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End-of-Life Communication from Interdisciplinary Perspectives

End-of-Life Communication from Interdisciplinary Perspectives . Learning to Care for the Patient’s Lived Body. Speakers. Sandra Sanchez-Reilly, MD University of Texas Health Science Center and the South Texas Veterans Health Care System, San Antonio, TX Elaine Wittenberg-Lyles, PhD

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End-of-Life Communication from Interdisciplinary Perspectives

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  1. End-of-Life Communication from Interdisciplinary Perspectives Learning to Care for the Patient’s Lived Body

  2. Speakers Sandra Sanchez-Reilly, MD University of Texas Health Science Center and the South Texas Veterans Health Care System, San Antonio, TX Elaine Wittenberg-Lyles, PhD University of North Texas Michele Saunders, MD University of Texas Health Science Center and the South Texas Veterans Health Care System, San Antonio, TX

  3. Objectives • To present an overview of several innovative educational methods currently used in end-of-life care communication training (Education and Communication) • To acknowledge the importance of interdisciplinary team approach in end-of-life care and training (Interdisciplinary and Communication)

  4. General Definitions • Palliative Care • End-of-Life • Interdisciplinary • Lived Body

  5. General Definitions • Palliative Care • End-of-Life • Interdisciplinary • Lived Body

  6. The Cure - Care Model: The Old System D E A T H Life Prolonging Care Palliative/ Hospice Care Disease Progression

  7. Palliative Care’s Place in the Course of Illness Life Prolonging Therapy Death Diagnosis of serious illness Palliative Care Medicare Hospice Benefit

  8. “Modern Medicine” End-of-Life Palliative Care

  9. General Definitions • Palliative Care • End-of-Life • Interdisciplinary • Lived Body

  10. Interdisciplinary Teams • Consist of a medical director, the patient’s physician, a nurse who functions as the case manager, social worker, pastoral care, and certified nurse assistant. • Team members who work from different orientations while at the same time engaging in joint work. • Care plans that have been assessed by experts in different disciplines Hoyer T: A history of the Medicare Hospice Benefit. The Hospice Journal 1998;13:61-69. Dyeson TB: The home health care team: What can we learn from the hospice experience? Home Health Care Management & Practice 2005;17:125-127.

  11. The patient’s lived body • Communication about the psychological and social aspects of dying. • includes good health care professional and patient communication • team attention to psychosocial issues such as depression • efficient interdisciplinary staff communication

  12. EDUCATION IN END-OF-LIFE COMMUNICATION Where are we?

  13. Goals of Education • Increase knowledge/expertise • Communication skills • Interdisciplinary team awareness

  14. Goals of Education • Increase knowledge/expertise • Communication skills • Interdisciplinary team awareness

  15. Deficiencies in Medical Education • 74% of residencies in U.S. offer no training in end of life care. • 83% of residencies offer no hospice rotation. • 41% of medical students never witnessed an attending talking with a dying person or his family, and 35% never discussed the care of a dying patient with a teaching attending. • Billings & Block JAMA 1997;278:733.

  16. The Good News: Palliative Care Education Is Improving • Medical school LCME requirement: “Clinical instruction must include important aspects of … end of life care.” 2000 • Residency ACGME requirements for internal medicine and internal medicine subspecialties: “Each resident should receive instruction in the principles of palliative care…it is desirable that residents participate in hospice and home care…The program must evaluate residents’ technical proficiency,…communication, humanistic qualities, and professional attitudes and behavior…” 2000

  17. Palliative Care Education in Medical Schools Is Improving • Annual medical school exit questionnaire 2002-2003 • 126 LCME accredited medical schools • 110 (87%) require instructional hours in palliative care • Average # of hours required: 12, but highly variable (4-14) • Barzansky B, Etzel SI. JAMA 2003; 290:1190-6 • Dickinson GE. Am J Hosp Palliat Care. 2006 23(3): 197-204

  18. Current State of Nursing Education in Palliative Care • Only 3% of nursing programs in the United States reported having a course dedicated to end-of-life issues in 2002. • 40% focus groups felt a need to increase this content in their curricula. • Nursing textbooks offer little in the way of end-of-life care • Nurses report wishing they had learned more about caring for the dying while in their undergraduate and graduate nursing programs. Robinson R. End-of-life education in undergraduate nursing curricula. Dimens Crit Care Nurs. 2004 Mar-Apr;23(2):89-92

  19. Special Initiatives • Objective Structured Clinical Examination (OSCE) with Standardized Patients • End of Life Nursing Education Curriculum (ELNEC) • Education on Palliative and End-of-life-care (EPEC) • Education on Palliative and End-of-life-care for Oncologists (EPEC-O) • Palliative Care Education and Practice (PCEP) • Center for Advanced Palliative Care (CAPC)

  20. GERIATRICS AND PALLIATIVE CARE

  21. University of Texas Health Science Center at San Antonio and The South Texas Veterans Health Care System

  22. Palliative Care: Educational Programs • Interprofessional Palliative Care Fellowship • Community Hospice Settings • Medical Students

  23. Models of Care: A Geriatric Palliative Care Team

  24. Goals of Education • Increase knowledge/expertise • Communication skills • Interdisciplinary team awareness

  25. Clinical Barriers Uncertainty anxiety (patient & doctor) feelings of failure expressed emotion lack of training Time End-of-Life Communication

