Serious Illness Care Program Workshop
Jo Paladino, MDJoshua Lakin, MD
Agenda
Agenda
• Didactic and Reflection 9:15‐9:35• Describe the benefits of serious illness conversations 9:35‐9:50• Demonstration and debriefing 9:50‐10:15• Describe the Serious Illness Conversation Guide 10:15‐10:30• Break/Get in Small Groups 10:30‐10:45• Small group learning 10:45‐11:40• Wrap Up 11:45‐12:00
Objectives
• Describe your role in improving serious illness conversations - And the benefits of conversations to patients and families
• Practice using the Serious Illness Conversation Guide with a colleague- Ask about values and goals before discussing medical decisions
• Try the guide with two of your patients over the next month
Your stories
The goal : Better care for patients and families
Where we are now Where we want to be
Doing some of the right things some of the time for some of our patients with serious illness
Doing all the right things all of the time for all of our patients with serious illness
Improve the lives of all people with serious illness by increasing meaningful conversations with their
clinicians about their values and priorities
Serious Illness Care Program: Mission
High quality communication is linked to better serious illness careEarly conversations about patient goals and priorities in serious illness are associated with:
- Enhanced goal‐concordant care Time to make informed decisions and fulfill personal goals
- Improved quality of life / patient well‐being- Fewer hospitalizations
More and earlier hospice care- Better patient and family coping
Eased burden of decision‐making for families Improved bereavement outcomes
Mack JCO 2010; Wright JAMA 2008; Chiarchiaro AATS 2015; Detering BMJ 2010; Zhang Annals 2009
Conversations in the context of serious illness• Fewer than one‐third of patients with end‐stage medical diagnoses reported discussing end‐of‐life (EOL) preferences with clinicians
• Patients with advanced cancer: • First EOL discussion occurred median 33 days before death• 55% of initial EOL discussions occurred in the hospital
• Conversations often fail to address key elements of quality discussions
Heyland DK Open Med 2009; Mack AIM 2012; Wright 2008
Palliative Care is a high value but limited resource• Palliative care – with strong emphasis on high quality communication – is
a high value intervention- Better quality of life- Less use of aggressive care- 25% increase in survival - Lower costs
• We do not and we will not have enough palliative care providers to reach all patients who would benefit
• We need scalable interventions for generalists and non‐palliative care specialists
Temel NEJM 2010; Zimmerman Lancet 2014; Bakitas JAMA 2009; Higginson Cancer J 2010; Jacobsen JPM 2011; Back JPM 2014; Lupu JPSM 2010
You have a critical role in improving patient care by improving conversations
Identify patients at high‐risk of dying who would benefit most from serious illness conversations
Initiate conversations using best practices in serious illness communication
Document the discussions in the EHR so that all providers can access the patient’s care goals
Set an example of high‐quality communication for colleagues, residents and medical students
Tools
Education
Systems Change
The Serious Illness Care Program
Measurement and Improvement (QI)
Reminder System
Conversation using the Guide
Documentation template in EMR
Patient & Family
Resources
Patient Screening
Serious Illness Conversation Guide
Clinician ReferenceGuide
Patient preparation materials
Family Comm.Guide
Train Clinicians
2.5‐hour clinician training sessions
Serious Illness Conversation Guide
Research
• Randomized Controlled Trial- Oncology (Dana‐Farber Cancer Institute)- High‐risk primary care (Atrius)
• Implementation trial - High‐risk Medicare patients Integrated Care Management Program
(iCMP)
• Feasibility and Acceptability Pilots- Chronic Critical Illness (Spaulding)- Rural African American patients (South Carolina)
Case description• SETTING: Clinic, one month after hospitalization
- 68 year‐old retired salesperson- Stage IV adenocarcinoma of the lung; COPD; diabetes; CKD- Progressing on chemotherapy- Three hospitalizations this year- Two ED visits, once for a fall, and once for dehydration- Worsening shortness of breath, increasing weakness, fatigue- Declining functional status at home- Spouse very involved, 28 yr old daughter lives locally
Case description• The goal of the discussion today is to explore Mr. S’s values, goals and the type
of care he would want as his illness progresses, using the Serious Illness Conversation Guide. The focus should be on values and goals for the months ahead rather than procedures and treatments.
• As you prepare to meet with Mr. Smith, you consider the following:- Mr. S has stage IV lung cancer and multiple co‐morbidities (COPD, diabetes,
kidney disease) - Given the hospitalizations and declining functional status, you are worried that
he will have a harder time managing at home and that something serious could happen quickly, so you want to begin a conversation
Video demonstration• https://www.youtube.com/watch?v=fhwa9f5O_U4
The Serious Illness Conversation Guide is a framework for best communication practices
Set up the conversationSetting up the conversation builds trust, helps patient feel in control
- Introduce the idea: “I’d like to take a step back today and
talk together about where things are with your illness and where they might be going.”
- Ask permission: “Is this ok?”
- Introduce the benefits: “The goal is to make sure that I have all
of the information I need about what matters most to you so I can provide you with the care you want, and so I can best support your family if they ever have to make decisions for you.”
Assess illness understanding and information preferencesLearning about the patient’s illness understanding allows the clinician to assess alignment between beliefs and reality
• “What is your understanding now of where you are with your illness?”
Information preferences guide clinicians in titrating information to patient preferences, and helps clinicians feel confident in moving forward with providing prognostic information
• “How much information about what is likely to be ahead would you like from me?”
