IDT Can Score Big With Communication in the Playbook

Abstract

PHOENIX — Addressing end-of-life issues with patients and families is never easy for physicians. However, they have a whole team of professionals who can offer support and assistance and make end-of-life planning more effective and less stressful for everyone. At the AMDA — the Society for Post-Acute and Long-Term Care Medicine’s Annual Conference, a session on the effective use of interdisciplinary team (IDT) communications in end-of-life care gave audience members an opportunity to share their experiences and insights on this topic. “The interdisciplinary team approach to end-of-life care is based on an understanding and respect for the variety of roles and functions of the interdisciplinary team and the ethical dimensions of care embodied in cross-cultural communications,” said Jeffrey Nichols, MD, CMD, chief medical officer for Gouverneur Skilled Nursing in New York and president of the New York Medical Directors Association. “This includes a sensitivity to low health literacy and the successful engagement with families, the goal of which is to develop consensus that both maximizes family satisfaction and team performance,” he said. “We want to have conversations about significant issues around end of life.” The presenters offered two key case studies to demonstrate ways that participants can offer their insights into the challenges related to hospice and end-of-life care. The first case involved an incontinent, bedbound 78-year-old woman on hospice with end-stage dementia. She lives with her son, who has been her primary caregiver for several years. He speaks some English, but it is not his or his mother’s native language. The son promised his mother he would never put her in a nursing home, but he often has to leave her alone at home, including several afternoons a week when he goes to work and runs errands. Nonetheless, he refuses to consider bringing in a home aide because of his culture, in which it would be inappropriate for a stranger to be alone with his mother. Some IDT members think is unsafe and inhumane for the ill, confused elderly woman to be left alone, and that the case should be reported to Adult Protective Services if he refuses to accept necessary support. Others argue that his mother likely shares her son’s cultural beliefs and would agree with his decisions. Members of the audience suggested that, in such situations, it is important to communicate the team’s concerns in a way that the son can understand the risks to his loved one. For instance, it would be useful to help the son understand the implications of his mother’s incontinence and how it could result in rashes, skin irritation, and even pressure ulcers that would cause her extreme pain and potentially lead to life-threatening infections. Other attendees recommended that the team seek out other family members who possibly could reason with the son or help him care for his mother so that she doesn’t have to be alone. “This is where empathy comes in,” said presenter Neela Patel, MD, MPH, CMD, associate professor of Medicine at University of Texas Health Sciences, San Antonio, and medical director of the UT Medicine Senior Health Clinic and Acute Care for the Elderly and Palliative Care Program. “We believe that his intentions are good, and we want to try and work with him. We don’t know what relationship the son has with the hospice team. Maybe he doesn’t trust the team. If that is the case, we need to figure out how the team can earn his trust.” At the same time, Dr. Patel said it is important to consider the team’s needs and limitations. “We need to look at how we can help them best support the patient and family,” she said. Giving everyone involved an opportunity to express their feelings is key, said Dr. Patel. Patients and families are happiest in meetings where they have the opportunity to talk more. Nonetheless, she said, there are several common barriers to effective communication. These include cultural issues or differences, inexperience with death, and unrealistic expectations of the health care system. “You can’t come to a solution if you can’t identify and overcome these barriers,” she said. Dr. Patel offered several strategies for effective communication, such as recognizing that much interpersonal communication is non-verbal, and staying alert to body language and facial expressions. And although this kind of communication can provide a clue to the person’s feelings, this should not be used exclusively to reach conclusions. “Even experts misinterpret nonverbal cues up to 50% of the time,” Dr. Patel noted. To maximize input from patients and families, Dr. Patel said, ask open-ended questions that let them guide the conversation and express themselves fully. “We first must always be advocates in support of the patient’s voice,” Dr. Patel said. She described 10 ethical principles that should be observed in any conversation with patients and family: beneficence, non-maleficence, futility of treatment, confidentiality, autonomy and informed consent, physician-patient relationship, truth telling, justice, non-abandonment, and limited resources. The second case involved an 80-year-old male who had sustained several strokes that left him severely impaired both cognitively and functionally. He no longer can make his wishes or thoughts known, and he is on a feeding tube. His periods of alertness have shortened as his condition has declined. The man has several children, but his younger daughter is the only one who lives nearby and visits regularly. She believes that her father wouldn’t want to have his life prolonged in this condition and requests that his gastrostomy tube be removed and several medications discontinued. She wants only comfort feedings and medications. His eldest son, on the other hand, believes his father would want him to make the decisions; he wants to keep his father alive as long as possible with any medical, nutritional, hospital, or surgical intervention that might achieve that aim. To resolve this situation, the audience members said they would focus on what is best for the father. They would educate the son about the implications of life-prolonging interventions such as resuscitation, tube feedings, and hospitalizations. They stressed that it is important to respect the family’s culture and the son’s position in the family. Therefore, instead of focusing on getting him to change his mind, they recommended concentrating on educating him about his father’s condition, what wishes he has expressed in the past, the benefits and risks of various interventions, and how best to ensure his father’s comfort and dignity. “It is our obligation to act for the good of the patient and family whenever possible. Most people make decisions in the context of family and friends, and we need to respect and support that,” Dr. Nichols said. Senior contributing writer Joanne Kaldy is a freelance writer in Harrisburg, PA, and a communications consultant for the Society and other organizations. In communicating with patients and families, it is essential to consider their health literacy — the degree to which individuals have the capacity to obtain, process, and understand basic health information and services. Practitioners and others need to realize that others may not have the same education and language levels that they have. In fact, the National Assessment of Adult Literacy (NAAL) suggests that 36% of the U.S. population has a basic or below basic health literacy. According to NAAL, low health literacy is more common in Hispanic, black, Native American, and Alaskan Native populations, as well as among individuals 65 years old and older. A “teach-back” method, where the health care provider explains something to the patient or family member then has them repeat back what they understood, can help identify communication problems or disconnects. This isn’t a test of the person’s knowledge but an assessment of his or her understanding of what they were told. It can be less threatening to the patient for the provider to say something like, “I just want to be sure I did a good job of explaining it.” In addition, team members should be advised to avoid complicated language or descriptions, technical terms, medical jargon, and slang in their conversations with patients and family. They should speak clearly and use educational aids such as handouts, videos, or pictures when possible and appropriate. They should give people ample opportunity to ask questions and seek clarifications without feeling judged or diminished. —Joanne Kaldy