End-of-Life Communication from Interdisciplinary Perspectives Learning to Care for the Patient’s Lived Body.

End-of-Life Communication End-of-Life Communication

from from

Interdisciplinary Interdisciplinary Perspectives Perspectives

Learning to Care for the Learning to Care for the

Patient’s Lived BodyPatient’s Lived Body

Sandra Sanchez-Reilly, MD University of Texas Health Science Center and the South Texas Veterans Health Care System, San Antonio, TX

Elaine Wittenberg-Lyles, PhDUniversity of North Texas

Michele Saunders, MD University of Texas Health Science Center and the South Texas Veterans Health Care System, San Antonio, TX

SpeakersSpeakers

ObjectivesObjectives

• To present an overview of several To present an overview of several innovative educational methods currently innovative educational methods currently used in end-of-life care communication used in end-of-life care communication training training (Education and Communication)(Education and Communication)

• To acknowledge the importance of To acknowledge the importance of interdisciplinary team approach in end-of-interdisciplinary team approach in end-of-life care and training life care and training (Interdisciplinary (Interdisciplinary and Communication)and Communication)

General DefinitionsGeneral Definitions

• Palliative CarePalliative Care• End-of-LifeEnd-of-Life• InterdisciplinaryInterdisciplinary• Lived BodyLived Body



The Cure - Care Model: The Cure - Care Model: The Old SystemThe Old System

Life Prolonging Care

Palliative/

Hospice

Care

D

E

A

T

HDisease ProgressionDisease Progression

Diagnosis of serious illness

Death

Palliative Care’s Place in the Course of Illness

Life Prolonging TherapyLife Prolonging Therapy

Palliative CarePalliative Care Medicare Hospice Medicare Hospice BenefitBenefit

“Modern Medicine

”

End-of-Life

Palliative Care



Interdisciplinary TeamsInterdisciplinary Teams• Consist of a medical director, the Consist of a medical director, the

patient’s physician, a nurse who patient’s physician, a nurse who functions as the case manager, social functions as the case manager, social worker, pastoral care, and certified worker, pastoral care, and certified nurse assistant. nurse assistant.

• Team members who work from Team members who work from different orientations while at the different orientations while at the same time engaging in joint work. same time engaging in joint work.

• Care plans that have been assessed Care plans that have been assessed by experts in different disciplinesby experts in different disciplines

Hoyer T: A history of the Medicare Hospice Benefit. The Hospice Journal Hoyer T: A history of the Medicare Hospice Benefit. The Hospice Journal 1998;13:61-69.1998;13:61-69.Dyeson TB: The home health care team: What can we learn from the hospice Dyeson TB: The home health care team: What can we learn from the hospice experience? Home Health Care Management & Practice 2005;17:125-127.experience? Home Health Care Management & Practice 2005;17:125-127.

The patient’s lived bodyThe patient’s lived body

• Communication about the Communication about the psychological and social aspects psychological and social aspects of dying. of dying. – includes good health care includes good health care

professional and patient professional and patient communicationcommunication

– team attention to psychosocial team attention to psychosocial issues such as depressionissues such as depression

– efficient interdisciplinary staff efficient interdisciplinary staff communicationcommunication

EDUCATION IN EDUCATION IN END-OF-LIFE END-OF-LIFE

COMMUNICATIONCOMMUNICATION

Where are we?Where are we?

Goals of EducationGoals of Education

•Increase knowledge/expertiseIncrease knowledge/expertise•Communication skillsCommunication skills•Interdisciplinary team awarenessInterdisciplinary team awareness



Deficiencies in Medical Deficiencies in Medical EducationEducation

• 74% of residencies in U.S. offer no 74% of residencies in U.S. offer no training in end of life care.training in end of life care.

• 83% of residencies offer no hospice 83% of residencies offer no hospice rotation.rotation.

• 41% of medical students never witnessed 41% of medical students never witnessed an attending talking with a dying person an attending talking with a dying person or his family, and 35% never discussed or his family, and 35% never discussed the care of a dying patient with a the care of a dying patient with a teaching attending.teaching attending. Billings & Block JAMA 1997;278:733.

