Identify essential primary palliative care (PPC) communication skills that every provider needs AND clinical triggers for PPC conversations Esmé Finlay, MD Division of Palliative Medicine University of New Mexico Palliative Care Update 2016 October 29, 2016 Apply SPIKES framework to difficult topics during patient provider conversations Identify 2 strategies from this talk you will apply in your clinical practice to improve patient physician communication PRIMARY PC Basic discussions about: Prognosis Goals of treatment Suffering Code status Hospice Basic pain and symptom management Basic management of depression and anxiety SPECIALIST PC Advanced communication skills Conflict about goals or treatments Conflict between people Complex pain and symptom management Management of more complex psychosocial distress: Suffering and total pain Existential distress 1
Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) project LANDMARK STUDY on communication and care for seriously ill patients at the end of life (EOL) Outcomes: Doctors, patients and families don t communicate very well 9105 patients enrolled 1989 1994 9 life threatening conditions with average 6 month survival 50% Patient and surrogate interviewed day 3, 2 mo, 6 mo after admission MD and primary RN interviewed during hospitalization What do dying patients want? Comfort A sense of control / dignity To relieve burden on loved ones To strengthen relationships To avoid prolongation of dying process To die at home, not in hospital Participation in funeral/legacy planning Singer, Martin, & Kelner (1999).JAMA, 28(2), 163 168. Steinhauser, KE, et al (2000). JAMA, 284(19), 2476 2483 Patients can t complete end of life planning if they don t know they are dying 2
Patients who rated their doctors communication very highly were less likely to have an accurate prognostic view Press Gainey?? Patient comprehension?? 3
A. Yes B. No C. It depends A. Breaking bad news B. Talking about dying and the transition to hospice C. Talking about code status and advance directives D. Discussing suffering E. Other A. Lack of training B. I don t know what to say C. I m uncomfortable with patient emotion D. I don t have enough time E. Other 4
Survey of 2850 British cancer patients; 1046 receiving palliative treatment Best Describes Your Attitude about Information I do not want to know any details, I leave it up to my doctor I want additional information only if it is good news I want as much information as possible, good and bad. Palliative Patients (n= 1032) Non palliative Patients (n=1777) 81 (7.8%) 126 (7.1%) 75 (7.3%) 69 (3.9%) 876 (84.9%) 1582 (89%) Fallowfield, L. Palliative Medicine. 2002. Truthful information about diagnosis, prognosis and treatment 95 7% side effects, symptoms 94% all treatment options 93% chance of cure 81% average survival Hope Fallowfield LJ et al, Palliative Medicine 2002; (16): 297. Hagerty,R. JCO, 2004 22(9):1721-31. 5
Serious Illness Conversation Guide TWO FRAMEWORKS TO CONSIDER: Serious Illness Conversation Guide (SICG) Bernacki, RE et al. Communicating about Serious Illness Care Goals: a Review and Synthesis of Best Practices. JAMA Internal Medicine. 2014 Dec; 174(12): 1994 2003. JAMA December 2014 SPIKES Back A, Arnold R, and Tulsky J. Mastering Communication with Seriously Ill Patients: Balancing Honesty with Empathy and Hope. Cambridge University Press. 2009. ACP High Value Task Force Advice: Communication about goals of care is a lowrisk, high value intervention for patients with serious* and life threatening illnesses. * Defined as </= 1 year life expectancy 6
1. A primary care provider/provider who knows the patient (and/or pt s values) well 2. Recognizes a clinical trigger 3. And uses a Cognitive Road Map to structure a discussion 4. That leads to creation of a personalized care plan. 5. Which is then documented in the patient s record. 1. A primary care provider/provider who knows the patient (and/or pt s values) well 2. Recognizes a clinical trigger 3. And uses a Cognitive Road Map to structure a discussion 4. That leads to creation of a personalized care plan. 5. Which is then documented in the patient s record. Communication is bi directional 1. A primary care provider/provider who knows the patient (and/or pt s values) well 2. Recognizes a clinical trigger 3. And uses a Cognitive Road Map to structure a discussion 4. That leads to creation of a personalized care plan. 5. Which is then documented in the patient s record. 7
Cancer ESRD CHF COPD ESLD Dementia Don t wait for a crisis! Would I be surprised if this patient died in the next year? Functional decline Increasing care intensity Hospital ED Medications 1. A primary care provider/provider who knows the patient (and/or pt s values) well 2. Recognizes a clinical trigger 3. And uses a Cognitive Road Map to structure a discussion 4. That leads to creation of a personalized care plan. 5. Which is then documented in the patient s record. 8
Primary Palliative Care Communication Skills In medical consultations, patients experience a double need: to know and understand and to feel known and understood. JCO 32(31): Nov 2014. Know patients, not just their diseases: Priorities Values Support systems, resources Belief systems Decision making preferences 9
SPIKES Set up/setting Perception Invitation Knowledge Emotion/Empathy Summarize NURSE Name the emotion Statements of Understanding Respect Support Explore emotion What do I want to accomplish? What do information do I need to share? What do I know about this patient s values and goals? Emotional preparation: What do I expect from this encounter? Review the chart Invite the right people Textbook vs Reality Make time Private room, chairs and tissues Introductions Sit down Appropriate eye and physical contact Inquire about patient s knowledge of their disease or situation What is your understanding about your cancer at this stage? the reason we ordered the CT scan? I see you were just discharged from the hospital? Tell me what they told you about your heart failure? 10
