Communication in Serious Illness: Courageous Conversations to Elicit Goals of Care - Tony Back

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Communication in Serious Illness: Courageous Conversations to Elicit Goals of Care Anthony Back University of Washington Cambia Palliative Care Center of Excellence

Transcript of Communication in Serious Illness: Courageous Conversations to Elicit Goals of Care - Tony Back

Communication in Serious Illness:

Courageous Conversations to Elicit Goals of Care

Anthony BackUniversity of Washington

Cambia Palliative Care Center of Excellence

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Goals of care

Not about selling hospice

Discovering values that shape medical decisions

“Clinicians need to initiate conversations…”

“frank…and explicit discussion…”

Do ‘big picture’ conversations matter?

• 332 patients identified prospectively• Asked “Have you and your doctor

discussed any particular wishes about the care you would want to receive if you were dying?”

• Yes/no: compared re– Distress/Depression p=NS– Accepts illness as terminal OR 2.19– Wants to know life expect OR 2.40

JAMA 300:1665, 2008

Outcomes correlated with a transition conversation

• Medical care in last week of life– ICU admission OR 0.35– Ventilator use 0.26– Resuscitation attempt 0.16– Outpt hospice >1 wk 1.58

• Caregiver bereavement– Better QOL p=0.001– Felt prepared for death p=0.001– Regret p>0.001

JAMA 300:1665, 2008

Close-­‐up  of  a  cri/cal  moment

• Excerpt  from  consult:  • “So  if  you  had  100  people,  the  survival  curve  drops  

down  because  people  die  of  one  thing  or  another,  including  relapse.  That  tends  to  level  off  at  about  2.5  years  aGer  transplant  and  stays  level  aGer  that.  It’s  about  30%  in  your  situa/on”  

• Pa/ent’s  pre-­‐visit  es/mate  of  cure:  90-­‐100%  • Pa/ent’s  post-­‐visit  es/mate  of  cure:  90-­‐100%

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Strong  emo/ons  hijack  cogni/on

“AGer  he  said  the  30%,  he  just  kept  dinging  along  in  his  facts,  and  I  was  stunned.  Literally,  my  notetaking  was  completely  done.    All  I  wrote  was  30%  the  rest  of  the  /me  all  over  my  paper.    And  I  mean,  I  just  couldn’t  get  past  that  point.  I  don’t  know  how  to  describe  it”

Doctor  self-­‐rated    competence

Pa/ent-­‐rated    competence

Physician  self-­‐assessment:  imperfect

Communication is a learned expertise

Our learning model

MODEL

PRACTICE

REFLECT

Scaffolding your learning

• Goal = what you’re trying to learn or get better at. Set your intention every time.

• Time out = Pausing the action before too much happens to remember. Take notes!

• Rewind & replay = Backing up to improve. Go slow now to go fast later—

• Take home = crystallizes learning to make it portable. Collect these!

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‘You don’t get benefits from mechanical repetition, but by

adjusting your execution over and over...’