1 Effective communication. 2 Introduction and note of caution Welcome Note of caution o Talking about last days of life is hard – professionally as well.

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Effective communication

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Introduction and note of caution

• Welcome

• Note of caution

o Talking about last days of life is hard – professionally as well as personally

o This session is designed to help you so you can help your patients and those important to them

o If you feel upset or emotional that is okay – you are encouraged to stay and we will help but if you must leave please speak to a friend or colleague so you have some support

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Objectives

• Explore a patient’s understanding of current disease state and what the patient wishes to know

• Explain and discuss in simple terms patient’s deterioration, prognosis and trajectory of deterioration, including symptoms that may develop and their management

• Ascertain patient’s wishes and preferences for care including preferred place of care and level of intervention

• Appropriately conduct discussion about Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) according to best practice and with an understanding of the implications of the Tracey case

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Example

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Introducti

on

• Set aside time/space for the discussion and introduce self to patient. Ensure patient is okay with those present to stay.

• Establish the patient's understanding current disease state, how much the patient wishes to know and wishes for those who are important to patient to know.

Information

• Explain in simple terms the patient's deterioration, prognosis, trajectory, and potential symptoms.

• Answer questions as they arise and regularly check what is being understood from the conversation, and how much information is wanted.

Wishes

and need

s

• Establish patient's wishes with regards to care and place of care.• Identify, explore and support patient's spiritual, religious and psychological needs.• Do the same for individuals important to the patient.

Structuring the conversation 1

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Structuring the conversation 2

Limitation

s

• Sensitively provide information about interventions and treatment to be continued.• Include limitations which are likely to be contrary to the patient’s wishes or inappropriate, and

unlikely to be successful within a discussion around the level of interventions.

DNACPR

• As part of the conversation of the plan of care, discuss DNACPR (according to best practice and the outcome of the Tracey case).

• If the healthcare team is as certain as it can be, the person is dying as an inevitable result of underlying disease or a catastrophic health event and CPR would not re-start the heart and breathing for a sustained period, CPR should not be attempted.

• It should be discussed in full with a patient with capacity and their family, who should be consulted and informed of the decision-making process.

Plan of

Care

• Develop an individualized plan of care in conjunction with patient and those important to patient to meet symptom control, physical, nutritional, hydration, emotional, psychological, social, spiritual cultural and religious needs.

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Introduction - ascertain preferences regarding:

• How much information the patient wants about his /her condition, and whether this is the correct time for this discussion

• Who the patient wishes to be present during the discussion

• How much the patient wishes the people who are important to him/her to know

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Introduction – explore patient’s understanding of current disease state

• Why is it important to ascertain:o What the patient wishes to know?o How much the patient wishes those important to him/her to know?

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Introduction – ask:

What do you understand of your admission so far?

or

What have you been told about your illness/disease?

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Information – Explain patient’s condition/deterioration

• Use simple, direct, plain and clear language, avoiding jargon, euphemisms or complex medical terminology

• Sensitively communicate and discuss the information provided and its implications for the patient

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Information

• Answer questions as they arise, identifying and clarifying misunderstandings

• Check regularly what the person has understood from the conversation, and his/her desire to continue

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Information - prognosis and trajectory of deterioration

• Check out patient’s desire for information and understanding of prognosis, before giving estimate

• Acknowledge, accept and communicate the likely nature, but uncertainty that exists around prognosis (avoid precise numbers) and trajectory of deterioration

• Discuss any symptoms that may arise, their cause and the management and care that will be provided

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Wishes and needs

Explore patient’s wishes and preferences by asking:• What are your preferences and priorities for your future care? or What is

important to you now?

• Have you thought about where you would like to be cared for in the future?

• Are there any other issues that are important to you?

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Wishes and needs - spiritual and religious needs

• Explore with open an question: What gives you strength at this time?

