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DIFFICULT DISCUSSIONS BETTER DECISIONS

DIFFICULT DISCUSSIONS BETTER DECISIONS. Christine Welsh RN, John Scott MD February 27th 2013. Disclosures. WHO ARE WE?. Who are you?. What do Patients Want?. End of life planning (Hungry beast) you tube. Decision making. Last Session?. Barrriers

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DIFFICULT DISCUSSIONS BETTER DECISIONS

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  1. DIFFICULT DISCUSSIONSBETTER DECISIONS Christine Welsh RN, John Scott MD February 27th 2013

  2. Disclosures

  3. WHO ARE WE? Who are you?

  4. What do Patients Want? End of life planning (Hungry beast) you tube

  5. Decision making

  6. Last Session? • Barrriers • Cultural and spiritual aspects • Reframing hope • Triggers for difficult conversations • Lessons from Critical care • Gold Standards Framework • Illness trajectories • Communication goals • Research in Ottawa

  7. A Department of Medicine & TOH Project The Divisions of Palliative Care, Medical Oncology, Internal Medicine and Cardiology In collaboration with the Department of Radiation Oncology Funded by The TOHAMO Innovation Fund, the Associate Medical Services Palliative Care Fund and the Bruyère Academic Medical Organization and Bruyère Research Institute In collaboration with The PALLIUM Program of Canada New Study Difficult DiscussionsBetter Decisions 7

  8. Movie (20 & 22)

  9. QUESTION What percentage of cancer patients visited ED in the last 2 weeks of life in Ontario? 9

  10. 40% 10

  11. QUESTION What percentage of cancer patients die in acute care hospitals in Ontario? 11

  12. ANSWER 53% 12

  13. QUESTION in a study of cancer patients who visited a TOH emergency department in the last 2 weeks of life, what % had advance directives & DNRs? 13

  14. ANSWER 14

  15. Reflecting on the videos • How did you feel while viewing the video? • What was done well? • What can be done better? • What are some useful phrases? 15

  16. Video 1B

  17. Cue Cards • Adapt to individual situations • Behaviors to avoid • Blocking • Lecturing • Collusion • Premature reassurance • Behaviors to cultivate • Behaviors to cultivate • Ask-Tell-Ask • Tell me more • Respond to emotions • NURSE • Name the emotion • Understand • Respect (verbal or non-verbal) • Supporting • Explore 17

  18. Key behaviors in the conversations 18

  19. Key behaviors in the conversations 19

  20. QUESTIONS What is the annual mortality rate of patients with NYHA Class II? What is annual mortality rate of pts with NYHA Class IV?

  21. CHF Mortality NYHA Class II Annual mortality rate 5-15% 50-80% die suddenly NYHA Class IV Annual mortality rate 30-70% 5-30% die suddenly

  22. Reflecting on the videos • How did you feel while viewing the video? • What was done well? • What can be done better? • What are some useful phrases? 22

  23. Film – 8a & 8b

  24. Cue Cards • Adapt to individual situations • How long do I have to live? • “We are not very good at predicting?” • “I think it is in the order of [days/weeks/months/many months/years]” • “That must be an important question for you?” • Or • “I don’t know, I will talk to the specialist to get more information” • “Does this come as a surprise to you?” • “Remember we could be wrong..it may be longer…or shorter than what I think” • “I want you to know that no matter what the time is we will get you the best care” app 24

  25. Heyland Dk et al. Open Medicine 2009 Heyland DK et al. Discussing prognosis with patients and their families near the end of life: impact on satisfaction with end-of-life care. Open Medicine 2009;3(2):101-110 Question • In a study of 440 pts with end-stage disease, the % of pts who recalled prognosis discussions with their families : • Cancer pts? • CHF pts? • COPD pts? 25

  26. Participants who recalled prognosis discussions: Heyland DK et al. Discussing prognosis with patients and their families near the end of life: impact on satisfaction with end-of-life care. Open Medicine 2009;3(2):101-110 • Patients (n=440) : 18% • Family members (n=160): 30% 26

  27. “I didn’t expect him to die so soon. I got the feeling the doctors weren’t entirely honest with us about his condition. My husband resisted talking about dying and after 40 years of marriage I feel he let me down by not opening up and I guess I let him down for not knowing how to talk about some of the things that I needed to discuss. It would have been nice closure if things had been different in the end. I can never get that time back.”– Wife of participant in end-of-life study Heyland DK et al. Discussing prognosis with patients and their families near the end of life: impact on satisfaction with end-of-life care. Open Medicine 2009;3(2):101-110 27

  28. Although most family members had not had a prognosis discussion, 90% of them indicated that they would like to have such a discussion. Heyland DK et al. Discussing prognosis with patients and their families near the end of life: impact on satisfaction with end-of-life care. Open Medicine 2009;3(2):101-110 28

  29. Heart study of 220 pt’s (mean age 88y) McCarthy EP, et al. Advance care planning and health care preferences of community-dwelling elders: the Framingham Heart Study. J Gerontol A BiolSci Med Sci 2008;63(9):951-9. • 70% said they had discussed their wishes for end-of-life care with someone, • 17% had discussed them with a physician or other health care provider. • Two-thirds said they had health care proxies and 55% said they had living wills, 29

