Presentation on theme: "CASE PRESENTATION 80 Man with respiratory failure admitted to ICU and found to have metastatic cancer… Patient deemed“un-weanable” ICU care perceived as."— Presentation transcript:
1 CASE PRESENTATION80 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 surrogateWhen 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 communicationHow to communicate regarding difficult decisionsHow to incorporate patient preferences into decisionsEthical issues involvedFocus on the concept of medical futility
3 Communication Premises Most people interpret and construct their lives based on storiesProblems often occur when personal storylines have been disruptedPatient/family stories conflict with medical storiesProblem resolution is enhanced by effective communication and mutual construction of a new storylineWhich 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 confusedWith no surrogate decision maker, will they be forced to continue to “do everything,” even it such care is useless and harmful?
5 The Patient’s Story …In the process of writing a book – wants a year to finishWas unaware that he was this ill – acute illness took him by surpriseTrying to come to grips with prognosis – all happening too fastQuestion:“What can we do for you?”Answer: “Give me TIME
6 Communication – specific skills required GeneralActive ListeningVerbal and Non-VerbalAddressing emotional as well as cognitive components of communicationRecognition of barriersLanguage, Hearing, SpeakingAbove presumes a connection between participants that may not in fact be present
7 Entrainment as a Communication Skill Like gears must touch, but not crowdSpacingGears must be synchronizedAligned temporallyWork toward a common purposeShared narrative construction
8 Space as an Aspect of Communication Culturally defined, out of general consciousnessVaries with roles and relationshipsFormal SpaceFriendly SpaceIntimate SpaceFor Elders distance may be appropriate in representing respect. However, to the extent personal caring and concern is being communicated may be more intimate, requiring close proximity, even intimate space. In this case relatively intimate space used – holding hand, putting on patient’s glasses etc..
9 Time as an Aspect of Communication With age time experienced more slowlyPerception of time correlates with the inverse of the square root of chronological ageElders perceive the young to move too quicklyThe young perceive elders to move too slowlyPoint out that when we instruct clinicians to sit and “listen” to some degree we may be unwittingly be slowly them down enough so they become visible. Speed in healthcare (need to move people quickly) also way out of synch with many elders? Star Treck story . In this case had to speak slowly, wait for written, nodded responses. Inquired, “I bet this all seems like it is happening very fast to you…” Nodded emphatically yes.Young and Old out of Synch:
10 Working toward a Common Purpose Demonstration of respect for the personInquire regarding current understanding of illnessExplanatory ModelExplaining one’s own explanatory model (and story)Inquire regarding goals (where is story headed)Look for opportunities to come into synch with these goalsIn case: Let patient know I knew about “The Silk Road” etc.“What have you been told” “ What is your body telling you”Empathetic statements, “This must have taken you by surprise. It must be very hard for you to figure out what to do given this sudden turn of events.Suggested that he probably did have time to do some things, but probably not finish the book. Suggested a “frame shift” in goals to: “If I am dying, where and how would I like to live until I die.”Response: “What about my estate” (Patient adjust goals, opportunity for us to help)Discussion of how to get his will and “say good-bye” – Intubation now re-framed as giving time to say good-bye and adjust to diagnosis.
11 So What Happened?How to establish synchronicity between patient and ICU staff?Shifting goals of careFor PatientFor StaffBringing stories into alignmentNegotiating a mutually satisfactory story ending
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“Let’s look at the big picture, what is most important to you?”Use case to illustrate:Stakeholders here fairly clear – pt and clinicians, who were appeared ‘on the same page’Patient understood he had cancerHis ‘big picture’ goal was to finish his book, which would take a year
14 Options Identify relevant options and priorities Address benefits and burdens of optionsDo your homeworkAddress probability of successLink options to identified goalsSuggested frame shift of goals based on opinion that nobody had the power to give one year. Strengthening alliance, started with acknowledgement of the wish, “wouldn’t that be great…”Frame shift – not so much how long to live, but how and where to live for what time leftOptions – continue on vent indefinitely, consider new goals and use time on vent, transition to comfort care goals and ? Hospice WardWith this patient wrote, “What about my estate?” He drew a picture of a box with his will in it.Demonstrating shifting goals based on new information.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 chestMassage the heartPress on the chestBe clear what is data and what opinionIncorporate goals, benefits/burdens and values into your opinionListen to other’s opinionsOffered my opinion that A) he did seem to need a bit more time to let things sink in.B) He could use the time he had on the vent to ensure certain goals were met.Thus, we colluded on a new, mutually constructed story – using his time on the vent to ‘take care of business’ before he died. Note this was different than original two stories – live for a year or discontinue futile care.Two days later, asked what if… question (iterating back to options) what if you were ‘unable to meaningfully interact with your environment and doing poorly and this thought irreversible’, could we then transition to comfort care, including discontinuing the vent? Strong, affirmative node.
16 Document Who said what What you did/will do with this information “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 …”Documented initial discussion and follow-up with advance, advance directive. A witnessing note also included for this.
17 SUMMARYGood communication manifests in real relationships between real people and facilitates problem solvingEstablishing such relationships requires:EntrainmentTrustSharing of storiesNegotiationMutual construction of a new story