  26. Educational Barriers One-way communication End-of-Life Communication

  27. End-of-Life Communication • Team Barriers • Working together as a team • Different disciplines • Psychologist

  28. Potential Solutions • Clinical Barriers: EDUCATION • Team Barriers: • INTERDISCIPLINARY TEAM MEETINGS • SELF CARE: “SPIRITUAL ROUNDS” • Educational Barriers: • FAMILY MEETINGS

  29. Potential Solutions • Family meetings • Provides for team environment • Includes patient and family • Based on communication • Necessary for treating the patient’s lived body

  30. Family Meetings: Background • The importance of involving patients and family members in healthcare teams is well documented* • Family meetings improve satisfaction, coordination of care, and communication** *(Saltz & Schaefer, 1996; McDonald et al., 2002; Fischer, Schulz, & Ogletree, 1999; Andrews et al., 1998) ** (Andrews et al, 1998; Axford, Askill, & Jones, 2002)

  31. What Do Family Members Want? Study of 475 family members 1-2 years after bereavement • Loved one’s wishes honored • Inclusion in decision processes • Support/assistance at home • Practical help (transportation, medicines, equipment) • Personal care needs (bathing, feeding, toileting) • Honest information • 24/7 access • To be listened to • Privacy • To be remembered and contacted after the death Tolle et al. Oregon report card.1999 www.ohsu.edu/ethics

  32. Family Meetings • Challenges • Difficulty listening – Physician Perspective • Difficulty making decisions – Social Worker Perspective • Difficult family dynamics

  33. Family Meetings: A Framework PRE-MEETING “BRING THE PATIENT INTO THE ROOM” “SPIKES” MODEL

  34. THE S.P.I.K.E.S. MODEL • S:Setting. Pick a private location. • P:Perception. Find out how the patient views the medical situation. • I:Invitation. Ask whether the patient wants to know. • K:Knowledge. Warn before dropping bad news. • E:Empathy. Respond to the patient’s emotions. • S:Strategy/Summary. Once they know, include patients in treatment decisions. Walter F. Bailea, Robert Buckman. The Oncologist, Vol. 5, No. 4, 302-311, August 2000

  35. Family Meetings: A Framework PRE-MEETING “BRING THE PATIENT INTO THE ROOM” “SPIKES” MODEL COMFORT AND REFRAME

  36. Family Meetings: ROLE PLAY • 85 YEAR-OLD MAN WITH PAST MEDICAL HISTORY OF DIABETES, HYPERTENSION, AND RECENTLY DIAGNOSED METASTASIC LUNG CANCER. PT IS IN THE HOSPITAL WITH EXCRUTIATING PAIN, BUT ALERT, WITH HIS WIFE AND DAUGHTER AT BEDSIDE. THEY ARE HOPING FOR A CURE…

  37. Family Meetings: ROLE PLAY • DR. R., HIS PRIMARY PHYSICIAN AND A MEDICINE RESIDENT, IS NOT VERY COMFORTABLE WITH DELIVERING BAD NEWS, HE WAS NEVER PROPERLY TRAINED… • HIS ATTENDING PHYSICIAN IS NOT WILLING TO DO IT EITHER: “THE FAMILY SHOULD KNOW BY NOW”

  38. Family Meetings: ROLE PLAY • PT LIVES WITH HIS WIFE, AND HIS PENSION IS THEIR ONLY SOURCE OF INCOME • HIS DAUGHTER HAS NOT BEEN INVOLVED IN THEIR LIVES SINCE HE RE-MARRIED • THE PALLIATIVE CARE TEAM IS CALLED TO “PROVIDE HOSPICE CARE”…

  39. Family Meetings: A GOOD SKILL TO MASTER • Rewards/Learning about communication • Family understanding • Understanding your role • Facilitating difficult conversations • Understanding the context

  40. Goals of Education • Increase knowledge/expertise • Communication skills • Interdisciplinary team awareness

  41. End-of-Life Communication is team based!

  42. Geriatrics Interdisciplinary Advisory Group, 2006 Interdisciplinary care: • Improves healthcare processes • Benefits the healthcare system and caregivers, • Adequately prepares healthcare providers for better care of older adults

  43. Interdisciplinary Collaboration • Interdependence and flexibility • Deviation from specific discipline specific boundaries; flexibility of job responsibilities Bronstein LR: Index of interdisciplinary collaboration. Social Work Research 2002;26:113-126. Bronstein LR: A model for interdisciplinary collaboration. Social Work 2003;48: 297-306.

  44. Interdisciplinary Collaboration • Newly created professional activities • Expansion of an individual’s specific job responsibilities • New activities that evolve through interdisciplinary collaboration include: (1) information sharing to educate others; and (2) additional tasks.

  45. Interdisciplinary Collaboration • Collective ownership of goals • Individuals share responsibilities for all aspects of decision-making and implement decision together • The discussion of “special cases” illustrated a collective ownership of goals. Such cases warrant additional information sharing.

  46. Interdisciplinary Collaboration • Reflective process • Team evaluation of team’s outcomes • Includes information about (1) procedural issues, (2) reviews of deaths, and (3) the sharing of workplace stress.

  47. Interdisciplinary Perspectives • Team member collaboration provides for holistic care of the patient’s lived body Example: Treatment of all pain • Physical • Spiritual • Emotional • Psychological

  48. Thank you Sandra Sanchez-Reilly sanchezreill@uthscsa.edu210-617-5237 Elaine Wittenberg-Lyles lyles@unt.edu940-565-4450

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