CASE PRESENTATION 80 Man with respiratory failure

admitted to ICU and found to have metastatic cancer…

Patient deemed“un-weanable” ICU care perceived as “futile” Patient has capacity, no

surrogate When asked for permission to

discontinue life-support, patient asked for “everything to be done.”

Ethics and Palliative Care consults were obtained

Session Goals

Discuss this case relative to: General issues in physician-

patient communication How to communicate

regarding difficult decisions How to incorporate patient

preferences into decisions Ethical issues involved

Focus on the concept of medical futility

CommunicationPremises Most people interpret and

construct their lives based on stories

Problems often occur when personal storylines have been disrupted Patient/family stories conflict

with medical stories Problem resolution is

enhanced by effective communication and mutual construction of a new storyline Which requires patient/family

and provider to be “in-synch”

ICU Clinician Story Continued care is

medically futile Patient does not get how

sick he is - ? “in denial” Running out of time before

patient becomes confused With no surrogate decision

maker, will they be forced to continue to “do everything,” even it such care is useless and harmful?

The Patient’s Story ……

In the process of writing a book – wants a year to finish

Was unaware that he was this ill – acute illness took him by surprise

Trying to come to grips with prognosis – all happening too fastQuestion:“What can we

do for you?”

Answer: “Give me TIME

Communication – specific skills required

General Active Listening Verbal and Non-Verbal Addressing emotional as

well as cognitive components of communication

Recognition of barriers Language, Hearing,

Speaking

Above presumes a connection between participants that may not in fact be present

Entrainment as a Communication Skill

Like gears must touch, but not crowd Spacing

Gears must be synchronized Aligned temporally

Work toward a common purpose Shared narrative

construction

Space as an Aspect of Communication

Culturally defined, out of general consciousness

Varies with roles and relationships Formal Space Friendly Space Intimate Space

Time as an Aspect of Communication With age time

experienced more slowly Perception of time

correlates with the inverse of the square root of chronological age

Elders perceive the young to move too quickly

The young perceive elders to move too slowly

Young and Old out of Synch:

Working toward a Common Purpose Demonstration of respect for

the person Inquire regarding current

understanding of illness Explanatory Model

Explaining one’s own explanatory model (and story)

Inquire regarding goals (where is story headed)

Look for opportunities to come into synch with these goals

So What Happened?

How to establish synchronicity between patient and ICU staff?

Shifting goals of care For Patient For Staff

Bringing stories into alignment

Negotiating a mutually satisfactory story ending

The Good Acronym

Goals

Options

Opinion

Document

Goals

Identify stakeholders and their goals

Future goals based on current understanding “What is your

understanding of” “What did your doctor tell

you” Identify ‘big picture’ goals

first “Let’s look at the big

picture, what is most important to you?”

Options

Identify relevant options and priorities

Address benefits and burdens of options Do your homework

Address probability of success

Link options to identified goalsPearl: Too often clinicians get bogged

down in discussions over specific options without understanding how options relate to overall goals.

Opinion

In offering your opinion… Present data using neutral

language: Crush the chest Massage the heart Press on the chest

Be clear what is data and what opinion

Incorporate goals, benefits/burdens and values into your opinion

Listen to other’s opinions

Document

Who said what “Patient said he didn’t

want tube feeding” What you did/will do with

this information “Will cancel PEG tube

insertion” Your assessment

“This reasonable given …”

SUMMARY Good communication

manifests in real relationships between real people and facilitates problem solving

Establishing such relationships requires: Entrainment Trust Sharing of stories Negotiation Mutual construction of a new

story