The Good News: The Good News: Palliative Care Education Is ImprovingPalliative Care Education Is Improving• Medical school LCME requirement:Medical school LCME requirement: ““Clinical instruction must include important Clinical instruction must include important

aspects of … end of life care.” 2000aspects of … end of life care.” 2000

• Residency ACGME requirements for Residency ACGME requirements for internal medicine and internal internal medicine and internal medicine subspecialties:medicine subspecialties: ““Each resident should receive instruction in the Each resident should receive instruction in the principles of palliative care…it is desirable that principles of palliative care…it is desirable that residents participate in hospice and home care…residents participate in hospice and home care…The program must evaluate residents’ technical The program must evaluate residents’ technical proficiency,…communication, humanistic proficiency,…communication, humanistic qualities, and professional attitudes and qualities, and professional attitudes and behavior…” 2000behavior…” 2000

Palliative Care Education in Palliative Care Education in Medical Schools Is ImprovingMedical Schools Is Improving

• Annual medical school exit Annual medical school exit questionnaire 2002-2003questionnaire 2002-2003

• 126 LCME accredited medical 126 LCME accredited medical schoolsschools

• 110 (87%) require instructional 110 (87%) require instructional hours in palliative carehours in palliative care

• Average # of hours required: 12, but Average # of hours required: 12, but highly variable (4-14) highly variable (4-14)

Barzansky B, Etzel SI. JAMA 2003; 290:1190-6Dickinson GE. Am J Hosp Palliat Care. 2006 23(3): 197-204

Current State of Nursing Current State of Nursing Education in Palliative CareEducation in Palliative Care• Only 3% of nursing programs in the Only 3% of nursing programs in the

United States reported having a course United States reported having a course dedicated to end-of-life issues in 2002. dedicated to end-of-life issues in 2002.

• 40% focus groups felt a need to increase 40% focus groups felt a need to increase this content in their curricula. this content in their curricula.

• Nursing textbooks offer little in the way of Nursing textbooks offer little in the way of end-of-life careend-of-life care

• Nurses report wishing they had learned Nurses report wishing they had learned more about caring for the dying while in more about caring for the dying while in their undergraduate and graduate nursing their undergraduate and graduate nursing programs. programs.

Robinson R. End-of-life education in undergraduate nursing curricula. Dimens Crit Care Nurs. 2004 Mar-Apr;23(2):89-92

Special InitiativesSpecial Initiatives

• Objective Structured Clinical Examination Objective Structured Clinical Examination (OSCE) with Standardized Patients(OSCE) with Standardized Patients

• End of Life Nursing Education Curriculum End of Life Nursing Education Curriculum (ELNEC)(ELNEC)

• Education on Palliative and End-of-life-care Education on Palliative and End-of-life-care (EPEC)(EPEC)

• Education on Palliative and End-of-life-care Education on Palliative and End-of-life-care for Oncologists (EPEC-O)for Oncologists (EPEC-O)

• Palliative Care Education and Practice (PCEP)Palliative Care Education and Practice (PCEP)• Center for Advanced Palliative Care (CAPC)Center for Advanced Palliative Care (CAPC)

GERIATRICS AND GERIATRICS AND PALLIATIVE CAREPALLIATIVE CARE

FACTSFACTS GERIATRICSGERIATRICS PALLIATIVE PALLIATIVE CARECARE

POPULATIONPOPULATION OLDEROLDER EVERYONE: EVERYONE: MANY OLDER MANY OLDER ADULTSADULTS

QUALITY OF LIFEQUALITY OF LIFE VERY VERY IMPORTANTIMPORTANT

VERY VERY IMPORTANTIMPORTANT

GERIATRIC GERIATRIC SYNDROMESSYNDROMES

MENTAL STATUS MENTAL STATUS CHANGES, PAIN, CHANGES, PAIN, FALLS, FALLS, WEAKNESSWEAKNESS

MANY MANY SYMPTOMSSYMPTOMS

FAMILYFAMILY VERY VERY IMPORTANTIMPORTANT


SUB-SPECIALTYSUB-SPECIALTY YESYES YESYES

FUNCTIONAL FUNCTIONAL STATUSSTATUS


COMFORT AND COMFORT AND QUALITY OF LIFEQUALITY OF LIFE

University of Texas Health Science University of Texas Health Science Center at San Antonio and The South Center at San Antonio and The South Texas Veterans Health Care SystemTexas Veterans Health Care System

Geriatric Palliative Care

Program:

ConsultationService

Inpatient Hospice Unit

Community Home Hospices

ClinicsPediatric

Palliative Care

Fellowship

Palliative Care: Palliative Care: Educational ProgramsEducational Programs

• Interprofessional Palliative Care Interprofessional Palliative Care FellowshipFellowship

• Community Hospice SettingsCommunity Hospice Settings• Medical StudentsMedical Students

Models of Care: Models of Care: A Geriatric Palliative Care A Geriatric Palliative Care

TeamTeam

COMM.EXPERTS

PSYCHOLOGIST

CHAPLAINS

SOCIAL WORK

RESEARCH STAFF

IDT. TRAINEES

PHYSICIANS

NURSES

PATIENT AND

FAMILY



End-of-Life End-of-Life CommunicationCommunication

• Clinical BarriersClinical Barriers– UncertaintyUncertainty– anxiety (patient & doctor)anxiety (patient & doctor)– feelings of failurefeelings of failure– expressed emotionexpressed emotion– lack of traininglack of training– TimeTime


