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Communicating at the EOL: Communicating with Patients/Families

Communicating at the EOL: Communicating with Patients/Families. Sharing Poor Prognosis Stu Farber MD sfarber@u.washington.edu Gregg VandeKieft, MD, MA gregg.vandekieft@providence.org July 2011. Caring Conversations: Transitioning from Cure to Care. Giving Information Telling.

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Communicating at the EOL: Communicating with Patients/Families

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  1. Communicating at the EOL: Communicating with Patients/Families Sharing Poor Prognosis Stu Farber MD sfarber@u.washington.edu Gregg VandeKieft, MD, MA gregg.vandekieft@providence.org July 2011

  2. Caring Conversations: Transitioning from Cure to Care Giving Information Telling

  3. Caring Conversations: Transitioning from Cure to Care Sharing Information Dialogue

  4. Caring Conversations: Transitioning from Cure to Care Special Dialogue • Helping pt/family understand where: • Disease and treatment end • Aging and the natural life cycle event we call end of life begins • You have a unique opportunity to assist: • Pre-existing relationship • We know this conversation effects pt/family choice

  5. Caring Conversations: Transitioning from Cure to Care Special Dialogue • Accepting this role takes courage • To succeed you enter into the pt/family story (values/goals) • You become a part of the story • You become vulnerable as another human sharing the mystery, pain, suffering, joy and wonder of mortality

  6. Caring Conversations: Transitioning from Cure to Care Special Dialogue When is the “right time” to have this dialogue? Surprise Question: Would you be surprised if this patient died in the next 6-12 months? If you wouldn’t be surprised then it is your professional responsibility to assist the patient/family prepare for the “worst” while expecting the “best”

  7. Caring Conversations: Transitioning from Cure to Care Making it Safe Setting the Stage within the Concept of Paradox • Certainty and Uncertainty • Life and Death

  8. Caring Conversations: Transitioning from Cure to Care Special Dialogue • What does the pt/family already know? • What does the pt/family want to know? • What does the pt/family need to know?

  9. Caring Conversations: Transitioning from Cure to Care Communication Basics • Tell-Ask-Tell • Ask-Tell-Ask • Ask(listen) Ask(listen) Ask(listen)-Tell-Ask • Silence • Pt/Family Cues • Terminators • Continuers

  10. Caring Conversations: Transitioning from Cure to CareCase of John • John is 68 with far advanced lung Ca • Just out of ICU • If he lives 24-48 hrs will be a miracle • He and his family still are asking for tx that will make him better • You are asked to talk with him and his family: wife, son and daughter

  11. Caring Conversations: Transitioning from Cure to Care Evidence Based Best Practice • Set a “safe context” for dialogue • Explore the patient/family story • Use evidence based domains • Language = skill • Create shared story among pt/family/medical team • Co-Create care plan among patient, family, medical team

  12. Caring Conversations: Transitioning from Cure to CareMy DeathRaymond Carver If I'm lucky, I'll be wired every which way in a hospital bed. Tubes running into my nose. But try not to be scared of me, friends!  I'm telling you right now that this is okay.     It's little enough to ask for at the end. Someone, I hope, will have phoned everyone to say,"Come quick, he's failing!"And they will come. And there will be time for meto bid goodbye to each of myloved ones....   

  13. Caring Conversations: Transitioning from Cure to Care Late Fragment And did you get what you wanted from this life, even so? I did. And what did you want? To call myself beloved. To feel myself beloved on the earth. Raymond Carver

  14. Caring Conversations: Transitioning from Cure to Care • Joan Borzoff and Phyllis Silverman Eds, Living with Dying, Columbia University Press, July, 2004, Chapter 5: A Respectful Death, Authors: Stuart Farber, Thomas Egnew, and Annalu Farber: pp102-127. • When the Healing Professional Weeps, Katz RS, Johnson TA Editors; Chapter Title: A Respectful Death: The Power of Relationship in End-of-Life Care, Authors: Lu Farber and Stu Farber, Routeledge (a member of the Taylor & Francis Group), New York, 2006 • Farber S, Egnew T, Stempel J, Vleck J, Monograph in End-of-life Care, American Academy of Family Practice, Vol 250/251 March/April, 2000 • Farber S, Egnew T, Bertsch J, Taylor TR, Guldin G, Issues in End-of-Life Care: Patient, Caregiver, & Clinician Perceptions, Journal of Palliative Medicine, Vol 6(1) 003:19-31. • Stewart M, Brown JB, Weston WW et al, Patient Centered Medicine, Sage Publications, Thousand Oaks, 1995 • Butow PN, Brown RF, Cogar S et al, Oncologists’ reactions to cancer patients’ verbal cues, Psycho-oncology 11:47-58 (2002) • Wright A, Zhang B, Ray A, et al, Associations among EOL discussions, pt mental health, medical care near death, and caregiver bereavement adjustment, JAMA, 2008; 300(14): 1665-1673

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