Communicating at the EOL: Communicating with Patients/Families

1
Communicating at the EOL Communicating with
Patients/Families

• Sharing Poor Prognosis
• Stu Farber MD
• sfarber_at_u.washington.edu
• Gregg VandeKieft, MD, MA
• gregg.vandekieft_at_providence.org
• July 2011

2
Caring Conversations Transitioning from Cure to
Care

• Giving Information
• Telling

3
Caring Conversations Transitioning from Cure to
Care

• Sharing Information
• Dialogue

4
Caring Conversations Transitioning from Cure to
Care

• Special Dialogue
• Helping pt/family understand where
• Disease and treatment end
• Aging and the natural life cycle event we call
  end of life begins
• You have a unique opportunity to assist
• Pre-existing relationship
• We know this conversation effects pt/family choice

5
Caring Conversations Transitioning from Cure to
Care

• Special Dialogue
• Accepting this role takes courage
• To succeed you enter into the pt/family story
  (values/goals)
• You become a part of the story
• You become vulnerable as another human sharing
  the mystery, pain, suffering, joy and wonder of
  mortality

6
Caring Conversations Transitioning from Cure to
Care

• Special Dialogue
• When is the right time to have this dialogue?
• Surprise Question Would you be surprised if this
  patient died in the next 6-12 months?
• If you wouldnt be surprised then it is your
  professional responsibility to assist the
  patient/family prepare for the worst while
  expecting the best

7
Caring Conversations Transitioning from Cure to
Care

• Making it Safe
• Setting the Stage
• within the Concept of Paradox
• Certainty and Uncertainty
• Life and Death

8
Caring Conversations Transitioning from Cure to
Care

• Special Dialogue
• What does the pt/family already know?
• What does the pt/family want to know?
• What does the pt/family need to know?

9
Caring Conversations Transitioning from Cure to
Care

• Communication Basics
• Tell-Ask-Tell
• Ask-Tell-Ask
• Ask(listen) Ask(listen) Ask(listen)-Tell-Ask
• Silence
• Pt/Family Cues
• Terminators
• Continuers

10
Caring Conversations Transitioning from Cure to
Care Case of John

• John is 68 with far advanced lung Ca
• Just out of ICU
• If he lives 24-48 hrs will be a miracle
• He and his family still are asking for tx that
  will make him better
• You are asked to talk with him and his family
  wife, son and daughter

11
Caring Conversations Transitioning from Cure to
Care

• Evidence Based Best Practice
• Set a safe context for dialogue
• Explore the patient/family story
• Use evidence based domains
• Language skill
• Create shared story among pt/family/medical team
• Co-Create care plan among patient, family,
  medical team

12
Caring Conversations Transitioning from Cure to
Care My Death Raymond Carver

• If I'm lucky, I'll be wired every which way in a
  hospital bed. Tubes running into my nose. 
• But try not to be scared of me, friends!  I'm
  telling you right now that this is okay.     It's
  little enough to ask for at the end.
• Someone, I hope, will have phoned everyone to
  say,"Come quick, he's failing!"And they will
  come.
• And there will be time for meto bid goodbye to
  each of myloved ones....   

13
Caring Conversations Transitioning from Cure to
Care

• Late Fragment
• And did you get what you wanted
• from this life, even so?
• I did.
• And what did you want?
• To call myself beloved.
• To feel myself beloved on the earth.
• Raymond Carver

14
Caring Conversations Transitioning from Cure to
Care

• Joan Borzoff and Phyllis Silverman Eds, Living
  with Dying, Columbia University Press, July,
  2004, Chapter 5 A Respectful Death, Authors
  Stuart Farber, Thomas Egnew, and Annalu Farber
  pp102-127.
• When the Healing Professional Weeps, Katz RS,
  Johnson TA Editors Chapter Title A Respectful
  Death The Power of Relationship in End-of-Life
  Care, Authors Lu Farber and Stu Farber,
  Routeledge (a member of the Taylor Francis
  Group), New York, 2006
• Farber S, Egnew T, Stempel J, Vleck J, Monograph
  in End-of-life Care, American Academy of Family
  Practice, Vol 250/251 March/April, 2000
• Farber S, Egnew T, Bertsch J, Taylor TR, Guldin
  G, Issues in End-of-Life Care Patient,
  Caregiver, Clinician Perceptions, Journal of
  Palliative Medicine, Vol 6(1) 00319-31.
• Stewart M, Brown JB, Weston WW et al, Patient
  Centered Medicine, Sage Publications, Thousand
  Oaks, 1995
• Butow PN, Brown RF, Cogar S et al, Oncologists
  reactions to cancer patients verbal cues,
  Psycho-oncology 1147-58 (2002)
• Wright A, Zhang B, Ray A, et al, Associations
  among EOL discussions, pt mental health, medical
  care near death, and caregiver bereavement
  adjustment, JAMA, 2008 300(14) 1665-1673