CLEAR Conversations in the Henry Ford Physician News, March 2016

March 2016 HFH Physician Newsletter Article

More on CLEAR Conversations…
“What do you want us to do for you if you are too sick to make decisions for yourself?”

When our patients become seriously ill and are not able to make their own decisions, we rely on surrogate decision makers.  However, many of our patients have not completed advanced directives.  We are often left wondering, “Would there be less emotional conflict in making a medical plan if the patient had been clear about their wishes?”  Relying on a surrogate decision-maker who has not received clear instructions can be overwhelming to loved ones and the medical team, alike.
How can we do better?
We have to recognize that this is a challenging topic for patients as well as providers. By improving the effectiveness of our own communication skills, we can improve the experience and care of our patients.  The next time you find yourself in an “average office visit,” take a moment to consider a patient-centered approach for discussing advance directives: PAUSE.
Using this roadmap will improve your chances of successfully navigating advance-directives conversations as well as the success of future medical care plans. Think of it as a series of signposts—you might find that not all apply to a particular patient.

We have a responsibility to guide our patients through their health and their illnesses. We can acknowledge the importance of planning for unfortunate times and the emotional challenge inherent in end-of-life discussions. This understandable discomfort need not diminish our value as physicians; a clear roadmap can be the beginning of a new conversation.

For more reading on published evidence about discussing prognosis: Tulsky, JA, “Beyond Advance Directives: importance of communication skills at the end of life.”; JAMA 2005, v294(3): 359-65.
This is one of many skills that can be practiced with the CLEAR Conversations Program. Established by a group of Henry Ford physicians in 2012, the goal of the program is to improve conversations between providers and patients.
CLEAR Conversations has roots in the VitalTalk format and accordingly, utilizes highly skilled improvisational actors to create an ideal environment for experiential learning.
Henry Ford Health System CLEAR Conversations team members are: Rana Awdish, M.D.; Dana Buick, M.D.; Kristen Chasteen, M.D.; Erin Zimny, M.D.; Maria Kokas, Ph.D.; Hannah Beels, Michelle Turylo.

4th Annual Critical Care and Palliative Medicine Retreat

scars you share

The CLEAR Conversations Group hosted their 4th Annual Critical Care and Palliative Medicine Retreat on July 21st and 22nd at the Detroit Athetic Club. The Group of Trainees was comprised of Critical Care Fellows from Surgical, Medicine and Emergency Departments. Palliative Care Fellows from Henry Ford and DMC also participated. The group trained in Serious News with Empathy, REMAPing Goals of Care, Death and Dying.

CLEAR Conversations in the Henry Ford Physician News, February 2016

October 2015 HFH Physician Newsletter Article

More on Caring Conversations…
‘You can’t tell me how long I have to live, only God knows what will happen to me.”

When faced with a patient or surrogate decision-maker who is avoiding a discussion of prognosis, we are often left wondering, “How can we discuss reasonable treatment plan options if they won’t acknowledge that their condition is terminal?” At times, we spend hours trying to convince them of their prognosis and other times we throw our hands up in frustration, capitulate to their demands or avoid future discussion altogether.  None of these reactions accomplish what we physicians want: to provide our patients with the best medical care.
How can we do better?
We have to recognize that this is a challenging topic for patients as well as providers. Then we can acknowledge the effectiveness of our own communication skills.  The next time you find yourself considering a prognosis discussion, take a pause and consider a patient-centered approach: ADAPT.

Ask what they already know
Discover what information about the future would be useful for them
Anticipate ambivalence
Provide information in the form the patient/surrogate wants
Track & respond to emotion

Using this roadmap will improve your chances of successfully navigating prognosis discussions and minimize feelings of defeat and burn-out. Read examples of each tool used in the example conversations below.

We have a responsibility to guide our patients and their surrogates through their illness. We can acknowledge the uncertainty of prognosis and that at times our patients/surrogates will not be comfortable discussing prognosis. This understandable discomfort need not be the end of our value as physicians; it can be the beginning of a new conversation.

