Professional Documents
Culture Documents
Table of Contents
Getting Started
Technical Information ............................................................................ 2 Program Features and Functions ............................................................. 3 Navigation ........................................................................................... 4 Curriculum Synopsis ............................................................................. 5
Module I:
Appendix
Common Themes ................................................................................ 47 Using Multimedia to Enhance Physician-patient Communication at the End of Life .................................................... 48 Credits ............................................................................................... 50 Facilitator Survey ................................................................................ 51
Disclaimer
The case presented in Caring at the End of Life illustrates several difficult issues in health care at the end of life. All persons portrayed in this program are fictional portraits and are not representative of any one individual. The caregivers in this case are role-played by real physicians and nurses, who for educational purposes have intentionally modeled both medically appropriate and inappropriate behavior.
Getting Started
Technical Information
System Requirements and Settings
Windows 95 / 98 K 120 MHz Pentium PC K 16 MB RAM (32 MB recommended) K 4 speed CD-ROM drive (8 speed recommended) K High (16bit) or True (24bit) color display; will run poorly in 256 colors K Speakers and Sound Card K Designed for 640 x 480 screen resolution Macintosh System 8 or higher K 120 MHz PowerPC K 16 MB RAM (32MB recommended) K 4 speed CD-ROM drive (8 speed recommended) K Thousands (16bit) or Million (24bit) color display; will run poorly in 256 colors Also:
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Disable any screen saver when viewing program Turn off any CPU sleep function, or set it to a minimum of 15 minutes Unless you have speaker volume controls, set the system volume prior to viewing; no volume adjustment exists within program.
Getting Started
Program Features and Functions
This facilitators guide accompanies a curriculum consisting of four CD-ROM modules which illustrate and probe difficult topics facing health professionals in caring for patients at the end of life. Centered on the story of a woman with a life-threatening illness, each module introduces themes that raise strategy and management issues in end-of-life care. The program format is designed to engage you, to be clinically relevant, and to give new insight into the problems faced by providers and patients. Curriculum Modules The Caring at the End of Life curriculum contains four modules: Module I: Delivering Bad News Introduction Mrs. Nelsons Story Potential Pitfalls in Giving Bad News Patient-centered Decision Making References Module II: Advance Care Planning Introduction Mrs. Nelsons Story Themes References Module III: Informed Consent in the Emergency Department Introduction Mrs. Nelsons Story Themes References Module IV: Withdrawing Life-sustaining Treatment Introduction Mrs. Nelsons Story Themes References
Getting Started
Navigation
Main Menu Click on the MAIN MENU within each module to display the various sections available. You can turn the background music on or off by clicking on the MUSIC button, and you can also toggle between the MAIN MENU and the SITEMAP by clicking the SITEMAP button. To exit the program, click the QUIT button.
Sitemap Clicking the BULLET POINTS icon will take you directly to the summary screens for each of the themes within a module. The NARRATION icon will take you to a narrated introduction to each section or theme. The VIDEO icon brings you directly to the video portion of a section or theme. HOW TO USE provides general user information on select sections of the module. You can print out each theme by clicking on the individual PRINT icon or use the PRINT ALL button (only on the SITEMAP ) to get a printout of all module screens.
Navigating through the Module From the MAIN MENU, you can click on a section title to display that section. From the SITEMAP , you can view an entire section or theme by clicking on either its title or the NARRATION icon next to the title. To jump right to the video segment, click on the VIDEO icon next to the title. Click the theme BULLET POINTS icon to move directly to the summary screens for that theme. The QUIT button exits you from the program. Certain sections display a HOW TO USE icon that will provide you with general information on using that section.