Prognosis1. Time‐based prognosis:
- “I wish it were different, but I’m worried that, in terms of time, we may be talking about months to a year.”
2. Functional prognosis:- “I wish it were different, but I worry that this
may be as strong as you feel. I’m worried that in the future, you may not be able to manage as well as you are right now, and it is important that we plan for future changes.”
3.Unpredictable prognosis:- “Although we could hit the jackpot with this
treatment, and you could have a lot of time, it’s also possible that something could happen suddenly. It would be helpful to know what you would want if you became very sick quickly.”
Allow silence, explore emotion• Allow silence immediately after giving prognosis- It is therapeutic to give a patient time to process emotions
after hearing difficult news.
• Respond to emotion by naming it and exploring: - “I can see this is upsetting. Tell me more about what you
are feeling.”- “You seem surprised. Tell me about what you were
expecting to hear.”- “This is really hard to hear. Tell me what you’re thinking
about.”
Explore goals and fearsUnderstanding patient goals helps restore sense of a positive future and guides clinician recommendations
• “What are your most important goals if you health situation worsens?”
Expressing fears is therapeutic, even if they cannot be fixed.
• “What are your biggest fears and worries about the future with your illness?”
Explore sources of strengthExploring strengths reminds patients of their own resources and supports for coping with their illness
• “What gives you strength as you think about the future with your illness?”
Explore function, tradeoffs, and family This information guides decisions and care planning and also indicates to patient that there may be some difficult choices ahead
• “What abilities are so critical to your life that you can’t imagine living without them?”
• “If you become sicker, how much are you willing to go through for the possibility of gaining more time?”
• “How much does your family know about your priorities and wishes?”
Close the conversation1. Summarize: - “It sounds like being at home is
really important…”
2. Recommend: - “Given your goals and priorities, and
what we know about your illness at this stage, I recommend…”
3. Affirm commitment:- “I will do whatever I can to help you
through this.”
Document the conversation• Document the conversation in the medical record
• Documentation is a form of communication to the next clinician.
Principles
• Listen more than talk• Ask about values and goals before discussing treatments, care plans, and medical decisions
• Address patient emotions• Many fears will arise that cannot be fixed. Talking about them makes them more bearable for the patient.
Break into small groups• Now it is time for you to practice• There will be 1 facilitator per group• You will practice in pairs, there are two cases, rotating roles
- Clinician- Patient
• Facilitator will frame the session and keep time• Materials will be provided• We will have a brief closing as a large group when done
Next steps• Pick two patients for conversations over the next 2 months• Set yourself up for success – start easy!Pts with whom you can have a less stressful conversationPts who already seem to have a prognostic awareness (patients who are ‘waiting’ for this conversation)
• Commit to a small group of co‐learners ‐ ask them to be available for feedback, debriefing, & peer support for these two conversations
Principles
• Listen more than talk• Ask about values and goals before discussing care plans and medical decisions- Make a recommendation based on what is important to the patient
• Address patient emotions• Many fears will arise that cannot be fixed. Talking about them makes them more bearable for the patient.
Break into small groups• Now it is time for you to practice• There will be 1 facilitator per group• You will practice in pairs, there are two cases, rotating roles
- Clinician- Patient
• Facilitator will frame the session and keep time• Materials will be provided• We will have a brief closing as a large group when done
Next steps• Pick two patients for conversations over the next 2 weeks• Set yourself up for success – start easy!Pts with whom you can have a less stressful conversationPts who already seem to have a prognostic awareness (patients who are ‘waiting’ for this conversation)
• Commit to a small group of co‐learners ‐ ask them to be available for feedback, debriefing, & peer support for these two conversations
The Quadruple Aim
Better population health- Every patient, every time
Better patient experience and outcomes- Reduced anxiety, depression- Improved well‐being
Smarter spending- Care in alignment with patient values
Improved clinician satisfaction - To be determined
To Join SICP Community of Practice: 1) Open your web browser (Safari, Chrome, Firefox, Internet Explorer, etc.)
1) Go to: https://portal.ariadnelabs.org
2) Click “Create an Account” on the right side of the page
3) Complete the account information page. You will receive an email to authenticate your account.
4) Return to https://portal.ariadnelabs.org and click on Serious Illness Community of Practice on the bottom left of the page.
5) Click “Request Membership.” Complete the additional profile information.
6) You will receive an email once the Administrator has accepted your request.
Ariadne Labs/Serious Illness Care Program TeamAriadne Labs• Atul Gawande, MD, MPH• William Berry, MD, MPA, MPH• Lisa Hirschhorn, MD• Stu Lipsitz, ScD• Bridget Neville, MPH• Sue Czajak• Jonathon Gass, MPH
Serious Illness Care Program• Director: Susan Block, MD• Assoc. Dir: Rachelle Bernacki, MD, MS
SICP Research faculty and fellows:• Joshua Lakin, MD• Daniela Lamas, MD• Joanna Paladino, MD• Justin Sanders, MD
Program Management:• Rich Lawson, PhD• Francine Maloney, MPH• Mathilde Hutchings, MPH• Luca Koritsanszky, MPH• Jane Kavanaugh
Research/Program Staff:• Sam Epstein• Sergey Goryachev, MS• Jenna Ogden• Nate Pertsch• Katrinka Quirk• Maribel Valenzuela, MS• Judith Vick• Alyssa Vigliotti• Chris Kohberger