Aspects of Communication in Quality End-of Life Care Presented by Stephen Goldfine, MD Chief Medical Officer Samaritan Healthcare & Hospice SamaritanNJ.org
Objectives To know and understand: The importance of good communication from diagnosis through end of life The types, purposes, and factors that influence communication Ways to discuss hospice and palliative care The purpose of POLST & how it differs from DNR Strategies to understand and resolve conflict related to patient care and treatment goals
Definition Sharing of information through utilization of a set of common rules Types Verbal or nonverbal Body language, eye contact, gestures, tone of voice 80% of communication is nonverbal Oral or written Personal or impersonal Issue oriented or relationship oriented
Benefits of Good Communication Improve accuracy of diagnosis and quality of management Improve eliciting and imparting of information Improve patients understanding, retention of information, compliance Reduce anxiety, uncertainty, and litigation Improve doctor and patient satisfaction Dias et al. (2003). Breaking Bad News: A Patient s Perspective, The Oncologist, 8:592.
Benefits of Good Communication Without clear, goal-directed communication, care loses its purpose. When the purpose of care (aggressive treatment or quality-of-life preservation) becomes muddied or even lost in an unfortunate battle of wills, distress is certain to occur in patients, families, and caregivers. Marcus & Mott (2014). Difficult Conversations: From Diagnosis to Death, The Ochsner Journal, 14:712
Communication in End-of-Life Care Fundamental aspect of palliative care Ethical obligation* Advanced or terminal illness is a family experience Is a major area of need Requires interdisciplinary collaboration * Lenherr, G., Meyer-Zehnder, B., Kressig, R., Reiter-Theil, S. (April 5, 2012). To speak, or not to speak do clinicians speak about dying and death with geriatric patients at the end of life? Swiss Med Wkly, 142: w13563, p. 1
Communication in End-of-Life Care (cont) Cannot share too much information But individual preferences should be assessed; time may be needed to accept new information* Is therapeutic Patients/families consider good communication, including emotional and spiritual aspects, key to a good death (Lenherr et al., p. 6) Providers must often initiate the conversation (Lenherr et al., p. 6) * Cherlin, E., et al. (2005). Communication between Physicians and Family Caregivers about Care at End of Life, J. Palliat Med, 8(6) 1176-1185.
Factors Influencing Communication Patient/Family Family systems/culture Financial/educational Physical/cognitive limitations (Lenherr et al., p. 4) Coping/grief
Factors Influencing Communication Health care professionals Fear of own mortality Discomfort / lack of confidence to give bad news (Lenherr et al., p.4) Inaccuracy of prognostication Fear of patient thinking doctor has given up (Lenherr et al., p. 5)
Factors Influencing Communication Health care professionals (cont.) Lack of cultural understanding Fear of removing hope Lack of training Lack of time Gender differences
Other Barriers Lack of privacy Interruptions & distractions Palliative care stigma* All contribute to stress. Granek, L., Krzyzanowska, M., Tozer, R., Mazzotta, P. (July 2013). Oncologists Strategies and Barriers to Effective Communication About the End of Life, jop.ascopubs.org, p. e132. Downloaded February 24, 2015.
Study: End-of-Life Communication Yale study of 200 hospice patients and families: 21% of physicians did not tell family caregiver patient s illness could not be cured 32% never discussed using hospice First discussions of above often occurred within one month of patient s death Cherlin, E., et al.
Study: End-of-Life Communication (cont.) Communication about end-of-life care is often limited Causes include physicians lack of discussion and family caregivers difficulty hearing the news A clear understanding of the illness and treatment options is important to patients and families Cherlin et al.
Who are the Dying? : Prognostic Accuracy in Terminally Ill Patients 343 physicians provided survival estimates for 468 patients Median survival was 24 days 20% (92/468) predictions were accurate 63% were over-optimistic 17% were over-pessimistic Christakis, N., & Lamont, E. (2000). Extent and determinants of error in doctors prognoses in terminally ill patients: Prospective Cohort Study, BMJ, 320, 469-473.
