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End-of-Life Communication End-of-Life Communication
from from
Interdisciplinary Interdisciplinary Perspectives Perspectives
Learning to Care for the Learning to Care for the
Patient’s Lived BodyPatient’s Lived Body
Sandra Sanchez-Reilly, MD University of Texas Health Science Center and the South Texas Veterans Health Care System, San Antonio, TX
Elaine Wittenberg-Lyles, PhDUniversity of North Texas
Michele Saunders, MD University of Texas Health Science Center and the South Texas Veterans Health Care System, San Antonio, TX
SpeakersSpeakers
ObjectivesObjectives
• To present an overview of several To present an overview of several innovative educational methods currently innovative educational methods currently used in end-of-life care communication used in end-of-life care communication training training (Education and Communication)(Education and Communication)
• To acknowledge the importance of To acknowledge the importance of interdisciplinary team approach in end-of-interdisciplinary team approach in end-of-life care and training life care and training (Interdisciplinary (Interdisciplinary and Communication)and Communication)
General DefinitionsGeneral Definitions
• Palliative CarePalliative Care• End-of-LifeEnd-of-Life• InterdisciplinaryInterdisciplinary• Lived BodyLived Body
General DefinitionsGeneral Definitions
• Palliative CarePalliative Care• End-of-LifeEnd-of-Life• InterdisciplinaryInterdisciplinary• Lived BodyLived Body
The Cure - Care Model: The Cure - Care Model: The Old SystemThe Old System
Life Prolonging Care
Palliative/
Hospice
Care
D
E
A
T
HDisease ProgressionDisease Progression
Diagnosis of serious illness
Death
Palliative Care’s Place in the Course of Illness
Life Prolonging TherapyLife Prolonging Therapy
Palliative CarePalliative Care Medicare Hospice Medicare Hospice BenefitBenefit
“Modern Medicine
”
End-of-Life
Palliative Care
General DefinitionsGeneral Definitions
• Palliative CarePalliative Care• End-of-LifeEnd-of-Life• InterdisciplinaryInterdisciplinary• Lived BodyLived Body
Interdisciplinary TeamsInterdisciplinary Teams• Consist of a medical director, the Consist of a medical director, the
patient’s physician, a nurse who patient’s physician, a nurse who functions as the case manager, social functions as the case manager, social worker, pastoral care, and certified worker, pastoral care, and certified nurse assistant. nurse assistant.
• Team members who work from Team members who work from different orientations while at the different orientations while at the same time engaging in joint work. same time engaging in joint work.
• Care plans that have been assessed Care plans that have been assessed by experts in different disciplinesby experts in different disciplines
Hoyer T: A history of the Medicare Hospice Benefit. The Hospice Journal Hoyer T: A history of the Medicare Hospice Benefit. The Hospice Journal 1998;13:61-69.1998;13:61-69.Dyeson TB: The home health care team: What can we learn from the hospice Dyeson TB: The home health care team: What can we learn from the hospice experience? Home Health Care Management & Practice 2005;17:125-127.experience? Home Health Care Management & Practice 2005;17:125-127.
The patient’s lived bodyThe patient’s lived body
• Communication about the Communication about the psychological and social aspects psychological and social aspects of dying. of dying. – includes good health care includes good health care
professional and patient professional and patient communicationcommunication
– team attention to psychosocial team attention to psychosocial issues such as depressionissues such as depression
– efficient interdisciplinary staff efficient interdisciplinary staff communicationcommunication
EDUCATION IN EDUCATION IN END-OF-LIFE END-OF-LIFE
COMMUNICATIONCOMMUNICATION
Where are we?Where are we?
Goals of EducationGoals of Education
•Increase knowledge/expertiseIncrease knowledge/expertise•Communication skillsCommunication skills•Interdisciplinary team awarenessInterdisciplinary team awareness
Goals of EducationGoals of Education
•Increase knowledge/expertiseIncrease knowledge/expertise•Communication skillsCommunication skills•Interdisciplinary team awarenessInterdisciplinary team awareness
Deficiencies in Medical Deficiencies in Medical EducationEducation
• 74% of residencies in U.S. offer no 74% of residencies in U.S. offer no training in end of life care.training in end of life care.
