1. Meaningful Conversations
Jennifer Gentry
Duke Palliative Care

2. Disclosures
Jennifer Gentry has no real or perceived conflicts of interest that relate to this presentation

3. Objectives Describe the unique decision making needs of older adults
Discuss communication strategies and techniques useful in facilitating meaningful conversations

4. What Makes a Conversation Meaningful?

5. Conversations Can…

6. Or…

9. Prognosis Discussing prognosis does NOT mean losing hope
Prognosis related to functional outcome may be just as important as length of survival
Wright AA, Zhang B, Ray A, et al. Associations between end of life discussions,
patient mental health, medical care near death and caregiver bereavement adjustment. JAMA, 2008.

11. Mr. S
Admitted to SNF following hospitalization for community acquired PNA, delirium in hospital
Past history of metastatic prostate cancer, heart failure, diabetes, chronic kidney disease, falls
Full code, goals of care discussions not mentioned in hospital records
Patient reports feeling poorly, complains of “weakness”
Children live “out of town”, neighbors worried about him living alone
Staff, friends report on-going confusion (hallucinations, thinks he is at home). He tells staff “I just want to die”

12. Mr. S: Questions and Decisions
You are concerned about how well he will rehab and what the discharge plan is
Is Mr. S capable of making his own decisions?
If not, who should make decisions on his behalf?

15. Most people do not listen With the intent to understand;
They listen with the
intent to reply
Steven Covey

19. “Tact is the art of a making a point without making an enemy” Sir Isaac Newton

20. Skills
Ask-Tell-Ask
Wish and Worry
NURSE

23. Using Wish and Worry Communicates prognosis Conveys empathy
Avoid “I’m sorry”…

25. Discussing Specific Treatments
Technology: withholding & withdrawing
Do not withdraw “care”
Resuscitation
Cardiac devices
Artificial nutrition & hydration

27. Conflict Expected when the team is more than one
Emotion may be at the core
Don’t ignore it

30. Knowledge of Advance Care Planning
Wide variations in knowledge of what is advance care planning and more specifically advance directives
Lack of knowledge about state laws
Lack of knowledge of the Patient Self- Determination Act
Confusion regarding:
Hierarchy of decision makers
legal issues
decision making capacity

31. Terminally and incurably ill
Unable to express your wishes
Life prolonging measures
Nutrition and hydration

35. Domains of Decision Making Capacity
Medical Decisions
Decisions of Self Care
Finances
Last Will and Testament

36. Decision Making Capacity
Does the patient have capacity ( can they consent to or refuse care/treatment)?
Ability to communicate a choice
Ability to understand relevant information
Ability to appreciate a situation and its consequences
Ability to reason rationally (how did you reach this decision, what was the process)

37. Hierarchy of Decision Making
Guardian
Attorney-in-fact with healthcare decision-making power
Patient’s spouse
A majority of the patient’s reasonably available parents and children who are at least 18 years of age
A majority of the patient’s reasonably available siblings who are at least 18 years of age
An individual who has an established relationship with the patient who is acting in good faith on behalf of the patient, and who can reliably convey the patient’s wishes.