1. BASIC PRINCIPLES OF PALLIATIVE CARE A. Reed Thompson, MD Donald W. Reynolds Department of Geriatrics University of Arkansas for Medical Sciences

2. PALLIATIVE CARE Palliative care is the active total care of patients with far advanced illnesses whose disease is not amenable to curative treatment. Control of symptoms, such as pain, is the focus of treatment rather than control of disease. The goal is to improve the quality of life rather than to increase the length of life.

3. HOSPICE A philosophy of care that incorporates an interdisciplinary team for the management of all the issues that surround the dying process, with the patient and family considered as a unit. The best way to provide palliative care.

4. HOSPICE BENEFIT The financial arrangement between HCFA and providers for hospice patients.

5. THE INTERDISCIPLINARY TEAM Physician Nurse RNP, clinical care coordinator Social worker Pharmacist Mental health care professional Hospital chaplain Volunteer coordinator

6. COMMON SYMPTOMS IN FAR ADVANCED ILLNESSES l Pain89% l Weight Loss58% l Anorexia55% l Dyspnea48% l Constipation40% l Fatigue 40% l Weakness36% l Nausea32% l Depression31% l Insomnia28% l Cough28% l Vomiting23% l Dizziness23% l Bloating11% l Edema11% l Confusion11% Curtis EB, et al., J Palliative Care, 7:25 - 29, 1991

7. BASIC PRINCIPLES OF PALLIATIAVE CARE Discuss the diagnosis and prognosis Set new treatment goals Ask what the patient’s goals are Assess each symptom thoroughly

8. BASIC PRINCIPLES OF PALLIATIAVE CARE Discuss the treatment options with the patient (or proxy) outlining the benefits vs. burdens of each option Discuss do not resuscitate (DNR) status Monitor the patient frequently Never say “there is nothing more to be done”

9. Communication at the End of Life A. Reed Thompson, MD Donald W. Reynolds Department of Geriatrics University of Arkansas for Medical Sciences

10. Identified Deficits in Physician Communication Skills When communicating with patients, physicians… - Talk too much - Rarely explore patients’ values & attitudes - Discuss uncertainty using vague language Tulsky, et al, 1998 - Avoid patients’ affective concerns Parle, et al, 1997 Parle, et al, 1997 - Overemphasize cognitive communication - Overemphasize cognitive communication - Fail to assess patient understanding - Fail to assess patient understanding Braddock, et al, 1999 Braddock, et al, 1999

11. General Challenges to Patient- Physician Communication l Time constraints l Language differences l Mismatch of agendas l Lack of teamwork l Discomfort with strong emotions l Quality of physician training l Resistance to change habit Buckman, 1984; Ford et al, 1994; Buss, 1998

12. Some Unique Challenges to End-of- Life Communication l Emotionally - laden material For patient, for family, for providers For patient, for family, for providers l Issues of uncertainty are common Prognosis Prognosis What is it like to die? What is it like to die? Meaning of death Meaning of death

13. Three Techniques Critical to End- of- Life Communication l Distinguish between cognitive and affective elements of communication, and respond appropriately l Clarify ambiguity l Listen in balance with speaking Suchman, 1997 Suchman, 1997

14. Examples of Cognitive and Affective Reponses l Cognitive: “Studies show that an IV is not necessarily going to improve the situation here, and could actually cause additional problems.” “Studies show that an IV is not necessarily going to improve the situation here, and could actually cause additional problems.” l Affective: 1. “You seem angry about this; can you help me understand what’s going on for you?” 1. “You seem angry about this; can you help me understand what’s going on for you?” 2.“You’ve been through a lot; I’m not surprised that you are angry about this.” 2.“You’ve been through a lot; I’m not surprised that you are angry about this.”

15. Clarify Ambiguity l Ambiguous statements: “I want you to take care of me when the time comes” “I want you to take care of me when the time comes” “I want everything done for my father” “I want everything done for my father” l What do you hear? “I want compassionate care” “I want compassionate care” or or “I want assisted suicide” “I want assisted suicide” l Clarification “Help me understand what you mean” “Help me understand what you mean”

16. Sharing Bad News Step 1: Prepare Step 1: Prepare Step 2: Share Information Step 2: Share Information Step 3: Follow Up Step 3: Follow Up

17. Step 1: Prepare l Yourself l The recipients l The environment

18. Step 2: Convey Information l Establish empathic connection l Give an advance alert l Convey realistic information in a clear manner l Observe and respond to cognitive and affective reactions l Clarify ambiguity l Restore and catalyze hope

19. Step 3: Follow Up l Set Concrete goals l Connect patient/family with support systems l Arrange follow-up meetings l Convey commitment and nonabandonment l Communicate with treatment team