1. COMMUNICATION ISSUES IN PALLIATIVE CARE Mike Harlos Professor, Faculty of Medicine, University of Manitoba Medical Director, WRHA Adult & Pediatric Palliative Care

2. Objectives Review fundamental components of effective communication with patients and their families Explore boundary issues when addressing difficult scenarios in palliative care Discuss potential barriers to effective communication in palliative care Consider an approaches/framework to challenging communication issues Review an approach to decision making in palliative care

4. Silence Is Not Golden Dont assume that the absence of question reflects an absence of concerns Upon becoming aware of a life-limiting Dx, it would be very unusual not to wonder: – How long do I have? –How will I die Waiting for such questions to be posed may result in missed opportunities to address concerns; consider exploring preemptively

6. In Palliative Care… …we acknowledge the elephant but make it wait in the corner while we get on with living

7. 7 Set the Stage In person Sitting down Minimize distractions Family / friend possibly present

8. Macro-Culture Experiences Ethnicity, Faith, Values of a Community & Micro-Culture How does this family work?

9. 9 Dont simply respond with Its their right to know and dive in. Rarely an emergent need to share information Explore reasons / concerns – the micro-culture of the family Perhaps negotiate an in their time, in their manner resolution Ultimately, may need to check with patient: Some people want to know everything they can about their illness, such as results, prognosis, what to expect. Others dont want to know very much at all, perhaps having their family more involved. How involved would you like to be regarding information and decisions about your illness? When Families Wish To Filter Or Block Information

10. A foundational component of effective communication is to connect / engage with that person… i.e. try to understand what their experience might be –If you were in their position, how might you react or behave? –What might you be hoping for? Concerned about? This does not mean you try to take on that person's suffering as your own, or actually experience what they are going through, or pretend that you could even if you wanted to Connecting

12. 1.Normalize Often people in circumstances similar to this have concerns about __________ 2.Explore Im wondering if that is something you had been thinking about? 3.Seek Permission Would you like to talk about that? Initiating Conversations

13. Patient/Family Understanding and Expectations Health Care Teams Assessment and Expectations What if…?

14. Responding To Difficult Questions You might be thrown off-balance by a very direct and difficult question How long have I got? Am I dying? Why cant you just give me something to end everything right now?! Helps to have a framework to help you pause, regroup, rebalance… perhaps even guide the patient to answer the question

15. 1.Acknowledge/Validate and Normalize Thats a very good question, and one that we should talk about. Many people in these circumstances wonder about that… 2.Is there a reason this has come up? Im wondering if something has come up that prompted you to ask this? 3.Gently explore their thoughts/understanding Sometimes when people ask questions such as this, they have an idea in their mind about what the answer might be. Is that the case for you? It would help me to have a feel for what your understanding is of your condition, and what you might expect 4.Respond, if possible and appropriate If you feel unable to provide a satisfactory reply, then be honest about that and indicate how you will help them explore that Responding To Difficult Questions

16. 16 Be Clear Make sure youre both talking about the same thing Theres a tendency to use euphemisms and vague terms in dealing with difficult matters… this can lead to confusion… eg: How long have I got? Am I going to get better? The single biggest problem in communication is the illusion that it has taken place. George Bernard Shaw

18. 18 Preemptive Discussions You might be wondering… Or At some point soon you will likely wonder about… Food / fluid intake Meds or illness to blame for being weaker / tired / sleepy /dying?

19. Titrate information with measured honesty Check Response: Observed & Expressed The response of the patient determines the nature & pace of the sharing of information Feedback Loop

20. Discussing Prognosis

21. 21 How long have I got? DISCUSSING PROGNOSIS 1.Confirm what is being asked 2.Acknowledge / validate / normalize 3.Check if theres a reason that this is has come up now 4.Explore frame of reference - understanding of illness 5.Tell them that it would be helpful to you in answering the question if they could describe how the last month or so has been for them 6.How would they answer that question themselves? 7.Answer the question

22. 22 Many people think about what they might experience as things change, and they become closer to dying. Have you thought about this regarding yourself? Do you want me to talk about what changes are likely to happen? TALKING ABOUT DYING

23. First, lets talk about what you should not expect. You should not expect: – pain that cant be controlled. – breathing troubles that cant be controlled. –going crazy or losing your mind

24. If any of those problems come up, I will make sure that youre comfortable and calm, even if it means that with the medications that we use youll be sleeping most of the time, or possibly all of the time. Do you understand that? Is that approach OK with you?

25. Youll find that your energy will be less, as youve likely noticed in the last while. Youll want to spend more of the day resting, and there will be a point where youll be resting (sleeping) most or all of the day.

26. Gradually your body systems will shut down, and at the end your heart will stop while you are sleeping. No dramatic crisis of pain, breathing, agitation, or confusion will occur - we wont let that happen.

27. Day 1 Final Day 3 Day 2 The Perception of the Sudden Change Melting ice = diminishing reserves When reserves are depleted, the change seems sudden and unforeseen. However, the changes had been happening. That was fast!

