MAKING DIFFICULT CONVERSATIONS EASIER:

1. MAKING DIFFICULT CONVERSATIONS EASIER: THE CARDS, THE KIT, AND THE QUILL Dr. Eric Fairbank, Director of Palliative Care South West Healthcare, Warrnambool

2. Difficult conversations Communication is a vital skill for health professionals offering end of life care. But… We continue to pretend that our lives will never end! Don’t mention dying! Who is going to start the conversation? We tend to wait for the ‘right’ moment.

3. The Rose “it’s the one who won’t be taken that cannot seem to give, and the soul afraid of dying that never learns to live.”

4. The Clear Moment of Death “ the only thing that scares me about the moment of death is that I may come to it unprepared” Ian Gawler.

5. The scene… • Physical deterioration, symptoms • Tired, weak • Sense of being a burden • Cheated, frustrated, sad • Powerless, helpless

6. How to respond… “We do not fail if we do not cure, but we do fail, if in our attempts to cure, we cause our patients to sacrifice their healing journey” Dr. Michael Barbato Palliative Care Physician NSW Australia

7. Health Promoting Palliative Care • Bring your attention, genuine interest, and compassion • Develop courageous therapeutic relationships • Provide effective strategies, a sense of control and dignity, encourage hope, peace of mind • Improve community resilience

8. The cards, the kit, and the quill. • GoWish cards • Palliative Care: The ‘Doing-it-in-Style’ Kit • Advance Care Planning

9. Would you like a game of cards? • Easy to learn • Even entertaining • Statements on the cards could be important to you, if you were seriously ill • How do you want to be treated? • Who do you want around? • What matters?

10. GoWish Solitaire • 35 cards, and a wild card. Read the statements on the cards, and sort them into 3 piles: very important somewhat important not important • Choose the top 10 • The wild card is for something that is important that isn’t on the other cards • Discuss your choices

11. GoWish Pairs • Play with the person who might become your MEPOA • Play together, or separately • Compare the cards, • Discuss the differences www.codaalliance.org

12. Palliative Care: The ‘Doing-it-in-Style’ Kit 10 steps to take… • Understand as much as you can about your illness, and what to expect later. • Be organised • Complete an Advance Care Plan • Make opportunities to resolve ‘unfinished business’ • Live as well as you can (Wellness Wheels)

13. Palliative Care:The ‘Doing-it-in-Style’ Kit 6. Learn about meditation, and mindfulness • Record your story in a life review • Put legal and financial matters in order, particularly a will • Perhaps give some thought to funeral • Make use of available resources

14. Things we could talk about… Here is a list of things we could talk about. You may have some suggestions as well. Between us, we can decide the priorities.

15. The Glow Worm Poem I wish I were a glow worm, A glow worm’s never glum, It’s hard to be unhappy, When the sun shines out your bum!

16. Things you could read about Palliative Care Victoria ‘About…’ series pain , fatigue, nausea and vomiting, the process of dying, what to do when someone dies, etc.

17. Things you could look up Palliative Care Knowledge Network www.caresearch.com.au Palliative Care Victoria www.pallcarevic.asn.au

18. This is my life • In particular important relationships roles and achievements passions, hobbies, interests, activities decisions, turning points, ups & downs things I have learned about life things I would like to say my hopes and dreams for my family

19. What will matter…Michael Josephson …..so much becomes irrelevant… there is so much that won’t matter What will matter is not your memories, but the memories that live in those who loved you… Choose to live a life that will matter.

20. The Quill: Advance Care Planning 3 steps • Appoint someone to speak for you, if you couldn’t speak for yourself. • Talk to your Medical Enduring Power of Attorney (MEPOA) • Put it on paper.

21. The Medical Treatment Act Victoria 1988 • The right to refuse medical treatment • Agent, alternate agent – the power to refuse • The Refusal of Treatment Certificate • Witnesses • The issue of competency

22. Important medical points: • CPR (cardiopulmonary resuscitation) in perspective… • Life prolonging treatments… • Palliative care treatments will always be continued • Food and water will be offered while this is feasible.

23. The Emergency Plan Cardiopulmonary Resuscitation (CPR) If I have no pulse, and am not breathing: Option A Option B (1) (2) Option C (1) (2)

24. Life prolonging treatments May, or may not, be beneficial High tech. or low tech. A reasonable outcome? Palliative Care always Artificial hydration/ feeding Nothing to prolong the dying phase

25. Life prolonging treatments… A. I want the following life prolonging treatments……………………………………………………………………………………... but only if the doctors expect a reasonable outcome. To me, a reasonable outcome means…………………………………….………………………………………………….

26. Life prolonging treatments However if I become so seriously ill that my doctors consider that my condition has become irreversible and terminal, I want to be allowed to die naturally with well managed pain, in comfort, and with dignity. I request that life prolonging treatments that would only prolong mydyingbe discontinued.

27. Life prolonging treatments B. I do not want life prolonging treatments at all. If they have been commenced I request that they be discontinued. I want to be allowed to die naturally with well managed pain, in comfort, and with dignity.

28. Supplementary questions • Is there anything that would make you more comfortable? • Where would you be preferred to be cared for if you become seriously ill? • If it would be helpful, are there any other people…..to involve in discussions…? • Please tell us about any personal, cultural, religious or spiritual beliefs and practices that you would like respected.

29. And remember… “The most powerful therapeutic tool you’ll ever have is your own personality”. Dr. David Sackett (father of evidence based medicine) “Who you are matters more than what you know”. Dr. Rachel Remen (Kitchen Table Wisdom)

30. Difficult conversations will be made easier if you… • Bring your attention, genuine interest, and compassion • Develop courageous therapeutic relationships • Provide effective strategies, a sense of control and dignity, encourage hope, and peace of mind – using the cards, the kit, and the quill !