Amanda W Brown MD FAAP Assistant Professor of Pediatrics Supportive Care Program Childrens Hospital of Pittsburgh October 5 2018 Objectives Describe the AskTellAsk framework for giving serious news ID: 932415
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Having Difficult Conversations: Giving Serious News and Introducing Palliative and Hospice Care to Patients and Families
Amanda W. Brown, MD, FAAP
Assistant Professor of Pediatrics
Supportive Care Program
Children’s Hospital of Pittsburgh
October 5, 2018
Slide2Objectives
Describe the Ask-Tell-Ask framework for giving serious news
Name at least two examples of empathic statements using the NURSE mnemonic
Identify a strategy for introducing palliative and hospice care to patients and families
Slide3outline
Background
Giving the news: Ask-Tell-Ask
Responding to the news: Expect emotion
Talking to children about serious news
Introducing “our team”
Slide4Group introductions
Slide5Background
“Be brave enough to start a conversation that matters.”
-Margaret Wheatley
Slide6What is “Serious News”?
Serious news
“
is
any information which seriously and adversely affects one’s view of the future.
”
(
Buckman
)
“
results in a cognitive, behavioral, or
emotional deficit that persists for some time” (Ptacek et al.)“Serious news” vs “ bad news”: does it matter?Examples?
Buckman
, “ How to break bad news: A guide for health care professionals”, 1992
Ptacek
JT,
Eberhardt
TL. Breaking bad news: a review of the
literature.
JAMA. 1996
Slide7What we know about giving serious news
Giving serious news is hard
Parents/families don’t think we do it very well (
Contro
et al.)
Recipients of serious news hear less than half of what is said (Kuttner
)
Physicians express discomfort having these conversations (McCabe et al.)
We can get better at it with training and practice
Contro
N, Larson J, Scofield S,
Sourkes
B, Cohen H. Family Perspectives on the Quality of Pediatric Palliative Care. Arch Pediatr Adolesc Med. 2002Kuttner, L. Talking with families when their
children
are dying. Medical Principles and Practice, 2007
McCabe M, Hunt E,
Serwint
J. Pediatric residents’ clinical and educational experiences with end-of-life care.
Pediatrics
, 2007
;
Slide8Why is this so hard to do?
Slide9Why is this so hard to do?
Hard to know exactly what words to say (fear of saying the wrong thing)
Fear of taking away a patient or family member’s hope
Time (distractions, etc.)
Lack of formal education/training
These are often emotion-laden conversations especially in pediatrics
Prognostication can be challenging (hard to predict the future)
Others?
Slide10Giving the news: Ask-Tell-ASK
“ The single biggest problem in communication is the illusion that it has taken place.”
-George Bernard Shaw
Slide11REMAP: A Communication Framework
R
eframe why the status quo isn’t working.
ASK- TELL- ASK
E
xpect emotion and empathize.
NURSE
M
ap the future
A
lign with the patient’s values.
P
lan medical treatments that match patient values.Our focus today
http://vitaltalk.org/guides/transitionsgoals-of-care/
Slide12Giving the news:ASK-TELL-ASK
ASK:
“ What have the doctors been saying about….?”
“ What do you already know about what is happening…?”
“Is now a good time to discuss….?”
“What do you want to know about….?”
“Some people like to know lots of details whereas other people want to know more about the big picture. What kind of person are you?”
Slide13Giving the news:ASK-tEll-ASK
TELL
Warning shot
Headlines are succinct descriptions of the big picture
Give the headline then stop!!!
Avoid jargon
If there is a lot of news to discuss, give in small pieces
Slide14Giving the news: ASK-
tEll
-ASK
Scenario #1:
Rebecca is a 2 week old former FT infant who presented to the PICU with altered mental status and on further evaluation was found to be a victim of NAT. She is currently intubated and makes no spontaneous respiratory effort on the ventilator. Her neurologic exam reveals no evidence of purposeful movements and she is currently off of all sedation. Her brain imaging reveals significant injury consistent with hypoxic ischemic encephalopathy.
Slide15Giving the news: ASK-tEll-ASK
Scenario #1: Example Headline
Rebecca has unfortunately suffered a significant brain injury to the thinking/feeling part of her brain. We are
worried
that she will not be able to talk, walk, eat, or breathe on her own.
GIVE NEWS AND STOP TALKING……
Slide16Giving the news: ASK-tEll-ASK
Scenario #2:
Marcus is a 7 year old boy with a history of diffuse intrinsic pontine glioma which has progressed despite multiple rounds of therapy. He is currently admitted to the oncology service after he developed new neurologic deficits at home and unfortunately his repeat MRI now shows further progression of his disease.
Slide17Giving the news:ASK-tEll-ASK
Scenario #2: Example Headline
Unfortunately, Marcus’ scan shows his tumor is growing. His cancer is getting worse despite the treatment.
