End-of-life discussions are not associated with more patient worry or depression Wright et al, JAMA, 2008 Bereaved family members who participated in endof-life discussions for loved ones had less depression and anxiety and rated patient s quality of death higher Yamaguchi et al, J Pain Symp Manage, 2017 Lautrette et al, New Eng J Med, 2007 S L I D E 21
Are we trained to have these conversations? S L I D E 22
Majority of practicing physicians report no prior training in end-of-life communication with patients Conversation Stopper, Physician Survey, 2016 Daugherty and Hlubocky, J Clin Oncol, 2008 Fellows report low rates of end-of-life communication training Combs et al, Am J Kidney Dis, 2015 Buss et al, Cancer, 2011 Holley et al, Am J Kidney Dis, 2003 S L I D E 23
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How do we teach these skills? S L I D E 25
Teaching Methods Simulation Role playing Simulated or standardized patients Use of Specific Tools Acronyms Helpful phrases and scripting Pearls Videotaping with Feedback Webinars, modules, courses Bernacki and Block, JAMA IM, 2014 American Academy on Communication in Healthcare Vital Talk S L I D E 26
Simulation-based training has shown improvements in: 1) self-efficacy ratings for skills Kelley et al, J Amer Geriatr Soc, 2012 2) scores from pre to post training for observed skills Bays et al, J Pall Med, 2014 S L I D E 27
Palliative Care Fast Facts app VitalTalk Tips app
Our Agenda Responding to the Question The Science The Tools REMAP demonstration Yale Curricular Initiatives S L I D E 29
Relationship Building S L I D E 30
Patient-Centered Interview 1) Set the Stage 2) Elicit Chief Concerns and Set Agenda 3) Begin the interview with non-focusing skills that help patient express him/herself 4) Use focusing skills to learn: symptom story, personal and emotional contexts 5) Transition to middle of interview American Academy of Communication in Healthcare S L I D E 31
Scripts and Pearls S L I D E 32
SPIKES (Breaking Bad News) Setting Up Perception Invitation/Information Knowledge Emotion/Empathy Summary Prepare medical information p Anticipate What questions Organize have the other doctors p Introductions told you today Is about it okay your if condition? we review the p treatment options we have I wish I had better news, at this point? but we are no p So, this wasn t Silence the longer news able we I can were to understand hoping consider p for. the why We ll LVAD you re p regroup and scared review option current options tomorrow. Buckman and Baile, 1992 S L I D E 33
Tell me more Useful approach for exploration and drawing out Expresses empathy through curiosity S L I D E 34
NURSE (Ways to Express Empathy) Naming Understanding Respecting Supporting Exploring You seem upset This must be hard I am so impressed Our team will be here Tell me more about Back et al, Mastering communication with seriously ill patients, 2009 S L I D E 35
I wish things were different. Promotes alignment over hierarchy Expression of empathy within reality Use for: unrealistic hopes, bad news disappointment in limits of medicine Quill et al, Ann Intern Med, 2001 S L I D E 36
REMAP (Goals of Care) R Reframe why the status quo isn t working E Expect emotion, respond with empathy M Map out what s important A Align with the patient s values P Plan to match values http://vitaltalk.org/ S L I D E 37
Our Agenda Responding to the Question The Science The Tools REMAP demonstration Yale Curricular Initiatives S L I D E 38
REMAP (Goals of Care) R Reframe why the status quo isn t working E Expect emotion, respond with empathy M Map out what s important A Align with the patient s values P Plan to match values http://vitaltalk.org/ S L I D E 39
Our Agenda Responding to the Question The Science The Tools REMAP demonstration Yale Curricular Initiatives S L I D E 40
Yale Developmental Framework Communication Skills Training Patient-Centered Interview Breaking Bad News Shared Decision Making Motivational Interviewing Medical Error Serious Illness Communication S L I D E 41
Medical Students Existing: - Medical Interview and Difficult News - Palliative Care Experiential Curriculum New: MS4 Spring Objective Structured Clinical Exams (OSCEs) Pilot Medical error disclosure Palliative care case Emotional patient Goals of care S L I D E 42
Residents Existing: - Orientation Goals of Care Session - Patient Centered Interview New: PGY3 Goals of Care 4 hour session Simulated patients S L I D E 43
Fellows Multispecialty Fellows Serious Illness Communication Workshop Series 3 half days annually Geriatrics, Hematology/Oncology, Pulmonary/Critical Care/Sleep, Hospice and Palliative Medicine = 20 fellows Role play, simulated patients, longitudinal small groups with faculty facilitation S L I D E 44
Faculty Multiple training sessions for faculty each year Opportunities to facilitate Fellow and Resident training S L I D E 45
I want to know what happens Can we stop doing this? if I decide against more cancer I want to know what happens if I decide against more cancer treatment. treatment. S L I D E 46
Practical Final Points 1) Skills can be taught and learned tools 2) Assess patient/family understanding first 3) Lean into emotion 4) Look for opportunities to assess what s important - REMAP S L I D E 47
Gratitude Questions? Laura J. Morrison, MD laura.morrison@yale.edu Yale Palliative Care Team 2016-17 S L I D E 48
Bibliography 1) Schaefer KG, Chittenden EH, Sullivan AM, Periyakoil VS, Morrison LJ, Carey EC, et al. Raising the Bar: A National Survey to Define Essential Palliative Care Competencies for Medical Students and Residents. Acad Med. 2014 July;89(7):1024-1031. 2) Bernacki RE, Block SD; American College of Physicians High Value Care Task Force. Communication about serious illness care goals: a review and synthesis of best practices. JAMA Intern Med. 2014 Dec;174(12):1994-2003. 3) Wright AA, Zhang B, Ray A, Mack JW, Trice E, Balboni T, et al. Associations between endof-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA. 2008 Oct 8;300(14):1665-73. 4) Bays AM, Engelberg RA, Back AL, Ford DW, Downey L, Shannon SE, et al. Interprofessional communication skills training for serious illness: evaluation of a smallgroup, simulated patient intervention. J Palliat Med. 2014 Feb;17(2):159-66. 5) Quill TE, Arnold RM, Platt F."I wish things were different": expressing wishes in response to loss, futility, and unrealistic hopes. Ann Intern Med. 2001 Oct 2;135(7):551-5. 6) Back A, Arnold R, Tulsky J. Mastering communication with seriously ill patients; Cambridge University Press, 2009. S L I D E 49