• 83% of residencies offer no hospice 83% of residencies offer no hospice rotation.rotation.
• 41% of medical students never witnessed 41% of medical students never witnessed an attending talking with a dying person an attending talking with a dying person or his family, and 35% never discussed or his family, and 35% never discussed the care of a dying patient with a the care of a dying patient with a teaching attending.teaching attending. Billings & Block JAMA 1997;278:733.
The Good News: The Good News: Palliative Care Education Is ImprovingPalliative Care Education Is Improving• Medical school LCME requirement:Medical school LCME requirement: ““Clinical instruction must include important Clinical instruction must include important
aspects of … end of life care.” 2000aspects of … end of life care.” 2000
• Residency ACGME requirements for Residency ACGME requirements for internal medicine and internal internal medicine and internal medicine subspecialties:medicine subspecialties: ““Each resident should receive instruction in the Each resident should receive instruction in the principles of palliative care…it is desirable that principles of palliative care…it is desirable that residents participate in hospice and home care…residents participate in hospice and home care…The program must evaluate residents’ technical The program must evaluate residents’ technical proficiency,…communication, humanistic proficiency,…communication, humanistic qualities, and professional attitudes and qualities, and professional attitudes and behavior…” 2000behavior…” 2000
Palliative Care Education in Palliative Care Education in Medical Schools Is ImprovingMedical Schools Is Improving
• Annual medical school exit Annual medical school exit questionnaire 2002-2003questionnaire 2002-2003
• 126 LCME accredited medical 126 LCME accredited medical schoolsschools
• 110 (87%) require instructional 110 (87%) require instructional hours in palliative carehours in palliative care
• Average # of hours required: 12, but Average # of hours required: 12, but highly variable (4-14) highly variable (4-14)
Barzansky B, Etzel SI. JAMA 2003; 290:1190-6Dickinson GE. Am J Hosp Palliat Care. 2006 23(3): 197-204
Current State of Nursing Current State of Nursing Education in Palliative CareEducation in Palliative Care• Only 3% of nursing programs in the Only 3% of nursing programs in the
United States reported having a course United States reported having a course dedicated to end-of-life issues in 2002. dedicated to end-of-life issues in 2002.
• 40% focus groups felt a need to increase 40% focus groups felt a need to increase this content in their curricula. this content in their curricula.
• Nursing textbooks offer little in the way of Nursing textbooks offer little in the way of end-of-life careend-of-life care
• Nurses report wishing they had learned Nurses report wishing they had learned more about caring for the dying while in more about caring for the dying while in their undergraduate and graduate nursing their undergraduate and graduate nursing programs. programs.
Robinson R. End-of-life education in undergraduate nursing curricula. Dimens Crit Care Nurs. 2004 Mar-Apr;23(2):89-92
Special InitiativesSpecial Initiatives
• Objective Structured Clinical Examination Objective Structured Clinical Examination (OSCE) with Standardized Patients(OSCE) with Standardized Patients
• End of Life Nursing Education Curriculum End of Life Nursing Education Curriculum (ELNEC)(ELNEC)
• Education on Palliative and End-of-life-care Education on Palliative and End-of-life-care (EPEC)(EPEC)
• Education on Palliative and End-of-life-care Education on Palliative and End-of-life-care for Oncologists (EPEC-O)for Oncologists (EPEC-O)
• Palliative Care Education and Practice (PCEP)Palliative Care Education and Practice (PCEP)• Center for Advanced Palliative Care (CAPC)Center for Advanced Palliative Care (CAPC)
