1. AOA Council on Palliatve Care Goals of Care Breaking Bad News Unity Convention October 24, 2010 Bruce Bates, D.O., FACOFP, CMD Chair - Department of Geriatric Medicine University of New England College of Osteopathic Medicine Breaking Bad News Unity Convention October 24, 2010 Bruce Bates, D.O., FACOFP, CMD Chair - Department of Geriatric Medicine University of New England College of Osteopathic Medicine

2. Case l 84 y/o W/F living independently, falls at home suffering L femur Fx l Undergoes ORIF with post op delerium, dysphagia, renal failure. l Aspirates, intubated difficult to wean l Attentive daughter l 84 y/o W/F living independently, falls at home suffering L femur Fx l Undergoes ORIF with post op delerium, dysphagia, renal failure. l Aspirates, intubated difficult to wean l Attentive daughter

3. Case continued l Day #14 – many doctors talk to daughter Nephrologist: making more urine but probably will need dialysis long term Intensivist: able to turn O2 down to 50% Gastroenterologist: plan for a PEG will never eat regular Internist – not doing well Case manager – doctor ordered hospice Daughter calls PCP to complain l Day #14 – many doctors talk to daughter Nephrologist: making more urine but probably will need dialysis long term Intensivist: able to turn O2 down to 50% Gastroenterologist: plan for a PEG will never eat regular Internist – not doing well Case manager – doctor ordered hospice Daughter calls PCP to complain

4. Objectives... l Know why defining goals fo care is important l Understand a 7-step protocol for delivering bad news l Communicate uncertainty and conflict l Adjust care to changing goals l Know why defining goals fo care is important l Understand a 7-step protocol for delivering bad news l Communicate uncertainty and conflict l Adjust care to changing goals

5. Most people want to Know if facing a serious illness Strengthens the physician- patient relationship Fosters collaboration Establishes an appropriate allocation of resources Permits patients, families to plan, cope Most people want to Know if facing a serious illness Strengthens the physician- patient relationship Fosters collaboration Establishes an appropriate allocation of resources Permits patients, families to plan, cope Importance of Goals of Care

6. Potential goals of care l Cure of disease l Avoidance of premature death l Maintenance or improvement in function l Prolongation of life l Cure of disease l Avoidance of premature death l Maintenance or improvement in function l Prolongation of life l Relief of suffering l Quality of life l Staying in control l A good death l Support for families and loved ones

7. Osteopathic Tenet THE WHOLE PERSON BODYMINDSPIRIT BODYMINDSPIRIT

8. Multiple goals of care l Multiple goals often apply simultaneously l Goals are often contradictory l Certain goals may take priority over others l Multiple goals often apply simultaneously l Goals are often contradictory l Certain goals may take priority over others

9. Patient Centered Care l Goals of Patient - initial assessment l May Vary over time - ongoing assessment curative palliative self family physical spiritual integrated focused l Goals of Patient - initial assessment l May Vary over time - ongoing assessment curative palliative self family physical spiritual integrated focused

10. Goals may change l Osteopathic Principles make very clear the distinction of caring for disease and caring for the patient who has disease l Some goals take precedence over others l The shift in focus of care Requires the patient (Guardian) to understand is gradual is an expected part of the continuum of medical care l Osteopathic Principles make very clear the distinction of caring for disease and caring for the patient who has disease l Some goals take precedence over others l The shift in focus of care Requires the patient (Guardian) to understand is gradual is an expected part of the continuum of medical care

11. 7-step protocol to communicate bad news... 1. Create the right setting 2. Determine what the patient and family know 3. What do they want to Know 1. Create the right setting 2. Determine what the patient and family know 3. What do they want to Know

12. ... 7-step protocol to negotiate goals of care 4. Sharing the information 5. Respond with empathy 6. Make a plan and follow-through 7. Review and revise periodically, as appropriate 4. Sharing the information 5. Respond with empathy 6. Make a plan and follow-through 7. Review and revise periodically, as appropriate

13. 1. Create the Right Setting l Quiet - private space l Allot enough open ended time l Determine that the right people are present FAMILY CLERGY GUARDIAN OTHER l Quiet - private space l Allot enough open ended time l Determine that the right people are present FAMILY CLERGY GUARDIAN OTHER

14. 2. What Does the Patient Know l Establish Patients Knowledge and Understanding l Asses ability to comprehend l Correct misunderstanding l Reschedule if unprepared or unresolvable conflict of info l Establish Patients Knowledge and Understanding l Asses ability to comprehend l Correct misunderstanding l Reschedule if unprepared or unresolvable conflict of info

15. 3. How Much Does the Patient Want to Know l Recognize patient preferences May decline voluntarily May designate someone to communicate on his/her behalf Consider Power of Attorney or advanced directive – 5 wishes l Recognize patient preferences May decline voluntarily May designate someone to communicate on his/her behalf Consider Power of Attorney or advanced directive – 5 wishes

