MAKING DIFFICULT
CONVERSATIONS
EASIER:
THE CARDS, THE KIT,
AND THE QUILL
Dr. Eric Fairbank, Director of Palliative Care
South West Healthcare, Warrnambool
Difficult conversations
Communication is a vital skill for health
professionals offering end of life care.
But…
We continue to pretend that our lives will
never end! Don’t mention dying!
Who is going to start the conversation?
We tend to wait for the ‘right’ moment.
The Rose
“it’s the one who won’t be taken
that cannot seem to give,
and the soul afraid of dying
that never learns to live.”
The Clear Moment of Death
“ the only thing that scares me about the
moment of death is that I may come to it
unprepared”
Ian Gawler.
The scene…
 Physical
deterioration, symptoms
 Tired, weak
 Sense of being a burden
 Cheated, frustrated, sad
 Powerless, helpless
How to respond…
“We do not fail if we do not cure, but we do
fail, if in our attempts to cure, we cause
our patients to sacrifice their healing
journey”
Dr. Michael Barbato
Palliative Care Physician
NSW
Australia
Health Promoting Palliative Care
 Bring
your attention, genuine interest, and
compassion
 Develop courageous therapeutic
relationships
 Provide effective strategies, a sense of
control and dignity, encourage hope,
peace of mind
 Improve community resilience
The cards, the kit, and the quill.
 GoWish
cards
 Palliative
Care: The ‘Doing-it-in-Style’ Kit
 Advance
Care Planning
Would you like a game of cards?
 Easy
to learn
 Even entertaining
 Statements on the cards could be
important to you, if you were seriously ill
 How do you want to be treated?
 Who do you want around?
 What matters?
GoWish Solitaire




35 cards, and a wild card. Read the
statements on the cards, and sort them into 3
piles:
very important
somewhat important
not important
Choose the top 10
The wild card is for something that is important
that isn’t on the other cards
Discuss your choices
GoWish Pairs
 Play
with the person who might become
your MEPOA
 Play together, or separately
 Compare the cards,
 Discuss the differences
www.codaalliance.org
Palliative Care:
The ‘Doing-it-in-Style’ Kit
1.
2.
3.
4.
5.
10 steps to take…
Understand as much as you can about your
illness, and what to expect later.
Be organised
Complete an Advance Care Plan
Make opportunities to resolve ‘unfinished
business’
Live as well as you can
(Wellness Wheels)
Palliative Care:
The ‘Doing-it-in-Style’ Kit
6. Learn about meditation, and mindfulness
7. Record your story in a life review
8. Put legal and financial matters in order,
particularly a will
9. Perhaps give some thought to funeral
10. Make use of available resources
Things we could talk about…
Here is a list of things we could talk about.
You may have some suggestions as well.
Between us, we can decide the priorities.
The Glow Worm Poem
I wish I were a glow worm,
A glow worm’s never glum,
It’s hard to be unhappy,
When the sun shines out your bum!
Things you could read about
Palliative Care Victoria
‘About…’ series
pain , fatigue, nausea and vomiting,
the process of dying, what to do when
someone dies, etc.
Things you could look up
Palliative Care Knowledge Network
www.caresearch.com.au
Palliative Care Victoria
www.pallcarevic.asn.au
This is my life
 In
particular
important relationships
roles and achievements
passions, hobbies, interests, activities
decisions, turning points, ups & downs
things I have learned about life
things I would like to say
my hopes and dreams for my family
What will matter…
Michael Josephson
…..so much becomes irrelevant…
there is so much that won’t matter
What will matter is not your memories,
but the memories that live
in those who loved you…
Choose to live a life that will matter.
The Quill: Advance Care Planning
3 steps
1. Appoint someone to speak for you, if you
couldn’t speak for yourself.
2. Talk to your Medical Enduring Power of
Attorney (MEPOA)
3. Put it on paper.
The Medical Treatment Act Victoria
1988
 The
right to refuse medical treatment
 Agent, alternate agent – the power to
refuse
 The Refusal of Treatment Certificate
 Witnesses
 The issue of competency
Important medical points:
 CPR
(cardiopulmonary resuscitation) in
perspective…
 Life prolonging treatments…
 Palliative care treatments will always be
continued
 Food and water will be offered while this is
feasible.
The Emergency Plan
Cardiopulmonary Resuscitation (CPR)
If I have no pulse, and am not breathing:
Option A
Option B
(1)
(2)
Option C
(1)
(2)
Life prolonging treatments
May, or may not, be beneficial
High tech. or low tech.
A reasonable outcome?
Palliative Care always
Artificial hydration/ feeding
Nothing to prolong the dying phase
Life prolonging treatments…
A. I want the following life prolonging
treatments……………………………………
………………………………………………...
but only if the doctors expect a reasonable
outcome. To me, a reasonable outcome
means…………………………………….…
……………………………………………….
Life prolonging treatments
However if I become so seriously ill that
my doctors consider that my condition has
become irreversible and terminal, I want to
be allowed to die naturally with well
managed pain, in comfort, and with dignity.
I request that life prolonging treatments
that would only prolong my dying be
discontinued.
Life prolonging treatments
B. I do not want life prolonging treatments
at all. If they have been commenced I
request that they be discontinued. I want
to be allowed to die naturally with well
managed pain, in comfort, and with dignity.
Supplementary questions
 Is
there anything that would make you
more comfortable?
 Where would you be preferred to be cared
for if you become seriously ill?
 If it would be helpful, are there any other
people…..to involve in discussions…?
 Please tell us about any personal, cultural,
religious or spiritual beliefs and practices
that you would like respected.
And remember…
“The most powerful therapeutic tool you’ll
ever have is your own personality”.
Dr. David Sackett
(father of evidence based medicine)
“Who you are matters more than what you
know”.
Dr. Rachel Remen
(Kitchen Table Wisdom)
Difficult conversations will be made
easier if you…
 Bring
your attention, genuine interest, and
compassion
 Develop courageous therapeutic
relationships
 Provide effective strategies, a sense of
control and dignity, encourage hope, and
peace of mind – using the cards, the kit,
and the quill !