Getting Started
Curriculum Synopsis
It is assumed that individuals using the Caring at the End of Life curriculum and the Facilitator Guide have previous knowledge of the content contained within the curriculum and have group facilitation experience. The Caring at the End of Life curriculum is designed to be used by both individuals and groups. This guide has been developed to assist those facilitating use with a group to become familiar with the content, format, and functionality of the program. An overview of the curriculum modules is provided below. Later chapters look at each module in detail, providing objectives, themes, discussion points, and suggested teaching strategies. Facilitators should familiarize themselves with the content prior to conducting a group session by reviewing the guide and previewing the modules. In addition, it is recommended that, before conducting a session, facilitators should observe or participate in a group discussion run by another facilitator. Module I: Delivering Bad News The first module introduces viewers to the story of Mrs. Edith Nelson, a 63-year-old patient who has just been diagnosed with Stage IV ovarian cancer discovered unexpectedly during an operation for a hiatal hernia. Her caregivers each face the tough situation of giving her the unfortunate news and raising treatment options. Each encounters potential pitfalls in delivering bad news, illustrating how dealing with the facts of an unexpected life-threatening illness are unavoidably linked with emotions and coping. Module II: Advance Care Planning During the second module, viewers join Mrs. Nelson and her primary care physician as they start to address advance care planning. They discuss living wills, identification of a health care proxy, and heroic measures. Module III: Informed Consent in the Emergency Department In Module III, severe abdominal pain sends Mrs. Nelson to the hospital emergency department where the discussions center around the potential benefits and risks of exploratory surgery. Mrs. Nelson is asked if she wants to suspend her Do Not Resuscitate (DNR) order for the purpose of surgery. The module concludes with Mrs. Nelson signing the informed consent form for the surgery. Module IV: Withdrawing Life-sustaining Treatment Following surgery, Mrs. Nelson is in the intensive care unit on a ventilator and diagnosed with recurrent cancer. This module includes the discussion of withdrawal of life-sustaining care and some conflict among the caregivers and family regarding the best course of action in this circumstance.
Learning Objectives
K K
Recognize that the manner in which the clinician delivers bad news influences how the patient frames the diagnosis and the prognosis. Recognize that personal communication skills can be enhanced and made more adequate.
Themes
Discovering a life-threatening illness and then delivering this information opens a new chapter in the clinician-patient relationship. This is evident whether the clinician is meeting the patient for the first time or beginning a more demanding relationship between acquainted individuals. Although learning about a serious diagnosis will be overwhelming for the patient regardless of the care that the physician uses in communicating the news, communication done well can reduce stress for both patients and Module I Themes clinicians. What the physician says, and the 1) Openings ..................................... 7 manner in which it is said, can have a lasting 2) Uncertainty .................................. 8 impact on patients. Delivering news about a patients status is as fundamental a part of medi- 3) Family ......................................... 9 cal care as the treatment prescribed for the illness. 4) Giving Advice ............................ 10 In many ways, clinicians can assist patients in 5) Personal Responsibility and Guilt . 11 coping and can shape the tone of future inter6) Nonverbal Communication .......... 12 actions, thereby potentially improving patient 7) Goals ......................................... 13 satisfaction and welfare. Mrs. Nelsons story is 8) Surprise ..................................... 14 broken into 10 themes, described below in terms 9) Taking Control ........................... 15 of the associated objectives and discussion points. 10) Leavings .................................... 16
Discussion Points 1. What techniques (e.g., pacing, repetition, paraphrasing) clarify or emphasize the difficult facts being given to her? How does the physicians use of technical language help or hinder Mrs. Nelsons understanding of her situation? 2. Was there anything about the dynamic of Mrs. Nelsons conversation with Dr. Adams that discouraged her from asking him the same questions she asked Dr. Bono? 3. Both Drs. Adams and Bono try to alleviate Mrs. Nelsons distress by offering reassurance. How does Dr. Bonos honesty promote or interfere with reassurance and hope? How does that compare with Dr. Adams approach? 4. How well does each physician listen to Mrs. Nelson? 5. By beginning with and reinforcing the information that Mrs. Nelson conveys, does Dr. Bono increase her understanding of her ovarian cancer?
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4. From what you have seen so far, what treatment options do you think Mrs. Nelson will consider? 5. If she stays with Dr. Bono, what treatment is he likely to recommend? 6. Should Mrs. Nelson review other options as well? 7. Consider how the initial discussion of treatment was presented and framed by the physicians. 8. Presently, standard treatment involves debulking surgery and combination chemotherapy with paclitaxel and a platinum agent such as cisplatin or carboplatin. Is this the best option for Mrs. Nelson? Why or why not? 9. What would lead you to persuade Mrs. Nelson to consider a clinical trial or alternative therapy?
