ADDRESSING Goals of Care for the CRNA

1. ADDRESSING Goals of Care for the CRNA Donna E Coletti MD, MS, FACOG Palliative Care Scholar-in-Residence (PCSiR) Kanarek Center for Palliative Care Egan School of Nursing, Fairfield University

2. WORKSHOP OBJECTIVES 1. Defining a CRNA’s role in Goals of Care 2. Demonstrating Core Communication Skills 3. Applying Core Communication Skills

3. PALLIATIVE CARE: commonly misunderstood • CONFLICT MANAGEMENT • Patient: Symptom Management • Family: Preventing Complicated Grief (PTSD)

4. “TOTAL PAIN”Dame Cicely saunders (1964) • “Suffering Encompassing All Struggles” • Physical • Social • Psychological • Spiritual • Practical

5. Patient Beliefs About MD (>50%) (CAPC 2012: Palliative Care STATS and FACTS) Might not provide all of the treatment options or choices available Might not talk and share information with each other Might not choose the best treatment option for a seriously ill patient’s medical condition Do not spend enough time talking with and listening to patients and their families They leave a doctor’s office or hospital feeling unsure about what they are supposed to do when they get home Patients with serious illness and their families do not have enough control over their treatment options

6. ETHICAL DILEMMAS(ClinicianBarriers)Robert D. Orr, MD (2012) • Increased Technology • Physician-Patient Dynamics • Cost Containment • Societal Diversity • Fear of Litigation

7. PRINCIPLES OF SHARED DECISION MAKING Robert D. Orr, MD (2012) • Participants: Clinicians, Consultants, Patient, Family, Advisors • Goals of Treatment: Cure, Palliation • Hierarchy: Competent > Substituted Judgment > Best Interests • Honest Discussions May Result in Different Decision Making

8. Patient perspective

9. “The Talk”: Redefining Hope Stone MD, MJ. Proc(Bayl UM Cent). 2001 April;14(2): 134–37. Setting Goals Sustains Hope Goals based on: diagnosis, prognosis, potential benefits, burdens, risks associated with various therapies & personal priorities Over time, goals of care and treatment priorities will change

10. COMMUNICATION CHALLENGES • AVOIDING EMOTIONAL LANGUAGE • REFRAME: “STARVING; SUFFOCATING; DROWNING” • FOCUS ON CLINICAL INDICATIONS AND INTENTION • CLARIFY MYTHS • CLEARLY DEFINE FAMILY ROLES & EXPECTATIONS

11. APPROACHING PATIENT & FAMILY COGNITIVE DISSONANCE • Maintain Patient Pain Free but Awake & Communicative • (Addressing Emotion-charged Language ) • We Know He/SheCan’t Eat but…………... • We Don’t Want Them to Starve or Dehydrate • MEET THEM WHERE THEY ARE • TAKE THEM WHERE THEY NEED TO BE

12. COGNITIVE DISSONANCE https://youtu.be/BbNi_-wYXJE

13. A BALANCING ACT (diverging goals)(Quill, T.E.; AMA J of Ethics) • Relief of Suffering vs. Prolonging Life • (Preserve Life and Provide Comfort to Dying) • Caring for Patient vs. Treating Disease • (Benefiting Patient While Minimizing Burden) • Patient/Family Values vs. Clinical/Team Values • (Meeting Individual vs. Societal needs) • Personal, Family, Existential, Spiritual issues • Partnership and Non-Abandonment

14. Intelligence & behavioral metrics Intelligence Quotient A value that indicates a person’s ability to learn, understand and apply information and skills in a meaningful way Emotional Quotient (EQ) A way to measure how person recognizes emotion to him/herself and others and then manages these states to work better as a group or team.

15. Intelligence & behavioral metrics Major Difference between IQ and EQ What part of the person’s mental abilities they measure? Understanding Emotion or Understanding Information

16. VitalTALK TIPS APP

17. Core Communication SKILLS(Back, et.al.)responding to Informational concerns

18. Core Communication SKILLS(Back, et.al.)identifying and recognizing cues

19. Core Communication SKILLS(Back, et.al.)Responding to Emotional Concerns Nonverbal Cues Verbal Cues

20. Vital talk: REMAP

21. Standard role modeling Role Modeling #1Ask Tell Ask https://youtu.be/0kRGvXLJM_4 Role Modeling #2Emotional Cues https://youtu.be/USf81JGehFA Role Modeling #3N.U.R.S.E. Getting Stuck/Unstuck https://youtu.be/l0kexuI5fdw

22. Ideal Role Modeling (eprognosis.ucsf) • http://eprognosis.ucsf.edu/communication/video-goals.php

23. Role Modeling EMOTIONAL vs. INFORMATIONAL DEBRIEF How did it make you FEEL?? What was Went Well and Why? Who was “Stuck”…Where and Why??

25. Thank You!

26. Resources • About the Center to Advance Palliative Care The Center to Advance Palliative Care (CAPC) is a national organization dedicated to increasing the availability of quality palliative care services for people facing serious illness. www.capc.orgwww.getpalliativecare.org • https://getpalliativecare.org/whatis/pediatric • Robert D. Orr, MD Medical Ethics and the Faith Factor. Lecture, AAHPM General Assembly 2012 • Quill,TE Clinical, Ethical and Legal Decision-Making: Principles, Precedents & Processes.Lecture, Gen. Assembly AAHPM 2010 • American Academy on Physician and Patient : AAPP is devoted to the enhancement of physician-patient communication. This organization hosts an annual course on communication skills training. http://www.physicianpatient.org

27. Resources OncoTalk : A National Cancer Institute–supported biannual retreat for oncology fellows to improve communication skills at the end of life. http://www.oncotalk.info www.vitaltalk.org https://eprognosis.ucsf.edu/