4/12/19 Do Do I Have To? St Strat ategi gies for Hav aving ng - PDF document

4/12/19 Do Do I Have To? St Strat ategi gies for Hav aving ng Challenging Con Ch Conversation ons wi with Confidence and I have no financial disclosures to report. Disclosures Com Compassion on Brook Calton MD, MHS Assistant Professor of Clinical Medicine UCSF Division of Palliative Medicine Objectives � All medical care flows � The single biggest through the problem in relationship between communication is the By the end of today’s talk, you will be able to: physician and patient • Identify specific communication techniques illusion that it has and the spoken word you can use to approach challenging taken place.” interactions in clinical practice is the most important • Apply these techniques to two challenging tool in medicine. � patient scenarios • Describe how challenging conversations in clinical practice influence clinician well- being and identify strategies to care for - Eric Cassell MD - George Bernard Shaw yourself 1

4/12/19 15-30% of family physician visits • Breaking bad news • Taking away driver’s license Can be due to disparity between the the expectations, perceptions, or actions of the patient and physician • Conflict with a colleague • Navigating unrealistic expectations Challenging Examples Some conversations just plain hard to have • Advance care planning Conversations • Medical errors Association with less time in practice, long work hours, • Medication non-compliance or subspecialty work, perception of greater # patients w/ frequent clinic no-shows psychosocial concerns or substance abuse • Dishonesty/trust Best practice to move away from labeling patients and families Why are Challenging Conversations So Challenging? • We are all just trying to do a good job • Humans are humans Ke Key Communication Techniques • Emotions can be high • Stakes can be high • System issues • Role of unconscious bias 2

4/12/19 Assess understanding ASK: and how much they want to know TELL: Give information Check for ASK: understanding ”It sounds like you are frustrated” N ame “Some people would feel…in this situation” • Most patients will have some U nderstand “I can understand how that might upset you” emotional response when “I can’t imagine what that would feel like!” discussing topics where difficult information is conveyed Responding R espect “You’ve been through a lot” • Patient’s emotional response may to Emotions “I’m impressed with how you’ve handled this” sound like a factual question/statement “Our team will be here for you through all of this” • Both non-verbal and verbal S upport “I want to help in any way I can” responses to emotion key ”Tell me more…” E xplore “How are you coping with this?” 3

4/12/19 Empathy Enhances Efficiency • An expression of empathy Made empathic Didn’t make empathic • Aligns you with patient statements (min/visit) statements (min/visit) • Examples: • “I wish we had more effective “I Wish” treatments for your dad’s Internists 17.6 20.1 dementia” • ”I wish I had better news to share” • “I wish you could eat twelve Surgeons 12.5 14 cookies before bedtime” Quill et al, Ann Int Med, 2001 Levinson et al, JAMA, 2000. 4

4/12/19 Self-Awareness Mindfulness Groundedness Ca Capaci citi ties Non-Anxious Presence Ca Capacities es Curiosity What do you to explore Compassion how you are feeling before or during a conversation with a patient/family? Response Flexibility “You doctors don’t tell me anything-I need to “Are you sure we’ve tried everything?” know what’s going on with my mom!” (choose best response) (all responses are acceptable except…) 1. “I wish you didn’t feel this way.” 1. “I wish there was another treatment for your cancer.” 2. “I’d like to help. Do you mind sharing with me what you understand 2. “We have nothing more to offer you.” about your mom’s dementia?” 3. “I can’t imagine how upsetting this is.” 3. “Would it be OK if I tried to explain more about your mom’s 4. A & C dementia?” 5. “You had treatment X, Y, and Z --- we don’t have another one.” 4. Use capacity of “curiosity” to explore family member’s feelings 5. “You seem really frustrated.” 5

