Necessary Conversations: Enhancing Communication with Patients and Families 9am-4pm Meeting location: Mercy Hospital Springfield Catherine McAuley Conference Center Time Topic Responsible Parties 9:00am Welcome & Check-in 9:10am 9:15am 9:20am Opening Prayer Objectives & Disclosures Introduction to Course Participant Introductions Mark Longenecker & Amber Wheeler James Duff, MD 9:30am Why Enhance Communication Skills: Evidence and Important Concepts Albert Leonardo, MD 10:00am Speaking the Same Language Videotape and Discussion Julie Mercer Kidd 10:45am Break 11:00pm Importance of Advanced Care Planning Albert Leonardo, MD 11:30pm Sharing Our Experience: Narrative and Reflection Over Lunch James Duff, MD 12:30pm Starting the Conversation Need to be better prepared James Duff, MD/Albert Leonardo, MD 1:00pm Necessary Conversation 1 Debriefing & Feedback James Duff, MD 1:30pm Necessary Conversation 2 Debriefing & Feedback James Duff, MD 2:00pm Break 2:15pm Necessary Conversation 3 Debriefing & Feedback Albert Leonardo, MD 2:45pm Strategies for Implementation in Our Daily Practice James Duff, MD 3:15pm Reflections and Take Home Lessons James Duff, MD 3:45pm Post Event Evaluation for Continuing Education Credits Jordan Nelson & Debbie Ream CME & CNE certificates will be recorded on your MyEducation transcript within 10 business days of this activity. Mercy Hospital Springfield is accredited by the Missouri State Medical Association to provide continuing Medical Education for physicians. Mercy Hospital Springfield designates this live activity for a maximum of 5.5 AMA PRA Category 1 Credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Mercy Hospital Springfield is an approved provider of continuing nursing education by the Midwest Multistate Division, an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation. This activity provides 5.5 contact hours per day of continuing nursing education. To receive a Certificate of Attendance and Successful Completion for this educational activity, the participant must attend 85% of the scheduled program and complete all program requirements.
Patient and Familie es Seeking Mercy s Care AllCo-workers High Quality, Compassionate Care Treat each individual as created in the image of God Listen and watch for signs of physical, emotional, psychosocial or spiritual distress Know the resources in your facility and/or community, or know who can provide the information Cultureof a Patient Focused Ministry Providers/Clinicians/Care Managers Primary Palliative Skills Basic management of pain and symptoms Basic management of depression and/or anxiety Basic discussions about: Prognosis Goals of treatment Suffering Code status Know when to consult a palliative care specialist Know when to refer for hospice care Interdisciplinary Palliative Care Teams Specialty Palliative Skills Assistance with newly diagnosed or complex illness Management of refractory pain or symptoms Management of more complex depression, anxiety, grief and existential distress Assistance with conflict resolutions regarding goals or methods of treatment: Within families Between staff and families Among treatment teams Assistance in addressing cases of near futility
3/7/2016 Necessary Conversations Enhancing Communication with Patients and Families Why Bother? The practice of Medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. - Sir William Osler (Aequanimitas, 1932) Outline: Communication Skills Why bother to enhance communication skills and relational capacities? Is there evidence to support the effort? Concepts for relationship centered care Interpersonal and communication capacities/skills o Relational Skills o Listening Skills o Team work Patient-centered and relationship-centered care 1
3/7/2016 The single greatest problem in communication is the illusion that it has taken place. George Bernard Shaw Why Enhance Communication Skills? Communication is a core clinical skill The medical interview is the most commonly performed procedure in clinical medicine The average physician performs at least 200,000 interviews in a 40 year career Why Enhance Communication Skills? It s Evidence Based Effective communication skills are associated with Improved patient outcomes Improved clinical performance and efficiency Improved outcomes for health professionals 2
3/7/2016 Why Enhance Communication Skills? It s Evidence Based Ineffective interpersonal and communication skills are associated with: Medication errors and other medical errors Kohn LT, Corrigan JM, et al eds. To err is human. Building a safer health system, 1999; Malpractice claims and suits Vincent C, Young M, Phillips A. Lancet 1994; Beckman HM, Markakis KM, et al. Arch Intern Med 1993 Effective Interpersonal and Communication Skills are associated with Improved Patient Outcomes Patient compliance Kjellgren KI,Sajio R. Inter J Car 1995; Garrity TF, Soc Sci Med 1981; Symptom improvement and resolution Eghert LD, et al. New England Jl Med 1964; Little P, et al. BMJ 1997 Improved health outcomes Schillinger D, et al. Arch Intern Med 2003; Greater overall patient satisfaction with care Flocke SA, et al. J Fam Pract 2002 Effective interpersonal and communication skills are associated with improved outcomes for healthcare professionals Improved clinical performance and efficiency Roter DL et al. Social Scienced and Medicine, 1984; Stewart M, et al. J Fam Pract 2000. Greater physician satisfaction Suchman A, Roter D, et al. Med care 1993; Meier D, et al. The inner life of physicians and care of the seriously ill. JAMA 2009 3