• Providing spiritual support involves sensitive questioning and observation to identify spiritual need (for example personal artefacts) and a patient’s spiritual disposition and emotions

• Religious care ‘is given in the context of shared religious beliefs, values, liturgies and lifestyle of a faith community’*

• Consider and offer referral onwards to specialist support/services

*Standards for NHS Scotland Chaplaincy Services in NICE (2011)

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Wishes and needs – psychological support

• Use exploratory, open questions to support and help identify psychological needs:

Can you tell me what is worrying you?

• Acknowledge the emotions being expressed and name them to give them legitimacy.

This must be very difficult for youI can see this is very overwhelming/distressing/frustrating

• Allow time, space and opportunity for the expression of emotion

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Limitations - level of intervention

• Discuss a patient’s wishes regarding intensity, focus and ceiling of treatment

• Sensitively discuss and provide information about: o interventions and treatments to be continued for management of symptoms or

comfort (e.g. fluids, antibiotics, analgesia)o Interventions and treatments to be discontinued that are contrary to the patient’s

wishes, are inappropriate and/or are likely to be ineffective (e.g. fluids, antibiotics, analgesia)

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DNACPR

Reflect on your own practice of undertaking or observing DNACPR discussions:

1. What went well and what didn’t go so well? 2. What phrases or language were inappropriately or poorly used? 3. What phrases or language did you feel worked well and are examples of best

practice?

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Best practice – DNACPR discussion:

Understand the patient’s background, history, and views. Offer as much information as wanted. Detail what CPR does and doesn’t involve.

Be open, honest, using clear and unambiguous language. Provide accurate and consistent information.

Regularly check understanding, allow time for discussion and reflection. Document fully and clearly.

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The Tracey case and implications for practice

The case

• 2014 Court of Appeal decision in R (Tracey) v Cambridge University Hospitals NHS Foundation Trust & Ors concerned the DNACPR decision making process after Janet Tracey’s admission in 2011

• Key issue: Whether competent adults should be involved in the decision-making process for DNACPR decisions

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The Tracey case and implications for practice

The judgement

• By failing to discuss the making of the first DNACPR decision with a patient who had capacity and had expressed a clear wish to be involved in discussions about her treatment, Cambridge University Hospitals NHS Foundation Trust was in breach of Janet Tracey’s human rights

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The Tracey case and implications for practice

The implications

• If the team is as certain as it can be:o that a person is dying as an inevitable result of underlying disease or a catastrophic

health event, ando CPR would not re-start the heart and breathing for a sustained period

• CPR should not be attempted. • This should be discussed in full with a patient and their family, who should be

consulted and informed of the decision-making process. • Note: Ultimate responsibility for the decision lies with the treating consultant

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The Tracey case and implications for practice

• There are situations where a patient will be distressed by being consulted; this distress must be likely to cause the patient actual physical or psychological harm to warrant not discussing/explaining the decision to them

• Patients / those important to them can be offered a second opinion if they are not happy with the decision that has been made

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Step 1 : Ascertain patient's own wishes and feelings to inform decision making

Step 2 : Doctor/MDT decides what treatment options are clinically indicated ('the menu')

Step 3 : Offer treatment options to the patient, explaining risks, benefits and side effects (discuss CPR and explain whether clinically indicated or not*)

Step 4 : Patient chooses or declines treatment offered or may inform the doctor that he wishes to have a form of treatment that the doctor has not offered

Step 5 : If, after discussion with the patient, the doctor decides that the form of treatment required is not clinically indicated, he is not required to provide it and should offer a second opinion**

DNACPR decision making guide

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The Tracey case and implications for practice

• DNACPR decision making process for patients assessed to lack capacityo invoke Mental Capacity Act, i.e. ‘best interest’ decision making process

• Document and review decisions

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Plan of care

• Summarise discussion to ensure that patient and those important to them understand the plan of care

• Document individualised care plan in medical/nursing notes

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Reflection and questions

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Effective communication