16. 3. How much does the patient want to know? l People handle information differently CapacityRaceEthnicityReligionEducation Socio economic Age and developmental level l People handle information differently CapacityRaceEthnicityReligionEducation Socio economic Age and developmental level

17. Cultural differences l Who gets the information? l How to talk about information? l Who makes decisions? l Ask the patient l Consider a family meeting l Who gets the information? l How to talk about information? l Who makes decisions? l Ask the patient l Consider a family meeting

18. 4. Sharing the Information l Say it then STOP Avoid monologue- promote dialogue Avoid Jargon and Euphemisms Pause frequently Validate understanding Use Silence and Body Language l Dont minimize severity l Implications of Im Sorry l Say it then STOP Avoid monologue- promote dialogue Avoid Jargon and Euphemisms Pause frequently Validate understanding Use Silence and Body Language l Dont minimize severity l Implications of Im Sorry

19. Language with unintended consequences -Negative l Do you want us to do everything possible? l Will you agree to discontinue care? l Its time we talk about pulling back l I think we should stop aggressive therapy l Im going to make it so he wont suffer l Do you want us to do everything possible? l Will you agree to discontinue care? l Its time we talk about pulling back l I think we should stop aggressive therapy l Im going to make it so he wont suffer

20. Language to describe the goals of care - positive.. l I want to seek the most comfort and dignity possible until the day you die l We will concentrate on improving the quality of your childs remaining life l Lets discuss your needs and wants l I want to seek the most comfort and dignity possible until the day you die l We will concentrate on improving the quality of your childs remaining life l Lets discuss your needs and wants

21. 5. Respond with Empathy l Affective response Tears anger sadness love anxiety relief l Cognitive response Denial blame guilt disbelief fear loss shame l Basic psychophysiologic response Fight – Flight l Affective response Tears anger sadness love anxiety relief l Cognitive response Denial blame guilt disbelief fear loss shame l Basic psychophysiologic response Fight – Flight

22. 5. Respond with Empathy l Listen Listen Listen l Encourage descriptions of Feelings l Use Non Verbal communication l Physician: Acknowledge Yurself l Listen Listen Listen l Encourage descriptions of Feelings l Use Non Verbal communication l Physician: Acknowledge Yurself

23. 6. Planning and followup l Explore what their hopes expectations and Fears are l Plan for Next Steps Added tests, treatment/non treatment, Care vs cure, referrals l Sources of Support for patient/family Medical, spiritual, emotional, social, legal l Explore what their hopes expectations and Fears are l Plan for Next Steps Added tests, treatment/non treatment, Care vs cure, referrals l Sources of Support for patient/family Medical, spiritual, emotional, social, legal

24. 7. Review and Revise l Give Contact info / next appointment l Assess Safety l Assess informal and formal support l Be Prepared to repeat info at next visit – it was not all heard l Goals Change with time and progression of condition l Give Contact info / next appointment l Assess Safety l Assess informal and formal support l Be Prepared to repeat info at next visit – it was not all heard l Goals Change with time and progression of condition

25. Reviewing goals, treatment priorities l Goals guide care – whose? l Assess priorities to develop initial plan of care l Review with any change in health status advancing illness setting of care treatment preferences l Goals guide care – whose? l Assess priorities to develop initial plan of care l Review with any change in health status advancing illness setting of care treatment preferences

26. Communicating prognosis l Providers markedly over-estimate prognosis Either way raises fears and stresses l Helps patient / family cope, plan increase access to hospice, other services l Offer a range or average for life expectancy l Providers markedly over-estimate prognosis Either way raises fears and stresses l Helps patient / family cope, plan increase access to hospice, other services l Offer a range or average for life expectancy

27. Truth-telling and maintaining hope l False hope may deflect from other important issues l True clinical skill to help find hope for realistic goals l False hope may deflect from other important issues l True clinical skill to help find hope for realistic goals

28. When Family Says: Dont Tell l Ask Family Why not? What are you afraid I will say? What are previous experiences? Personal,religious, or cultural context? Patient knows something - why this conspiracy? Will it feed mistrust? l Talk To patient together l Legal Obligation to obtain consent to treat or not treat (assuming capacity) l Ask Family Why not? What are you afraid I will say? What are previous experiences? Personal,religious, or cultural context? Patient knows something - why this conspiracy? Will it feed mistrust? l Talk To patient together l Legal Obligation to obtain consent to treat or not treat (assuming capacity)

29. Determine specific priorities l Based on Patient values, preferences, clinical circumstances l Influenced by information from physician(s), team members, Patient and family Clinical Jazz l Based on Patient values, preferences, clinical circumstances l Influenced by information from physician(s), team members, Patient and family Clinical Jazz

30. Summary l Begin the conversation Early Keep seven steps in mind l Understand the Goal of Care Patient centered values and preferences l Seek permission to involve family and others l Give Permission to react/accept/reject l Revise and renew l Begin the conversation Early Keep seven steps in mind l Understand the Goal of Care Patient centered values and preferences l Seek permission to involve family and others l Give Permission to react/accept/reject l Revise and renew

31. IATP ITs ABOUT THE PATIENT