Vol. 43 No. 2 February 2012 395Schedule With Abstracts

3. Discuss how to reduce the risk for harm tothe patient, family and staff from experienc-ing the prolonged dying phase.

Prognostication is an under-researched skill inthe provision of health care despite the founda-tional importance to medical decision making.Patients, families, and staff often discuss thelikely time frame before death in open, closed,formal and informal communication styles.One distinct phenomenon of the uncertaintyin prognostication is the dilemma of the pro-longed dying phase. This phenomenon is oneof both perception and reality, in that it canbe induced by errors in forecasting declineand understanding that statistically some pa-tient will progress more slowly through thevery last stages of dying regardless of prognosti-cating acumen.The dilemma of the prolonged dying phase hasnot been comprehensively defined in the litera-ture despite the numerous problems it maycause including: direct and indirect requestsfor hastened death, secondary psychologicalharm as family and staff search for ‘‘reasonsshe is still hanging on,’’ staffing problems causedby prolonged 11th hour programs, increased re-source use at inpatient hospice units and hospi-tals, and second-guessing of previous decisionsregarding goals of care among others.Since this phenomenon is potentially rooted inperception, there are ways to reduce the risk ofimposing ‘‘prolonged dying’’ on patients by themanner of communicating prognosis and set-ting expectations. In addition there will alwaysbe statistical outliers that could truly representprolonged dying and with accurate definitionsthis dilemma will begin to be named and likelystudied to determine frequency and potentiallyeven causes. Given the emerging discussion ofthe ‘‘prolonged dying phase’’ much of this ses-sion will be open to audience input and discus-sion of key points.

Communication as a Dance: WhatPalliative Care Providers Can Learn fromMotivational Interviewing (426)Julie Childers, MD, University of Pittsburgh,Pittsburgh, PA. Robert Arnold, MD FAAHPM,University of Pittsburgh, Pittsburgh, PA. KathrynPollak, PhD, Duke University Medical Center,Durham, NC.(All authors listed above for this session have dis-closed no relevant financial relationships.)

Objectives1. Recognize how the spirit of motivational inter-

viewing (empathy, evoking values and motiva-tions, and respecting autonomy) parallels thecommunication style of palliative care.

2. Usemotivational interviewing skills to helppa-tients and families work through ambivalence.

3. Use reflections as a way to express empathyand help patients and families tell theirstories.

Palliative care clinicians often are called uponto help patients and families make decisions.Most times, clinicians ask questions to learnmore about patient values. However, this maylead to the provider dominating the conversa-tion, asking question after question. Evenopen-ended questions reflect the provider’sagenda and may throw up a roadblock againstthe patient telling her own story. In this session,we introduce a set of techniques derived frommotivational interviewing (MI). The philoso-phy of MI involves exploring ambivalence non-judgmentally and supporting patient autonomyand self-efficacy while individuals find theirown solutions. The skillful use of MI oftenmakes motivational interviewing sessions lookmore like a dance than a typical patient inter-view. These strategies may prove useful to palli-ative care clinicians who are helping patients orfamilies explore their values and make difficultclinical decisions.To create the dance, MI providers use fourstrategies: open-ended questions, affirmations, re-flections, and summaries. This session will focuson the skill least taught to cliniciansdturningquestions into reflections. In MI, reflections arestatements that mirror back what the speaker hasexpressed (simple reflection) and may also pres-ent a hypothesis about the speaker’s deepermean-ing or feelings (complex reflection). Skillfulreflections show that clinicians hear what patientshave said and create a unique atmosphere of em-pathic communication that often allows less ver-bal individuals to express their feelings.Participantswill be introduced to theMIapproachand how it can be used non-directively to help pa-tients and families work through ambivalenceabout end of life decision-making. Through videoexamples and role-play, participants will see thecontrast between a question-centered patientinterview and a more-naturally flowing reflec-tion-centered one. The session will also includeinteractive group exercises to develop reflective

396 Vol. 43 No. 2 February 2012Schedule With Abstracts

listening. Participants will leave the session witha new skill in their communication toolbox.

