1. Communicating at the EOL: Communicating with Patients/Families
Sharing Poor Prognosis
Stu Farber MD
Gregg VandeKieft, MD, MA
July 2011

2. Caring Conversations: Transitioning from Cure to Care
Giving Information
Telling

3. Caring Conversations: Transitioning from Cure to Care
Sharing Information
Dialogue

4. Caring Conversations: Transitioning from Cure to Care
Special Dialogue
Helping pt/family understand where:
Disease and treatment end
Aging and the natural life cycle event we call end of life begins
You have a unique opportunity to assist:
Pre-existing relationship
We know this conversation effects pt/family choice

5. Caring Conversations: Transitioning from Cure to Care
Special Dialogue
Accepting this role takes courage
To succeed you enter into the pt/family story (values/goals)
You become a part of the story
You become vulnerable as another human sharing the mystery, pain, suffering, joy and wonder of mortality

6. Caring Conversations: Transitioning from Cure to Care
Special Dialogue
When is the “right time” to have this dialogue?
Surprise Question: Would you be surprised if this patient died in the next 6-12 months?
If you wouldn’t be surprised then it is your professional responsibility to assist the patient/family prepare for the “worst” while expecting the “best”

7. Caring Conversations: Transitioning from Cure to Care
Making it Safe
Setting the Stage
within the Concept of Paradox
Certainty and Uncertainty
Life and Death

8. Caring Conversations: Transitioning from Cure to Care
Special Dialogue
What does the pt/family already know?
What does the pt/family want to know?
What does the pt/family need to know?

9. Caring Conversations: Transitioning from Cure to Care
Communication Basics
Tell-Ask-Tell
Ask-Tell-Ask
Ask(listen) Ask(listen) Ask(listen)-Tell-Ask
Silence
Pt/Family Cues
Terminators
Continuers

10. Caring Conversations: Transitioning from Cure to Care Case of John
John is 68 with far advanced lung Ca
Just out of ICU
If he lives hrs will be a miracle
He and his family still are asking for tx that will make him better
You are asked to talk with him and his family: wife, son and daughter

11. Caring Conversations: Transitioning from Cure to Care
Evidence Based Best Practice
Set a “safe context” for dialogue
Explore the patient/family story
Use evidence based domains
Language = skill
Create shared story among pt/family/medical team
Co-Create care plan among patient, family, medical team

12. Caring Conversations: Transitioning from Cure to Care My Death Raymond Carver
If I'm lucky, I'll be wired every which way in a hospital bed. Tubes running into my nose.  
But try not to be scared of me, friends!  I'm telling you right now that this is okay.     It's little enough to ask for at the end.
Someone, I hope, will have phoned everyone to say, "Come quick, he's failing!" And they will come.
And there will be time for me to bid goodbye to each of my loved ones....   

13. Caring Conversations: Transitioning from Cure to Care
Late Fragment
And did you get what you wanted
from this life, even so?
I did.
And what did you want?
To call myself beloved.
To feel myself beloved on the earth.
Raymond Carver

14. Caring Conversations: Transitioning from Cure to Care
Joan Borzoff and Phyllis Silverman Eds, Living with Dying, Columbia University Press, July, 2004, Chapter 5: A Respectful Death, Authors: Stuart Farber, Thomas Egnew, and Annalu Farber: pp
When the Healing Professional Weeps, Katz RS, Johnson TA Editors; Chapter Title: A Respectful Death: The Power of Relationship in End-of-Life Care, Authors: Lu Farber and Stu Farber, Routeledge (a member of the Taylor & Francis Group), New York, 2006
Farber S, Egnew T, Stempel J, Vleck J, Monograph in End-of-life Care, American Academy of Family Practice, Vol 250/251 March/April, 2000
Farber S, Egnew T, Bertsch J, Taylor TR, Guldin G, Issues in End-of-Life Care: Patient, Caregiver, & Clinician Perceptions, Journal of Palliative Medicine, Vol 6(1) 003:19-31.
Stewart M, Brown JB, Weston WW et al, Patient Centered Medicine, Sage Publications, Thousand Oaks, 1995
Butow PN, Brown RF, Cogar S et al, Oncologists’ reactions to cancer patients’ verbal cues, Psycho-oncology 11:47-58 (2002)
Wright A, Zhang B, Ray A, et al, Associations among EOL discussions, pt mental health, medical care near death, and caregiver bereavement adjustment, JAMA, 2008; 300(14):