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CASE PRESENTATION 80 Man with respiratory failure admitted to ICU and found to have metastatic cancer… Patient deemedun-weanable ICU care perceived as.

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Presentation on theme: "CASE PRESENTATION 80 Man with respiratory failure admitted to ICU and found to have metastatic cancer… Patient deemedun-weanable ICU care perceived as."— Presentation transcript:

1 CASE PRESENTATION 80 Man with respiratory failure admitted to ICU and found to have metastatic cancer… Patient deemedun-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

2 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

3 Communication Premises 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

4 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?

5 … The Patients 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 fast Question:What can we do for you? Answer: Give me TIME

6 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

7 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

8 Space as an Aspect of Communication Culturally defined, out of general consciousness Varies with roles and relationships Formal Space Friendly Space Intimate Space

9 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:

10 Working toward a Common Purpose Demonstration of respect for the person Inquire regarding current understanding of illness Explanatory Model Explaining ones own explanatory model (and story) Inquire regarding goals (where is story headed) Look for opportunities to come into synch with these goals

11 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

12 The Good Acronym Goals Options Opinion Document

13 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 Lets look at the big picture, what is most important to you?

14 Options Identify relevant options and priorities Address benefits and burdens of options Do your homework Address probability of success Link options to identified goals Pearl: Too often clinicians get bogged down in discussions over specific options without understanding how options relate to overall goals.

15 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 others opinions

16 Document Who said what Patient said he didnt want tube feeding What you did/will do with this information Will cancel PEG tube insertion Your assessment This reasonable given …

17 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


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