For more reading on published evidence about discussing prognosis: Back, Anthony L.; Arnold, Robert M., “Discussing Prognosis: ‘How Much Do You Want to Know?’ Talking to Patients Who Do Not Want Information or Who Are Ambivalent”; The Art of Oncology 2006, v24(25): 4214-4217, or Smith, Alexander K et al, “Uncertainty: The Other Side of Prognosis”; NEJM 2013. v368(26): 2448-2450.
This is one of many skills that can be practiced with the Caring Conversations Program. Established by a group of Henry Ford physicians in 2012, the goal of the program is to improve conversations between providers and patients.
Caring Conversations has roots in the VitalTalk format and accordingly, utilizes highly skilled improvisational actors to create an ideal environment for experiential learning.
Henry Ford Health System Caring Conversations team members are: Rana Awdish, M.D.; Dana Buick, M.D.; Kristen Chasteen, M.D.; Erin Zimny, M.D.; Maria Kokas, Ph.D.

Faculty Workshop: Emergency Medicine

CLEAR conversations hosted the inaugural workshop for Emergency Medicine Faculty at Henry Ford Hospital. Facilitators led participants in a series of family meetings simulating challenging conversations that typically occur in the Emergency Department.

CLEAR Conversations in the Henry Ford Physician’s News, January 2016

Screenshot 2015-07-24 08.15.57

“Doctor, why did this happen to me?”

 When faced with a patient or surrogate decision-maker who asks a difficult question, one to which we may not have answers, we are often left feeling inadequate. So much of our training has focused us on the importance of having answers for our patients. We can forget that these very tough, sometimes un-answerable, questions can be interpreted as expressions of emotion rather than primarily cognitive.

  How can we do better?

 The best medical care requires that we “attend,” or accompany, our patients through their illness. We have to acknowledge that recognizing and responding to emotion is very challenging. Then we can reflect on the effectiveness of our own communication skills. The next time you find yourself considering how you might answer those “impossible” questions, or respond to expressions of emotion, pause and consider a patient-centered approach: respond to the underlying emotion with a NURSE statement and then pause and allow the patient to respond.

 1.       Name the emotion

2.       Understanding response

3.       Respect

4.       Support

5.       Explore

 Using this roadmap will improve your chances of successfully navigating tough questions and connecting with your patient, while minimizing feelings of defeat. Read examples of each tool used in the sample conversations below and consider them as responses to questions such as, “Doctor, why did this happen to me?”

Step

What you say

1.    Name the emotion

“You seem very sad [overwhelmed, etc.]”

“I can see this is not what you were hoping for.”

2.    Understanding response

“I can only imagine what you are going through.”

“This is an overwhelming situation.”

“This is very difficult news.”

3.    Respect

“You are doing a great job managing a difficult illness.”

4.    Support

“I/The team will continue to work with you to figure out the next steps.”

“I wish I had better news.”

5.    Explore

“Tell me more about what worries you.”

 We have a responsibility to guide our patients and their surrogates through illness. We can acknowledge the challenge in navigating strong emotions and that, at times, our patients/surrogates will express their emotion by asking difficult or existential questions. This understandable discomfort need not be the end of our value as physicians; it can be the beginning of a new conversation.

 For more reading on published evidence about discussing prognosis: Back, Anthony L.; Arnold, Robert M., “‘Isn’t There Anything More You Can Do?’: When Empathic Statements Work and When They Don’t”; Journal of Palliative Medicine, 2013, v16(11): 1429-1432 and Back, Anthony L, et al, “Approaching Difficult Communication Tasks in Oncology.”; CA: Cancer J Clin 2005;55;164-177.

 This is one of many skills that can be practiced with the CLEAR Conversations Program. Established by a group of Henry Ford physicians in 2012, the goal of the program is to improve conversations between providers and patients.

Fellow Session: Dealing with Conflict

Conflict

On January 29th, the CLEAR Conversations team hosted a workshop for Critical Care and Palliative Medicine Fellows from Henry Ford Hospital/Wayne State University Training Programs.  Participants practiced an approach built upon Ask-Tell-Ask, NURSE, and REMAP to deal with Conflict.  Together, the group recalled some of their own experiences with conflict.  Using those examples, they then practiced their new skills in a real time simulated family meetings facilitated by the CLEAR Conversations team.