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AOA Council on Palliatve Care Goals of Care. Breaking Bad News Unity Convention October 24, 2010 Bruce Bates, D.O., FACOFP , CMD Chair - Department of Geriatric Medicine University of New England College of Osteopathic Medicine. Case .

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aoa council on palliatve care goals of care
AOA Council on Palliatve CareGoals of Care

Breaking Bad News

Unity Convention

October 24, 2010

Bruce Bates, D.O., FACOFP, CMD

Chair - Department of Geriatric Medicine

University of New England College of Osteopathic Medicine

  • 84 y/o W/F living independently, falls at home suffering L femur Fx
  • Undergoes ORIF with post op delerium, dysphagia, renal failure.
  • Aspirates, intubated difficult to wean
  • Attentive daughter
case continued
Case continued
  • Day #14 – many doctors talk to daughter
    • Nephrologist: making more urine but probably will need dialysis long term
    • Intensivist: able to turn O2 down to 50%
    • Gastroenterologist: plan for a PEG will never eat regular
    • Internist – not doing well
    • Case manager – doctor ordered hospice
    • Daughter calls PCP to complain
Objectives . . .
  • Know why defining goals fo care is important
  • Understand a 7-step protocol for delivering bad news
  • Communicate uncertainty and conflict
  • Adjust care to changing goals
importance of goals of care
Importance of Goals of Care
  • Most people want to Know if facing a serious illness
  • Strengthens the physician- patient relationship
  • Fosters collaboration
  • Establishes an appropriate allocation of resources
  • Permits patients, families to plan, cope
potential goals of care
Cure of disease

Avoidance of premature death

Maintenance or improvement in function

Prolongation of life

Relief of suffering

Quality of life

Staying in control

A good death

Support for families and loved ones

Potential goals of care
osteopathic tenet
Osteopathic Tenet





multiple goals of care
Multiple goals of care
  • Multiple goals often apply simultaneously
  • Goals are often contradictory
  • Certain goals may take priority over others
patient centered care
Patient Centered Care
  • Goals of Patient - initial assessment
  • May Vary over time - ongoing assessment
    • curative  palliative
    • self  family
    • physical  spiritual
    • integrated  focused
goals may change
Goals may change
  • Osteopathic Principles make very clear the distinction of caring for disease and caring for the patient who has disease
  • Some goals take precedence over others
  • The shift in focus of care
    • Requires the patient (Guardian) to understand
    • is gradual
    • is an expected part of the continuum of medical care
7 step protocol to communicate bad news
7-step protocol to communicate bad news . . .

1. Create the right setting

2. Determine what the patient and family know

3. What do they want to Know

7 step protocol to negotiate goals of care
. . . 7-step protocol to negotiate goals of care

4. Sharing the information

5. Respond with empathy

6. Make a plan and follow-through

7. Review and revise periodically, as appropriate

1 create the right setting
1. Create the Right Setting
  • Quiet - private space
  • Allot enough open ended time
  • Determine that the right people are present
2 what does the patient know
2. What Does the Patient Know
  • Establish Patients Knowledge and Understanding
  • Asses ability to comprehend
  • Correct misunderstanding
  • Reschedule if unprepared or unresolvable conflict of info
3 how much does the patient want to know
3. How Much Does the Patient Want to Know
  • Recognize patient preferences
    • May decline voluntarily
    • May designate someone to communicate on his/her behalf
    • Consider Power of Attorney or advanced directive – 5 wishes
3 how much does the patient want to know16
3. How much does the patient want to know?
  • People handle information differently
    • Capacity
    • Race
    • Ethnicity
    • Religion
    • Education
    • Socio economic
    • Age and developmental level
cultural differences
Cultural differences
  • Who gets the information?
  • How to talk about information?
  • Who makes decisions?
  • Ask the patient
  • Consider a family meeting
4 sharing the information
4. Sharing the Information
  • Say it then STOP
    • Avoid monologue- promote dialogue
    • Avoid Jargon and Euphemisms
    • Pause frequently
    • Validate understanding
    • Use Silence and Body Language
  • Don’t minimize severity
  • Implications of “I’m Sorry”
language with unintended consequences negative
Language with unintended consequences -Negative
  • Do you want us to do everything possible?
  • Will you agree to discontinue care?
  • It’s time we talk about pulling back
  • I think we should stop aggressive therapy
  • I’m going to make it so he won’t suffer
language to describe the goals of care positive
Language to describethe goals of care - positive . .
  • I want to seek the most comfort and dignity possible until the day you die
  • We will concentrate on improving the quality of your child’s remaining life
  • Let’s discuss your needs and wants
5 respond with empathy
5. Respond with Empathy
  • Affective response
    • Tears anger sadness love anxiety relief
  • Cognitive response
    • Denial blame guilt disbelief fear loss shame
  • Basic psychophysiologic response
    • Fight – Flight
5 respond with empathy22
5. Respond with Empathy
  • Listen ListenListen
  • Encourage descriptions of Feelings
  • Use Non Verbal communication
  • Physician: Acknowledge Yurself
6 planning and followup
6. Planning and followup
  • Explore what their hopes expectations and Fears are
  • Plan for Next Steps
    • Added tests, treatment/non treatment,
    • Care vs cure, referrals
  • Sources of Support for patient/family
    • Medical, spiritual, emotional, social, legal
7 review and revise
7. Review and Revise
  • Give Contact info / next appointment
  • Assess Safety
  • Assess informal and formal support
  • Be Prepared to repeat info at next visit – it was not all heard
  • Goals Change with time and progression of condition
reviewing goals treatment priorities
Reviewing goals,treatment priorities
  • Goals guide care – whose?
  • Assess priorities to develop initial plan of care
  • Review with any change in
    • health status
    • advancing illness
    • setting of care
    • treatment preferences
communicating prognosis
Communicating prognosis
  • Providers markedly over-estimate prognosis
    • Either way raises fears and stresses
  • Helps patient / family cope, plan
    • increase access to hospice, other services
  • Offer a range or average for life expectancy
truth telling and maintaining hope
Truth-telling and maintaining hope
  • False hope may deflect from other important issues
  • True clinical skill to help find hope for realistic goals
when family says don t tell
When Family Says:“Don’t Tell”
  • Ask Family
    • Why not? What are you afraid I will say?
    • What are previous experiences?
    • Personal,religious, or cultural context?
    • Patient knows something - why this conspiracy? Will it feed mistrust?
  • Talk To patient together
  • Legal Obligation to obtain consent to treat or not treat (assuming capacity)
determine specific priorities
Determine specific priorities
  • Based on Patient values, preferences, clinical circumstances
  • Influenced by information from physician(s), team members, Patient and family
    • Clinical Jazz
  • Begin the conversation Early
    • Keep seven steps in mind
  • Understand the Goal of Care
    • Patient centered values and preferences
  • Seek permission to involve family and others
  • Give Permission to react/accept/reject
  • Revise and renew