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Discussion Points 1. How is the reality that clinicians must also efficiently manage a busy schedule and negotiate boundaries with patients illustrated in the leaving of each clinician? 2. What techniques do Drs. Bono and Sanders use to end the conversation in a timely fashion while not appearing abrupt or leaving Mrs. Nelson with a feeling of abandonment? 3. Was the information given tailored to meet Mrs. Nelsons immediate needs? 4. Sometimes patients have bottled-up concerns that for a variety of reasons are raised during the last minutes of a conversation. How do you think each clinician would have handled this with Mrs. Nelson? 5. What is the effect of Drs. Bono and Sanders making a point of saying when they will be back to talk with Mrs. Nelson again? Would it have been helpful if Dr. Adams had also done this? 6. How well does each clinician lay out a short-term plan so that Mrs. Nelson can know what to expect in the near future?
Distribute Module I to all group participants in advance of the session. Ask participants to view the introduction and the four video segments within the section Mrs. Nelsons Story. While viewing Mrs. Nelsons Story, ask participants to consider the following: l From Mrs. Nelsons perspective, how well did the caregivers function? l What went well? What went poorly? l Considering the overall strategy of delivering bad news, could the professionals have helped Mrs. Nelson by giving the news differently? When the group convenes, the facilitator can ask several open-ended questions aimed at initiating a whole-group discussion of the issues raised within Module I. Opening questions should strive to stimulate discussion and encourage continued exploration. Cast question nets out to see what they bring in. This type of exploration typically uncovers the specific considerations, issues, and concerns of importance to the group. These can become the major themes for closer, more detailed discussion. Examples of opening questions might include those listed above, and the following: l What happened in the story? l What do you make of what you viewed? l Can you identify any issues? Why is that issue of importance? l What would you have done differently? How? The group session is likely to center on the key themes presented in Module I. Whether the groups discussion naturally gravitates towards these, or whether the topic(s) are of particular relevance to them or the setting, the module themes can offer an effective approach to focusing discussion. Refer to the discussion points listed for each theme.
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Learning Objectives
K K
Emphasize the importance of advance care planning in caring for a patient. Examine the reasons why patients should be autonomous decision makers for their care.
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Themes
Advance care planning is complex, especially in the context of a life-threatening illness. In order to examine and understand the advantages and potential problems of this process, Module II is divided into the following seven themes, described below in terms of the associated objectives and discussion points.
Module II Themes
1) Structuring the Discussion .......... 19 2) Health Care Proxy and Advance Directives .................. 20 3) Framing with Hope .................... 21 4) Goals and Values ....................... 22 5) Supporting the Proxy .................. 23 6) Trust ........................................ 24 7) Listening and Responding ........... 25
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3. Mrs. Nelson spontaneously indicates her love for and desire to see her grandchild. Dr. Sanders embraces this value and indicates how the medical team can help preserve it. Discussion Points 1. Mrs. Nelson tells Dr. Sanders about some of the things that are important to her. How would you clarify these values further? 2. How would you connect these values with treatment preferences in the future? 3. Would it be helpful for Dr. Sanders to use Mrs. Nelsons example of her friend with ovarian cancer to find out more specifically what she would want or want to avoid? 4. Could Mrs. Nelsons desire to see her grandson grow up be used to find out how Mrs. Nelson would balance aggressive treatment versus comfort care? 5. What is the relative importance of these patient-oriented examples, versus asking about items like antibiotics, feeding tubes, or ventilators? 6. Some patients refuse to talk about the circumstances of dying or advance care planning in any direct way. This can be for cultural reasons or a fear of being manipulated to forgo expensive treatment options. To what extent can knowledge of such a patients personal goals or values play a role in treatment decisions if he or she becomes incapacitated?
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3. Dr. Sanders reaffirms her commitment to assisting Mr. Nelson and to helping Mrs. Nelson realize her values and goals. Discussion Points 1. What does this discussion do to foster Mrs. Nelsons trust? 2. To what extent does Mrs. Nelsons trust depend on Dr. Sanders? 3. To what extent does Mrs. Nelsons trust depend on a hospital or a system of care in which Dr. Sanders practices? 4. What can be done to ensure that Mrs. Nelsons advance care planning will be put into effect when necessary? 5. How does advance care planning impact resource allocation of physician time as well as health care resources? 6. How might the following contribute to Mrs. Nelsons trust?