GERIATRICS AND GERIATRICS AND PALLIATIVE CAREPALLIATIVE CARE
FACTSFACTS GERIATRICSGERIATRICS PALLIATIVE PALLIATIVE CARECARE
POPULATIONPOPULATION OLDEROLDER EVERYONE: EVERYONE: MANY OLDER MANY OLDER ADULTSADULTS
QUALITY OF LIFEQUALITY OF LIFE VERY VERY IMPORTANTIMPORTANT
VERY VERY IMPORTANTIMPORTANT
GERIATRIC GERIATRIC SYNDROMESSYNDROMES
MENTAL STATUS MENTAL STATUS CHANGES, PAIN, CHANGES, PAIN, FALLS, FALLS, WEAKNESSWEAKNESS
MANY MANY SYMPTOMSSYMPTOMS
FAMILYFAMILY VERY VERY IMPORTANTIMPORTANT
VERY VERY IMPORTANTIMPORTANT
SUB-SPECIALTYSUB-SPECIALTY YESYES YESYES
FUNCTIONAL FUNCTIONAL STATUSSTATUS
VERY VERY IMPORTANTIMPORTANT
COMFORT AND COMFORT AND QUALITY OF LIFEQUALITY OF LIFE
University of Texas Health Science University of Texas Health Science Center at San Antonio and The South Center at San Antonio and The South Texas Veterans Health Care SystemTexas Veterans Health Care System
Geriatric Palliative Care
Program:
ConsultationService
Inpatient Hospice Unit
Community Home Hospices
ClinicsPediatric
Palliative Care
Fellowship
Palliative Care: Palliative Care: Educational ProgramsEducational Programs
• Interprofessional Palliative Care Interprofessional Palliative Care FellowshipFellowship
• Community Hospice SettingsCommunity Hospice Settings• Medical StudentsMedical Students
Models of Care: Models of Care: A Geriatric Palliative Care A Geriatric Palliative Care
TeamTeam
COMM.EXPERTS
PSYCHOLOGIST
CHAPLAINS
SOCIAL WORK
RESEARCH STAFF
IDT. TRAINEES
PHYSICIANS
NURSES
PATIENT AND
FAMILY
Goals of EducationGoals of Education
•Increase knowledge/expertiseIncrease knowledge/expertise•Communication skillsCommunication skills•Interdisciplinary team awarenessInterdisciplinary team awareness
End-of-Life End-of-Life CommunicationCommunication
• Clinical BarriersClinical Barriers– UncertaintyUncertainty– anxiety (patient & doctor)anxiety (patient & doctor)– feelings of failurefeelings of failure– expressed emotionexpressed emotion– lack of traininglack of training– TimeTime
End-of-Life End-of-Life CommunicationCommunication
• Educational BarriersEducational BarriersOne-way One-way
communicationcommunication
End-of-Life End-of-Life CommunicationCommunication
• Team BarriersTeam Barriers– Working together as a teamWorking together as a team– Different disciplinesDifferent disciplines
•PsychologistPsychologist
Potential SolutionsPotential Solutions
• Clinical Barriers: EDUCATIONClinical Barriers: EDUCATION• Team Barriers: Team Barriers:
– INTERDISCIPLINARY TEAM INTERDISCIPLINARY TEAM MEETINGSMEETINGS
– SELF CARE: “SPIRITUAL ROUNDS”SELF CARE: “SPIRITUAL ROUNDS”
• Educational Barriers:Educational Barriers:– FAMILY MEETINGSFAMILY MEETINGS
Potential SolutionsPotential Solutions
• Family meetingsFamily meetings– Provides for team environmentProvides for team environment– Includes patient and familyIncludes patient and family– Based on communicationBased on communication– Necessary for treating the Necessary for treating the patient’s patient’s
lived bodylived body
Family Meetings: Family Meetings: BackgroundBackground
• The importance of involving patients The importance of involving patients and family members in healthcare and family members in healthcare teams is well documented* teams is well documented*
• Family meetings improve Family meetings improve satisfaction, coordination of care, satisfaction, coordination of care, and communication**and communication**
*(Saltz & Schaefer, 1996; McDonald et al., 2002; *(Saltz & Schaefer, 1996; McDonald et al., 2002; Fischer, Schulz, & Ogletree, 1999; Andrews et al., 1998)Fischer, Schulz, & Ogletree, 1999; Andrews et al., 1998)
** (Andrews et al, 1998; Axford, Askill, & Jones, 2002)** (Andrews et al, 1998; Axford, Askill, & Jones, 2002)
What Do Family Members What Do Family Members Want?Want?
