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End-of-Life Communication from Interdisciplinary Perspectives Learning to Care for the Patient’s Lived Body.

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Presentation on theme: "End-of-Life Communication from Interdisciplinary Perspectives Learning to Care for the Patient’s Lived Body."— Presentation transcript:

1 End-of-Life Communication from Interdisciplinary Perspectives Learning to Care for the Patient’s Lived Body

2 Sandra Sanchez-Reilly, MD University of Texas Health Science Center and the South Texas Veterans Health Care System, San Antonio, TX Elaine Wittenberg-Lyles, PhD University of North Texas Michele Saunders, MD University of Texas Health Science Center and the South Texas Veterans Health Care System, San Antonio, TX Speakers

3 Objectives To present an overview of several innovative educational methods currently used in end-of-life care communication training (Education and Communication)To present an overview of several innovative educational methods currently used in end-of-life care communication training (Education and Communication) To acknowledge the importance of interdisciplinary team approach in end-of-life care and training (Interdisciplinary and Communication)To acknowledge the importance of interdisciplinary team approach in end-of-life care and training (Interdisciplinary and Communication)

4 General Definitions Palliative CarePalliative Care End-of-LifeEnd-of-Life InterdisciplinaryInterdisciplinary Lived BodyLived Body

5 General Definitions Palliative CarePalliative Care End-of-LifeEnd-of-Life InterdisciplinaryInterdisciplinary Lived BodyLived Body

6 The Cure - Care Model: The Old System Life Prolonging Care Palliative/ Hospice Care DEATHDEATH Disease Progression

7 Diagnosis of serious illness Death Palliative Care’s Place in the Course of Illness Life Prolonging Therapy Palliative Care Medicare Hospice Benefit

8 “Modern Medicine” End-of- Life Palliative Care

9 General Definitions Palliative CarePalliative Care End-of-LifeEnd-of-Life InterdisciplinaryInterdisciplinary Lived BodyLived Body

10 Interdisciplinary Teams Consist of a medical director, the patient’s physician, a nurse who functions as the case manager, social worker, pastoral care, and certified nurse assistant.Consist of a medical director, the patient’s physician, a nurse who functions as the case manager, social worker, pastoral care, and certified nurse assistant. Team members who work from different orientations while at the same time engaging in joint work.Team members who work from different orientations while at the same time engaging in joint work. Care plans that have been assessed by experts in different disciplinesCare plans that have been assessed by experts in different disciplines Hoyer T: A history of the Medicare Hospice Benefit. The Hospice Journal 1998;13:61-69. Dyeson TB: The home health care team: What can we learn from the hospice experience? Home Health Care Management & Practice 2005;17:125-127.

11 The patient’s lived body Communication about the psychological and social aspects of dying.Communication about the psychological and social aspects of dying. –includes good health care professional and patient communication –team attention to psychosocial issues such as depression –efficient interdisciplinary staff communication

12 EDUCATION IN END-OF-LIFE COMMUNICATION Where are we?

13 Goals of Education Increase knowledge/expertiseIncrease knowledge/expertise Communication skillsCommunication skills Interdisciplinary team awarenessInterdisciplinary team awareness

14 Goals of Education Increase knowledge/expertiseIncrease knowledge/expertise Communication skillsCommunication skills Interdisciplinary team awarenessInterdisciplinary team awareness

15 Deficiencies in Medical Education 74% of residencies in U.S. offer no training in end of life care.74% of residencies in U.S. offer no training in end of life care. 83% of residencies offer no hospice rotation.83% of residencies offer no hospice rotation. 41% of medical students never witnessed an attending talking with a dying person or his family, and 35% never discussed the care of a dying patient with a teaching attending.41% of medical students never witnessed an attending talking with a dying person or his family, and 35% never discussed the care of a dying patient with a teaching attending. Billings & Block JAMA 1997;278:733.

16 The Good News: Palliative Care Education Is Improving Medical school LCME requirement:Medical school LCME requirement: “Clinical instruction must include important aspects of … end of life care.” 2000 “Clinical instruction must include important aspects of … end of life care.” 2000 Residency ACGME requirements for internal medicine and internal medicine subspecialties:Residency ACGME requirements for internal medicine and internal medicine subspecialties: “Each resident should receive instruction in the principles of palliative care…it is desirable that residents participate in hospice and home care…The program must evaluate residents’ technical proficiency,…communication, humanistic qualities, and professional attitudes and behavior…” 2000

17 Palliative Care Education in Medical Schools Is Improving Annual medical school exit questionnaire 2002- 2003Annual medical school exit questionnaire 2002- 2003 126 LCME accredited medical schools126 LCME accredited medical schools 110 (87%) require instructional hours in palliative care110 (87%) require instructional hours in palliative care Average # of hours required: 12, but highly variable (4-14)Average # of hours required: 12, but highly variable (4-14) Barzansky B, Etzel SI. JAMA 2003; 290:1190-6 Dickinson GE. Am J Hosp Palliat Care. 2006 23(3): 197-204