3/7/2016 Concepts for Relationship-Centered Care Components of Interpersonal and Communication Skills Relational Skills Listening skills Team Work Patient centered and Relationship centered care Patient -Centered Care Emphasizes the patient s illness experience Views each patient/family as unique Focuses on patient/family needs, perspectives, values Tailors approach to patient based on knowledge of patient/family Relationship -Centered Care The focus is on how patients and clinicians relate to each other Relationships are the medium of care Relationships are therapeutic Both patients and clinicians are active participants Partnership and respect for patient s participation in decisionmaking is valued 4
3/7/2016 Relationship -Centered Care: What does the clinician bring? Being present for self and others goes beyond the patientcentered process Awareness of ideas, feelings, and values that influence the relationship Paying attention to one s own behavior. Not just what but how.. I may not remember what you said to me, I may not remember what you did to me, but I will always remember how you made me feel. - Maya Angelou Service Serving is different from fixing. When I fix aperson I perceive them as broken and their brokenness requires me to act. When I fix I do not see the wholeness in the other person or trust the integrity of the life in them. When I serve, I see and trust that wholeness. It is what I am responding to and collaborating with. There is a distance between ourselves and whatever or whomever we are fixing. Fixing is a form of judgement, and judgement creates distance, a disconnection, an experience of difference. We cannot serve at a distance. We can only serve that to which we are profoundly connected, that which we are willing to touch. This is Mother Teresa s basic message. We serve life not because it is broken, but because it is holy. -Rachel Naomi Remen, MD 5
3/7/2016 Necessary Conversations 1 Advance Care Planning version 1.0 8/19/2015 2 Agenda What is advance care planning? Why is advance care planning important? What are the benefits of early conversation? How to overcome common barriers to having conversation in office setting? Defining written documents used in advance care planning. 3 1
3/7/2016 Advance Care Planning Physician/Patient/Family Conversation Educates on diagnosis/prognosis Explores patient/family concerns; encourages openended questions Explores patient s dreams/hopes for future Defines goals for care and links goals to care plan; identifies care issues re: benefit vs. burden for patient 4 Benefits of Early Conversation Builds trust and teamwork between patient and physician Uncertainty and anxiety is reduced Avoids future confusion and conflict Provides peace of mind for patient, family and care providers 5 Myths About Advance Directivs It is not appropriate to begin advance directive planning on an outpatient basis. ~ patients want their doctors to discuss advance care planning with them before they become ill. ~ positive response from patients when advance directive discussions are held during outpatient visits. 6 2
3/7/2016 Myths About Advance Directives Overcoming this barrier: Do you know what an advance directive is? Do you have one? If you are afraid the patient may respond negatively, perhaps saying to you Is there something wrong with me? Am I sicker than you are letting on? Respond by saying, I ask all of my patients this question, sick or well: the best time to start thinking about this is before something serious occurs. 7 Myths About Advance Directives Patient Self Determination Act of 1991 mandates that every person be asked about advance directives when seen (inpatient and outpatient) The requirements of the PSDA are as follows: Patients are given written notice upon admission to the health care facility of their decisionmaking rights, and policies regarding advance health care directives in their state and in the institution to which they have been admitted. Patient rights include: The right to facilitate their own health care decisions The right to accept or refuse medical treatment The right to make an advance health care directive Facilities must inquire as to whether the patient already has an advance health care directive, and make note of this in their medical records. Facilities must provide education to their staff and affiliates about advance health care directives. Health care providers are not allowed to discriminately admit or treat patients based on whether or not they have an advance health care directive. 8 Myths About Advance Directivs If I have a financial power of attorney, I don t need a separate medical power of attorney. Not always True. Most often these are separate legal documents. Overcoming this barrier: When discussing Power of Attorney with your patient, assess his/her understanding. Have literature in your office to clear up discrepancies. 9 3
