1. CASE PRESENTATION
80 Man with respiratory failure admitted to ICU and found to have metastatic cancer…
Patient deemed“un-weanable”
ICU care perceived as “futile”
Patient has capacity, no surrogate
When asked for permission to discontinue life-support, patient asked for “everything to be done.”
Ethics and Palliative Care consults were obtained

2. Session Goals Discuss this case relative to:
General issues in physician-patient communication
How to communicate regarding difficult decisions
How to incorporate patient preferences into decisions
Ethical issues involved
Focus on the concept of medical futility

3. Communication Premises
Most people interpret and construct their lives based on stories
Problems often occur when personal storylines have been disrupted
Patient/family stories conflict with medical stories
Problem resolution is enhanced by effective communication and mutual construction of a new storyline
Which requires patient/family and provider to be “in-synch”

4. ICU Clinician Story Continued care is medically futile
Patient does not get how sick he is - ? “in denial”
Running out of time before patient becomes confused
With no surrogate decision maker, will they be forced to continue to “do everything,” even it such care is useless and harmful?

5. The Patient’s Story …
In the process of writing a book – wants a year to finish
Was unaware that he was this ill – acute illness took him by surprise
Trying to come to grips with prognosis – all happening too fast
Question:“What can we do for you?”
Answer: “Give me TIME

6. Communication – specific skills required
General
Active Listening
Verbal and Non-Verbal
Addressing emotional as well as cognitive components of communication
Recognition of barriers
Language, Hearing, Speaking
Above presumes a connection between participants that may not in fact be present

7. Entrainment as a Communication Skill
Like gears must touch, but not crowd
Spacing
Gears must be synchronized
Aligned temporally
Work toward a common purpose
Shared narrative construction

8. Space as an Aspect of Communication
Culturally defined, out of general consciousness
Varies with roles and relationships
Formal Space
Friendly Space
Intimate Space
For Elders distance may be appropriate in representing respect. However, to the extent personal caring and concern is being communicated may be more intimate, requiring close proximity, even intimate space. In this case relatively intimate space used – holding hand, putting on patient’s glasses etc..

9. Time as an Aspect of Communication
With age time experienced more slowly
Perception of time correlates with the inverse of the square root of chronological age
Elders perceive the young to move too quickly
The young perceive elders to move too slowly
Point out that when we instruct clinicians to sit and “listen” to some degree we may be unwittingly be slowly them down enough so they become visible. Speed in healthcare (need to move people quickly) also way out of synch with many elders
? Star Treck story . In this case had to speak slowly, wait for written, nodded responses. Inquired, “I bet this all seems like it is happening very fast to you…” Nodded emphatically yes.
Young and Old out of Synch:

10. Working toward a Common Purpose
Demonstration of respect for the person
Inquire regarding current understanding of illness
Explanatory Model
Explaining one’s own explanatory model (and story)
Inquire regarding goals (where is story headed)
Look for opportunities to come into synch with these goals
In case: Let patient know I knew about “The Silk Road” etc.
“What have you been told” “ What is your body telling you”
Empathetic statements, “This must have taken you by surprise. It must be very hard for you to figure out what to do given this sudden turn of events.
Suggested that he probably did have time to do some things, but probably not finish the book. Suggested a “frame shift” in goals to: “If I am dying, where and how would I like to live until I die.”
Response: “What about my estate” (Patient adjust goals, opportunity for us to help)
Discussion of how to get his will and “say good-bye” – Intubation now re-framed as giving time to say good-bye and adjust to diagnosis.

11. So What Happened?
How to establish synchronicity between patient and ICU staff?
Shifting goals of care
For Patient
For Staff
Bringing stories into alignment
Negotiating a mutually satisfactory story ending

12. The Good Acronym
Goals
Options
Opinion
Document

13. Goals Identify stakeholders and their goals
Future goals based on current understanding
“What is your understanding of”
“What did your doctor tell you”
Identify ‘big picture’ goals first
“Let’s look at the big picture, what is most important to you?”
Use case to illustrate:
Stakeholders here fairly clear – pt and clinicians, who were appeared ‘on the same page’
Patient understood he had cancer
His ‘big picture’ goal was to finish his book, which would take a year

14. Options Identify relevant options and priorities
Address benefits and burdens of options
Do your homework
Address probability of success
Link options to identified goals
Suggested frame shift of goals based on opinion that nobody had the power to give one year. Strengthening alliance, started with acknowledgement of the wish, “wouldn’t that be great…”
Frame shift – not so much how long to live, but how and where to live for what time left
Options – continue on vent indefinitely, consider new goals and use time on vent, transition to comfort care goals and ? Hospice Ward
With this patient wrote, “What about my estate?” He drew a picture of a box with his will in it.
Demonstrating shifting goals based on new information.
Pearl: Too often clinicians get bogged down in discussions over specific options without understanding how options relate to overall goals.

15. Opinion In offering your opinion…
Present data using neutral language:
Crush the chest
Massage the heart
Press on the chest
Be clear what is data and what opinion
Incorporate goals, benefits/burdens and values into your opinion
Listen to other’s opinions
Offered my opinion that A) he did seem to need a bit more time to let things sink in.
B) He could use the time he had on the vent to ensure certain goals were met.
Thus, we colluded on a new, mutually constructed story – using his time on the vent to ‘take care of business’ before he died. Note this was different than original two stories – live for a year or discontinue futile care.
Two days later, asked what if… question (iterating back to options) what if you were ‘unable to meaningfully interact with your environment and doing poorly and this thought irreversible’, could we then transition to comfort care, including discontinuing the vent? Strong, affirmative node.

16. Document Who said what What you did/will do with this information
“Patient said he didn’t want tube feeding”
What you did/will do with this information
“Will cancel PEG tube insertion”
Your assessment
“This reasonable given …”
Documented initial discussion and follow-up with advance, advance directive. A witnessing note also included for this.

17. SUMMARY
Good communication manifests in real relationships between real people and facilitates problem solving
Establishing such relationships requires:
Entrainment
Trust
Sharing of stories
Negotiation
Mutual construction of a new story