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The honest acknowledgment by Dr. Sanders of the possibility of her not being there at the time. The importance of Dr. Sanders as a specific person, not just a doctor. The importance of other health care professionals being present. The existence of an information system that contains and transports Mrs. Nelsons proxy directives.
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Distribute Module II to all group participants in advance of the session. Ask participants to view the introduction and the video within the section Mrs. Nelsons Story. While viewing Mrs. Nelsons Story, ask participants to consider the following: l From Mrs. Nelsons perspective, how well did Dr. Sanders function? l What went well? What went poorly? l Considering the overall strategy of advance care planning, are there aspects that you would handle differently?
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When the group convenes, the facilitator can ask several open-ended questions aimed at initiating a whole-group discussion of the issues raised within Module II. Opening questions should strive to stimulate discussion and encourage continued exploration. Cast question nets out to see what they bring in. This type of exploration typically uncovers the specific considerations, issues, and concerns of importance to the group. These can become the major themes for closer, more detailed discussion. Examples of opening questions might include those listed above, and the following: l What happened in the story? l What is your impression of what you viewed? l Can you identify any issues? Why is that issue of importance? l As a professional, what would you have done differently? Why? The group session is likely to center on the key themes presented in Module II. Whether the groups discussion naturally gravitates towards these, or whether the topic(s) are of particular relevance to them or the setting, the module themes can offer an effective approach to focusing discussion. Refer to the discussion points listed for each theme.
Learning Objective
K
Emphasize that informed consent is a process that includes involving strategies for the support of the patient during decision making.
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Themes
In order to understand informed consent and strategies for supporting Mrs. Nelson during decision making, the story is divided into the following eight themes, described below in terms of the objective and discussion points associated with each. Note that the first two of the four video segments illustrating Theme 5 (nonverbal communication) are intentionally presented without sound.
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Discussion Points 1. Consider how each decision was made. Has there been an effective process in this situation? 2. What are Mrs. Nelsons reactions and indications of her level of understanding? Does she understand, know what to expect, and consent to the operation? 3. Does Mrs. Nelson really have a choice? 4. What harm might have occurred if Dr. Adams detailed other options? 5. Might the presentation of other options confuse or frighten Mrs. Nelson, resulting in delay? Would the consent process have been improved if other options had been discussed?
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Discussion Points 1. Does Dr. Adams way of describing possible adverse outcomes help Mrs. Nelson? 2. Would Mrs. Nelson have been helped or distressed by a longer list or more detail about possible adverse outcomes? 3. How does the balance between hope and honesty influence both Mrs. Nelsons expectations and her coping? 4. How are Mrs. Nelsons previous expectations likely to affect her ability to cope with the current situation?
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4. Mrs. Nelson expresses her anxiety and fear by rubbing her stomach and turning her head when Dr. Adams presents some of the awful possibilities. Discussion Points 1. What are some of the intentional and non-intentional ways that both Dr. Adams and Mrs. Nelson convey how they are thinking and feeling? 2. What is revealed in their use of eye contact, body position, hand gestures, facial expressions, and touching? 3. Would you expect the meaning or methods of nonverbal communication to change if there were other differences in race, culture, economic class, or gender? 4. Is Dr. Adams listening to Mrs. Nelson? How can you tell? 5. How well does Dr. Adams acknowledge and respond to Mrs. Nelsons concerns? What impact does this have on Mrs. Nelson?
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2. Mrs. Nelson is greatly distressed by the possibility of a poor prognosis. She wants some assurance that she will be able to maintain her sense of dignity and self-respect. The clip ends with a handshake. Discussion Points 1. What is the difference between a relationship built on a contract versus one built on trust? Are they mutually exclusive? 2. To what extent does Mrs. Nelsons trust depend on her relationship with her primary care physician, Dr. Sanders, and others participating in her care? 3. What can an emergency physician do to promote Mrs. Nelsons trust? 4. Given that in an emergency there is less time to deliberate and a presumption for prompt action, is there anything that Dr. Adams or the primary care physician could have done to prepare Mrs. Nelson? 5. How does the handshake compare with signing a form or documenting wishes in a record?