4/12/19 The Primary Emotion I Feel Reading this Case is…. On a day when you are very behind schedule, you see Mr. Smith, a 56 yo man with a CC of acute low back pain. Mr. Smith has a history of questioning your 1. Frustration care plans. The back pain started three 2. Despair days ago, is fairly severe, with no red flag Mr. Smith Mr 3. Excited – I love a challenge! Bring it On symptoms and a normal exam except 4. Empathy paraspinal tenderness. Before you describe your treatment plan, Mr. Smith 5. Nothing – this is the last lecture of the whole CME course, when’s states, “Doc, I’m in a ton of pain! I’m not lunch? leaving here without an order for a MRI!”. Slide c/o Ryan Laponis MD Provider’s View Mr. Smith’s View Conclusion I don’t like this patient I am so glad I have a caring doc Reasoning Trying to understand entitled patients is a waste My doctor will certainly order one of time The Ladder of Inference Assumptions When patients ask for things that aren’t The only way to really know how to treat this indicated, they are entitled is to get an MRI. Directly Observable Data Mr. Smith requests an MRI I’m in so much pain and I want to enjoy my vacation next week that I’ve planned for a year Slide c/o Ryan Laponis MD Slide c/o Ryan Laponis MD 6

4/12/19 Conflict with a Patient Case Revisited Capacities • Provider notes patient demand for a MRI is making their heart beat faster and turn red. Decides to pause and take two deep breaths before responding. • Use capacities to climb down the ladder of inference Respond • Provider: “It must be really hard to be in so much pain”. Respond to • Respond to emotion (before fixing) • Patient: “Yeah doc, it stinks! I can’t do anything.” to Emotion Emotion • Provider: “It sounds like you think an MRI is important here. Help me • Elicit the other’s perspective understand that.” • Patient: “Well, actually, my wife said I should ask. To be honest, I just want to • “Sounds like you think an MRI is going to be important here. Help me feel better during my vacation next week and try to find a way to keep this understand your perspective on that…” from happening again.” • Provider: “Sounds like we should focus on controlling your pain and talk about • Break the “ICE” – Ideas, Concerns, Expectations ASK- some prevention strategies?” TELL- • “What ideas do you have about what is causing your pain?” ASK • Patient: “Yeah” • “What concerns you the most about this?” ASK- • Provider: “Let’s work together to find a way to treat your pain so you can • “What are you expecting we can accomplish today?” enjoy your vacation. Also, having heard your concerns and completing the TELL- physical exam, I have a good idea of what is causing your pain and an MRI isn’t ASK going to help us right now. Can I share with you what I think is happening with your back and then talk about pain relief options?” • Patient: “Yes, please do.” Tate P. The doctor’s com m unication handbook . 4th ed. O xford: Radcliffe M edical Press, 2004. Kleinm an A, Benson P (2006) Anthropology in the clinic: The problem of cultural com petency and how to fix it. PLoS M ed 3(10): e294. DO I: 10.1371/ journal.pm ed.0030294 Slide c/o Ryan Laponis MD Slide c/o Ryan Laponis MD The primary emotion I feel preparing to deliver this difficult news to Mrs. Ford is… You are seeing Mrs. Ford, a 70 yo woman with a past medical history of hypertension you’ve taken care of for over 15 years. You saw Mrs. Ford two 1. Fear months ago for vague abdominal pain you thought was from constipation. Over the past 2. Anger – Cancer only happens to the nicest people month her symptoms have worsened --- she has Mrs. Ford 3. Anxiety been having nightsweats, weight loss, worsening abdominal pain, and yellowing of her eyes. You 4. Sadness run basic labs concerning for abnormal liver enzymes and anemia; a CT scan is concerning for 5. Guilt -- Why didn’t I catch this sooner? widely metastatic cancer obstructing the biliary tree. She is returning to your office to follow-up on the results of these tests. 7

4/12/19 Diagnosis I deliver difficult information to patients…. Prognosis Sh Sharing 1. Once every clinic Di Difficul ult Test Results 2. Multiple times every clinic Inform In rmatio ion 3. Once a week Bad Outcomes 4. Once a month 5. Never – I chose to vacation on Maui permanently Medical Errors Patient Perspectives Clinician Perspectives • How difficult information is delivered makes a difference to • Although clinicians share difficult information often… patients • The skill is not taught well in medical training • Understanding of information • Clinicians generally rate poorly • Satisfaction with medical care • Can contribute to clinicians short- term (i.e. anxiety) • Level of hopefulness and long-term effects (i.e. feelings of failure, regret, • Psychological and emotional adjustment identification, higher rate of � burn-out � ) 8