Anatomy / dissection of a home based palliative visit David Thimons, D.O., C.M.D. July 26, 2016

Introduction PART 1: Tips on improving bedside manner and patient care PART 2: Longitudinal Approach to the Visit

Palliative Medicine PALLIATIVE MEDICINE: A multidisciplinary approach to specialized medical care for people with serious illnesses. It focuses on providing patients with relief from symptoms, pain, physical stress and mental stress – whatever the diagnosis. The goal of such therapy is to improve quality of life for both the patient and the family. PUT SIMPLY: We work together to make patients and families FEEL BETTER!!!!! (This is what it is all about)

The Simple Way Doctors Can Make Their Patients Feel Understood – Washington Post 12/28/15 The stronger the connection to the patient, the more likely patients are to take medications and work with their doctors Being engaged helps doctors reconnect with a deeper meaning in their work We are trained to diagnose and treat, and are ill equipped to handle situations where we can’t “fix” a problem. NEED TO: turn towards the patients and recognize their suffering. Treat them as a whole person. Be authentic, available and engaged “What’s the worst part of this for you?”

4 Ways to Make a Big Difference in Patient Care – nursetogether 4 Ways to Make a Big Difference in Patient Care – nursetogether.com 7/21/13 1. Help Me Feel Human -use my name, look me in the eye, take my hand and talk TO me 2. Empower Me -Allow me to be an active player in this game I’ve been forced to play. Communicate my choices to me and let me be involved *Set Default 3. Ease My Fear -Fear often manifested as anger. Stay calm and composed for me. 4. Treat Me With Respect -Ask me before you call me by my first name. Honor my family. Be polite and let patience reign.

10 Bedside Manners to Improve the Patient Experience – Hospital Careers.com 1. Focus on the Patient 2. Don’t Argue 3. Listen Intently 4. Be empathetic (look at the world from their point of view) 5. Be Detailed 6. Don’t Judge 7. Ensure Privacy 8. Be Observant (demeanor, body language, etc) 9. Validate Patient Concerns 10. BE NICE!!!!!

Good Bedside Manner Tips 1. Active listening skills 2. Non – verbal active listening -eye contact, smile, empathy, lean towards patient, etc 3. Communication -speak “their language”, not yours 4. Attention to Detail

Rules of a Successful Visit For a visit to be successful, you must do 2 things: 1. Make the right diagnose and appropriately treat illness or symptoms 2. The patient MUST have an overall sense of feeling better before you leave the home!

Anatomy / Dissection of a Visit: Visit Diagram “The Music Sheet”

Anatomy / Dissection of a Visit: Introduction What is your name? What is Aspire / AIS Home visit Program and why are you here? Who are YOU? Goal is to give them understanding as to why you are there, who YOU are, and…..MAKE YOURSELF MEMORABLE

Anatomy / Dissection of a Visit Chit Chat Goal: Get them to like you Have conversation about the them, their life, family, etc Use clues in the home Find common ground Be nice They must feel like you are interested and not in a rush

Anatomy / Dissection of a Visit Open Ended Questions How are you feeling? What’s the worst part of this for you? If I could fix 3 things, what would they be? What are your biggest fears? How can I make you and your family feel better and ease your suffering? What things are most important to you? What do you want out of your healthcare team?

Anatomy / Dissection of a Visit Open Ended Questions Stay quiet for at least 35 seconds Goal is to get the big picture of the patient’s: -Life -Functionality -Values -Goals -Find out what is important to them Look for “openings”

Anatomy / Dissection of a Visit: Understand Diagnosis Do you know what medically is wrong with you? What is wrong and what do you understand about the condition, your prognosis and your treatment plan? Take time to make sure YOU know the diagnosis, prognosis, and treatment plan Work to get us “on the same page” -Communication – talk “their language” -SET THE DEFAULT

Anatomy / Dissection of a Visit: Understand Diagnosis Look for “openings” here OPENINGS: -Patient guardedly opens door to talk about intimate topics -Have to listen and watch for clues/”openings” *verbal *non-verbal -An “opening” is really any statement that doesn’t make sense, is vague, or incomplete and you need to wean out the important hidden information.

Anatomy / Dissection of a Visit: Symptoms (Palliative) Work hard to stay quiet again for at least 35 seconds Clear mind and don’t have an “agenda” Look for openings Organize patient’s thoughts and concerns for them

Anatomy / Dissection of a Visit: Visit Diagram “The Music Sheet”

Anatomy / Dissection of a Visit: Breathe….. Step Back Regroup Lighten up Make them smile Bring “Feel Good Factor” back to 5 or greater

Anatomy / Dissection of a Visit: Physical Examination Benign Targeted exam Respectful Keep patient comfortable 95% of all information is obtained though history and conversation Light conversation through examination

Anatomy / Dissection of a Visit: Medication Review and Discussion Review current med list Involve patient in this review Does list match what’s in the home and what they are actually taking Discuss what we CAN do to help Very important part of the visit!

Anatomy / Dissection of a Visit: ACP Conversation Who do you want involved in making important decisions? Setting the Default Look for OPENINGS!!!!! What are they afraid of and are fears rational?

Anatomy / Dissection of a Visit: Leave / Close on a High Note Leave behinds When to Call LEAVE MAKING THEM LAUGH AND SMILE, AND OVERALL FEELING BETTER AS A RESULT OF YOUR VISIT! Close at a “9” “The Encore”

Anatomy / Dissection of a Visit: Visit Diagram “The Music Sheet”

Anatomy / Dissection of a Visit: Closing Prepare -Failing to prepare is preparing to fail! -Be nice, be likeable, they must like you, and you must be MEMORABLE to the patient in a good way. -Have fun! -If patient not feeling better as a result of your visit, don’t leave until they are; anything else is failure!