Who are the Dying? : Prognostic Accuracy in Terminally Ill Patients Prognosis Christakis et al. (BMJ 2000) found that only 20% of predictions were accurate, overestimated survival by a factor of 5.3%, and as the duration of physician patient relationship increased, prognostic accuracy decreased. Christakis el al.* found that physicians disdained prognostication: 60.4% find it stressful ; 58.7% find it difficult; 43.7% wait to be asked by patients before offering predictions. *Christakis, Nicholas A., MD, PhD, MPH, Iwashyna, Theodore J., Attitude and Selfreported Practice Regarding Prognostication in a National Sample of Internists, Arch Intern Med/ Vol. 158, Nov 23 1998, 2390-93
Communication process Seven key elements Medium Message Speaker Listener Feedback Interference Context
Communication Process The Message Most difficult aspect in end-of-life discussions Doctors are poor prognosticators and tend to avoid this subject Influenced by culture The Speaker Clear, sensitive, and have proper vocabulary Be direct, but not excessively blunt Balance honesty/realism with sensitivity/support Give realistic hope (for comfort if not cure) Convey that patient/family will not be abandoned (Dias et al.)
Communication Process (cont.) The Listener Actively involved in the conversation Nonverbal communication Must be present Occurs at 5 levels Hearing, understanding, retaining, analyzing, and active empathizing Offers feedback
Communication Process (cont.) Interference Internal External Context Time Place
Communications Strategies and Techniques Oncotalk SPIKES model Motivational Interviewing (MI) - Avoid closed-ended questions - Ask for the story in patient s words Solution-Focused Brief Therapy (SFBT) - Miracle question Cognitive Behavioral Therapy (CBT) MI and CBT help patients acknowledge difficult truths Marcus & Mott, p 714
Broaching the Topic of Hospice and Palliative Care Initiate conversation early in disease course, when patient is still feeling well * Ask what the patient/family already know Ask how much they want to know Advanced age, level of depression etc. may limit what patient wants to know (Dias et al.) Use language they understand *Ngo-Metzler, Q., August, K., Srinivasan, M., Liao, S., Meyskens, F. (January 15, 2008). End-of-Life Care: Guidelines for Patient-Centered Communication, American Family Physician, 77(2): 168. Downloaded February 24, 2015.
Common Statements to Avoid There s nothing we can do for you. It s time to think about withdrawal of care. You ve failed the treatment. I think you should consider hospice. Ngo-Metzger et al., p. 172
Alternatives: Statements to Use We can offer many options to control your symptoms and make you feel better. Do you think it s time to consider a different type of treatment, which focuses on your symptoms? I ll be here with you no matter what you decide. I want to provide intense, coordinated care with a team of professionals who will treat your symptoms and help you stay comfortable. Ngo-Metzger et al., p. 172
General Tips: Discussing Difficult Topics: Prioritize 2-4 key points patient should retain Coordinate key prognosis points with all providers, for consistent messages Multiple visits may be needed (Ngo-Metzger et al.) Continually probe patient s understanding Ask patient how he/she feels Leave time for questions (Dias et al.)
Broaching the Topic of Hospice and Palliative Care Studies indicate: Patients and families value being able to prepare for death Delays in discussions often lead to later hospice admission and fewer opportunities to say goodbye, complete personal and financial arrangements, and plan for last phase of patient s life. Cherlin et al.