18 Current State of Nursing Education in Palliative Care Only 3% of nursing programs in the United States reported having a course dedicated to end-of-life issues in 2002.Only 3% of nursing programs in the United States reported having a course dedicated to end-of-life issues in 2002. 40% focus groups felt a need to increase this content in their curricula.40% focus groups felt a need to increase this content in their curricula. Nursing textbooks offer little in the way of end-of-life careNursing textbooks offer little in the way of end-of-life care Nurses report wishing they had learned more about caring for the dying while in their undergraduate and graduate nursing programs.Nurses report wishing they had learned more about caring for the dying while in their undergraduate and graduate nursing programs. Robinson R. End-of-life education in undergraduate nursing curricula. Dimens Crit Care Nurs. 2004 Mar-Apr;23(2):89-92

19 Special Initiatives Objective Structured Clinical Examination (OSCE) with Standardized PatientsObjective Structured Clinical Examination (OSCE) with Standardized Patients End of Life Nursing Education Curriculum (ELNEC)End of Life Nursing Education Curriculum (ELNEC) Education on Palliative and End-of-life-care (EPEC)Education on Palliative and End-of-life-care (EPEC) Education on Palliative and End-of-life-care for Oncologists (EPEC-O)Education on Palliative and End-of-life-care 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)

20 GERIATRICS AND PALLIATIVE CARE FACTSGERIATRICS PALLIATIVE CARE POPULATIONOLDER EVERYONE: MANY OLDER ADULTS QUALITY OF LIFE VERY IMPORTANT GERIATRIC SYNDROMES MENTAL STATUS CHANGES, PAIN, FALLS, WEAKNESS MANY SYMPTOMS FAMILY VERY IMPORTANT SUB-SPECIALTYYESYES FUNCTIONAL STATUS VERY IMPORTANT COMFORT AND QUALITY OF LIFE

21 University of Texas Health Science Center at San Antonio and The South Texas Veterans Health Care System Geriatric Palliative Care Program: Consultation Service Inpatient Hospice Unit Community Home Hospices Clinics Pediatric Palliative Care Fellowship

22 Palliative Care: Educational Programs Interprofessional Palliative Care FellowshipInterprofessional Palliative Care Fellowship Community Hospice SettingsCommunity Hospice Settings Medical StudentsMedical Students

23 Models of Care: A Geriatric Palliative Care Team PATIENT AND FAMILY NURSESPHYSICIANS IDT. TRAINEES RESEARCH STAFF SOCIAL WORKCHAPLAINSPSYCHOLOGIST COMM. EXPERTS

24 Goals of Education Increase knowledge/expertiseIncrease knowledge/expertise Communication skillsCommunication skills Interdisciplinary team awarenessInterdisciplinary team awareness

25 End-of-Life Communication Clinical BarriersClinical Barriers –Uncertainty –anxiety (patient & doctor) –feelings of failure –expressed emotion –lack of training –Time

26 End-of-Life Communication Educational BarriersEducational Barriers One-way communication

27 End-of-Life Communication Team BarriersTeam Barriers –Working together as a team –Different disciplines PsychologistPsychologist

28 Potential Solutions Clinical Barriers: EDUCATIONClinical Barriers: EDUCATION Team Barriers:Team Barriers: –INTERDISCIPLINARY TEAM MEETINGS –SELF CARE: “SPIRITUAL ROUNDS” Educational Barriers:Educational Barriers: –FAMILY MEETINGS

29 Potential Solutions Family meetingsFamily meetings –Provides for team environment –Includes patient and family –Based on communication –Necessary for treating the patient’s lived body

30 Family Meetings: Background The importance of involving patients and family members in healthcare teams is well documented*The importance of involving patients and family members in healthcare teams is well documented* Family meetings improve satisfaction, coordination of care, and communication**Family meetings improve satisfaction, coordination of care, and communication** *(Saltz & Schaefer, 1996; McDonald et al., 2002; Fischer, Schulz, & Ogletree, 1999; Andrews et al., 1998) ** (Andrews et al, 1998; Axford, Askill, & Jones, 2002)

31 What Do Family Members Want? Study of 475 family members 1-2 years after bereavement 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, equipment)Practical help (transportation, medicines, 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 www.ohsu.edu/ethics

32 Family Meetings ChallengesChallenges –Difficulty listening – Physician Perspective –Difficulty making decisions – Social Worker Perspective –Difficult family dynamics

33 Family Meetings: A Framework “BRING THE PATIENT INTO THE ROOM” “SPIKES” MODEL PRE-MEETING

34 THE S.P.I.K.E.S. MODEL S: Setting. Pick a private location.S: Setting. Pick a private location. P: Perception. Find out how the patient views the medical situation.P: Perception. Find out how the patient views the medical situation. I: Invitation. Ask whether the patient wants to know.I: Invitation. Ask whether the patient wants to know. K: Knowledge. Warn before dropping bad news.K: Knowledge. Warn before dropping bad news. E: Empathy. Respond to the patient’s emotions.E: Empathy. Respond to the patient’s emotions. S: Strategy/Summary. Once they know, include patients in treatment decisions.S: Strategy/Summary. Once they know, include patients in treatment decisions. Walter F. Bailea, Robert Buckman. The Oncologist, Vol. 5, No. 4, 302-311, August 2000

