END-OF-LIFE CARE: Module 3

1. END-OF-LIFE CARE:Module 3 • Communicating with Patients and Families Module #3

2. Identified Deficits in Physician Communication Skills • Talk too much • Rarely explore patients’ values & attitudes • Discuss uncertainty using vague language • Tulsky, et al., 1998 • Avoid patients’ affective concerns • Parle, et al., 1997 • Overemphasize cognitive communication • Fail to assess patient understanding • Braddock, et al., 1999 Module #3

3. Learning Objectives • Recognize the importance of effective end-of-life (EOL) communication • Increase your EOL communication skills in: • Listening • Sharing bad news • Pronouncing death • Improve your ability to incorporate this content into your clinical teaching Module #3

4. Outline of Module • Background • Three techniques critical to EOL communication • Skills training • Listening • Sharing bad news • Death pronouncement • Diversity • Physician self-care strategies Module #3

5. General Challenges to Patient-Physician Communication • Time constraints • Language differences • Mismatch of agendas • Lack of teamwork • Discomfort with strong emotions • Quality of physician training • Resistance to change habits • Buckman (1984), Ford et al (1994), Buss (1998) Module #3

6. Unique Challenges in Communication at the end of life: • Emotionally laden material • For patient, for family, for providers • Issues of uncertainty are common • Prognosis • What is it like to die? • The meaning of death Module #3

7. Three Techniques Critical to End-of-Life Communication • Distinguish between cognitive and affective elements of communication, and respond appropriately • Clarify ambiguity • Listen in balance with speaking Suchman,1997 Module #3

8. Two Elements to Keep in Mind: • Cognition = intellectual component • Affect = emotional component Module #3

9. Cognitive Response • How might you respond to the cognitive component of the patient or family member’s communication? Module #3

10. Affective Response • Identify and explore the affect: • “You seem angry (worried, upset) about this. Can you help me understand what’s going on for you?” • Acknowledge the probable source of affect and connect it with its source • “You’ve been through a lot. No wonder you’re feeling like this.” Module #3

11. Clarify Ambiguity • Ambiguous statements: • “I want you to take care of me when the time comes” • “I want everything done for my father” • What do you hear? • “I want compassionate care” • “I want assisted suicide” Module #3

12. Listen in Balance with Speaking • Convey listening nonverbally • Delay your response for a few moments • Reflect the affective component Module #3

13. Delay Exercise • A’s: Talk about a memorable experience with dying, that you have had as a practitioner • B’s: • Distinguish between cognitive and affective components • Listen for ambiguity • Listen in balance with speaking • Convey listening nonverbally • Delay response for a few moments • Reflect the affective component Module #3

14. Debrief Module #3

15. Sharing Bad News • Step 1: Prepare • Step 2: Convey Information • Step 3: Follow Up Module #3

16. Step 1: Prepare • Prepare yourself • Prepare the recipients • Prepare the environment Module #3

17. Step 2: Convey Information • Establish empathic connection • Give an advance alert • Convey realistic information in a clear manner • Observe and respond to cognitive and affective reactions • Clarify ambiguity • Restore and catalyze hope Module #3

18. Step 3: Follow Up • Set concrete goals • Connect patient/family with support systems • Arrange follow-up meetings • Convey commitment and non-abandonment • Communicate with treatment team Module #3

19. Training Tape • Sharing Bad News in Two Different Ways • Two scenarios from the End-of-Life Physician Education Resource Center • http://www.eperc.mcw.edu Module #3

20. Discussion • First scenario Module #3

21. Discussion • Second scenario Module #3

22. Skills Practice Skills • Sharing Bad News: • Step 1: Prepare • Step 2: Convey Information • Step 3: Follow Up Module #3

23. Debrief Module #3

24. Action Plan • Summarizing the Bad News Role Play Module #3

25. Death Pronouncement Death Pronouncement • Not just a medical event • Very important to family • Most physicians have not been trained to do this • A skill that requires practice Module #3

26. Steps in Pronouncing Death • Find out about the situation • Pronounce/say goodbye • Console the family • Silence • Follow-up paperwork and other business Module #3

27. Role Play #1 • A patient died on the wards • The nurse has just called you to “pronounce the patient” • The patient is alone in the room • Model saying goodbye • There is no ‘right’ or ‘wrong’ way to do this Module #3

28. Role Play #2 • A patient has died on the wards • The nurse has just called you to “pronounce the patient” • Family member(s) present in the room • Model the communication aspects of pronouncing a person dead • There is no ‘right’ or ‘wrong’ way to do this Module #3

29. Debrief Module #3

30. Summary • Most of us have not been taught how to pronounce death • We may never have seen it done • We are there as a guest in the room • How does a doctor say goodbye to a human being? Module #3

31. Death Notification by Telephone • Anticipate death where possible, and keep family up-to-date beforehand • Use skills of sharing bad news • Allow time for immediate reaction • Suggest they take their time coming in • Provide contact person and explicit instructions • Arrange follow-up Module #3

32. Learning Objectives Learning Objectives • Recognize the importance of effective end-of-life communication • Increase your EOL communication skills in: • Listening • Sharing bad news • Pronouncing death • Improve your ability to incorporate this content into your clinical practice Module #3