Study of 475 family members 1-2 years after Study of 475 family members 1-2 years after bereavementbereavement
• Loved one’s wishes honoredLoved one’s wishes honored• Inclusion in decision processesInclusion in decision processes• Support/assistance at homeSupport/assistance at home• Practical help (transportation, medicines, Practical help (transportation, medicines,
equipment)equipment)• Personal care needs (bathing, feeding, toileting)Personal care needs (bathing, feeding, toileting)• Honest informationHonest information• 24/7 access24/7 access• To be listened toTo be listened to• PrivacyPrivacy• To be remembered and contacted after the deathTo be remembered and contacted after the death
Tolle et al. Oregon report card.1999 Tolle et al. Oregon report card.1999 www.ohsu.edu/ethicswww.ohsu.edu/ethics
Family MeetingsFamily Meetings
• ChallengesChallenges
– Difficulty listening – Physician Difficulty listening – Physician PerspectivePerspective
– Difficulty making decisions – Social Difficulty making decisions – Social Worker PerspectiveWorker Perspective
– Difficult family dynamicsDifficult family dynamics
Family Meetings: A Family Meetings: A FrameworkFramework
“BRING THE PATIENT INTO
THE ROOM”
“SPIKES” MODEL
PRE-MEETING
THE S.P.I.K.E.S. MODELTHE S.P.I.K.E.S. MODEL
• S:S: SettingSetting. Pick a private location. . Pick a private location. • P:P: PerceptionPerception. Find out how the patient views . Find out how the patient views
the medical situation. the medical situation. • I:I: InvitationInvitation. Ask whether the patient wants to . Ask whether the patient wants to
know. know. • K:K: KnowledgeKnowledge. Warn before dropping bad . Warn before dropping bad
news. news. • E:E: EmpathyEmpathy. Respond to the patient’s emotions. . Respond to the patient’s emotions. • S:S: Strategy/SummaryStrategy/Summary. Once they know, include . Once they know, include
patients in treatment decisions. patients in treatment decisions. Walter F. Bailea, Robert Buckman. The Oncologist, Vol. 5, No. 4, 302-311, August 2000
Family Meetings: A Family Meetings: A FrameworkFramework
“BRING THE PATIENT INTO
THE ROOM”
“SPIKES” MODEL
COMFORT AND REFRAME
PRE-MEETING
Family Meetings: ROLE Family Meetings: ROLE PLAYPLAY
• 85 YEAR-OLD MAN WITH PAST 85 YEAR-OLD MAN WITH PAST MEDICAL HISTORY OF DIABETES, MEDICAL HISTORY OF DIABETES, HYPERTENSION, AND RECENTLY HYPERTENSION, AND RECENTLY DIAGNOSED METASTASIC LUNG DIAGNOSED METASTASIC LUNG CANCER. PT IS IN THE HOSPITAL CANCER. PT IS IN THE HOSPITAL WITH EXCRUTIATING PAIN, BUT WITH EXCRUTIATING PAIN, BUT ALERT, WITH HIS WIFE AND ALERT, WITH HIS WIFE AND DAUGHTER AT BEDSIDE. THEY DAUGHTER AT BEDSIDE. THEY ARE HOPING FOR A CURE…ARE HOPING FOR A CURE…
Family Meetings: ROLE Family Meetings: ROLE PLAYPLAY
• DR. R., HIS PRIMARY PHYSICIAN DR. R., HIS PRIMARY PHYSICIAN AND A MEDICINE RESIDENT, IS AND A MEDICINE RESIDENT, IS NOT VERY COMFORTABLE WITH NOT VERY COMFORTABLE WITH DELIVERING BAD NEWS, HE WAS DELIVERING BAD NEWS, HE WAS NEVER PROPERLY TRAINED…NEVER PROPERLY TRAINED…
• HIS ATTENDING PHYSICIAN IS HIS ATTENDING PHYSICIAN IS NOT WILLING TO DO IT EITHER: NOT WILLING TO DO IT EITHER: “THE FAMILY SHOULD KNOW BY “THE FAMILY SHOULD KNOW BY NOW”NOW”
Family Meetings: ROLE Family Meetings: ROLE PLAYPLAY
• PT LIVES WITH HIS WIFE, AND HIS PT LIVES WITH HIS WIFE, AND HIS PENSION IS THEIR ONLY SOURCE PENSION IS THEIR ONLY SOURCE OF INCOMEOF INCOME
• HIS DAUGHTER HAS NOT BEEN HIS DAUGHTER HAS NOT BEEN INVOLVED IN THEIR LIVES SINCE INVOLVED IN THEIR LIVES SINCE HE RE-MARRIEDHE RE-MARRIED
• THE PALLIATIVE CARE TEAM IS THE PALLIATIVE CARE TEAM IS CALLED TO “PROVIDE HOSPICE CALLED TO “PROVIDE HOSPICE CARE”…CARE”…
Family Meetings: A GOOD Family Meetings: A GOOD SKILL TO MASTERSKILL TO MASTER