Slide18Giving the news: ASK-
tEll
-ASK
Let’s practice some of your own scenarios
Take a few minutes to think of a recent case you have had where you have had to give serious news
Think about what headline you would give and write it down
Slide19Giving the news: ask-Tell-ASk
Clarify the patient’s/family member’s understanding
“Sometimes as doctors we don’t explain things very well and I was wondering if you could tell me how you might tell your family members about what is going on so I make sure I explained it correctly.”
This is not always necessary but can be helpful to ensure on same page
Invite questions: “What questions do you have?”
Slide20ASK TELL ASK…
VITAL Talk Video (ASK-TELL-ASK)
Slide21Responding to the news: Expect emotion and Empathize
“At the end of the day people won’t remember what you said or did, they will remember how you made them feel.”
-Maya Angelou
Slide22Responding to the news: Expect Emotion and Empathize
After giving serious news, what is the typical patient response?
Emotion (sadness, anger, etc.)
Can be directed at the provider
May be followed by a question or statement
“How can this be happening?”
“Isn’t there something you can do?”
“You have to do something. You guys are supposed to be the experts!”
FM Radio: Emotional Data
AM Radio: Cognitive Data
Slide23Emotion and Cognition
Vital Talk Video
Slide24EMOTIONs AS data
Vital Talk Video
Slide25Responding to the news: Expect Emotion and Empathize
After giving serious news, what is the typical provider response?
Remember when they give you emotion, that means they heard the news so…..
Take a deep breath
Remember to STOP talking!
Respond to the emotion using NURSE statements
Slide26NURSE statements: Expect emotion and empathize
N
aming
“I can see this was really surprising news”.
“It sounds like you are frustrated”.
U
nderstanding
“I can’t imagine how hard this must be for you.”
R
especting
“ I can see how hard you have been advocating for your son.”
S
upporting“Our team is here to help you with this.”Exploring“Tell me more….”
Slide27Talking to children about serious news
“ The most important thing in communication is hearing what isn’t said.”
-Peter Drucker
Slide28Talking to Children about serious news
Children as young as 3 years can be aware of a terminal prognosis even without an adult telling them.
Avoidance can lead to:
Feelings of abandonment
Causes child to feel the need to protect the seemingly unknowing adult
We must encourage and help parents talk about this difficult subject
Levetown
, M.
Pediatrics
. 2008
Slide29Talking to Children about serious news
Remember ASK-TELL-ASK?
ASK:
What do you understand about what is going on right now?
TELL:
Sometimes we don’t have all the medications we need to make you better. I wish we did.
ASK:
What questions do you have for me? Can you say what we just talked about in your own words?
Slide30Talking to Children about serious news
Is talking about death harmful?
Kreicbergs
et al, NEJM 2004, Talking about death with children
(N=429 Bereaved Parents)
1/3 talked, 2/3 did not talk
No parents regretted talking
Decisional regret more likely in parents who sensed (47%) vs. did not sense (13%) that their child was aware of his or her imminent death
Slide31Talking to Children about serious News
Will it cause patients and families to give up hope?
Mack, et al.
JCO
. 2007
Universally parents want their physician to be honest while providing hope
Parents are more likely to feel hopeful when they recalled detailed prognostic discussions
Increased disclosure correlates with
Increased trust
Decreased emotional distress
Slide32Introducing Palliative and Hospice Care
Slide33Take Home points
When giving serious news, remember the reframe and ASK-TELL-ASK
ASK
: For permission to talk about the news and what they understand so far
TELL
: Give the headline and give news in small chunks
ASK
: Encourage questions and ask for clarification
After giving serious news,
STOP!!!!!
Remember your NURSE statements to help you respond to emotion
Slide34References
Buckman
, R. How to Break Bad News: A Guide for Health Care Professionals. 223 pp. Baltimore, Johns Hopkins University Press, 1992
Ptacek
JT,
Eberhardt
TL. Breaking bad news: A review of the literature.
JAMA
. 1996; 276 (6):496-502
Contro
N, Larson J, Scofield S,
Sourkes
B, Cohen H. Family Perspectives on the Quality of Pediatric Palliative Care. Arch Pediatr Adolesc Med. 2002; 156:14-19 Kuttner, L. Talking with families when their children are dying. Medical Principles and Practice, 2007; 16:16-20McCabe M, Hunt E, Serwint J. Pediatric residents’ clinical and educational experiences with end-of-life care. Pediatrics, 2007; 121: e731-737Back A, Arnold R,
Tulsky
J. Mastering Communication with Seriously Ill patients: Balancing Honesty with Empathy and Hope. 158 pp. New York, Cambridge University Press, 2009
www.vitaltalk.org
Slide35What questions do you have?