BASIC PRINCIPLES OF PALLIATIVE CAREA. Reed Thompson, MD

Donald W. Reynolds Department of Geriatrics

University of Arkansas for Medical Sciences

PALLIATIVE CARE

Palliative care is the active total care of patients with far advanced illnesses whose disease is not amenable to curative treatment. Control of symptoms, such as pain, is the focus of treatment rather than control of disease. The goal is to improve the quality of life rather than to increase the length of life.

HOSPICE

A philosophy of care that incorporates an interdisciplinary team for the management of all the issues that surround the dying process, with the patient and family considered as a unit.

The best way to provide palliative care.

HOSPICE BENEFIT

The financial arrangement between HCFA and providers for hospice patients.

THE INTERDISCIPLINARY TEAM

Physician Nurse RNP, clinical care

coordinator Social worker Pharmacist Mental health care professional Hospital chaplain Volunteer coordinator

COMMON SYMPTOMS IN FAR ADVANCED ILLNESSES

PainPain 89% 89% Weight LossWeight Loss 58% 58% AnorexiaAnorexia 55%55% DyspneaDyspnea 48%48% ConstipationConstipation 40%40% FatigueFatigue 40% 40% WeaknessWeakness 36%36% NauseaNausea 32%32%

DepressionDepression 31%31% InsomniaInsomnia 28%28% CoughCough 28%28% VomitingVomiting 23%23% DizzinessDizziness 23%23% BloatingBloating 11%11% EdemaEdema 11%11% ConfusionConfusion 11%11%

Curtis EB, et al., J Palliative Care, 7:25 - 29, 1991

BASIC PRINCIPLES OF PALLIATIAVE CARE

Discuss the diagnosis and prognosis Set new treatment goals Ask what the patient’s goals are Assess each symptom thoroughly

BASIC PRINCIPLES OF PALLIATIAVE CARE

Discuss the treatment options with the patient (or proxy) outlining the benefits vs. burdens of each option

Discuss do not resuscitate (DNR) status

Monitor the patient frequently Never say “there is nothing more to

be done”

Communication at the End of LifeA. Reed Thompson, MD

Donald W. Reynolds Department of Geriatrics

University of Arkansas for Medical Sciences

Identified Deficits in Physician Identified Deficits in Physician Communication SkillsCommunication Skills

When communicating with patients, physicians… - Talk too much - Rarely explore patients’ values & attitudes - Discuss uncertainty using vague language Tulsky, et al, 1998 - Avoid patients’ affective concerns Parle, et al, 1997Parle, et al, 1997 - Overemphasize cognitive communication- Overemphasize cognitive communication - Fail to assess patient understanding- Fail to assess patient understanding Braddock, et al, Braddock, et al,

1999 1999

General Challenges to Patient-General Challenges to Patient-Physician CommunicationPhysician Communication

Time constraintsTime constraints Language differencesLanguage differences Mismatch of agendasMismatch of agendas Lack of teamworkLack of teamwork Discomfort with strong emotionsDiscomfort with strong emotions Quality of physician trainingQuality of physician training Resistance to change habitResistance to change habit

Buckman, 1984; Ford et al, 1994; Buss, 1998Buckman, 1984; Ford et al, 1994; Buss, 1998

Some Unique Challenges to End-of-Some Unique Challenges to End-of-Life CommunicationLife Communication

Emotionally - laden materialEmotionally - laden material

For patient, for family, for providersFor patient, for family, for providers

Issues of uncertainty are commonIssues of uncertainty are common

PrognosisPrognosis

What is it like to die?What is it like to die?

Meaning of deathMeaning of death

Three Techniques Critical to End- Three Techniques Critical to End- of- Life Communicationof- Life Communication

Distinguish between cognitive and affective Distinguish between cognitive and affective elements of communication, and respond elements of communication, and respond appropriatelyappropriately

Clarify ambiguityClarify ambiguity

Listen in balance with speakingListen in balance with speaking

Suchman, 1997Suchman, 1997

Examples of Cognitive and Examples of Cognitive and Affective ReponsesAffective Reponses

Cognitive: Cognitive:

“ “Studies show that an IV is not necessarily going to improve the Studies show that an IV is not necessarily going to improve the situation here, and could actually cause additional problems.”situation here, and could actually cause additional problems.”

Affective:Affective:

1. 1. “You seem angry about this; can you help me understand “You seem angry about this; can you help me understand what’s going on for you?”what’s going on for you?”

2.2. “You’ve been through a lot; I’m not surprised that you are “You’ve been through a lot; I’m not surprised that you are angry about this.” angry about this.”

Clarify AmbiguityClarify Ambiguity

Ambiguous statements:Ambiguous statements: “ “I want you to take care of me when the time comes”I want you to take care of me when the time comes” “ “I want everything done for my father”I want everything done for my father”

What do you hear?What do you hear? “ “I want compassionate care”I want compassionate care” or or “ “I want assisted suicide”I want assisted suicide”

ClarificationClarification “ “Help me understand what you mean”Help me understand what you mean”

Sharing Bad NewsSharing Bad News

Step 1: PrepareStep 1: Prepare

Step 2: Share InformationStep 2: Share Information

Step 3: Follow UpStep 3: Follow Up

Step 1: PrepareStep 1: Prepare

YourselfYourself

The recipientsThe recipients

The environmentThe environment

Step 2: Convey InformationStep 2: Convey Information

Establish empathic connectionEstablish empathic connection Give an advance alertGive an advance alert Convey realistic information in a clear mannerConvey realistic information in a clear manner Observe and respond to cognitive and Observe and respond to cognitive and

affective reactionsaffective reactions Clarify ambiguityClarify ambiguity Restore and catalyze hopeRestore and catalyze hope

Step 3: Follow UpStep 3: Follow Up

Set Concrete goalsSet Concrete goals Connect patient/family with support Connect patient/family with support

systemssystems Arrange follow-up meetingsArrange follow-up meetings Convey commitment and Convey commitment and

nonabandonmentnonabandonment Communicate with treatment teamCommunicate with treatment team