Grand Rounds Summary 3/8/17

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Palliative Care Guest Lecture with Dr. Ashley Shreves

What are some general challenges to providing palliative care?

  1. Identifying the dying trajectory of a patient
  2. Capacity assessment
  3. Advanced directives and applying them appropriately
  4. Difficult communication
  5. The language surrounding withdrawal of life sustaining treatment
  6. Resources to aggressively manage end-of-life symptoms
  7. Spiritual competency
  8. Difficult ethical situations

What is the state of palliative care today?

  • 67% of US hospitals (50+ beds) have some palliative care resources available
  • To meet today's current needs, the US requires 18K certified palliative care physicians; we currently have 3K
  • There likely will never be enough. Every physician needs some palliative care skill set

How can Emergency Physicians become involved in palliative care?

  • Fellowship
  • EPEC Course in Palliative and End of Life Care for Emergency Medicine
  • Harvard Center for Palliative Care PCEP Course
  • University of Colorado Palliative Care Course
  • Vital Talk - online courses in communication surrounding various topics including Palliative Care

Online resources available in palliative care:

  • PCNOW - Palliative Care Network of Wisconsin - Online 'fast facts' for palliative care communication
  • Vital Talk App "Vital Tips" for palliative care situations

Code Status Discussion: Barrier to a Peaceful Death

According to one study that observed physicians having code status and goals-of-care discussions, the average discussion about code status lasted 1 minute. Physicians shied away from giving recommendations regarding goals of care, as it was felt that doing so would violate patient autonomy.

To do better with goals-of-care discussions, consider:

  • The patient's values - you'll have to ask about them
  • Giving the facts straight - (See below)
  • Targeting the right patients - advanced age/terminal disease, critically ill

Some cardiac arrest outcomes data to consider:

  • OOHCA without immediate ROSC coding on way to hospital - 0.4% survival to hospital discharge
  • Advanced CA, expected to die, codes in hospital - 0.0% survival to hospital discharge
  • Critical illness (max pressure support, vent, in ICU) and codes - 3% survive to home return

Knowing these facts can help you to frame the discussion surrounding code status. CPR was an intervention created specifically for the heart that is too young to die, not necessarily all dying hearts.

Some disease processes are reversible:

  • COPD Exacerbation
  • CHF Exacerbation
  • Sepsis

Some disease processes are not reversible

  • ICH (generally)
  • Advanced dementia
  • Cancer (generally)

In irreversible disease processes, CPR is a tool to prolong dying.

A road map for goals of care discussion:

  1. Assess readiness/understanding (do this by listening)
    1. Ask family directly "what have the doctors told you?"
    2. Say something like "I'm really worried about your loved one, they're very sick," then assess the family's reaction.
  2. Give a medical summary (talk)
  3. Assess goals/hopes of the patient or family (listen)
    1. Try saying something like: "She's really sick. We are doing everything we can possibly do right now. I want to talk to you about the best way for us to take care of her if her condition worsens. Would that be OK?"
      • If the family says "no", they are pre-contemplative, so don't invest the energy for goals-of-care discussion at that moment
  4. Give a recommendation (talk)
    1. Start big, then give details: "Based on what I'm hearing, I think we should..."
    2. Take a moment at the end to insert empathy:
      • Say things like "I wish things were different" or "I can only imagine how disappointing this must be" or "You are clearly such devoted family members, you are doing a great job"
      • The term "I'm sorry" should generally be avoided in palliative care because it implies responsibility, when in fact responsibility falls on the terrible disease

The actual code status piece can be a single sentence, if the above discussion takes place. Once family wishes are known, a simple phrase like "In concordance with what we have discussed, when your loved one's breathing and heart stop, we will let their natural death take place. I will let the team know that by placing a DNR order in the chart."

Another option is to place the DNR/DNI as a limit.

  • "We are hopeful that our interventions for the patients illness will work, but I wonder if we can make a plan in case these interventions don't turn things around?"

According to one study, framing 'no CPR' as the norm lead to a 16% increase in patients choosing no CPR at the end of their life.

Changing the phrasing from DNR/DNI (which is medical jargon) to "allowing natural death" leads to similar decreased rates of CPR.

Leadership Curriculum: Communication Differences with Drs Kreitzer and Ronan

Drs. Kreitzer and Ronan led us through a discussion about different styles of communication. We had the opportunity to take the Communications Self Assessment from P Casse's Teaching for the Cross Cultural Mind.

The assessment separates people into four communication styles:

  1. Action-oriented people
    • These people are focused on objectives, results, and performance 
    • To effectively communicate with action-oriented people, focus on:
      • the result first, state your conclusion at the outset
      • state your best recommendation; do not offer lots of alternatives
      • be as brief as possible
      • emphasize the practicality of your ideas
      • use visual aids
  2. Process-oriented people
    • These people are focused on procedures, planning, and organization
    • To effectively communicate with process-oriented people, focus on:
      • being precise, and stating facts
      • organize your discussion in a logical order: background, present situation, outcome/conclusion
      • include alternatives to your recommendation, with pros and cons
      • do not rush a process-oriented person
  3. People-oriented people
    • These people are focused on teamwork, motivation, and individual needs and feelings
    • To effectively communicate with a people-oriented person, focus on:
      • allowing some small talk, do not delve into the discussion right away
      • stress the relationship between your proposal and the people it serves
      • show how your idea may have worked well in the past
      • indicate support from well-respected people
      • use informal writing style
  4. Idea-oriented people
    • These people are focused on concepts, innovation, and new methods
    • To effectively communicate with an idea-oriented person, focus on:
      • allowing enough time for discussion
      • do not get impatient if they go on a bit of a tangent
      • relate your discussion to broader concepts and ideas
      • stress the uniqueness of the idea or topic
      • emphasize future value or future impact