End-of-Life%20Communication%20%20from%20%20Interdisciplinary%20Perspectives

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End-of-Life Communication from
Interdisciplinary Perspectives

• Learning to Care for the
• Patients Lived Body

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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
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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)

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General Definitions

• Palliative Care
• End-of-Life
• Interdisciplinary
• Lived Body

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General Definitions

• Palliative Care
• End-of-Life
• Interdisciplinary
• Lived Body

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The Cure - Care Model The Old System
D E A T H
Life Prolonging Care
Palliative/ Hospice Care
Disease Progression
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Palliative Cares Place in the Course of Illness
Life Prolonging Therapy
Death
Diagnosis of serious illness
Palliative Care
Medicare Hospice Benefit
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Palliative Care
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General Definitions

• Palliative Care
• End-of-Life
• Interdisciplinary
• Lived Body

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Interdisciplinary Teams

• Consist of a medical director, the patients
  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 19981361-69. Dyeso
n TB The home health care team What can we
learn from the hospice experience? Home Health
Care Management Practice 200517125-127.
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The patients 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

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EDUCATION IN END-OF-LIFE COMMUNICATION

• Where are we?

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Goals of Education

• Increase knowledge/expertise
• Communication skills
• Interdisciplinary team awareness

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Goals of Education

• Increase knowledge/expertise
• Communication skills
• Interdisciplinary team awareness

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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 1997278733.

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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 careit is desirable
  that residents participate in hospice and home
  careThe program must evaluate residents
  technical proficiency,communication, humanistic
  qualities, and professional attitudes and
  behavior 2000

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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 2901190-6
• Dickinson GE. Am J Hosp Palliat Care. 2006 23(3)
  197-204

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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-Apr23(2)89-92
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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)

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GERIATRICS AND PALLIATIVE CARE
FACTS GERIATRICS PALLIATIVE CARE
POPULATION OLDER EVERYONE MANY OLDER ADULTS
QUALITY OF LIFE VERY IMPORTANT VERY IMPORTANT
GERIATRIC SYNDROMES MENTAL STATUS CHANGES, PAIN, FALLS, WEAKNESS MANY SYMPTOMS
FAMILY VERY IMPORTANT VERY IMPORTANT
SUB-SPECIALTY YES YES
FUNCTIONAL STATUS VERY IMPORTANT COMFORT AND QUALITY OF LIFE
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University of Texas Health Science Center at San
Antonio and The South Texas Veterans Health Care
System
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Palliative Care Educational Programs

• Interprofessional Palliative Care Fellowship
• Community Hospice Settings
• Medical Students

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Models of Care A Geriatric Palliative Care Team
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Goals of Education

• Increase knowledge/expertise
• Communication skills
• Interdisciplinary team awareness

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End-of-Life Communication

• Clinical Barriers
• Uncertainty
• anxiety (patient doctor)
• feelings of failure
• expressed emotion
• lack of training
• Time

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End-of-Life Communication

• Educational Barriers
• One-way communication

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End-of-Life Communication

• Team Barriers
• Working together as a team
• Different disciplines
• Psychologist

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Potential Solutions

• Clinical Barriers EDUCATION
• Team Barriers
• INTERDISCIPLINARY TEAM MEETINGS
• SELF CARE SPIRITUAL ROUNDS
• Educational Barriers
• FAMILY MEETINGS

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Potential Solutions

• Family meetings
• Provides for team environment
• Includes patient and family
• Based on communication
• Necessary for treating the patients lived body

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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)
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What Do Family Members Want?

• Study of 475 family members 1-2 years after
  bereavement
• Loved ones 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

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Family Meetings

• Challenges
• Difficulty listening Physician Perspective
• Difficulty making decisions Social Worker
  Perspective
• Difficult family dynamics

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Family Meetings A Framework
PRE-MEETING
BRING THE PATIENT INTO THE ROOM
SPIKES MODEL
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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 patients 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
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Family Meetings A Framework
PRE-MEETING
BRING THE PATIENT INTO THE ROOM
SPIKES MODEL
COMFORT AND REFRAME
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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

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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

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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

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Family Meetings A GOOD SKILL TO MASTER

• Rewards/Learning about communication
• Family understanding
• Understanding your role
• Facilitating difficult conversations
• Understanding the context

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Goals of Education

• Increase knowledge/expertise
• Communication skills
• Interdisciplinary team awareness

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End-of-Life Communication is team based!
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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

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Interdisciplinary Collaboration

• Interdependence and flexibility
• Deviation from specific discipline specific
  boundaries flexibility of job responsibilities

Bronstein LR Index of interdisciplinary
collaboration. Social Work Research
200226113-126. Bronstein LR A model for
interdisciplinary collaboration. Social Work
200348 297-306.
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Interdisciplinary Collaboration

• Newly created professional activities
• Expansion of an individuals specific job
  responsibilities
• New activities that evolve through
  interdisciplinary collaboration include (1)
  information sharing to educate others and (2)
  additional tasks.

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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.

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Interdisciplinary Collaboration

• Reflective process
• Team evaluation of teams outcomes
• Includes information about (1) procedural issues,
  (2) reviews of deaths, and (3) the sharing of
  workplace stress.

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Interdisciplinary Perspectives

• Team member collaboration provides for holistic
  care of the patients lived body
• Example Treatment of all pain
• Physical
• Spiritual
• Emotional
• Psychological

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Thank you

• Sandra Sanchez-Reilly
• sanchezreill_at_uthscsa.edu 210-617-5237
• Elaine Wittenberg-Lyles
• lyles_at_unt.edu 940-565-4450