ASK: What does your patient want to know? Don t make assumptions About culture About information preferences Use official interpreters I want to talk to you about your prognosis, but I am not sure what you want to know. Are you the sort of person who likes to know details or general information about your illness? Fire the warning shot I have some serious news to share. I have some bad news. Your cancer back and has spread to your liver. OR I want to talk about the results of your scan. The cancer has returned and has spread to your liver. Let s talk about what that means. Use jargon free language Know your audience Silence is helpful Tell the truth Repeat as necessary Stop and check for understanding Repeat family/patient s words to ask questions: You said you hate being in the hospital. Tell me more about that. You said she wouldn t want to be a vegetable. What does that mean to her? Silence Non verbal communication 11
N = Naming U = Understanding R = Respecting S = Supporting E = Exploring I can tell you are really frustrated. This helps me understand what you are thinking. You ve done an amazing job coping with your situation I m going to help you through the next steps. Tell me more What are your triggers? Which emotions make you nervous? Remember You are not responsible for the disease What s your technique for in the moment re orienting Ex. Three deep breathes VITALtalk.org Non abandonment: We will work together on this. I will be with you through this process. Check understanding: When you go home today, how will you explain what I told you to your family? Invite questions What questions do you have? Does the patient know the next step? Repeat as necessary What are the patient s goals? Can you connect prognosis, patient goals and service needs to resources you might offer? 12
1. A primary care provider/provider who knows the patient (and/or pt s values) well 2. Recognizes a clinical trigger 3. And uses a Cognitive Road Map to structure a discussion 4. That leads to creation of a personalized care plan. 5. Which is then documented in the patient s record. If your health situation worsens, what are your most important goals? I wish we had a way to make this better, too, but I m worried. Have you ever considered what would happen if the treatments didn t work anymore? What are your fears? Worries? What are you hoping for? SICG Clinical Scenario Values/Goals Service Needs Plan of Care 13
Mr. H is a 69 yo with ESLD and severe arthritis. Pace of ESLD is accelerating. You are going to have a conversation: 1. Setting: Office 2. Clinical Trigger: Another hospital stay 3. What do I need to do? Use SPIKES to have a discussion about advanced care planning (ACP) and hospitalizations Set Up: Review record Clinical Trigger! Perception: So you were just discharged from the hospital. Tell me what the team told you? Invitation: I m a little worried. I d like to talk about some ideas I have. Is that OK? K (continued) Prognosis Goals/Values: So you said you didn t want to be in the hospital again? Can you tell me what is important to you now? AD Wife Being with my grandson Patient Address Emotion Summary Connect goals and service needs Values/Goals: Ask about hospital, preferences Clinical Scenario: Provide info and care recs Plan of Care Service Needs: SW support for AD; Hospice consultation 14
Providers Like It Here What s Happening? (Knowledge) Back A et al, CA: A Cancer Journal for Clinicians: 55(3): 2005. What Does It Mean to Me? (Identity) How do I Feel About This? (Emotions) Consider Emotion or Identity Questions if You are Stuck in a Conversation Facts Identity/ Meaning Emotion Communication Outcome Tell Me More Statements: Facts: Could you tell me more about what information you need? Emotions: Could you tell me more about how you are feeling about this news? Identity: Tell me more about what this means for you? Back, Al et al. Approaching Difficult Tasks in Oncology. Ca: A Cancer Journal For Clinicians. 2005. 1. A primary care provider/provider who knows the patient (and/or pt s values) well 2. Recognizes a clinical trigger 3. And uses a Cognitive Road Map to structure a discussion 4. That leads to creation of a personalized care plan. 5. Which is then documented in the patient s record. Place DNR orders when appropriate Get a copy of advance directive (AD) or NM Medical Orders for Scope of Treatment (MOST) form and scan it! Write a clear note Code note, surrogate decision maker, etc.. IT systems can be challenging 15
Wait, you mean we get paid to talk about this stuff? CPT Codes 99497, 99498 Ist 30 min: $80 86 2nd 30 min: $75 Which concept or skill will you apply in the next month in your clinical practice? SPIKES? A NURSE skill? Eliciting values? Recognizing clinical triggers? Other Books and Articles: efinlay@salud.unm.edu Back A, Arnold R, and Tulsky J. Mastering Communication with Seriously Ill Patients: Balancing Honesty with Empathy and Hope. Cambridge University Press. 2009. Bernacki, RE et al. Communicating about Serious Illness Care Goals: a Review and Synthesis of Best Practices. JAMA Internal Medicine. 2014 Dec; 174(12): 1994 2003. Clayton, J et al. Clinical Practice Guidelines for Communicating Prognosis and End of Life Issues with Adults in the Advanced Stages of a Life Limiting Illness, and their Caregivers. MJA. 2007: 186(12) S77 S108. Websites: VITALtalk.org www.eprognosis.org www.mypcnow.org 16