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Distribute Module III to all group participants in advance of the session. Ask participants to view the introduction and the video within the section Mrs. Nelsons Story. While viewing Mrs. Nelsons Story, ask participants to consider the following: l l l l From Mrs. Nelsons perspective, how well did Dr. Adams function? What went well? What went poorly? Notice how the conversation begins and ends. Reflect on how Mrs. Nelson and Dr. Adams make you feel.
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K
When the group convenes, the facilitator can ask several open-ended questions aimed at initiating a whole-group discussion of the issues raised within Module III. Opening questions should strive to stimulate discussion and encourage continued exploration. Cast question nets out to see what they bring in. This type of exploration typically uncovers the specific considerations, issues, and concerns of importance to the group. These can become the major themes for closer, more detailed discussion. Examples of opening questions might include those listed above, and the following: l What happened in the story? l What do you make of what you viewed? l Can you identify any issues? Why is that issue of importance? l As a professional, what would you have done differently? Why? How? The group session is likely to center on the key themes presented in Module III. Whether the groups discussion naturally gravitates towards these, or whether the topic(s) are of particular relevance to them or the setting, the module themes can offer an effective approach to focusing discussion. Refer to the discussion points listed for each theme.
Learning Objective
Investigate the difficult decisions and situations surrounding the withdrawal of life-sustaining care.
Themes
To compare and contrast segments of Mrs. Nelsons story, Module IVs eight themes are described below in terms of the objectives and discussion points associated with each.
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Module IV Themes
1) 2) 3) 4) 5) 6) 7) Understanding the Prognosis ....... 38 Deliberative Decision Making ..... 39 Respecting Wishes ..................... 40 Managing Conflict ..................... 41 Mistake or Complication? ........... 42 Defining Comfort ...................... 43 Discussing Withdrawal of Life-support......................... 44 8) Assisting Dying in the ICU ......... 45
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2. To what extent is Dr. Concepcions view influenced by her sense of responsibility? How much should her view or feelings matter in deciding what to do or tell the Nelsons? 3. Does Dr. White give the Nelsons enough detail so they can understand what happened? Would more detail have created even more confusion and distrust in the Nelsons? 4. Does the fact that Dr. Concepcion explained the risk of aspiration to Mrs. Nelson before the surgery make any difference in terms of liability? 5. Dr. White learns directly from Drs. Adams and Concepcion about the adverse event, the findings at surgery, and Mrs. Nelsons previous wishes. Are there any advantages to a direct conversation as opposed to reading notes in a hospital chart or an e-mail message? 6. Dr. White tells the Nelsons that the pneumonia was a complication and tells them that he is sorry. Is this a good strategy for addressing an unexpected adverse event? Is the use of the word sorry an apology or an expression of sympathy? What makes it one or the other in this situation?
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3. Dr. White describes exactly what will happen, addressing the familys worry that something drastic or brutal might happen. 4. Dr. White explains the process and why it takes place that way. Notice that the nurse is present. Consider the impact of her presence as a witness as well as a participant and caregiver. Discussion Points 1. In this situation, are Dr. Whites answers to Andrea Nelsons questions sufficient? 2. Would additional explanation have been helpful in addressing her concerns about her mothers experience during the withdrawal of the ventilator? 3. What makes the action of withdrawing life-support justified in this case? 4. If Dr. White had explained to Andrea Nelson that withdrawing the ventilator would have been a matter of justified killing, rather than allowing Mrs. Nelson to die, would she have found this helpful or harmful? 5. Is the distinction between killing and allowing to die a matter of semantics or accuracy? 6. By emphasizing the kindness and compassion of the medical action is Dr. White euphemizing the situation and making himself and others more comfortable with what happens? 7. To what extent should the caregivers be concerned about making the family feel comfortable with the events that are to take place? 8. To what extent is the concern for the family separable from the concern for the patient?
The role of religion is important, as Reverend McWalters reciting a prayer demonstrates. Patients often find comfort in having final religious services or rituals performed. The cardiac monitor demonstrates the transition in the loss of cardiac activity. Some practitioners prefer to turn the monitor off so that it doesnt interfere with the familys experience. Mrs. Nelsons nurse administers sedative medication immediately after the endotracheal tube is removed. Another approach involves allowing death by reducing the ventilation and inspired oxygen but leaving the endotracheal tube until after death occurs. For some survivors, physical contact between the family and the loved ones body after death may be very important. Others may find it too traumatic.
