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Communication and Decision Making  Near the End of Life Dalhousie Critical Care Lecture Series
Learning Objectives ,[object Object],[object Object],[object Object]
Dying in Canada:  Is it an Institutionalized, Technologically Supported Experience? Proportion of Hospital Deaths in 1997 Heyland Journal of Palliative Care 2000;16:S10
Proportion of Hospital Deaths in a ICU Dying in Canada:  Is it an Institutionalized, Technologically Supported Experience? Heyland Journal of Palliative Care 2000;16:S10
“ Welcome to God’s waiting room!”
What is Quality End of Life Care?
Quality of End of Life Care in Canada Results from Patient’s Perspective N= 440 Heyland CMAJ 2006;174:627 41.8  To have an adequate plan of care and services available to look after you at home upon discharge  41.8  To not be a physical or emotional burden on your family  43.9 To complete things and prepare for life’s end  44.1 That information about your disease be communicated to you in a honest manner 55.7 Not to be kept alive on life support when there is little hope for a meaningful recovery 55.8 To have trust and confidence in the Doctor looking after you % “Extremely Important ” Areas of Greatest “Importance”
Quality of End of Life Care in Canada Results from Family Member’s Perspective N= 160  Heyland CMAJ 2006;174:627 69.4  To have an adequate plan of care and services available to look after you at home upon discharge  68.1  That your family member not be kept alive on life supports when there is little hope of recovery  70.6  That information about your disease be communicated to you in a honest manner 70.6  That your family member has relief of physical symptoms  74.4 To have trust and confidence in the Doctor looking after you % “Extremely Important ” Areas of Greatest “Importance”
End of Life Decisions ,[object Object],[object Object],[object Object],[object Object],[object Object]
Importance of Communication ,[object Object],[object Object],[object Object],[object Object],[object Object]
End of Life Decisions ,[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],Clinical Indications for Discussion EOL Care: Urgent Indications  Quill JAMA :282;2502
[object Object],[object Object],[object Object],[object Object],Clinical Indications for Discussion EOL Care: Routine Indications  Quill JAMA :282;2502
Patient Provider Surrogate Characteristics Relationship, Attitude, Knowledge, Values, Preferences, Perceptions, Insurance, Wealth 1) Info exchange 2) Deliberation 3) Decisional Responsibility Characteristics Age, Race, Gender, Capacity, Willingness to Discuss Attitude, Knowledge, Values, Preferences, Perceptions Symptoms, Quality of Life,  Wealth, Insurance Characteristics Age, Gender, Profession, Years of Practice,  Attitude, Knowledge, Values , Preferences, Training, Communication Strategies ,[object Object],[object Object],[object Object],[object Object],Resuscitation or WLS? Conceptual Framework for End of Life Decisions “ consideration of patient preferences” an essential element of physician competence.  CanMEDS
Models Describing Patient- Physician Relationships Active Role Shared Passive Role Patient Decides Physician Decides
Decision Making During Serious Illness:  What role do patients really want to play?   ,[object Object],[object Object],[object Object],[object Object],[object Object],(Degner et al.)
[object Object],[object Object],[object Object],Decision Making During Serious Illness:  What role do patients really want to play?
Patient Population (n=440) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Decision Making During Serious Illness:  What role do patients really want to play?
Patient Preferences for Decisional Responsibility Per cent Heyland Chest 2006
Who Would You Like to be Involved? Per cent Heyland Chest 2006 (in press)
Substitute Decision Makers’ Preferences  for Decisional Responsibility  Per cent n=789 Heyland Int Care Med 2003;29:75
Information Most Important to Patients Facing a Life-threatening Illness ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Heyland Chest 2006
ME Let Decide What do  you want us to do? US Let Decide
End-of-life discussions should not be like a fast food restaurant menu
Case Presentation  ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Principles of Communication  Around EOL issues ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Principles of Communication  Around EOL issues ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Principles of Communication  Around EOL issues ,[object Object],[object Object],[object Object],[object Object],[object Object]
EoL Communication ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],The Set
[object Object],[object Object],[object Object],[object Object],[object Object],EoL Communication The Set
[object Object],[object Object],[object Object],[object Object],[object Object],EoL Communication The Body
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],EoL Communication The Body
[object Object],[object Object],EoL Communication The Body
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Making the Decision   EOL Communication and Decision Making
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Developing the Plan Quill JAMA :282;2502
[object Object],[object Object],Developing the Plan
[object Object],[object Object],[object Object],EoL Communication The Body
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],EoL Communication The Closure
Language Problems ,[object Object],[object Object],[object Object],[object Object]
Substitute Decision Makers ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],^ LeClaire Chest 2005;128:1728
When Withdrawing Life Sustaining Technology ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Families Looking Back:  One year after discussion of withdrawal or withholding ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Abbott SCCM 2001;29:197
Family Satisfaction with family conferences about end of life care ,[object Object],[object Object],[object Object],[object Object],McDonagh Crit Care Med 2004;32:1484
Conclusions ,[object Object],[object Object],[object Object],[object Object]

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End Of Life Care

  • 1. Communication and Decision Making Near the End of Life Dalhousie Critical Care Lecture Series
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  • 3. Dying in Canada: Is it an Institutionalized, Technologically Supported Experience? Proportion of Hospital Deaths in 1997 Heyland Journal of Palliative Care 2000;16:S10
  • 4. Proportion of Hospital Deaths in a ICU Dying in Canada: Is it an Institutionalized, Technologically Supported Experience? Heyland Journal of Palliative Care 2000;16:S10
  • 5. “ Welcome to God’s waiting room!”
  • 6. What is Quality End of Life Care?
  • 7. Quality of End of Life Care in Canada Results from Patient’s Perspective N= 440 Heyland CMAJ 2006;174:627 41.8 To have an adequate plan of care and services available to look after you at home upon discharge 41.8 To not be a physical or emotional burden on your family 43.9 To complete things and prepare for life’s end 44.1 That information about your disease be communicated to you in a honest manner 55.7 Not to be kept alive on life support when there is little hope for a meaningful recovery 55.8 To have trust and confidence in the Doctor looking after you % “Extremely Important ” Areas of Greatest “Importance”
  • 8. Quality of End of Life Care in Canada Results from Family Member’s Perspective N= 160 Heyland CMAJ 2006;174:627 69.4 To have an adequate plan of care and services available to look after you at home upon discharge 68.1 That your family member not be kept alive on life supports when there is little hope of recovery 70.6 That information about your disease be communicated to you in a honest manner 70.6 That your family member has relief of physical symptoms 74.4 To have trust and confidence in the Doctor looking after you % “Extremely Important ” Areas of Greatest “Importance”
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  • 15. Models Describing Patient- Physician Relationships Active Role Shared Passive Role Patient Decides Physician Decides
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  • 19. Patient Preferences for Decisional Responsibility Per cent Heyland Chest 2006
  • 20. Who Would You Like to be Involved? Per cent Heyland Chest 2006 (in press)
  • 21. Substitute Decision Makers’ Preferences for Decisional Responsibility Per cent n=789 Heyland Int Care Med 2003;29:75
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  • 23. ME Let Decide What do you want us to do? US Let Decide
  • 24. End-of-life discussions should not be like a fast food restaurant menu
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