35 Family Meetings: A Framework “BRING THE PATIENT INTO THE ROOM” “SPIKES” MODEL COMFORT AND REFRAME PRE-MEETING

36 Family Meetings: ROLE PLAY 85 YEAR-OLD MAN WITH PAST MEDICAL HISTORY OF DIABETES, HYPERTENSION, AND RECENTLY DIAGNOSED METASTASIC LUNG CANCER. PT IS IN THE HOSPITAL WITH EXCRUTIATING PAIN, BUT ALERT, WITH HIS WIFE AND DAUGHTER AT BEDSIDE. THEY ARE HOPING FOR A CURE…85 YEAR-OLD MAN WITH PAST MEDICAL HISTORY OF DIABETES, HYPERTENSION, AND RECENTLY DIAGNOSED METASTASIC LUNG CANCER. PT IS IN THE HOSPITAL WITH EXCRUTIATING PAIN, BUT ALERT, WITH HIS WIFE AND DAUGHTER AT BEDSIDE. THEY ARE HOPING FOR A CURE…

37 Family Meetings: ROLE PLAY DR. R., HIS PRIMARY PHYSICIAN AND A MEDICINE RESIDENT, IS NOT VERY COMFORTABLE WITH DELIVERING BAD NEWS, HE WAS NEVER PROPERLY TRAINED…DR. R., HIS PRIMARY PHYSICIAN AND A MEDICINE RESIDENT, IS NOT VERY COMFORTABLE WITH DELIVERING BAD NEWS, HE WAS NEVER PROPERLY TRAINED… HIS ATTENDING PHYSICIAN IS NOT WILLING TO DO IT EITHER: “THE FAMILY SHOULD KNOW BY NOW”HIS ATTENDING PHYSICIAN IS NOT WILLING TO DO IT EITHER: “THE FAMILY SHOULD KNOW BY NOW”

38 Family Meetings: ROLE PLAY PT LIVES WITH HIS WIFE, AND HIS PENSION IS THEIR ONLY SOURCE OF INCOMEPT LIVES WITH HIS WIFE, AND HIS PENSION IS THEIR ONLY SOURCE OF INCOME HIS DAUGHTER HAS NOT BEEN INVOLVED IN THEIR LIVES SINCE HE RE-MARRIEDHIS DAUGHTER HAS NOT BEEN INVOLVED IN THEIR LIVES SINCE HE RE-MARRIED THE PALLIATIVE CARE TEAM IS CALLED TO “PROVIDE HOSPICE CARE”…THE PALLIATIVE CARE TEAM IS CALLED TO “PROVIDE HOSPICE CARE”…

39 Family Meetings: A GOOD SKILL TO MASTER Rewards/Learning about communicationRewards/Learning about communication –Family understanding Understanding your roleUnderstanding your role –Facilitating difficult conversations Understanding the contextUnderstanding the context

40 Goals of Education Increase knowledge/expertiseIncrease knowledge/expertise Communication skillsCommunication skills Interdisciplinary team awarenessInterdisciplinary team awareness

41 End-of-Life Communication is team based!

42 Geriatrics Interdisciplinary Advisory Group, 2006 Interdisciplinary care: Improves healthcare processesImproves healthcare processes Benefits the healthcare system and caregivers,Benefits the healthcare system and caregivers, Adequately prepares healthcare providers for better care of older adultsAdequately prepares healthcare providers for better care of older adults

43 Interdisciplinary Collaboration Interdependence and flexibilityInterdependence and flexibility –Deviation from specific discipline specific boundaries; flexibility of job 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.

44 Interdisciplinary Collaboration Newly created professional activitiesNewly created professional activities –Expansion of an individual’s specific job responsibilities –New activities that evolve through interdisciplinary collaboration include: (1) information sharing to educate others; and (2) additional tasks.

45 Interdisciplinary Collaboration Collective ownership of goalsCollective ownership of goals –Individuals share responsibilities for all aspects of decision-making and implement decision together –The discussion of “special cases” illustrated a collective ownership of goals. Such cases warrant additional information sharing.

46 Interdisciplinary Collaboration Reflective processReflective process –Team evaluation of team’s outcomes –Includes information about (1) procedural issues, (2) reviews of deaths, and (3) the sharing of workplace stress.

47 Interdisciplinary Perspectives Team member collaboration provides for holistic care of the patient’s lived bodyTeam member collaboration provides for holistic care of the patient’s lived body Example: Treatment of all pain PhysicalPhysical SpiritualSpiritual EmotionalEmotional PsychologicalPsychological

48 Thank you Sandra Sanchez-Reilly sanchezreill@uthscsa.edusanchezreill@uthscsa.edu210-617-5237 sanchezreill@uthscsa.edu Elaine Wittenberg-Lyles lyles@unt.edulyles@unt.edu940-565-4450 lyles@unt.edu


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