MODULE 1: DISCUSSING SERIOUS NEWS Goals of Care Communication Curriculum

1. MODULE 1: DISCUSSING SERIOUS NEWS Goals of Care Communication Curriculum Alpert Medical School of Brown University

2. Objectives • At the conclusion of this session, the participant should be able to: • Use curiosity and good listening skills to understand patient coping styles • Describe empathic and effective approaches to discussing serious news • Identify strategies for discussing prognosis

3. Assessing Patient Coping Styles and Understanding • Coping • Illness understanding • Prognostic integration

4. Patient-Physician Goals • Helping patient understand trajectory of disease • Integrate this understanding with their goals

5. Integration is not Instantaneous • Integration happens over time • Can be difficult to achieve integration if they are at either extreme

6. Use Open-Ended Questions • What is your understanding of your illness? • What are you hoping for? • What are you worried about?

7. Curiosity Approach • CAUTION: • If you think you know what they are feeling and thinking, you most likely don't • Use curiosity to figure it out • Become aware of your internal voice • Manage your internal voice D Stone, Difficult Conversation

9. Basic Techniques for Good Listening

10. 3 Steps to Good Listening • Inquire • Paraphrase • Acknowledge D Stone, Difficult Conversation

11. Inquire to Learn • Shows that you are invested • Open-ended questions to avoid bias • “Tell me more” • “Help me better understand” D Stone, Difficult Conversation

12. Paraphrase for Clarity • Shows that you are processing what has been said • Gives patient opportunity to clarify • Repeat in your own words • “It sounds like...” D Stone, Difficult Conversation

13. Acknowledge their Feelings • Shows that they are being heard • Name the emotion • Acknowledge emotion before jumping into problem-solving • “I can see that you're ___” D Stone, Difficult Conversation

14. Faculty Role Play

15. Discussing Serious News

16. Talking About Serious News • Not “breaking bad news” • CAUTION: • Don't ignore emotion Back A, et al. Mastering Communication with Seriously Ill Patients

18. Talking about Serious News • Prepare • Assess • “How much have your doctors told you?” • Negotiate • “How much do you want to know?” • Disclose • Acknowledge emotion • “I can see this is difficult” • Summarize plan Back A, et al. Mastering Communication with Seriously Ill Patients

19. Faculty Role Play

20. Discussing Prognosis

21. Discussing Prognosis • CAUTION • Don't assume you know what the patient wants to hear

23. Discussing Prognosis • Negotiate content • Disclose • Acknowledge • Assess understanding

24. Start by Negotiating Discussion • “How much do you want to know?” • 3 Types of Patient answers: • “Yes” • “No” • “I don't know” Back A, et al. Mastering Communication with Seriously Ill Patients

25. “Yes, I want to know” • Negotiate content: • “What kind of information do you want?” • Examples: • Stats: Average life expectancy • Best and worst case scenario • Making it to a specific date Back A, et al. Mastering Communication with Seriously Ill Patients

26. “Yes, I want to know” • Provide Information • Speak slowly and with intention • Pause (allows information to sink in) Back A, et al. Mastering Communication with Seriously Ill Patients

27. “Yes, I want to know” • Acknowledge reaction • “I can see this is upsetting” • Acknowledging gives safe space for expression and exploration of emotion • Caution: silence, touch, tissues Back A, et al. Mastering Communication with Seriously Ill Patients

28. “Yes, I want to know” • Check for understanding • “Tell me what you understand from our discussion.” Back A, et al. Mastering Communication with Seriously Ill Patients

29. “No, I don't want to know” • Assess why • Acknowledge concerns • Ask permission to revisit • ?Surrogate decison-maker • Private assessment (will prognostic information change outcome today). If yes, then renegotiate • “I understand you'd rather not talk about this today, and I want to honor your decision. But I also think it would be important to discuss some of these issues so that we can figure out what decision might make the most sense for you now. How would you feel about that?” Back A, et al. Mastering Communication with Seriously Ill Patients

30. “I don't know if I want to know” • Name the ambivalence • Explore pros and cons • Acknowledge difficulty • Outline options if appropriate Back A, et al. Mastering Communication with Seriously Ill Patients

31. Faculty Role Play

32. Summary: Fundamentals of good communication have the same basic principles.

33. 3 Steps to Good Listening • Inquire • Paraphrase • Acknowledge

34. Talking about Serious News • Prepare • Assess • Negotiate • Disclose • Acknowledge emotion • Summarize plan

35. Discussing Prognosis • Negotiate content • Disclose • Acknowledge • Assess understanding

36. Participant Role-Playing • You've been asked to see a woman in her 70s for Palliative Care initial inpatient consultation by the Medicine team. She has Stage IV colon cancer diagnosed 1 year ago.  She is s/p second line chemo and her oncologist wants to offer further chemo. The Medicine team feels like further chemo may not be in the patient's best interest and have asked you to speak to her. • In reviewing her case, you are worried that further chemo will shorten the patient's life and have discussed this with the oncologist who has said, “This is the only chance she has, so why wouldn't I offer it?”  The oncologist has not discussed prognosis with the patient though the patient has asked.  You assess her prognosis to be days to weeks.

37. Summary • Use good listening techniques to assess patient and family understanding and coping styles • Use PANDAs technique for communicating bad news • Use strong negotiating skills to address prognosis

38. Acknowledgments • Original Contribution by: • Jensy Stafford, MD • Revised by: • Edward Martin, MD • Lynn McNicoll, MD • Supported by: • Donald W. Reynolds Foundation Grant