Goals of Care Conversations Part 4 Life-Sustaining Treatment ...

Goals of Care Conversations Part 4 Life-Sustaining Treatment ...

Goals of Care Conversations Part 4 Discussing Life-Sustaining Treatments Training for Physicians, Advance Practice Nurses, and Physician Assistants Serious Illness Communication Skills Training Delivering Serious News Conducting Goals of Care Conversations

Part Part Part Part 1 2 3 4 -

Reframing: Were in a Different Place Mapping the Future: Clarifying Priorities Aligning with Patient Values Discussing Life-Sustaining Treatments Life-Sustaining Treatments Artificial nutrition Artificial hydration Mechanical ventilation CPR Others, e.g., dialysis, blood products Transfers to the hospital, ICU Successful Goals of Care Conversations

SKILL S Empathic Responses Responding to Challenging Questions KNOWLED GE See Handouts

CPR Outcomes Patient Education Booklet What are some unintended consequences of the following? Would you like us to try to restart your heart? Would you like us to do everything possible if your fathers heart stops beating and he stops breathing? I think its time to withdraw care. What are some unintended consequences of the following? Would you like us, in what would naturally be your

final moments, to press on your chest and break your ribs, shove a tube down your throat and poke you with needles in lots of places in a chaotic attempt that has a very small chance of giving you more time to be technically alive but unlikely to ever return to meaningful communication with others? http://www.cunniffdixon.org/resource/do-not-punctuate-the-end-of-your-life-with-a-senseless-act-of-brutality-2/ Our role Ensure patients receive treatment consistent with their values and goals by helping them Define what is important to them

Understand outcomes is the treatment likely to help them meet their goals? Make informed decisions REMAP: Discussing Goals of Care Reassess understanding & Reframe Expect emotion Map out whats important Align with patient values Plan treatment to match patient values REMAP: Plan Treatments that Match Values

AFTER mapping whats important and aligning with the patients values IF goals point to a clear plan about LST: Ask permission to make a recommendation Recommend treatments to support the patients goals, what might be possible, and what not to do because it wouldnt support the patients goals What We Will Learn What to do AFTER mapping and aligning IF:

The patients goals do not point to clear plans/ recommendations regarding lifesustaining treatment (LST) The patient wants information about LSTs There appear to be inconsistencies between the patients goals and LST decisions Explore Preferences and Understanding IF the patients goals dont point to a clear plan for LST: We want to be sure you get the care that helps achieve what matters most to you. Its helpful to know in advance whether you would or wouldnt want certain procedures.

As you think about your medical care, are there any treatments that you already know arent acceptable to you? Explore Knowledge When further exploration of the patients preferences is needed: One treatment that would be helpful to talk about is [a ventilator] [a feeding tube] [CPR] [other.]. Can you tell me what you know about it? Provide Information about the Treatment

Provide information in short chunks to fill in knowledge gaps, giving the patient time to process and respond: CPR can be used when someones heart and breathing stop. CPR involves forcefully pushing on the chest, and can include shocking the heart and putting a tube down the throat to try to get the heart and breathing to start again. A ventilator helps a person breathe when they can no longer breathe on their own. It involves a Explore Preferences for Additional Information To explore what information would be helpful to

the patient: Some people like to know the chances of living longer with a feeding tube, what the risks are, or what life might be like afterward. Other people have spiritual questions about these decisions. What about you? Do you prefer general information, or do you Explore Possible Inconsistencies IF the patients decisions about LST seem inconsistent with their stated goals: I worry that [a feeding tube] wont help you reach your goals.

Tell me more about what you are hoping for with [CPR]. Is there a situation you could imagine when you would [or would not] want [a ventilator]? Reviewing Goals & Decisions at a Later Date After LST decisions have been made and documented, it may be appropriate to review them at a later date Review to confirm decisions without casting doubt With surrogates, start with what you know about the patients goals and decisions NOTE: When clinical circumstances have changed, use

REMAP to explore goals before re-addressing decisions Verifying Decisions Without Casting Doubt When your mother met with Dr. Jones about two months ago, she knew her illness was getting worse, and she said it was her goal to stay as comfortable as possible. She wanted medical orders written so she wouldnt be put on a breathing machine or get CPR. Those orders are in place so everyone knows to honor her wishes. Is there anything more you can share to help us respect her decisions? Drill Reminders

Drills include discussions about CPR; use the same steps to discuss any life-sustaining treatment Purpose: to practice specific skills, not represent a perfect discussion Use these skills AFTER mapping what is important to the patient Drills Drill A: Transition into a discussion of life-sustaining treatment options when goals dont point to a clear recommendation Drill B: Provide information about risks

and outcomes Drill C: Explore possible inconsistencies between the patients goals and Drill Instructions Review drill as a group Divide into pairs Practice Switch roles Debrief with one another: How did it feel to say the words? One thing you noticed as the clinician One thing you noticed as the patient

A: Introduction Drill Drill A Clinician I want to be sure you get the care that helps achieve what matters most to you. Its helpful to know in advance whether you would or wouldnt want certain procedures. Are there any treatments that you already know arent acceptable

Patient Im not sure. I havent really thought about that. A: Perception / Invitation Drill Drill A Clinician Patient One treatment that we should talk about is CPR, or

cardiopulmonary resuscitation. Can you tell me what you know about it? Ive seen it on TV, but I dont know much about it. I think its used when people have a heart attack, but Im not sure. Would it be ok if I shared some information about it? Sure.