• Educational BarriersEducational BarriersOne-way One-way

communicationcommunication


• Team BarriersTeam Barriers– Working together as a teamWorking together as a team– Different disciplinesDifferent disciplines

•PsychologistPsychologist

Potential SolutionsPotential Solutions

• Clinical Barriers: EDUCATIONClinical Barriers: EDUCATION• Team Barriers: Team Barriers:

– INTERDISCIPLINARY TEAM INTERDISCIPLINARY TEAM MEETINGSMEETINGS

– SELF CARE: “SPIRITUAL ROUNDS”SELF CARE: “SPIRITUAL ROUNDS”

• Educational Barriers:Educational Barriers:– FAMILY MEETINGSFAMILY MEETINGS

Potential SolutionsPotential Solutions

• Family meetingsFamily meetings– Provides for team environmentProvides for team environment– Includes patient and familyIncludes patient and family– Based on communicationBased on communication– Necessary for treating the Necessary for treating the patient’s patient’s

lived bodylived body

Family Meetings: Family Meetings: BackgroundBackground

• The importance of involving patients The importance of involving patients and family members in healthcare and family members in healthcare teams is well documented* teams is well documented*

• Family meetings improve Family meetings improve satisfaction, coordination of care, satisfaction, coordination of care, and communication**and communication**

*(Saltz & Schaefer, 1996; McDonald et al., 2002; *(Saltz & Schaefer, 1996; McDonald et al., 2002; Fischer, Schulz, & Ogletree, 1999; Andrews et al., 1998)Fischer, Schulz, & Ogletree, 1999; Andrews et al., 1998)

** (Andrews et al, 1998; Axford, Askill, & Jones, 2002)** (Andrews et al, 1998; Axford, Askill, & Jones, 2002)

What Do Family Members What Do Family Members Want?Want?

Study of 475 family members 1-2 years after Study of 475 family members 1-2 years after bereavementbereavement

• Loved one’s wishes honoredLoved one’s wishes honored• Inclusion in decision processesInclusion in decision processes• Support/assistance at homeSupport/assistance at home• Practical help (transportation, medicines, Practical help (transportation, medicines,

equipment)equipment)• Personal care needs (bathing, feeding, toileting)Personal care needs (bathing, feeding, toileting)• Honest informationHonest information• 24/7 access24/7 access• To be listened toTo be listened to• PrivacyPrivacy• To be remembered and contacted after the deathTo be remembered and contacted after the death

Tolle et al. Oregon report card.1999 Tolle et al. Oregon report card.1999 www.ohsu.edu/ethicswww.ohsu.edu/ethics

Family MeetingsFamily Meetings

• ChallengesChallenges

– Difficulty listening – Physician Difficulty listening – Physician PerspectivePerspective

– Difficulty making decisions – Social Difficulty making decisions – Social Worker PerspectiveWorker Perspective

– Difficult family dynamicsDifficult family dynamics

Family Meetings: A Family Meetings: A FrameworkFramework

“BRING THE PATIENT INTO

THE ROOM”

“SPIKES” MODEL

PRE-MEETING

THE S.P.I.K.E.S. MODELTHE S.P.I.K.E.S. MODEL

• S:S: SettingSetting. Pick a private location. . Pick a private location. • P:P: PerceptionPerception. Find out how the patient views . Find out how the patient views

the medical situation. the medical situation. • I:I: InvitationInvitation. Ask whether the patient wants to . Ask whether the patient wants to

know. know. • K:K: KnowledgeKnowledge. Warn before dropping bad . Warn before dropping bad

news. news. • E:E: EmpathyEmpathy. Respond to the patient’s emotions. . Respond to the patient’s emotions. • S:S: Strategy/SummaryStrategy/Summary. Once they know, include . Once they know, include

patients in treatment decisions. patients in treatment decisions. Walter F. Bailea, Robert Buckman. The Oncologist, Vol. 5, No. 4, 302-311, August 2000

Family Meetings: A Family Meetings: A FrameworkFramework

“BRING THE PATIENT INTO

THE ROOM”

“SPIKES” MODEL

COMFORT AND REFRAME

PRE-MEETING

Family Meetings: ROLE Family Meetings: ROLE PLAYPLAY

• 85 YEAR-OLD MAN WITH PAST 85 YEAR-OLD MAN WITH PAST MEDICAL HISTORY OF DIABETES, MEDICAL HISTORY OF DIABETES, HYPERTENSION, AND RECENTLY HYPERTENSION, AND RECENTLY DIAGNOSED METASTASIC LUNG DIAGNOSED METASTASIC LUNG CANCER. PT IS IN THE HOSPITAL CANCER. PT IS IN THE HOSPITAL WITH EXCRUTIATING PAIN, BUT WITH EXCRUTIATING PAIN, BUT ALERT, WITH HIS WIFE AND ALERT, WITH HIS WIFE AND DAUGHTER AT BEDSIDE. THEY DAUGHTER AT BEDSIDE. THEY ARE HOPING FOR A CURE…ARE HOPING FOR A CURE…


