Talking to patients about palliative care is no joke.
In fact, many providers actively avoid the difficult conversation.
A recent sold-out “Palliative Improv” CME event at Lancaster Country Club used humor and role-playing to offer advice for raising the very serious subject with patients and their families. Internal Medicine Hospitalists’ Thomas Overholt, M.D., “director of acting,” coordinated the evening’s four scenarios.
“Actors” included physicians and advanced practice providers from IMH, Palliative Medicine Consultants, Roseville Pediatrics, Family & Maternity Medicine, and Hematology and Medical Oncology.
“Palliative care affects all patients and specialties, from pediatrics to geriatrics,” Jason Scott, M.D., of Internal Medicine Hospitalists, told attendees, who included physicians from both of those specialties and many others.
Kristina Newport, M.D., of Palliative Medicine Consultants, said many physicians avoid talking about palliative care because of discomfort or lack of time, experience or training. Some worry that the conversation will affect their relationship with the patient or diminish hope.
“You don’t have to use the perfect words,” Dr. Newport said. “People remember your approach and your empathy. But you must have structure to the conversation, or it won’t go well.”
A successful palliative care conversation increases patient satisfaction, shortens hospital stays and decreases aggressive care at end of life in appropriate cases. Patients want to know the truth, she said, and open, honest communication strengthens the physician-patient relationship and actually helps maintain hope.
Thomas Miller, M.D., of Palliative Medicine Consultants, said that successful palliative care discussions require preparation, practice and feedback. Providers should have a framework in mind before initiating the conversation.
“The skill of addressing it is learned in time,” Dr. Miller said. “You want to invite the patient into the truth as if they’re trying on a jacket: slowly, at their own pace and with their own effort.”
Basic communication strategies (“AIDET”) can decrease anxiety and increase compliance:
Acknowledge: All people in the room.
Introduce: Yourself and your role.
Duration: Give an accurate time expectation -- such as when you will be back or when results will be available -- so patients know what to expect.
Explain: The situation and leave a way to contact you.
Thank you: Let the patient know you value their time.
The pneumonic “SPIKES” can serve as a helpful guide for framing the conversation:
Set the stage: Gather information on the patient and the situation. Let the patient know that you will be having a difficult conversation. Invite family, and make sure to allow enough time.
Establish Perception: Find out what the patient knows. Understanding where the patient is coming from will guide you in starting the conversation and knowing what type of language to use.
Seek Invitation to share: Find out what the patient wants to know.
Provide Knowledge: Use clear, simple language and unmistakable terms. Then stop talking and let the patient and family react.
Respond to Emotion empathetically: Listen to and validate responses from the patient and family.
Strategy & summary (& share): Establish a plan for follow-up so everyone knows the next steps. Reassure the patient and family that you will be there for them.
Dr. Katherine McGeary (left) discusses the results of a positive cystic fibrosis test with “parents” Dr. Carrie Evans and Brian Kanaskie, CRNP, who are in denial.
Dr. Elizabeth Horenkamp (far left) recounts a grim lung cancer diagnosis to “patient” Dr. Lisa Kernic (far right), “husband” Dr. Phil Billoni and “daughter” Dr. Jennifer Nguyen. Despite disappointing test results, the family does not want to give up hope.
Dr. Kari Oftedal Moreno (center) comforts Ashley Kliewer, PA-C, whose “mother,” Dr. Tara Tawil, has suffered an intercranial hemorrhage. Dr. Oftedal Moreno encourages the daughter to reach out to her siblings and carefully consider what their mother would want.
Dr. James Probolus talks with COPD patient Andrew Mayfield, CRNP, and his “wife,” Dr. Michelle Jordan, helping them adjust their expectations to meet the seriousness of the situation.