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DIFFICULT DISCUSSIONS BETTER DECISIONS. Christine Welsh RN, John Scott MD February 27th 2013. Disclosures. WHO ARE WE?. Who are you?. What do Patients Want?. End of life planning (Hungry beast) you tube. Decision making. Last Session?. Barrriers

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Difficult discussions better decisions

DIFFICULT DISCUSSIONSBETTER DECISIONS

Christine Welsh RN, John Scott MD

February 27th 2013


Disclosures

Disclosures


Who are we

WHO ARE WE?

Who are you?


What do patients want

What do Patients Want?

End of life planning (Hungry beast) you tube


Decision making

Decision making


Last session

Last Session?

  • Barrriers

    • Cultural and spiritual aspects

  • Reframing hope

  • Triggers for difficult conversations

  • Lessons from Critical care

  • Gold Standards Framework

    • Illness trajectories

  • Communication goals

  • Research in Ottawa


Difficult discussions better decisions

A Department of Medicine & TOH Project

The Divisions of Palliative Care, Medical Oncology, Internal Medicine and Cardiology

In collaboration with the Department of Radiation Oncology

Funded by

The TOHAMO Innovation Fund, the Associate Medical Services Palliative Care Fund and the Bruyère Academic Medical Organization and Bruyère Research Institute

In collaboration with

The PALLIUM Program of Canada

New Study

Difficult DiscussionsBetter Decisions

7


Difficult discussions better decisions

  • Movie (20 & 22)


Question

QUESTION

What percentage of cancer patients visited ED in the last 2 weeks of life in Ontario?

9


Difficult discussions better decisions

40%

10


Question1

QUESTION

What percentage of cancer patients die in acute care hospitals in Ontario?

11


Answer

ANSWER

53%

12


Question2

QUESTION

in a study of cancer patients who visited a TOH emergency department in the last 2 weeks of life, what % had advance directives & DNRs?

13


Answer1

ANSWER

14


Reflecting on the videos

Reflecting on the videos

  • How did you feel while viewing the video?

  • What was done well?

  • What can be done better?

  • What are some useful phrases?

15


Difficult discussions better decisions

  • Video 1B


Difficult discussions better decisions

  • Cue Cards

  • Adapt to individual situations

  • Behaviors to avoid

  • Blocking

  • Lecturing

  • Collusion

  • Premature reassurance

  • Behaviors to cultivate

  • Behaviors to cultivate

  • Ask-Tell-Ask

  • Tell me more

  • Respond to emotions

    • NURSE

    • Name the emotion

    • Understand

    • Respect (verbal or non-verbal)

    • Supporting

    • Explore

17


Key behaviors in the conversations

Key behaviors in the conversations

18


Key behaviors in the conversations1

Key behaviors in the conversations

19


Questions

QUESTIONS

What is the annual mortality rate of patients with NYHA Class II?

What is annual mortality rate of pts with NYHA Class IV?


Chf mortality

CHF Mortality

NYHA Class II

Annual mortality rate 5-15%

50-80% die suddenly

NYHA Class IV

Annual mortality rate 30-70%

5-30% die suddenly


Reflecting on the videos1

Reflecting on the videos

  • How did you feel while viewing the video?

  • What was done well?

  • What can be done better?

  • What are some useful phrases?

22


Difficult discussions better decisions

  • Film – 8a & 8b


Difficult discussions better decisions

  • Cue Cards

  • Adapt to individual situations

  • How long do I have to live?

  • “We are not very good at predicting?”

  • “I think it is in the order of [days/weeks/months/many months/years]”

  • “That must be an important question for you?”

  • Or

  • “I don’t know, I will talk to the specialist to get more information”

  • “Does this come as a surprise to you?”

