Communicating at the EOL:
Communicating with Patients/Families
Sharing Poor Prognosis
Stu Farber MD
sfarber@u.washington.edu
Gregg VandeKieft, MD, MA
gregg.vandekieft@providence.org
July 2011
Caring Conversations:
Transitioning from Cure to Care
Giving Information
Telling
Caring Conversations:
Transitioning from Cure to Care
Sharing Information
Dialogue
Caring Conversations:
Transitioning from Cure to Care
Special Dialogue
• Helping pt/family understand where:
– Disease and treatment end
– Aging and the natural life cycle event we call end
of life begins
• You have a unique opportunity to assist:
– Pre-existing relationship
– We know this conversation effects pt/family choice
Caring Conversations:
Transitioning from Cure to Care
Special Dialogue
• Accepting this role takes courage
– To succeed you enter into the pt/family
story (values/goals)
– You become a part of the story
– You become vulnerable as another human
sharing the mystery, pain, suffering, joy
and wonder of mortality
Caring Conversations:
Transitioning from Cure to Care
Special Dialogue
When is the “right time” to have this dialogue?
Surprise Question: Would you be surprised if this
patient died in the next 6-12 months?
If you wouldn’t be surprised then it is your professional
responsibility to assist the patient/family prepare for
the “worst” while expecting the “best”
Caring Conversations:
Transitioning from Cure to Care
Making it Safe
Setting the Stage
within the Concept of Paradox
• Certainty and Uncertainty
• Life and Death
Caring Conversations:
Transitioning from Cure to Care
Special Dialogue
• What does the pt/family already know?
• What does the pt/family want to know?
• What does the pt/family need to know?
Caring Conversations:
Transitioning from Cure to Care
Communication Basics
• Tell-Ask-Tell
• Ask-Tell-Ask
– Ask(listen) Ask(listen) Ask(listen)-Tell-Ask
• Silence
• Pt/Family Cues
– Terminators
– Continuers
Caring Conversations:
Transitioning from Cure to Care
Case of John
• John is 68 with far advanced lung Ca
– Just out of ICU
– If he lives 24-48 hrs will be a miracle
• He and his family still are asking for tx that
will make him better
• You are asked to talk with him and his family:
wife, son and daughter
Caring Conversations:
Transitioning from Cure to Care
Evidence Based Best Practice
Set a “safe context” for dialogue
Explore the patient/family story
Use evidence based domains
Language = skill
Create shared story among pt/family/medical
team
Co-Create care plan among patient, family,
medical team
Caring Conversations:
Transitioning from Cure to Care
My Death
Raymond Carver
If I'm lucky, I'll be wired every which way in a hospital
bed. Tubes running into my nose.
But try not to be scared of me, friends! I'm telling you
right now that this is okay.
It's little enough to ask
for at the end.
Someone, I hope, will have phoned everyone to say,
"Come quick, he's failing!"
And they will come.
And there will be time for me
to bid goodbye to each of my
loved ones....
Caring Conversations:
Transitioning from Cure to Care
Late Fragment
And did you get what you wanted
from this life, even so?
I did.
And what did you want?
To call myself beloved.
To feel myself beloved on the earth.
Raymond Carver
Caring Conversations:
Transitioning from Cure to Care
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