Learning Objective K Explore ways to manage the steps involved in assisting dying with dignity. Video Segments 1. Dr. White indicates that medication will be given to Mrs. Nelson. He makes a distinction between medication given preventatively to make sure there is no discomfort, versus medication that would have the direct purpose of shortening life to reduce discomfort. 2. The spiritual aspect of dying is dealt with here with direct involvement of the chaplain. 3. The EKG is normal. The patient is apneic. The nurse administers two doses of morphine to insure comfort. Mrs. Nelsons comfort is insured by the extra medication. 4. The EKG shows the physiological change from fibrillation to asystole. Andrea Nelson expresses her feelings and recognizes the absence of Mrs. Nelson as a person. Dr. White confirms the accuracy of the cardiogram by auscultating the chest. Discussion Points 1. How does this discussion about the purpose for the medication help? 2. How can administering sedative medication be distinguished from assisting suicide? 3. How important is the religious service likely to be for the Nelsons and/or the caregivers? 4. Why should the gesture of turning off the monitor matter? 5. What is the relation between the spiritual aspect of patient care and the technical or physical aspect of patient care? Does an emphasis on one necessarily impair the other? 6. What is the role or importance of physical contact between the Nelsons and Mrs. Nelsons body after her death? 7. Would it have been more meaningful for the Nelsons to be alone with Mrs. Nelson when she died? 8. Should the hospital or managed care organization caring for Mrs. Nelson have any responsibility for initiating grief counseling for the Nelsons?
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Distribute Module IV to all group participants in advance of the session. Ask participants to view the introduction and the five video segments within the section Mrs. Nelsons Story. While viewing Mrs. Nelsons Story, ask participants to consider the following: l From Mrs. Nelsons perspective, how well did the caregivers function? l From the perspective of Mrs. Nelsons family, how well did the caregivers function? l What went well? What went poorly? l Considering the overall strategy of withdrawing life-sustaining treatment, could the professionals have helped Mrs. Nelson and her family by doing anything differently? When the group convenes, the facilitator can ask several open-ended questions aimed at initiating a whole-group discussion of the issues raised within Module IV. Opening questions should strive to stimulate discussion and encourage continued exploration. Cast question nets out to see what they bring in. This type of exploration typically uncovers the specific considerations, issues, and concerns of importance to the group. These can become the major themes for closer, more detailed discussion. Examples of opening questions might include those listed above, and the following: l What happened in the story? l What do you make of what you viewed? How did it make you feel? l Can you identify any issues? Why is that issue of importance? l As a professional, what would you have done differently? Why? How? The group session is likely to center on the key themes presented in Module IV. Whether the groups discussion naturally gravitates towards these, or whether the topic(s) are of particular relevance to them or the setting, the module themes can offer an effective approach to focusing discussion. Refer to the discussion points listed for each theme.
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Appendix
Common Themes
Common themes are represented throughout the four modules. The table below lists the themes within each module (vertically) and how they relate to themes within the other modules (horizontally). A cross-module teaching strategy can be useful with groups seeking to drill-down on specific thematic aspects within the curriculum.
Module I
Delivering Bad News
Module II
Advance Care Planning
Module III
Module IV
Informed Consent in the Withdrawing LifeEmergency Department sustaining Treatmen t Uncertainty & Hope Framing Risks Understanding the Prognosis
Uncertainty
Nonverbal Communication Trust Pain & Suffering Managing Conflict Defining Comfort
Trust Goals Openings Taking Control Surprise Personal Responsibility and Guilt Leavings Goals & Values
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Structuring the Discussion Process vs. Event Proxy & Advance Directives Suspending DNR Respecting Wishes Mistake or Complication? Discussing Withdrawal of Life-support Assisting Dying in the ICU
Appendix
Using Multimedia To Enhance Physician-patient Communication at the End of Life
On medical rounds, Dr. Winter attends her patient, Adam Colman, who is terminally ill with pancreatic cancer. Mr. Colmans daughter approaches Dr. Winter and declares, I want you to do everything possible to treat my father. We have got to try everything. How does a clinician respond to a request for futile life-sustaining care? Communication between health care providers, patients, and their families is difficult at times of critical, life-threatening illness. Efforts to help professionals become competent, compassionate communicators in situations surrounding the end of life must cover more than just individual interactions between practitioners and patients. The process involves orchestrating a whole series of appropriate conversations, meetings, and discussions among all involved parties.
by Luke Sato, M.D., and Denise Bisaillon, Ed.D. Adapted from the September 1998 issue of Forum, published by Risk Management Foundation of the Harvard Medical Institutions.