A: Knowledge Drill Drill B Clinician Patient CPR can be used when someones heart and breathing stop. CPR involves forcefully pushing on the chest, and can also include shocking the heart and putting a tube down the

throat to try to get the heart and breathing to start again. Wow, that sounds rough. A: Emotion / Knowledge Drill Drill B Clinician A lot of people are surprised by that. Yeah, its different to think about how CPR could affect

you personally. Patient I guess you dont really think about it when you see it on TV. Drill Drill Instructions: Swap Roles Instructions: Swap Roles Patient

Clinician title Debrief How did it feel to say the words? One thing you noticed as the clinician One thing you noticed as the patient Drill B Drill B shows how to provide information in three ways: 1. General outcomes 2. Specific odds 3. Possible outcomes linked to the patients goals

With patients, use the strategy that matches their preference for information. Drill B: Assess Type of Information the Drill A Patient Wants Patient Im not sure I know enough to make a decision. Clinician

Some people like to know the chances of surviving after CPR, or its risks, or what life might be like afterward. Other people have spiritual questions related to these decisions. What about you? Drill B: Strategy 1 Share General Drill A Outcomes Patient Doesnt CPR usually

work? Clinician Unfortunately, most adults who receive CPR dont survive. Young and otherwise healthy people have better chances of surviving, and people with serious health problems have lower chances. B: Strategy 2 Share Specific Odds

Drill Drill A Patient Clinician If 100 people in the hospital received CPR, about 18 would survive to leave the hospital. That means 82 out of 100 people would die. These are averages. For people with health problems like yours, the chances

of survival *customize per patients risk are using How many people survive after CPR? What are the odds that Id make it through? Drill B: Strategy 3 Share Outcomes Drill A Linked to Goals

Patient I dont want to be in pain or end up stuck on machines. Clinician Im concerned that CPR wouldnt help you live the life you want. Theres a high risk of broken ribs that would cause pain. If CPR worked to restart your heart, theres a [large chance]* youd need more help and wouldnt be able to live at home. After CPR, you

might need the support of a breathing machine to keep you alive. *customize per patients risk using general Drill Drill Instructions: Swap Roles Instructions: Swap Roles

Patient Clinician title Debrief How did it feel to say the words? One thing you noticed as the clinician One thing you noticed as the patient Drill C Drill C show how to explore possible inconsistencies between the patients goals and treatment decisions.

Use after thoroughly mapping the patients goals and values. Drill C: Recommend a Plan Based on Drill C Patients Goals Clinician Patient Since its really important to you to be I think I would still want to try independent and take care of yourself, I CPR if my heart stops.

would not recommend CPR if your heart stops. Even if it worked to restart your heart, I worry that you wouldnt be able to get off the machines afterward, or if you did, you would be too weak to take care of yourself Drill C: Explore Possible Drill C Inconsistencies Clinician Tell me what youre hoping for with CPR.

Patient When it comes right down to it, if theres any chance Id get another day with my family, it would be worth it, even if I ended up in pain or in the hospital on machines for a while. I know it might not work, and I might be in terrible C: Explore Limits Drill Drill

C Clinician Patient I can see how important your family is to you, and I really respect that. Can you think of a situation when you wouldnt want CPR? I want to give CPR a chance. But if you try it and I end up with brain damage, dont

try it again. C: Explore Limits Drill Drill C Clinician Patient Tell me what you mean when If I get CPR, and afterward Im you say, brain damage. not able to take care of myself or make my own decisions, then I wouldnt want CPR again. I dont

want to be a burden on my Ok. What if you develop family. those problems before CPR? C: Summarize Drill Drill C Clinician At this point, you would want an attempt at CPR if your heart and breathing stop. If you were ever permanently

unable to take care of yourself or make your own decisions, you wouldnt want CPR. Do I Patient Yes, thats right. C: Next Steps Drill Drill C Clinician Thanks for helping me

understand what you want. Your daughter should know about this, too, since you chose her to communicate your decisions if you cant speak for yourself. Can you bring her with you to your Patient Thats a good idea. She might have some questions, and I want her to know what I want.

C: Next Steps Drill Drill C Patient Clinician title Debrief How did it feel to say the words? One thing you noticed as the clinician One thing you noticed as the patient

Summary: Discussing LST If goals point to a clear LST plan, ask permission and make a recommendation If goals dont point to a clear LST plan: Ask permission to talk about treatments the patient may or may not want Assess understanding of the treatment Asses information the patient wants and provide it Explore decisions that do not appear to match goals Goals of Care Conversations: REMAP Reassess understanding & Reframe

Expect emotion Map out whats important Align with patient values Plan treatment to match patient values What surprised you? What do you want to take forward? Anywhere you might get stuck? Whats one thing you will try in the next two weeks? Goals of Care Conversations Goals of Care Conversations training materials were developed and made available for public use through

U.S. Department of Veterans Affairs contracts with VitalTalk [Orders VA777-14-P-0400 and VA777-16-C-0015]. Materials are available for download from VA National Center for Ethics in Health Care at www.ethics.va.gov/goalsofcaretraining.asp. Published Jan. 2017

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