Broaching the Topic of Hospice and Palliative Care Review the goals of palliative care Symptom management Achieve the best quality of life for the patient and his or her family Address all needs: physical, emotional, spiritual
DNR and POLST Need for these documents DNR vs. POLST Advance directives extend the patient s autonomy * Lack of DNR/POLST can signal lack of communication Only 20-30% of patients with metastatic cancer have a documented code status on their outpatient charts. *Daher, M., Ethical issues in the geriatric patient with advanced cancer living to the end Ann Oncol (2013) 24 (suppl 7): vii55-vii58 doi:10.1093/annonc/mdt262, p. vii56
Working with Emotions Sadness and anger are appropriate reactions to bad news Attentive listening Be silent allow time to process Acknowledge your own feelings I m so sorry I feel so bad for you. How can I help you?
Working with Emotions Reflect thoughts, emotions or behavior I can see how upset you are. This is so hard. Affirmation and respect Please tell me more about how you are feeling. Thank you for sharing your thoughts and feelings with me.
Working with Emotions Summarize/paraphrase We ve been talking for awhile about how things are going for you. Let me see if I can summarize and you can let me know if I m on track. Make a plan How can we help? We are here to answer any questions you or your family may have. Encourage reminiscing
Conflict Occurs in any situation in which the wants and needs of one party are incompatible with another s wants and needs Prolonged conflict will destroy relationships. Conflict resolution strategies
Areas of Potential Conflict What if you do not agree with patient goals and treatment choices? What if family is pushing for treatment considered to be futile, especially if the patient has expressed other wishes? Continuing futile treatment, or not pursuing treatment perceived as beneficial, is a source of moral distress.
Resolving Conflict Try to take a step back. Identify your own emotions. Define the conflict. Are your own values getting in the way? Obtain agreement on the conflict. Is this an ethical issue? Resources? Find a colleague and talk about it.
Prognostic Accuracy of Doctors? 1. 10% 2. 20% 3. 40% 4. 60%
Palliative Care Goals 1. Aggressive symptom management 2. To achieve best quality of life for patients and their families 3. To address physical, spiritual, and emotional needs of patients and their families 4. All of the above
References: Dias, L., Chabner, B., Lynch, T., Penson, R. (2003). Breaking Bad News: A Patient s Perspective, The Oncologist, 8:592, 595. Daher, M., Ethical issues in the geriatric patient with advanced cancer living to the end Ann Oncol (2013) 24 (suppl 7): vii55-vii58 doi:10.1093/annonc/mdt262 Marcus, J., & Mott, E. (2014). Difficult Conversations: From Diagnosis to Death, The Ochsner Journal, 14: 712 Lenherr, G., Meyer-Zehnder, B., Kressig, R., Reiter-Theil, S. (April 5, 2012). To speak, or not to speak do clinicians speak about dying and death with geriatric patients at the end of life? Swiss Med Wkly, 142: w13563, p. 1 Cherlin, E., Fried, T., Prigerson, H., Schulman-Green, D., Johnson-Hurzeler, R., Bradley, E. (December 2005). Communication between Physicians and Family Caregivers about Care at the End of Life: When Do Discussions Occur and What is Said, J. Palliat Med, 8(6): 1176-1185 Christakis, N., & Lamont, E. (2000). Extent and determinants of error in doctors prognoses in terminally ill patients: Prospective Cohort Study, BMJ, 320, 469-473. Christakis, Nicholas A., MD, PhD, MPH, Iwashyna, Theodore J., Attitude and Self-reported Practice Regarding Prognostication in a National Sample of Internists, Arch Intern Med/ Vol. 158, Nov 23 1998, 2390-93 Granek, L., Krzyzanowska, M., Tozer, R., Mazzotta, P. (July 2013). Oncologists Strategies and Barriers to Effective Communication About the End of Life, jop.ascopubs.org, p. e132. Downloaded February 24, 2015. Ngo-Metzler, Q., August, K., Srinivasan, M., Liao, S., Meyskens, F. (January 15, 2008). End-of-Life Care: Guidelines for Patient-Centered Communication, American Family Physician, 77(2): 168. Downloaded February 24, 2015. Center to Advance Palliative Care. For Policymakers: Overview. https://www.capc.org/policymakers/overview/, Downloaded March 18, 2015.