Caring Conversations in the Henry Ford Physicians Newsletter, April 2015

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More on Caring Conversations…

 Is your patient hoping for a miracle? If so, well done, doctor.

 “Focus on a miracle”, is an expression of understanding that the likelihood of recovery is minuscule. If your patient or surrogate is hoping for a miracle, then you have been successful in communicating serious news.

 Physicians are trained in a highly cognitive field. Patients’ belief in miracles can cause us to fear that the patient is “unrealistic” in their expectations of our ability to cure.

Our goal as “well-trained 21st Century physicians” is to guide our patients through disease treatment, which includes a recommendation for their plan of care. Our job is not to convince them out of the likelihood of a miracle, but to keep the conversation going.

 Consider the following dialogue:

Provider: “I’m sorry to tell you the pancreatic cancer has spread to an area that makes surgery too dangerous.”

Patient: “Oh Lord! You can’t be telling me this. I am not dying. What about surgery?”

Provider: “I’m sorry, but surgery is not an option.”

Patient: “My church member survived this. I have people praying for me and we believe in miracles. Let’s do chemo.”

We often respond with more data (albumin, creatinine or functional status) and a wish that the patient would respond more cognitively. However, responding to an emotional reaction with medical information can derail the conversation.

Hope for a miracle need not be the end of a conversation; it can be the beginning of a new conversation.

 Here are effective physician responses to the above patient comments:

A.      “I’ll hope for a miracle, too.”

B.      “It sounds like your faith is very important to you.”

C.      “It sounds like you are hoping for a miracle. What else do you hope for?”

Try one of these replies the next time a patient expresses their hope for a miracle, and then pause to listen to his or her response.

For more reading on published evidence about responding to hopes for a miracle, see:  Widera, Eric W.; Rosenfeld, Kenneth E.; Fromme Erik K.; Sulmasy Daniel P.; and Arnold Robert M, Approaching Patients and Family Members Who Hope for a Miracle; Journal of Pain and Symptom Management. July, 2011, volume 42 (1): 119-25.

This is one of many skills that can be practiced with the Caring Conversations Communication 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.; Michael Mendez, M.D.; Maria Kokas, Ph.D.; and Cari Williamson, BA.

CLEAR Conversations in the Henry Ford Physician News December 2015

More on CLEAR Conversations…

Will you do “everything” for your dying patient?

Although a common reaction is to try and convince our patients to change their request, our responsibilScreenshot 2014-10-03 16.29.45ity is to keep the conversation going and recommend a medical plan consistent with their values.  This necessitates de-coding what “everything” represents to them and can encompass misunderstandings about prognosis or treatment risks, fears about dying or the care of surviving dependents.

Do they mean Full Code?

  • “Would you tell me more about what ‘everything’ means to you?”
  • “Are there any situations that might change your decisions about being in the hospital or on machines?”

Are they fully informed about their prognosis?

  • “Would you please tell me what the other doctors have told you?”

Are they overwhelmed when considering their own death and dying?

  •     “How do you see the next few months (days or years) going?”

Do they have open communication with loved ones that depend on them?

  • “What have you told your loved ones about how treatment is going?”

Once you have deciphered your patient’s meaning of “everything” and their understanding of their own prognosis, the path is clear to explore what is most important to them.  For the majority of patients with a terminal prognosis, this will likely involve maximizing comfort and time with family while minimizing time in medical settings.  These patients should be engaged in discussion of hospice services.
A small number of patients will continue to request high-burden interventions at end of life, sometimes guided by religious beliefs.  If you have explored their understanding as above, and their stated values are best met with life prolongation using life-support and Full Code status, your expertise as a physician (and consultation with a religious leader if appropriate) allows you to craft a plan which respects their values while minimizing treatment harms.  Consideration of a time-limited trial of treatment and/or case manager involvement to discuss the practical aspects of placement for an individual with trach/peg/dialysis should be considered.
A request for “everything” may not mean Full Code, but may instead be an expression of underlying patient emotions.  Responding to an emotional reaction with medical information can derail the conversation.  A request for “everything” need not be the end of a conversation; it can be the beginning of a new conversation.
After you try this approach, please send an email and let us know how it goes.

For more reading on published evidence about responding to requests for “everything,” see:  Quill, Timothy E.; Arnold, Robert; Back, Anthony L., Discussing Treatment Preferences With Patients Who Want Everything; Annals of Internal Medicine. 2009, v151: 345-349.

This is one of many skills that can be practiced with the CLEAR Conversations Communication 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.; and Hannah Beels.  Please email us at HBEELS1@hfhs.org for more information.