Advanced Pulmonary Hypertension:Considerations for Care Planning at Endof Life (427)Jillian Gustin, MD, The Ohio State University,Columbus, OH. Amber Hartman, PharmD,TheOhio StateUniversityMedical Center, Colum-bus, OH. Robert Johnson, MD, The Ohio StateUniversity Medical Center, Columbus, OH.(All authors listed above for this session have dis-closed no relevant financial relationships.)

Objectives1. Explain the pathophysiology of and symp-

toms associated with advanced pulmonary hy-pertension including the mechanisms ofaction of medications commonly used for ad-vanced pulmonary hypertension and theirimpact on symptoms.

2. Discuss the current literature on managingpatients with advanced pulmonary hyperten-sion at the end-of-life.

3. Propose a guideline for providing end-of-lifecare for patients with advanced pulmonaryhypertension.

The survival of patientswithWorldHealthOrgani-zation functional class IV pulmonary hyperten-sion is less than one year if untreated. Althoughinitiation of prostacyclin analogues improvesfunctional status and survival, class IV pulmo-nary hypertension remains a terminal illness.Unfortunately, there is little evidence on howbest to manage these patients at the end-of-life. This session will use case studies of patientsadmitted to our MICU on continous IV prosta-cyclin analogues to discuss the challenges andconsiderations inherent in providing care topatients dying with advanced pulmonary hyper-tension. Briefly, we will describe the pathophys-iology of advanced pulmonary hypertensionincluding a review of associated symptoms.Next, we will outline the pharmacokinetics ofintravenous prostacyclin analogues (epoproste-nol and trepostinil) used for patients with classIV pulmonary hypertension, including theimpact of these medications on patient symp-toms. Given the dearth of literature on end-of-life care for patients with class IV pulmonaryhypertension, we will propose general guide-lines for medical management by extrapolatingfrom studies examining discontinuation or tran-sitions off of other medications with similar

mechanisms (eg, nitric oxide, sildenafil, andprostacyclin) as well as from our own experi-ences. Finally, we will use these cases to examinevarious psychosocial challenges associated withpatients dying from pulmonary hypertension,including considerations for place of death(eg, hospital setting, home hospice, inpatienthospice). A detailed handout will be providedthat outlines our proposed medical manage-ment guidelines for care of patients dyingfrom advanced pulmonary hypertension.

SIG Symposium

Lay Your Hands On Me: Using SimpleOsteopathic Manipulation Treatments(OMT) for Pain in Hospice and PalliativeMedicine Patients (428)Osteopathic SIGGrace Varas, DO, University of Texas MedicalSchool at Houston, Houston, TX. Robert Hunt-er, DO CMD WCC, Providence Medical Group,Huber Heights, OH. Abi Katz, DO MS, SutterVNA and Hospice, Emeryville, CA.(All authors listed above for this session have dis-closed no relevant financial relationships.)

Objectives1. Recognize how OMTcan be used in the Mind-

Body-Spirit approach to total pain relief.2. Identify simple OMT techniques that both os-

teopathic and non-osteopathic HPM practi-tioners can use to treat their patients’ pain.

3. Illustrate the techniques demonstrated un-der the supervision of the presenters.

Osteopathy recognizes that all parts of the bodywork together to create healing. Osteopathic Ma-nipulative Treatment (OMT) is a set of manualmedicine techniques used to relieve pain andother symptoms, restore range of motion andfunction, and enhance the body’s capacity toheal. There are barriers to patients being able toreceive this beneficial adjunct therapy. As of2010, there are only 70,480 DOs, very unevenlydistributed in the U.S. Per AAHPM membershipservices, there are approximately 300 active DOsin the Hospice and Palliative Medicine (HPM)field.Not all DOs practiceOMT.Osteopathic phy-sicians sometimes feel they cannot practice OMTbecause of difficulty mastering techniques or be-cause they do not know how to integrate OMTinto their practice. In HPM specifically, OMT isa useful adjunct pain treatment that has no