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A Risk Management Challenge Inadequate communication among health care providers, and poor rapport between family and clinicians, can trigger malpractice claims. CRICO1 claims data reveal that, since 1986, 20 percent of CRICOs claims involved communication failure as a key risk management issue. Among the most formidable conversations are those that may involve end-oflife issues such as giving bad news, deciding when care is futile, and discussing the withdrawal of sustaining care. While only a few claims and suits directly involve end-of-life issues, they are some of the most costly CRICO cases. The 21 resuscitation-related cases since 1986 account for almost three percent of CRICOs total incurred costs during that period. The risk management challenges faced when dealing with clinician-patient communication are predominantly educational. How does one approach the vast area of communication as curriculum content? What is teachable? Can clinicians be taught to change the complex process of how they interact with others? For one answer to these questions, RMF looks to multimedia technology that offers a unique medium for exploring and presenting communication skills. A Powerful Educational Tool The term multimedia here refers to computer technology that incorporates sound, animation, and graphical and video data. Currently, the majority of multimedia software is delivered via CD-ROM, but its future is most likely on-line. Five key educational advantages of multimedia training for medical professionals are: 1) Multisensory Experience Multimedia conveys information or content in a more vivid (hence more memorable) manner than a traditional single-medium presentation. Since experience builds knowledge, the more varied the experience, the richer the knowledge imparted. Software applications that incorporate multimedia, although far from virtual reality and the real world, can convey a sense of presence and bring users closer to gaining personal knowledge through directed experience. The video medium can bring alive the context of an issue. Video can effectively convey non-textual/verbal information and movement that changes over time, such as the body language of a patient, or a physical finding such as a seizure disorder. Animation, while similar to video, allows the representation of imagery and motion that might otherwise be difficult to capture and present, such as illustrating surgical procedures. The use of sound elements to exemplify audio findings Continued
Appendix
Using Multimedia To Enhance Physician-patient Communication at the End of Life
(such as tone of voice or heart sounds) adds another realistic dimension to the information conveyed. Voiceover (sound narration) augmenting textual information provides a way of maintaining and amplifying learner focus and attention. In general, each of the multimedia elements has a relevant and appropriate use. The content to be taught helps inform and determine which elements to incorporate into the software application to best enhance the overall experience. 2) Interactivity As with any delivery method, pedagogy should be more important than the technology. Teaching that focuses on the interaction between the learner and his or her experience is more successful than passive learning. The multimedia approach encourages active participation in the learning experience by allowing the learner to physically interact with the content. 3) Exploration Multimedia provides an opportunity to manipulate the content and make new connections. The learner can explore from multiple perspectives, which is particularly suitable for the case method approach familiar to clinicians. For instance, through a multimedia program, the user can observe how each of several providers discusses treatment options with his or her patients. Multimedia can also make the abstract more concrete. It permits the learner to explore content that is difficult to teach by conventional methods, such as the notion of empathy. 4) Consistency Multimedia programs can ensure that the teaching points are consistent. Instructionally sound multimedia applications are designed around measurable objectives. Depending on the intent of the program, learners can be presented with feedback, self-check exercises, and mastery testing. The content and teaching points are presented in a consistent manner over time and remain available to the learner as a tool for future reference. 