  30. QUESTION What is approximate life expectancy of a cancer patient with an ECOG functional level of 3? 40-50% PPS 30

  31. illness trajectory in cancer patients with progressive cancer Note that this data represents mean values N=7830 pts Death 31

  32. illness trajectory in cancer patients with progressive cancer Decline is generally gradual until PPS reaches about 50% to 60% (ECOG 3). Thereafter the decline is often more rapid. If not yet initiated, a Palliative Care approach should be activated. Generally has a life expectancy of weeks to a weeks to months Life expectancy of days to weeks Note that this data represents mean values N=7830 pts Death 32

  33. components of EOL care that patients with end-stage COPD would like to discuss with their physician Diagnosis & disease process Role of treatments in improving symptoms, QOL & duration of life Prognosis for survival & QOL What dying might be like Advance care planning for future medical care & exacerbations Curtis JR, Wet al. Patients’ perspectives on physicians’ skills at end-of-life care: differences between patients with COPD, cancer, and AIDS. Chest 2002; 122:356–362.

  34. Reflecting on the videos • How did you feel while viewing the video? • What was done well? • What can be done better? • What are some useful phrases? 34

  35. Video 6a & 6b

  36. Cue Cards • Adapt to individual situations • Disease progression • “What do you feel is happening with your illness?” • “I’m afraid there are signs that the disease is progressing” • “Have you noticed things changing?” • “I think it is important hope for the best and also prepare for worse” • “I wish I could be saying that we can cure or control your illness, but I would be lying if I did.” 36

  37. COPD Patients: Information needs Heffner J et al. Chest 2000;117:1474-81.

  38. QUESTION Does initiating palliative care increase depression, anxiety & hopelessness? 38

  39. Weeks JC et al. Patients’ expectations about effects of chemotherapy for advanced cancer. NEJM 2012;367(17):116-1625 • Of 1193 pts with newly diagnosed metastatic lung or colorectal cancer: • 69% of pts with lung cancer • 81% of pts with colorectal cancer Had inaccurate expectations about the curative potential of their chemotherapy: 39

  40. Pts reporting EOL discussions had1: 1. Wright AA, et al: Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA 2008;300:1665-1673 2. Smith TJ, Dow LA, Virago E, et al: Giving honest information to patients with advanced cancer maintains hope. Oncology 2010;24:521-525 • No higher rates of depression or anxiety • lower rates of ventilation & resuscitation • more & earlier hospice enrollment • Improved family bereavement • Hope is maintained even with truthful discussions • Physician honesty increases sense of hope2 40

  41. Impact of avoiding these discussions • Ratnapalan M, et al. Documentation of best interest by intensivists: a retrospective study in an Ontario critical care unit. BMC Medical Ethics 2010, 11:1 • Stajduhar K, et al. Preferences for location of death of seriously ill hospitalized patients: perspectives from Canadian patients and their family caregivers. Palliative Medicine 2008; 22(1): 85-88 • Adler ED, Golfinger JZ, Kalman J, Park ME, Meier DE. Palliative Care in the Treatment of Advanced Heart Failure. Circulation. 2009;120:2597-2606 • Gore JM, Brophy CJ, Greenstone MA. How well do we care for patients with end stage chronic obstructive pulmonary disease (COPD)? A comparison of palliative care and quality of life in COPD and lung cancer. Thorax 2000;55:1000-1006 • Davison SN. End-of-Life Care Preferences and Needs: Perceptions of Patients with Chronic Kidney Disease. Clin J Am Soc Nephrol 5: 195-204, 2010 • High burden of suffering for patients • Inappropriate utilization of resources • Care that is inconsistent with patients’ wishes • Cancer & non-cancer populations 41

  42. Impact of avoiding these discussions Harrington SE, Smith TJ: The role of chemotherapy at the end of life: “When is enough, enough?” JAMA 2008; 299:2667-2678 Patients lose good time with their families Lose opportunities for reflection and preparing for their life’s end Spend more time in the hospital and ICU 42

  43. key take-home messages • Help the patient & family be prepared earlier • Palliative care is not only about the last days or weeks of life • not mutually exclusive with disease-modifying treatments • Ask the question!- identify patients earlier • Look for cues and create opportunities for discussion • Be honest & sensitive • Use the phrases & tools • Reframe hope • Document 44

  44. Take home messages 1 Vogel L. Advance directives: obstacles in preparing for the worst. CMAJ 2011;183(1):E39-40. 2. Tierney WM, et al. The effects of discussions about advance directives on patient’s satisfaction with primary care. J Gen Intern Med 2001;16(1):32-40. 3. Detering KM, et al. The impact of advance care planning on end of life care in elderly patients: randomized controlled trial. BMJ 2010;340:c1345. 4. Robinson C, et al. Awareness of do-not-resuscitate orders. What do patients know and want? Can Fam Physician 2012;58:e229-33. • Many barriers prevent Canadians from having these difficult conversations1 • Evidence that discussions about advance directives2: • improve patients’ satisfaction with their primary care providers • improve end-of-life care • Improve patient and family satisfaction • Reduce stress, anxiety, and depression in surviving relatives.3 • [FPs well placed to have these discussions4] 45

  45. QUESTIONS 47

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