Meaningful Conversations Jennifer Gentry Duke Palliative Care

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

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

What Makes a Conversation Meaningful?

Conversations Can…

Or…

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.

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”

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?

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

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

Skills Ask-Tell-Ask Wish and Worry NURSE

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

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

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

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

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

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

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)

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.