5) Flexible Delivery The format of a multimedia application can be tailored as a stand-alone, self-paced program where the learner simply navigates independently. It can also be designed to support group learning where facilitators lead discussions. Alternatively, a single well-designed program can be used in either setting. Management and Communication Strategies. With this application, learners can follow one or more clinicians talking about similar themes, including how to open the interaction (greeting the patient), how to leave, how to give advice, and how to talk about future plans. Appropriate video clips, designed to portray different styles of patient-clinician interactions, were identified and digitized into computer format. The program allows close analysis of these interactions by placing them side-by-side for comparison. Collaborative Harvard Medical Project In 1997, RMF expanded the program to assist clinicians in the Harvard medical community with their communication with patients and families involved in medical decision making. Caring at the End of Life: Management and Communication Strategies has been designed for physicians, nurses, medical students, and house staff. In addition, ethics committees, hospital administrators, risk managers, and in-house counsel may find it similarly helpful. I
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Appendix
Credits
Sponsor Risk Management Foundation of the Harvard Medical Institutions (RMF) Executive Producer Luke Sato, MD, RMF Director Lynn Peterson, MD, Brigham and Womens Hospital (BWH)
Harvard Medical School (HMS)
Executive Consultants Lynn Peterson, MD, BWH, HMS and Joshua Hauser, MD, BWH, HMS Performers
( in order of appearance) Mrs. Nelson (patient) Dr. Adams (surgeon) Ms. Humphrey (nurse) Dr. Bono (oncologist) Dr. Sanders (primary care) Mr. Nelson (patients husband) Dr. Concepcion (anesthesiologist) Ms. Grady (ICU nurse) Dr. White (intensivist) Andrea Nelson (patients daughter) Dr. Forrow (medical ethicist) Ms. Mitchell (medical ethicist) Rev. McWalter (chaplain) Gloria Kennedy Lynn Peterson, MD, BWH Diane Gilworth, RN, Harvard Vanguard James Ferrara, MD, Childrens Hospital Paula Johnson, MD, BWH Jack Kennedy Mercedes Concepcion, MD, BWH Bonnie Grady, RN, BWH Robert Truog, MD, Childrens Hospital Helena Pisetsky, MPH Lachlan Forrow, MD, Beth Israel Deaconess Medical Center (BIDMC) Christine Mitchell, RN, Childrens Hospital Janet McWalter, DMin, Mount Auburn Hospital
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Program Engineers/ Adam Bialek, Decision Systems Group, BWH, HMS Designers Tom Dicesare, Decision Systems Group, BWH, HMS
Kathleen Keefe, Decision Systems Group, BWH, HMS Michael Murie, Decision Systems Group, BWH, HMS Jeremy F. Price, Decision Systems Group, BWH, HMS
Multimedia Consultant / Trisha Vaccari, EdM Facilitators Guide Music Luke Sato, MD, RMF Executive Priscilla Dasse, RMF Editorial Advisor Project Manager Denise Bisaillon, EdD, RMF Communications Advisor Jock Hoffman, RMF Education Advisor Annette Bender, MPH, RMF Quality Assurance Jill Hubbard, RMF Graphics/Design Alison Anderson, RMF Artwork Clasped Hands Images 1999 PhotoDisc, Inc. RMF Advisory Board on Communication and Educational Strategies for the End of Life
Troyen Brennan, MD, JD, MPH, BWH Edwin Cassem, MD, MGH Ezekiel Emanuel, MD (co-chair), DFCI Lachlan Forrow, MD, BIDMC Gail Gazelle, MD, Harvard Pilgrim Health Care Christine Mitchell, RN, Childrens Hospital Lynn Peterson, MD (co-chair), BWH Russ Phillips, MD, BIDMC
Appendix
Facilitator Survey
This survey has been designed to gather feedback from facilitators across the Harvard system using the Caring at the End of Life CD-ROM and the accompanying Facilitators Guide. In order to improve and enhance future editions of these materials, please complete the tear-out survey below and return it to the address provided. Thank you in advance for your valuable feedback.
Name _________________________ Institution _________________________________ E-mail address _____________________________________________________________ Location of program ________________________________________________________ Number of participants ______________________________________________________ Participants specialties ______________________________________________________ Which module(s) did you use for the program? I II III IV
Describe briefly what you like about using the CD-ROM program, Caring at the End of Life: Management and Communication Strategies. __________________________________________________________________________ __________________________________________________________________________ Describe what you didnt like about using the program.
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What changes or additions would you suggest? __________________________________
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Please describe any other issues (e.g., technical problems, participants responses) related to presenting this program. ____________________________________________ __________________________________________________________________________ Please detach and return this survey to: Annette Bender, MPH by mail Risk Management Foundation 13th Floor 101 Main Street Cambridge, MA 02142
Thank You