3/7/2016 Myths About Advance Directivs Physicians and patients feel that having an advance directive means "don't treat. ~ advance directives can be a trigger for disengagement by medical staff. ~ Conversely, some patients will think having an advance directive means they already have a do not resuscitate order when in fact a living will alone is not sufficient to ensure DNR status. 10 Myths About Advance Directivs Physicians and patients feel that having an advance directive means "don't treat. Overcoming this barrier: ~ Make sure your patient and staff understand that advance directives don t mean "don't treat me". ~ They mean, "treat me the way I want to be treated. For patients who want a do not resuscitate order, completion of a POLST (or your state s equivalent) is indicated. 11 Myths About Advance Directivs Patients often fear that once a person names a proxy in an advance directive they lose control of their own care. Overcoming this barrier: ~ explain to your patients make sure they understand that as long as they retain decision making capacity they retain control of their medical destiny. ~ Advance directives only become active when a person cannot speak for him or herself. 12 4
3/7/2016 Myths About Advance Directivs Only old people need advance directives Overcoming this barrier: The stakes may actually be higher for younger people if tragedy strikes. Use the example of the Terry Schiavocase as a trigger to enlighten the discussion. Ask What would you want if you were in her situation? 13 Myths About Advance Directivs Many people believe (hope) that having an advance directive will save their family from difficult decisions. ~ Surrogate decision makers often find that role troubling and even traumatizing, even withadvance directive documents. ~ Encourage patients, especially ones with serious medical illnesses, to discuss with their loved ones what they want and would not want, e.g., when is enough is enough, give permission to their loved ones to not prolong the dying process, 14 Myths About Advance Directivs Many people believe (hope) that having an advance directive will save their family from difficult decisions. ~ As a patient s medical provider, you yourself should be asking your patients with serious/advanced medical conditions these questions as well, to be better equipped to advocate for an appropriate plan of care when the patient is dying. The SUPPPORT Principal Investigators. A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). JAMA. 1995; 274:1591-1598. American Bar Association Commission of Law & Aging. Myths and Facts about Health Care Advance Directives. Available at: http://www.americanbar.org/content/dam/aba/uncategorized/2011/2011_aging_bk_myths_factshcad.authcheckdam.pdf. Accessed August 14, 2013. Messinger-Rapport BJ, Baum EE, Smith ML. Advance care planning: beyond the living will. Cleveland Clin J Med. 2009; 76:276-285. Available at: http://www.ccjm.org/content/76/5/276.long. Accessed August 14, 2013. Wendler D, Rid A. Systematic review: the effect on surrogates of making treatment decisions for others. Ann Int Med. 2011; 154:336-346. Available at: http://annals.org/article.aspx?articleid=746856. Accessed August 14, 2013. 15 5
3/7/2016 Written Documents Advance Directives ~ Living Will (Health care directive) ~ Durable Power of Attorney for Health Care ( Health care agent / Health care proxy ) 16 Written Document DNR Order Out of Hospital DNR Hospital DNR 17 Written document TPOPP Transportable Physician Orders for Patient Preferences 18 6
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Necessary Conversations: Enhancing Communication with Patients and Families Presented by: The Institute for Professionalism and Ethical Practice Boston Children s Hospital, Harvard Medical School Mercy 4/20/15 Oklahoma City, OK 4/22/15 Springfield, MO 4/24/15 St. Louis, MO Strategies for Implementation PARTICIPANT WORKSHEET We hope to discover, from your experiences, stories, and lessons learned today, the ingredients that will serve as building blocks for igniting and sustaining teaching and learning of relationship-centered care and communication skills throughout your institutions and practices. 1. In reflecting on what you have learned today about necessary conversations, what knowledge, ideas, and/or techniques will you share with your colleagues that would be beneficial to their patients? 2. What will your group do, or could you do, to put these into practice in your clinical setting / community? Consider: a. How will you teach what you have learned to others in your clinical setting / community? b. What are the next steps? 2015 Institute for Professionalism and Ethical Practice, Boston Children s Hospital, Boston, MA USA