1. http://www.growthhouse.org/stanford Module #3 END-OF-LIFE CARE: Module 3 Communicating with Patients and Families

2. http://www.growthhouse.org/stanford Module #3 Talk too much Rarely explore patients’ values & attitudes Discuss uncertainty using vague language Tulsky, et al., 1998 Avoid patients’ affective concerns Parle, et al., 1997 Overemphasize cognitive communication Fail to assess patient understanding Braddock, et al., 1999 Identified Deficits in Physician Communication Skills

3. http://www.growthhouse.org/stanford Module #3 Recognize the importance of effective end-of-life (EOL) communication Increase your EOL communication skills in: –Listening –Sharing bad news –Pronouncing death Improve your ability to incorporate this content into your clinical teaching Learning Objectives

4. http://www.growthhouse.org/stanford Module #3 Outline of Module Background Three techniques critical to EOL communication Skills training –Listening –Sharing bad news –Death pronouncement –Diversity Physician self-care strategies

5. http://www.growthhouse.org/stanford Module #3 General Challenges to Patient- Physician Communication Time constraints Language differences Mismatch of agendas Lack of teamwork Discomfort with strong emotions Quality of physician training Resistance to change habits Buckman (1984), Ford et al (1994), Buss (1998)

6. http://www.growthhouse.org/stanford Module #3 Unique Challenges in Communication at the end of life: Emotionally laden material –For patient, for family, for providers Issues of uncertainty are common –Prognosis –What is it like to die? –The meaning of death

7. http://www.growthhouse.org/stanford Module #3 Three Techniques Critical to End-of-Life Communication Distinguish between cognitive and affective elements of communication, and respond appropriately Clarify ambiguity Listen in balance with speaking Suchman,1997

8. http://www.growthhouse.org/stanford Module #3 Two Elements to Keep in Mind: Cognition = intellectual component Affect = emotional component

9. http://www.growthhouse.org/stanford Module #3 Cognitive Response How might you respond to the cognitive component of the patient or family member’s communication?

10. http://www.growthhouse.org/stanford Module #3 Affective Response Identify and explore the affect: –“You seem angry (worried, upset) about this. Can you help me understand what’s going on for you?” Acknowledge the probable source of affect and connect it with its source –“You’ve been through a lot. No wonder you’re feeling like this.”

11. http://www.growthhouse.org/stanford Module #3 Clarify Ambiguity Ambiguous statements: –“I want you to take care of me when the time comes” –“I want everything done for my father” What do you hear? –“I want compassionate care” –“I want assisted suicide”

12. http://www.growthhouse.org/stanford Module #3 Listen in Balance with Speaking Convey listening nonverbally Delay your response for a few moments Reflect the affective component

13. http://www.growthhouse.org/stanford Module #3 Delay Exercise A’s: Talk about a memorable experience with dying, that you have had as a practitioner B’s: Distinguish between cognitive and affective components Listen for ambiguity Listen in balance with speaking –Convey listening nonverbally –Delay response for a few moments –Reflect the affective component

14. http://www.growthhouse.org/stanford Module #3 Debrief

15. http://www.growthhouse.org/stanford Module #3 Sharing Bad News Step 1: Prepare Step 2: Convey Information Step 3: Follow Up

16. http://www.growthhouse.org/stanford Module #3 Step 1: Prepare Prepare yourself Prepare the recipients Prepare the environment

17. http://www.growthhouse.org/stanford Module #3 Step 2: Convey Information Establish empathic connection Give an advance alert Convey realistic information in a clear manner Observe and respond to cognitive and affective reactions Clarify ambiguity Restore and catalyze hope

18. http://www.growthhouse.org/stanford Module #3 Step 3: Follow Up Set concrete goals Connect patient/family with support systems Arrange follow-up meetings Convey commitment and non-abandonment Communicate with treatment team

19. http://www.growthhouse.org/stanford Module #3 Training Tape Sharing Bad News in Two Different Ways Two scenarios from the End-of-Life Physician Education Resource Center http://www.eperc.mcw.edu

20. http://www.growthhouse.org/stanford Module #3 Discussion First scenario

21. http://www.growthhouse.org/stanford Module #3 Discussion Second scenario

22. http://www.growthhouse.org/stanford Module #3 Skills Sharing Bad News: Step 1: Prepare Step 2: Convey Information Step 3: Follow Up Skills Practice

23. http://www.growthhouse.org/stanford Module #3 Debrief

24. http://www.growthhouse.org/stanford Module #3 Action Plan Summarizing the Bad News Role Play

25. http://www.growthhouse.org/stanford Module #3 Death Pronouncement Not just a medical event Very important to family Most physicians have not been trained to do this A skill that requires practice Death Pronouncement

26. http://www.growthhouse.org/stanford Module #3 Find out about the situation Pronounce/say goodbye Console the family Silence Follow-up paperwork and other business Steps in Pronouncing Death

27. http://www.growthhouse.org/stanford Module #3 Role Play #1 A patient died on the wards The nurse has just called you to “pronounce the patient” The patient is alone in the room Model saying goodbye There is no ‘right’ or ‘wrong’ way to do this

28. http://www.growthhouse.org/stanford Module #3 Role Play #2 A patient has died on the wards The nurse has just called you to “pronounce the patient” Family member(s) present in the room Model the communication aspects of pronouncing a person dead There is no ‘right’ or ‘wrong’ way to do this

29. http://www.growthhouse.org/stanford Module #3 Debrief

30. http://www.growthhouse.org/stanford Module #3 Summary Most of us have not been taught how to pronounce death We may never have seen it done We are there as a guest in the room How does a doctor say goodbye to a human being?

31. http://www.growthhouse.org/stanford Module #3 Anticipate death where possible, and keep family up-to-date beforehand Use skills of sharing bad news Allow time for immediate reaction Suggest they take their time coming in Provide contact person and explicit instructions Arrange follow-up Death Notification by Telephone

32. http://www.growthhouse.org/stanford Module #3 Learning Objectives Recognize the importance of effective end-of-life communication Increase your EOL communication skills in: –Listening –Sharing bad news –Pronouncing death Improve your ability to incorporate this content into your clinical practice Learning Objectives