• DR. R., HIS PRIMARY PHYSICIAN DR. R., HIS PRIMARY PHYSICIAN AND A MEDICINE RESIDENT, IS AND A MEDICINE RESIDENT, IS NOT VERY COMFORTABLE WITH NOT VERY COMFORTABLE WITH DELIVERING BAD NEWS, HE WAS DELIVERING BAD NEWS, HE WAS NEVER PROPERLY TRAINED…NEVER PROPERLY TRAINED…

• HIS ATTENDING PHYSICIAN IS HIS ATTENDING PHYSICIAN IS NOT WILLING TO DO IT EITHER: NOT WILLING TO DO IT EITHER: “THE FAMILY SHOULD KNOW BY “THE FAMILY SHOULD KNOW BY NOW”NOW”


• PT LIVES WITH HIS WIFE, AND HIS PT LIVES WITH HIS WIFE, AND HIS PENSION IS THEIR ONLY SOURCE PENSION IS THEIR ONLY SOURCE OF INCOMEOF INCOME

• HIS DAUGHTER HAS NOT BEEN HIS DAUGHTER HAS NOT BEEN INVOLVED IN THEIR LIVES SINCE INVOLVED IN THEIR LIVES SINCE HE RE-MARRIEDHE RE-MARRIED

• THE PALLIATIVE CARE TEAM IS THE PALLIATIVE CARE TEAM IS CALLED TO “PROVIDE HOSPICE CALLED TO “PROVIDE HOSPICE CARE”…CARE”…

Family Meetings: A GOOD Family Meetings: A GOOD SKILL TO MASTERSKILL TO MASTER

• Rewards/Learning about Rewards/Learning about communicationcommunication

– Family understandingFamily understanding• Understanding your roleUnderstanding your role

– Facilitating difficult conversationsFacilitating difficult conversations• Understanding the contextUnderstanding the context



End-of-Life Communication End-of-Life Communication

is team based!is team based!

Geriatrics Interdisciplinary Geriatrics Interdisciplinary Advisory Group, 2006 Advisory Group, 2006

Interdisciplinary care:Interdisciplinary care:• Improves healthcare processesImproves healthcare processes• Benefits the healthcare system Benefits the healthcare system

and caregivers, and caregivers, • Adequately prepares healthcare Adequately prepares healthcare

providers for better care of older providers for better care of older adults adults

Interdisciplinary Interdisciplinary CollaborationCollaboration

• Interdependence and Interdependence and flexibilityflexibility

– Deviation from specific discipline Deviation from specific discipline specific boundaries; flexibility of job specific boundaries; flexibility of job responsibilities responsibilities

Bronstein LR: Index of interdisciplinary collaboration. Social Work Research 2002;26:113-126.Bronstein LR: A model for interdisciplinary collaboration. Social Work 2003;48: 297-306.


• Newly created professional Newly created professional activitiesactivities

– Expansion of an individual’s specific job Expansion of an individual’s specific job responsibilities responsibilities

– New activities that evolve through New activities that evolve through interdisciplinary collaboration include: interdisciplinary collaboration include: (1) information sharing to educate others; (1) information sharing to educate others; and (2) additional tasks. and (2) additional tasks.


• Collective ownership of goalsCollective ownership of goals

– Individuals share responsibilities for all Individuals share responsibilities for all aspects of decision-making and aspects of decision-making and implement decision together implement decision together

– The discussion of “special cases” The discussion of “special cases” illustrated a collective ownership of illustrated a collective ownership of goals. Such cases warrant additional goals. Such cases warrant additional information sharing. information sharing.


• Reflective processReflective process

– Team evaluation of team’s outcomes Team evaluation of team’s outcomes

– Includes information about (1) Includes information about (1) procedural issues, (2) reviews of deaths, procedural issues, (2) reviews of deaths, and (3) the sharing of workplace stress. and (3) the sharing of workplace stress.

Interdisciplinary Interdisciplinary PerspectivesPerspectives

• Team member collaboration Team member collaboration provides for holistic care of the provides for holistic care of the patient’s lived bodypatient’s lived body

Example: Treatment of all painExample: Treatment of all pain•PhysicalPhysical•SpiritualSpiritual•EmotionalEmotional•PsychologicalPsychological

Thank youThank you

Sandra Sanchez-ReillySandra [email protected] 210-617-210-617-52375237

Elaine Wittenberg-LylesElaine [email protected] 940-565-4450940-565-4450

End-of-Life Communication from Interdisciplinary Perspectives Learning to Care for the Patient’s Lived Body.

Documents

life palliative care

pastoral care

life communication

home health care team

body communication

cure care model

good health care professional

bodylived body slide