R. Sean Morrison, MD Director, National Palliative Care Research Center Hermann Merkin Professor of Palliative Care Professor, Geriatrics and Medicine Vice-Chair for Research Brookdale Department of Geriatrics & Adult Development Mount Sinai School of Medicine New York, NY [email protected]www.nprc.org Isn’t It Time We Talked? Communicating With Patients With Serious Illness
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Isn’t It Time We Talked? Communicating With Patients With Serious Illness
Isn’t It Time We Talked? Communicating With Patients With Serious Illness. R. Sean Morrison, MD Director, National Palliative Care Research Center Hermann Merkin Professor of Palliative Care Professor, Geriatrics and Medicine Vice-Chair for Research - PowerPoint PPT Presentation
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R. Sean Morrison, MDDirector, National Palliative Care Research Center
Hermann Merkin Professor of Palliative Care
Professor, Geriatrics and Medicine
Vice-Chair for Research
Brookdale Department of Geriatrics & Adult Development
• Pain and symptom control• Avoid inappropriate prolongation of the dying
process• Achieve a sense of control• Relieve burdens on family• Strengthen relationships with loved ones
Singer et al, JAMA, 1999
The Role of The Health Care Professional• To plan for the future - the when, not if• To communicate bad news• To establish goals of care• To provide treatments that meet these goals
– Life prolonging and curative care– Pain and symptom management– Psychological, emotional, spiritual support
• To withdraw treatments that no longer meet these goals• To negotiate conflict around treatments and goals of
• It is important to be accurate– Allows patients/families to cope and plan– Gives time and opportunity to accomplish
critical life goals (financial, emotional)– Increases access to hospice, other services
• But it’s ok to hedge– Offer a range or average for life expectancy
Language With Unintended Consequences
• Do you want us to do everything possible?• Will you agree to discontinue care?• It’s time we talk about pulling back.• I think we should stop aggressive therapies.• I’m going to make it so that he won’t suffer.• There’s nothing more that we can do for
him.
Alternative Language to DescribeThe Goals of Care
• I will give you the best care possible• We will concentrate on getting you home with your family
and make sure you get whatever help you need to achieve that goal
• We want to help you live as fully and as meaningfully as possible in the time that you have
• I will continue all treatments that will help maximize your comfort and your ability to function for as long as possible in the face of this illness
• I will focus my efforts on treating your symptoms
When We Cannot Support a Patient’s Choices
• Typically occurs when goals are unreasonable, unattainable, or illegal
• Set limits without implication of abandonment
• Make the conflict explicit– “We disagree on the benefit of continuing the ventilator.
What are you hoping that we can accomplish for your father by leaving him on the machine?”
• Try to find an alternate solution
Withholding/Withdrawing Life Sustaining Treatments
Withholding/Withdrawing Life Sustaining Treatments
• Chronic diseasesModerate to severe acute illness
• Serious and Life Threatening Illness
Significant diagnosis
Multiple co-morbidities
High risk for death
•Actively dying
The Role of the Health Care Professional • The physician helps the patient and family:
– Elucidate their own values– Decide about life-sustaining (death
prolonging?) treatments– Dispel misconceptions– Understand goals of care
• Facilitate decisions
The Role of the Health Care Professional
• Discuss alternatives– Including palliative and hospice care
• Document preferences, medical orders
• Involve, inform other team members
• Assure comfort, non-abandonment
Common Concerns
• Legally required to ‘do everything’?
• Is withdrawal, withholding euthanasia?
• Are you killing the patient when you remove a ventilator or treat pain?
Common Concerns
• Can the treatment of symptoms constitute euthanasia?
• Is the use of substantial doses of opioids euthanasia?
Principle of Double Effect
• An action with a good and bad effect is ethically acceptable if:– The action is morally good– Only the good effect is intended (even if the
bad effect is foreseen)– The good effect is not achieved by way of the
bad effect– The good result outweighs the bad
Ethical Basis for Sedation for Refractory Symptoms
• Suffering individuals have a legitimate claim to comfort measures and relief of suffering is a professional obligation.
• Individuals can reject unwanted interventions: the right to bodily integrity, and to be free of unwanted intrusion allows individuals to refuse life sustaining therapies.
Sedation and Withholding Life Sustaining Therapy
• Grounded in the right to be free of unwanted intervention and the obligation to provide comfort measures
• Not equivalent to assisted suicide– An active intervention for the purpose of
causing death
Opioids and the Fear of Hastening Death
“The use of morphine in the relief of cancer pain carries no greater risk than that of aspirin when used correctly.” Rather than hastening death “the correct use of morphine is more
likely to prolong a patient’s life…because he (or she) is more rested and pain-free.”
Opioids and the Fear of Hastening Death• “Most doctors are more aware of the side-
effects of opioids…than of the side-effects of pain.” Grond et al. J Pain Sympt Manage 1991;6:411.
• “I can’t think of any other area in medicine in which such an extravagant concern for side effects so drastically limits treatment…” Angell M. N Engl J Med 1982;306:98-99.
Setting the Stage For Discussing Withdrawal of Life Sustaining Treatments
• Discuss general goals of care
• Establish context for the discussion
• Discuss specific treatment preferences
• Discuss the recommendation to withdraw a treatment (not care!) within this context
Misunderstanding: How to Respond • Choose a primary communicator
• Give information in– Small pieces– Multiple formats
• Use understandable language
• Frequent repetition may be required
• Ask patient or surrogate to repeat back
Misunderstanding: How to Respond• Assess understanding frequently
• Do not hedge to “provide hope”
• Encourage writing down questions
• Provide support
• Involve other health care professionals and try to ensure consistency of message before you talk to the patient/family
Differential Diagnosis of Futility Situations
• Personal factors– Distrust
– Guilt
– Grief
– Intra-family issues
– Secondary gain
– Physician/nurse/VIP as patient
Differential Diagnosis of Futility Situations• Values conflict
– Religious– Miracles– Value of life
• Basic differences of opinion– Disagreement over goals– Disagreement over benefits
A Due Process Approach to Futility • Earnest attempts in advance
Exploring the Conflict With Families
• What do you understand?• In what situations can you imagine ____ not
wanting to live?• What are you hoping that we can
accomplish?• What do you think ___ would want us to
accomplish for him/her?• Which of these are the most important?• Are there disagreements among family
members?(Goold et al, JAMA 2000)
A Due Process Approach to Futility • Earnest attempts in advance
• Joint decision-making
• Negotiation of disagreements
• Palliative care consultation
• Involvement of an institutional committee
• Transfer of care to another physician
• Transfer to another institution
What Is the Patient’s Good?
“If medicine takes aim at death prevention, rather than at health and relief of suffering, if it regards every death as premature, as a failure of today’s medicine- but avoidable by tomorrow’s- then it is tacitly asserting that its true goal is bodily immortality...Physicians should try to keep their eyes on the main business, restoring and correcting what can be corrected and restored, always acknowledging that death will and must come, that health is a mortal good, and that as embodied beings we are fragile beings that must stop sooner or later, medicine or no medicine.”