AOA Council on Palliatve Care
Goals of Care
Breaking Bad News
Unity Convention
October 24, 2010
Bruce Bates, D.O., FACOFP, CMD
Chair - Department of Geriatric Medicine
University of New England College of Osteopathic Medicine
Case

84 y/o W/F living independently, falls
at home suffering L femur Fx

Undergoes ORIF with post op
delerium, dysphagia, renal failure.

Aspirates, intubated difficult to wean

Attentive daughter
Case continued

Day #14 – many doctors talk to
daughter
Nephrologist: making more urine but
probably will need dialysis long term
Intensivist: able to turn O2 down to 50%
Gastroenterologist: plan for a PEG will
never eat regular
Internist – not doing well
Case manager – doctor ordered hospice
Daughter calls PCP to complain
Objectives . . .

Know why defining goals fo care is
important

Understand a 7-step protocol for
delivering bad news

Communicate uncertainty and conflict

Adjust care to changing goals
Importance of Goals of
Care
Most people want to Know if facing a
serious illness
Strengthens the physician- patient
relationship
Fosters collaboration
Establishes an appropriate allocation of
resources
Permits patients, families to plan, cope
Potential goals of care

Cure of disease

Relief of suffering

Avoidance of
premature death

Quality of life

Staying in control

A good death

Support for
families and loved
ones


Maintenance or
improvement in
function
Prolongation of life
Osteopathic Tenet
THE WHOLE PERSON
BODY
MIND
SPIRIT
Multiple goals of care

Multiple goals often apply
simultaneously

Goals are often contradictory

Certain goals may take priority over
others
Patient Centered Care

Goals of Patient - initial assessment

May Vary over time - ongoing
assessment
curative  palliative
self  family
physical  spiritual
integrated  focused
Goals may change

Osteopathic Principles make very clear
the distinction of caring for disease and
caring for the patient who has disease

Some goals take precedence over others

The shift in focus of care
Requires the patient (Guardian) to understand
is gradual
is an expected part of the continuum of
medical care
7-step protocol to
communicate bad news . . .
1. Create the right setting
2. Determine what the patient and
family know
3. What do they want to Know
. . . 7-step protocol to
negotiate goals of care
4. Sharing the information
5. Respond with empathy
6. Make a plan and follow-through
7. Review and revise periodically, as
appropriate
1. Create the Right
Setting

Quiet - private space

Allot enough open ended time

Determine that the right people are
present
FAMILY CLERGY GUARDIAN OTHER
2. What Does the Patient
Know

Establish Patients Knowledge and
Understanding

Asses ability to comprehend

Correct misunderstanding

Reschedule if unprepared or
unresolvable conflict of info
3. How Much Does the
Patient Want to Know

Recognize patient preferences
May decline voluntarily
May designate someone to
communicate on his/her behalf
Consider Power of Attorney or
advanced directive – 5 wishes
3. How much does the
patient want to know?

People handle information differently
Capacity
Race
Ethnicity
Religion
Education
Socio economic
Age and developmental level
Cultural differences

Who gets the information?

How to talk about information?

Who makes decisions?

Ask the patient

Consider a family meeting
4. Sharing the Information

Say it then STOP
Avoid monologue- promote dialogue
Avoid Jargon and Euphemisms
Pause frequently
Validate understanding
Use Silence and Body Language

Don’t minimize severity

Implications of “I’m Sorry”
Language with unintended
consequences -Negative

Do you want us to do everything
possible?

Will you agree to discontinue care?

It’s time we talk about pulling back


I think we should stop aggressive
therapy
I’m going to make it so he won’t suffer
Language to describe
the goals of care positive . .

I want to seek the most comfort and
dignity possible until the day you die

We will concentrate on improving the
quality of your child’s remaining life

Let’s discuss your needs and wants
5. Respond with Empathy

Affective response
Tears anger sadness love anxiety relief

Cognitive response
Denial blame guilt disbelief fear loss
shame

Basic psychophysiologic response
Fight – Flight
5. Respond with Empathy

Listen Listen Listen

Encourage descriptions of Feelings

Use Non Verbal communication

Physician: Acknowledge Yurself
6. Planning and followup

Explore what their hopes
expectations and Fears are

Plan for Next Steps
Added tests, treatment/non treatment,
Care vs cure, referrals

Sources of Support for patient/family
Medical, spiritual, emotional, social,
legal
7. Review and Revise

Give Contact info / next appointment

Assess Safety

Assess informal and formal support

Be Prepared to repeat info at next
visit – it was not all heard

Goals Change with time and
progression of condition
Reviewing goals,
treatment priorities

Goals guide care – whose?

Assess priorities to develop initial
plan of care

Review with any change in
health status
advancing illness
setting of care
treatment preferences
Communicating
prognosis

Providers markedly over-estimate
prognosis
Either way raises fears and stresses

Helps patient / family cope, plan
increase access to hospice, other
services

Offer a range or average for life
expectancy
Truth-telling and
maintaining hope

False hope may deflect from other
important issues

True clinical skill to help find hope
for realistic goals
When Family Says:
“Don’t Tell”

Ask Family
Why not? What are you afraid I will say?
What are previous experiences?
Personal,religious, or cultural context?
Patient knows something - why this
conspiracy? Will it feed mistrust?

Talk To patient together

Legal Obligation to obtain consent to
treat or not treat (assuming capacity)
Determine specific
priorities

Based on Patient values,
preferences, clinical circumstances

Influenced by information from
physician(s), team members, Patient
and family
Clinical Jazz
Summary

Begin the conversation Early
Keep seven steps in mind

Understand the Goal of Care
Patient centered values and preferences

Seek permission to involve family and
others

Give Permission to react/accept/reject

Revise and renew
IATP
IT’s ABOUT
THE PATIENT