“Grave” Lessons in End of Life Care

1. “Grave” Lessons in End of Life Care Hector López, DO Council on Minority Health Issues

2. EOL Learning Objectives Enjoy light-hearted vignettes about “Grave” EOL issues. Participants will learn how to initiate and conduct a patient-centered EOL discussion with diverse minority patients and their families. Participants will discover the importance of discussing a DPAHC (Durable Power of Attorney for Health Care). Participants will learn to dispel myths and misinformation about a multiplicity of EOL issues. Participants will learn how to discuss medical treatments that ease dying rather than those that prolong suffering and death. Participants will learn to perceptively discuss CPR and DNR status of patients with different cultural background than their own. Participants will be better able to provide cultural competent care to diverse minority groups.

3. First Video clip Modern day reaper

4. Patient’s values, desires & needs • Uneasy with our own mortality/training • DO must ease death process, not prolong it • Get big picture from patient • Base on patients’ concept of death/EOL issues • What concerns patient the most?

5. Patient’s values, desires… • Emotions and desires of family/patient • Ethnicity/culture versus patient’s goals • Patient’s spiritual beliefs/rituals/unresolved issues • Limit medical jargon:procedure/prognosis/diagnosis/resuscitation/ • Resuscitation and DNR discussion with patient.

6. ☺Second video clip☻ Wrong way to explain CPR & Resusitation

7. Just D.O. it • Studies: 95% patients want DO to discuss EOL care. • Kaiser: Drs. brief, gave few numerical CPR outcomes* • Address fears, beliefs & frame talk based on outcomes • Avoid euphemisms “restart your heart” Emanuel LL, Barry MJ, Stoeckle JD, et al. Advance directives for medical care—a case for greater use. N Engl J Med 1991;324(13):889-95 . *Grave Words video Dr. Bernard Lo

8. Just D.O. it • Only 1-12% survive CPR, patients think 90% do. • Potential versus Imminent death. • Negotiate with pt and family. May need different terms • Ensure a “good” dignified & peaceful death.

9. Cultural Competent Care • Don’t stereotype all patients of one culture • Seek each patient’s individual wishes • Is patient able to grasp grim diagnosis? • Confirm understanding, maybe pts “didn’t See what they Heard”

10. Cultural Competent Care • Note cultural pain differences • Discuss advance directives, only 10-15% have AD. • If no AD form, document in chart, or NOT VALID! • Cost savings with AD. Blacks, Latinos cost more at EOL *

11. Cultural Competent Care • Engage patient, family, other Decision Makers. • Initiate discussions as scenarios that affected other patients • Monitor non-verbal cues • In some cultures, discussing death directly is taboo • Use qualified interpreters. Don’t apply the Golden rule. *Arch of IM vol 169 #5, 3/9/09 Wilner, A, Pain Management Across Cultures. 10/14/2008, Medscape Neurology & Neurosurgery Green CR, Ndao-Brumblay SK, West B, et al Differences in prescription opioid analgesic availability: comparing minority and white pharmacies across MI. J Pain. 2005;6:689-699

12. Patients & EOL Discussion • Experienced a greater sense of trust and well-being. • Believe treatments and technology will be geared to their goals and wishes. • No adverse patient effects seen by having these EOL discussions. Virmani J, et al. Relationship of ADs to physcian-patient communication. AIMed.1994;154:154:909-913. Smucker WD, Ditto PH, et al. Elderly outpatients respond favorably to a physician-initiated irective discussion. J Am Board Fam Pract 1993;6(5):473-82. Tierney WM, Dexter PR, et al. The effect of discussions about advance directives on patients' satisfaction with primary care. J Gen Intern Med 2001;16:32-40

13. Third video clip…. A Sensitive Caring D.O.

14. EOL Cultural Competency Resources • http://www.fanlight.com/catalog/films/456_hyb.php • http://www.fanlight.com/downloads/HoldYourBreath.pdf • http://medethicsfilms.stanford.edu/holdyourbreath/howto.html • http://www.aahpm.org/about/index.html • http://ajh.sagepub.com/cgi/content/refs/23/5/404 • http://goliath.ecnext.com/coms2/gi_0199-6837217/Cultural-competency-key-in-end.html • http://cat.inist.fr/?aModele=afficheN&cpsidt=21884256 • http://www.amazon.com/Cultural-Issues-Life-Decision-Making/dp/0761912177 • http://www.ncbi.nlm.nih.gov/pubmed/12442876 • The American Academy of Hospice and Palliative Medicine ( Cultural competence group )

15. A minority patient’s verbal statement about their live support views is not considered valid unless documented in an advance directive. True False

16. Approximately 42% of people in the USA have completed a Durable Power of Attorney for Health Care. True False

17. The racial and ethnic health care disparities in the USA are pervasive until the time minority patients die. True False

18. Research shows that most minority patients find discussions about life support and end of life planning disturbing or upsetting. True False

19. Doctors and family members usually make decisions for incompetent patients that reflect the patient’s own wishes as opposed to their own values. True False

20. The survival to discharge outcomes of CPR in general in-patient wards is usually >35%. True False