Hospitals teach being “conversation-ready” for end-of-life care

Health care organizations are employing and training specialists to carry out these critical discussions with patients and families.

By — Posted April 15, 2013

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Physicians and hospitals are broadening their efforts to help patients and families talk earlier about their preferences for end-of-life care. One of the newer initiatives is the Conversation Project, launched by a coalition of doctors, health care executives and others.

Earlier efforts such as Aging With Dignity's Five Wishes program have as their goal the creation of legally enforceable advance directives and designation of health care proxies. The Conversation Project focuses on providing patient- and family-focused educational materials to help in broaching these difficult discussions.

The project's website has received more than 100,000 visitors and more than 30,000 downloads of its “conversation starter kit.” The packet prompts patients with questions such as “What matters to me is …” and asks them to rate how much they would like to defer to their physicians' judgment or “have a say in every decision.”

The need for action is great. Less than half of severely or terminally ill patients have an advance directive, according to the Agency for Healthcare Research and Quality. Twelve percent of patients who have such a document got input from a physician in creating it, the agency said. About 30% of patients told the Pew Research Center in 2006 that they had a living will. But a February 2012 California HealthCare Foundation poll of nearly 1,700 adults found that only 8% had ever been asked by a doctor about end-of-life treatment wishes.

Ten health systems across the country have joined the Conversation Project since it launched in August 2012, pledging to be “conversation-ready” for patients and families by implementing systems to help prompt the talks and document expressed preferences.

One of the participating organizations is Care New England Health System, based in Providence, R.I. Although doctors, nurses and others at the system have sought for years to help patients and families with advance care planning, the approach has not been programmatic in scope, said Kate M. Lally, MD, director of palliative care at the 275-bed, CNE-owned Kent Hospital in Warwick, R.I.

“Being conversation-ready in a systematic way hasn't been done in terms of helping patients think through what they want, what's important to them, what they value as a person and how that would influence what they want at the end of life. It's more than just advance directives,” said Dr. Lally, hospice medical director at VNA of Care New England in Warwick.

A key to the system's approach is to delegate the advance care planning talks. Physicians often do not have time to engage in long discussions, especially if patients are at earlier stages in the disease process when they are exploring what to do should their illness worsen considerably. While doctors are on call to handle clinical queries, Kent Hospital employs a “conversations nurse” to handle end-of-life care talks. The hospital also is promoting the value of such discussions in local news media and through lectures to physicians, residents and other health professionals.

Doctors, nurses, chaplains, social workers and others can request consultations for patients and families who want to talk more about end-of-life care. Such consultations have doubled to about 80 a month since November 2012, Dr. Lally said. CNE joined the Conversation Project in September 2012.

Earlier talks on comfort care

A separate effort at Northwestern Memorial Hospital in Chicago is aimed at improving the quality and timing of goals of care discussions with seriously ill patients. The Communication and Palliative Care initiative, part of a health plan-funded project to reduce readmissions, was started in September 2011. About 100 health professionals at 22 Illinois hospitals have received training on how to talk with seriously ill patients about their conditions, the value of palliative care and how to decide whether to continue disease-directed treatment.

“The goal is to start and improve conversations about what's most important to people around their care much earlier in the process,” said Eytan Szmuilowicz, MD, director of the palliative care medicine section at Northwestern. “This is about developing the key skills that we believe clinicians should all feel more comfortable doing — engaging patients and families about what's most important about not only their care but about their lives, and trying to match what's most important to them with what we provide medically.”

The Northwestern training conferences are held twice a year, and Dr. Szmuilowicz and his colleagues are collecting data to document the program's effectiveness.

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Questions to start end-of-life care conversations

It can be difficult for patients of any age to talk about end-of-life care scenarios, whether with their doctors or loved ones. An initiative co-sponsored by the Institute for Healthcare Improvement provides questions that can get the discussion going.

  • When you think about the last phase of your life, what's most important to you? How would you like this last phase to be?
  • Do you have any particular concerns about your health? About the last phase of your life?
  • Who do you want — or not want — to be involved in your care? Who would you like to make decisions on your behalf if you're not able to? (This person is your health care proxy.)
  • Would you prefer to be actively involved in decisions about your care? Or would you rather have your doctors do what they think is best?
  • Are there any disagreements or family tensions that you're concerned about?
  • Are there circumstances that you would consider worse than death? (For example: long-term need of a breathing machine or feeding tube, or not being able to recognize your loved ones.)
  • Are there important milestones you'd like to meet if possible? (For example: the birth of your grandchild or your 80th birthday.)

Source: “Your Conversation Starter Kit,” The Conversation Project (link)

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External links

The Conversation Project (link)

Institute for Healthcare Improvement's “conversation ready” initiative (link)

Five Wishes, Aging with Dignity (link)

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