Critical conversations about end-of-life can be some of the most uncomfortable, emotionally-packed, family and patient interactions a medical provider can have. Many people avoid critical conversations because they are so discomforting but these types of interactions with family can be the best experience of their time in the hospital. It is a time to focus on honesty, compassion, care, facts, education and patient advocacy. These conversations should happen as an outpatient while everyone is healthy, before anything emergent happens. However, these conversations are frequently, and unfortunetly, left for the last moments of someone's life when the family and the patient are emotionally charged and afraid. Insurance does not pay practitioners in the outpatient facilities to have these conversations.
For every critical conversation there is a step-by-step process most proficiently developed that can help turn those emotionally charged and angry circumstances into powerful dialoge between the health care team and the family as described by the AACN within their book "Crucial Conversations: Tools for Talking When Stakes are High" (Patterson et al, 2011). The steps include addressing self first before entering those conversations but after you are prepared then it is time to speak to the family. Five main themes go as follows: Review the past, describe the present, present the future, offer the family their three options of treatment with reasoning and rationale, and last, support them during follow-up.
The family will need to be updated to the current conditon of the patient which should include the facts of what has happened. Address the present damage in relation to the past damage. The LIP should have obtained an EEG to determine brain wave function after being off all pain medications for 12 hours. Inorder to talk to the family you need facts that are going to help them in their decision. Feelings should also be addressed and acknowledged but not re-iterated to the point of becoming a road-block in the conversation. For an LIP, coming into a critical conversation with vague ideas based on past experience with other people and probabilities is not enough for the typical African-American social population due to history and their, previously well-founded, distrust of medical professionals. The family will need to be given a prognosis spoken in no uncertain terms with facts they can verify.
After reviewing what has happened, what is happening, and what will happen, comes the fourth piece most essential to address in this conversation: education. The three options typically presented to families are the Full Code with medical treatment, DNR/DNI with medical treatment and DNR/DNI with Hospice. Educate the family that DNR/DNI is not equivalent to Comfort Care or Hospice. Many people do not understand the difference between them. DNR/DNI is allowing someone to go naturally should their heart give out naturally or should they lungs stop while continuing to treat the medical conditions in the same manner as before. Comfort care is allowing someone to go naturally, changing the direction of our medical treatment because it is not helping the patient and it could be even hurting them. It is changing our focus to treat the patient for discomfort, agitation, pain, anxiety and nausea without sticking for blood or causing pain or agitation with other procedures because the patient is not going to be able to support their own life and we do not want them to be in pain during their last few hours or days.
If the critical conversation interdisciplinary meeting is effective then these following objectives will have been met:
1. A main family decision maker is identified as a spokesperson for the family by the family, before intiation of the critical conversation conference, even though all members of the family are enocuraged to attend.
2. The family's spokesperson is able to correctly verbally report two pieces of information and expresses understanding about the patient's current medical state.
3. The family's spokesperson is able to correctly verbally report and expresses understanding about the expected prognosis.
4. The family's spokesperson is able to correctly identify the three major options of care for the patient.
5. The family states, at the end of the conference, that they have had all questions answered and that they feel supported by the medical professionals.
6. The family's spokesperson will have within their posession contact information for the unit for further questions or clarification should they require any.
7. Family reaches a decision about their mother's care that they all can agree upon to be intiated at a time agreed upon by the family's spokesperson and the LIP.
Besides the Licensed Independent Practitioner, team members should include the primary nurse and the chaplain. Too many health care practitioners at the conference may be intimidating to the family. Typically, hospital chaplains have some education in end-of-life discussions and may be a huge benefit in talking to highly religiously minded families. No matter how many facts you give, rationales you supply, logic you use or emotional support you offer, the final decision for these families are typically based off of religious beliefs and if you can have a professional from that field then perhaps the conversation can continue, passing another possible roadblock. Scripting your words can be helpful for the LIP and can be easily adapted to different families. However, on occasion, silence is the best thing to say.
What have you encountered in your practice?