28. Decisions

29. The Importance Of Context The decision about how to approach a new problem such as infection or bleeding may depend on what is happening with the illness in general; i.e. recent, present, and anticipated: Functional status Cognitive function Quality of life Advance Care Planning may need to accommodate for having to assess the context at the time of the decision Recent Experiences Present Circumstances Expectations

30. An Approach to Decision-Making in Palliative Care It helps to have a fundamental approach to guide decisions in palliative/end-of-life care A similar approach is used for virtually all clinical decisions

31. The Illusion of Choice Patients / families sometimes asked to make terribly difficult decisions about non-options i.e. there will be the same outcome regardless of which option is chosen.

32. CPR No CPR CPR No CPR Chemo No Chemo Chemo

34. The Unbearable Choice Usually in substituted judgment scenarios Misplaced burden of decision Eg: –Person imminently dying from pneumonia complicating CA lung; unresponsive –Family may be presented with option of trying to treat… which they are told will prolong suffering… or letting nature take its course, in which case he will soon die

35. Prolong Suffering Prolong Suffering Let Die Let Die

36. If he could come to the bedside as healthy as he was a year ago, and look at the situation for himself now, what would he tell us to do? Or If you had in your pocket a note from him telling you that to do under these circumstances, what would it say? Phrasing Request: Substituted Judgment

37. Helping Family And Other Substitute Decision Makers In situations where death will be an inescapable outcome, family may nonetheless feel that their choices about care are life-and-death decisions (treating infections, hydrating, tube feeding, etc.) It may be helpful to say something such as: I know that youre being asked to make some very difficult choices about care, and it must feel that youre having to make life-and-death decisions. You must remember that this is not a survivable condition, and none of the choices that you make can change that outcome. We are asking for guidance about how we can ensure that we provide the kind of care that he would have wanted at this time.

38. Food and Fluid Intake Fluid Intake Food Consider Concerns About Food And Fluids Separately Strong evidence base regarding absence of benefit in terminal phase Conflicting evidence regarding effect on thirst in terminal phase; cannot be dogmatic in discouraging artificial fluids in all situations

39. Intervention Considered or Proposed Discuss hoped-for goals - whose goals they are, and if they are achievable Intervention Considered or Proposed Discuss hoped-for goals - whose goals they are, and if they are achievable Yes, or at least perhaps Impossible Go ahead, or… Consider a trial, with: predefined goals reassessed at a specified time plan for care if the goals are not met Go ahead, or… Consider a trial, with: predefined goals reassessed at a specified time plan for care if the goals are not met Discuss; explain the intervention will not be offered or attempted. If needed, provide a process for conflict resolution : Mediated discussion 2nd medical opinion Ethics consultation Transfer of care to a setting/providers willing to pursue the intervention Discuss; explain the intervention will not be offered or attempted. If needed, provide a process for conflict resolution : Mediated discussion 2nd medical opinion Ethics consultation Transfer of care to a setting/providers willing to pursue the intervention Can the goals possibly be achieved?

40. 40 Can They Hear Us? Cerebral processing of auditory & noxious stimuli in severely brain injured patients: differences between Vegetative State & Minimally Conscious State H 2 15 O-PET scanning - measured changes in regional cerebral blood flow (rCBF) induced by simple auditory stimuli in 5 MCS patients, 15 unsedated VS patients, and 15 controls Compared to meaningless noise, presentation of cries or the patients own name produced a much more widespread activation, encompassing temporal, parietal and frontal associative areas Neuropsychological rehabilitation 2005; 15: 283-289. Boly M, Faymonville ME, Peigneux P et al.

41. These data suggest that MCS patients may be capable of extended cerebral processing of auditory stimuli, especially stimuli with emotional valence ControlMCS VS

42. Helping Families At The Bedside: Physical Changes physical changes of dying can be upsetting to those at the bedside: –skin colour – cyanosis, mottling –breathing patterns and rate –muscles used in breathing reflect inescapable physiological changes occurring in the dying process. may be comforting for families to distinguish between who their loved one is - the person to whom they are so connected in thought and spirit - versus the physical changes that are happening to their loved one's body.

43. Helping Families At The Bedside: Time Alone With The Patient family may arrive when the patient will no longer recover consciousness; they have missed the chance to say things they had wanted to individuals may wish for time alone with the patient, but not feel comfortable asking relatives to leave staff may have a role in raising this possibility, and suggesting they explore this as a family

44. Helping Families At The Bedside: Missed The Death some family members will miss being present at the time of death consider discussing the meaningfulness of their connection in thought & spirit vs physical proximity whether they were at the bedside, or had stepped out of the room for a much needed break, or were in fact in a different country, their connection in spirit was not diminished by physical distance.

45. 45 Summarizing, Debriefing Clarifications, further questions Are other supports wanted/needed (SW, Pastoral Care) Do they want help in discussing with relatives/friends? Next Steps