  • “Remember we could be wrong..it may be longer…or shorter than what I think”

  • “I want you to know that no matter what the time is we will get you the best care”

app

24


Heyland dk et al open medicine 2009

Heyland Dk et al. Open Medicine 2009

Heyland DK et al. Discussing prognosis with patients and their families near the end of life: impact on satisfaction with end-of-life care. Open Medicine 2009;3(2):101-110

Question

  • In a study of 440 pts with end-stage disease, the % of pts who recalled prognosis discussions with their families :

    • Cancer pts?

    • CHF pts?

    • COPD pts?

25


Participants who recalled prognosis discussions

Participants who recalled prognosis discussions:

Heyland DK et al. Discussing prognosis with patients and their families near the end of life: impact on satisfaction with end-of-life care. Open Medicine 2009;3(2):101-110

  • Patients (n=440) :18%

  • Family members (n=160): 30%

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Difficult discussions better decisions

“I didn’t expect him to die so soon. I got the feeling the doctors weren’t entirely honest with us about his condition. My husband resisted talking about dying and after 40 years of marriage I feel he let me down by not opening up and I guess I let him down for not knowing how to talk about some of the things that I needed to discuss. It would have been nice closure if things had been different in the end. I can never get that time back.”–

Wife of participant in end-of-life study

Heyland DK et al. Discussing prognosis with patients and their families near the end of life: impact on satisfaction with end-of-life care. Open Medicine 2009;3(2):101-110

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Difficult discussions better decisions

Although most family members had not had a prognosis discussion, 90% of them indicated that they would like to have such a discussion.

Heyland DK et al. Discussing prognosis with patients and their families near the end of life: impact on satisfaction with end-of-life care. Open Medicine 2009;3(2):101-110

28


Heart study of 220 pt s mean age 88y

Heart study of 220 pt’s (mean age 88y)

McCarthy EP, et al. Advance care planning and health care preferences of community-dwelling elders: the Framingham Heart Study. J Gerontol A BiolSci Med Sci 2008;63(9):951-9.

  • 70% said they had discussed their wishes for end-of-life care with someone,

  • 17% had discussed them with a physician or other health care provider.

  • Two-thirds said they had health care proxies and 55% said they had living wills,

29


Question3

QUESTION

What is approximate life expectancy of a cancer patient with an ECOG functional level of 3?

40-50% PPS

30


Illness trajectory in cancer patients with progressive cancer

illness trajectory in cancer patients with progressive cancer

Note that this data represents mean values

N=7830 pts

Death

31


Illness trajectory in cancer patients with progressive cancer1

illness trajectory in cancer patients with progressive cancer

Decline is generally gradual until PPS reaches about 50% to 60% (ECOG 3). Thereafter the decline is often more rapid.

If not yet initiated, a Palliative Care approach should be activated.

Generally has a life expectancy of weeks to a weeks to months

Life expectancy of days to weeks

Note that this data represents mean values

N=7830 pts

Death

32


Components of eol care that patients with end stage copd would like to discuss with their physician

components of EOL care that patients with end-stage COPD would like to discuss with their physician

Diagnosis & disease process

Role of treatments in improving symptoms, QOL & duration of life

Prognosis for survival & QOL

What dying might be like

Advance care planning for future medical care & exacerbations

Curtis JR, Wet al. Patients’ perspectives on physicians’ skills at end-of-life care: differences between patients with COPD, cancer, and AIDS. Chest 2002; 122:356–362.


Reflecting on the videos2

Reflecting on the videos

  • How did you feel while viewing the video?

  • What was done well?

  • What can be done better?

  • What are some useful phrases?

34


Difficult discussions better decisions

  • Video 6a & 6b


Difficult discussions better decisions

  • Cue Cards

  • Adapt to individual situations

  • Disease progression

  • “What do you feel is happening with your illness?”

  • “I’m afraid there are signs that the disease is progressing”

  • “Have you noticed things changing?”

  • “I think it is important hope for the best and also prepare for worse”

  • “I wish I could be saying that we can cure or control your illness, but I would be lying if I did.”

36


Copd patients information needs

COPD Patients: Information needs

Heffner J et al. Chest 2000;117:1474-81.