• Rewards/Learning about Rewards/Learning about communicationcommunication
– Family understandingFamily understanding• Understanding your roleUnderstanding your role
– Facilitating difficult conversationsFacilitating difficult conversations• Understanding the contextUnderstanding the context
Goals of EducationGoals of Education
•Increase knowledge/expertiseIncrease knowledge/expertise•Communication skillsCommunication skills•Interdisciplinary team awarenessInterdisciplinary team awareness
End-of-Life Communication End-of-Life Communication
is team based!is team based!
Geriatrics Interdisciplinary Geriatrics Interdisciplinary Advisory Group, 2006 Advisory Group, 2006
Interdisciplinary care:Interdisciplinary care:• Improves healthcare processesImproves healthcare processes• Benefits the healthcare system Benefits the healthcare system
and caregivers, and caregivers, • Adequately prepares healthcare Adequately prepares healthcare
providers for better care of older providers for better care of older adults adults
Interdisciplinary Interdisciplinary CollaborationCollaboration
• Interdependence and Interdependence and flexibilityflexibility
– Deviation from specific discipline Deviation from specific discipline specific boundaries; flexibility of job specific boundaries; flexibility of job responsibilities responsibilities
Bronstein LR: Index of interdisciplinary collaboration. Social Work Research 2002;26:113-126.Bronstein LR: A model for interdisciplinary collaboration. Social Work 2003;48: 297-306.
Interdisciplinary Interdisciplinary CollaborationCollaboration
• Newly created professional Newly created professional activitiesactivities
– Expansion of an individual’s specific job Expansion of an individual’s specific job responsibilities responsibilities
– New activities that evolve through New activities that evolve through interdisciplinary collaboration include: interdisciplinary collaboration include: (1) information sharing to educate others; (1) information sharing to educate others; and (2) additional tasks. and (2) additional tasks.
Interdisciplinary Interdisciplinary CollaborationCollaboration
• Collective ownership of goalsCollective ownership of goals
– Individuals share responsibilities for all Individuals share responsibilities for all aspects of decision-making and aspects of decision-making and implement decision together implement decision together
– The discussion of “special cases” The discussion of “special cases” illustrated a collective ownership of illustrated a collective ownership of goals. Such cases warrant additional goals. Such cases warrant additional information sharing. information sharing.
Interdisciplinary Interdisciplinary CollaborationCollaboration
• Reflective processReflective process
– Team evaluation of team’s outcomes Team evaluation of team’s outcomes
– Includes information about (1) Includes information about (1) procedural issues, (2) reviews of deaths, procedural issues, (2) reviews of deaths, and (3) the sharing of workplace stress. and (3) the sharing of workplace stress.
Interdisciplinary Interdisciplinary PerspectivesPerspectives
• Team member collaboration Team member collaboration provides for holistic care of the provides for holistic care of the patient’s lived bodypatient’s lived body
Example: Treatment of all painExample: Treatment of all pain•PhysicalPhysical•SpiritualSpiritual•EmotionalEmotional•PsychologicalPsychological
Thank youThank you
Sandra Sanchez-ReillySandra Sanchez-Reillysanchezreill@uthscsa.edu 210-617-210-617-52375237
Elaine Wittenberg-LylesElaine Wittenberg-Lyleslyles@unt.edu 940-565-4450940-565-4450
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