Question4

QUESTION

Does initiating palliative care increase depression, anxiety & hopelessness?

38


Difficult discussions better decisions

Weeks JC et al. Patients’ expectations about effects of chemotherapy for advanced cancer. NEJM 2012;367(17):116-1625

  • Of 1193 pts with newly diagnosed metastatic lung or colorectal cancer:

    • 69% of pts with lung cancer

    • 81% of pts with colorectal cancer

      Had inaccurate expectations about the curative potential of their chemotherapy:

39


Pts reporting eol discussions had 1

Pts reporting EOL discussions had1:

1. Wright AA, et al: Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA 2008;300:1665-1673

2. Smith TJ, Dow LA, Virago E, et al: Giving honest information to patients with advanced cancer maintains hope. Oncology 2010;24:521-525

  • No higher rates of depression or anxiety

    • lower rates of ventilation & resuscitation

    • more & earlier hospice enrollment

    • Improved family bereavement

  • Hope is maintained even with truthful discussions

  • Physician honesty increases sense of hope2

40


Impact of avoiding these discussions

Impact of avoiding these discussions

  • Ratnapalan M, et al. Documentation of best interest by intensivists: a retrospective study in an Ontario critical care unit. BMC Medical Ethics 2010, 11:1

  • Stajduhar K, et al. Preferences for location of death of seriously ill hospitalized patients: perspectives from Canadian patients and their family caregivers. Palliative Medicine 2008; 22(1): 85-88

  • Adler ED, Golfinger JZ, Kalman J, Park ME, Meier DE. Palliative Care in the Treatment of Advanced Heart Failure. Circulation. 2009;120:2597-2606

  • Gore JM, Brophy CJ, Greenstone MA. How well do we care for patients with end stage chronic obstructive pulmonary disease (COPD)? A comparison of palliative care and quality of life in COPD and lung cancer. Thorax 2000;55:1000-1006

  • Davison SN. End-of-Life Care Preferences and Needs: Perceptions of Patients with Chronic Kidney Disease. Clin J Am Soc Nephrol 5: 195-204, 2010

  • High burden of suffering for patients

  • Inappropriate utilization of resources

  • Care that is inconsistent with patients’ wishes

  • Cancer & non-cancer populations

41


Impact of avoiding these discussions1

Impact of avoiding these discussions

Harrington SE, Smith TJ: The role of chemotherapy at the end of life:

“When is enough, enough?” JAMA 2008; 299:2667-2678

Patients lose good time with their families

Lose opportunities for reflection and preparing for their life’s end

Spend more time in the hospital and ICU

42


Key take home messages

key take-home messages

  • Help the patient & family be prepared earlier

    • Palliative care is not only about the last days or weeks of life

    • not mutually exclusive with disease-modifying treatments

  • Ask the question!- identify patients earlier

  • Look for cues and create opportunities for discussion

  • Be honest & sensitive

  • Use the phrases & tools

  • Reframe hope

  • Document

44


Take home messages

Take home messages

1 Vogel L. Advance directives: obstacles in preparing for the worst. CMAJ 2011;183(1):E39-40.

2. Tierney WM, et al. The effects of discussions about advance directives on patient’s satisfaction with primary care. J Gen Intern Med 2001;16(1):32-40.

3. Detering KM, et al. The impact of advance care planning on end of life care in elderly patients: randomized controlled trial. BMJ 2010;340:c1345.

4. Robinson C, et al. Awareness of do-not-resuscitate orders. What do patients know and want? Can Fam Physician 2012;58:e229-33.

  • Many barriers prevent Canadians from having these difficult conversations1

  • Evidence that discussions about advance directives2:

    • improve patients’ satisfaction with their primary care providers

    • improve end-of-life care

    • Improve patient and family satisfaction

    • Reduce stress, anxiety, and depression in surviving relatives.3

  • [FPs well placed to have these discussions4]

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Questions1

QUESTIONS

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