Palliative care motivational style?

Manuel Campíñez &Jesús Novo

Family physicians

Some communication needs in palliative and end of life care

Six functions of patient/family-clinician communication in cancer settings

Fostering healing relationships Exchanging information Responding to emotions Managing uncertainty Making decisions Enabling patient self-management

Changing the goals of careShare information Talking about prognosisTalking about death and dyingWithholding and withdrawing life-supporting

medical treatmentsDo no attempt resuscitation decisionsStopping palliative chemotherapyDealing with inappropriate treatment requests

Dealing with information needsdenialdisappointment (treatment unsuccessful)loss of hopedespair (when life´s not worth living)angercommunication problems within families

Vídeo de ambivalencia en la toma de morfina

Oncology

Doctor, do not tell my husband

that is cancer

Breaking collusion

Acknowledge the collusionand then explore and validate the reasons for it.Establish the emotional cost of the collusion.Ask permission to check what the patient knowsSeek the patient permission to convey his/her

awareness to their relatives

Maguire and Faulkner 1988

SPIKES protocol for breaking bad news

Setting up the interview: privacy, make connection,…

Assess patient’s Perception: ‘‘what have you been told about your medical situation so far?’’

Obtain the patient’s Invitation: ask how patient wants to get information

Give Knowledge and information to the patient

Address patient’s Emotions with empathetic responses

Strategy and SummaryBayle et al 2000

An exercise…with a palliative care situation

Small groups 5-7Few minutes 5-7

Make a summary

Summary

CASE 168 year-old man, hospitalized for locally extended bladder cancer. It has been rejected in the cancer evaluation committee to follow on chemotherapy and the patient was informed in this regard. Urologists requested transfer to palliative care. When the palliative care specialist meets the patient´s wife, out of the room, she tells him that the patient knows the diagnosis and has also been informed of the decision to stop chemotherapy , but she doesn't want him to be moved to the palliative care unit because "that means you are hopeless ."

Summary

CASE 2

48 year-old physician diagnosed with lung carcinoma 2 years ago. He has been treated with several lines of chemotherapy with partial and no durable responses, and at present is suffering from severe renal toxicity that compels to stop that treatment. He has been bedridden for several months and is dependent for most activities of daily living. He is hardly able to control the pain and that requires high doses of opioids. He hopes to continue with another line of chemotherapy because "you never know".

SummaryCASE 3

57 year-old patient diagnosed with amyotrophic lateral sclerosis, carrier of invasive home mechanical ventilation and gastrostomy tube feeding for 2 years. He always said that he wanted to go ahead as long as he maintains his ability to communicate and relate in some way with the environment. He only preserves ocular motility and very some weak movement in one arm, so that he communicates very poorly, and he does so with an adapted computer. His wife tells us that on numerous occasions, "when his arm responds " he has removed the vent pipe. He says "he wants to end ", to "withdraw this torture" and that "life does not make sense". However talks about plans for the future, is writing a book, has the upcoming wedding of a nephew who would like to attend and says that "his biggest problem is that his wife does not understand his suffering“.

Summary

CASE 4

Antonio, 93, no cognitive impairment, very advanced heart failure with severe dyspnea so from the last hospital admission needs help for any activity. He insists that he wants to die, that his life is lived, that he does not wants to live if he is dependent on others for everything and he does not want to return to hospital. His family agrees and you assure him that you will respect his wishes. Some days after he starts to notice a pain in epigastrium and he asks if you cannot do something to find the cause.

SummaryCASE 5

53 year-old woman suffering from breast cancer with bone metastases treated with palliative radiotherapy and chemotherapy. She suffers from important physical deterioration so spends most of the day in bed with pain, treated with high-dose of opioids. She knows her diagnosis and says that the end is near. She clearly does not want to have pain even if it means taking high doses "I know that I'll be sleeping all day but I don't care: I have arranged all my affairs." Three days later she calls because she has a lot of pain and she couldn't sleep all night; when you ask her, she confesses that she's taken fewer doses of painkillers because “I have slept all day and things cannot be that way”.

As the field of palliative care has matured, communication strategies have developed to guide common tasks…

These strategies do not directly address resistance or ambivalence— two common situations in palliative care consultations.

The MI philosophy and principles fit easily into palliative care.

Most of palliative care involves discussing patients’ values and priorities.

Not all the MI techniques are applicable, however, in part because palliative care clinicians do not guide patients to make particular choices but, instead, help patients make choices that are consistent with patient values

The illusion of choice

• Information about prognosis is not accurate• Choice is determined by system characteristics

and clinicians point of view• Many patients find other values more

important than autonomy• Patient express conflicting values• Decisions are a process with cognitive,

emotional and moral components

Ambivalence is very common in palliative care.

MI fits very well in palliative care communication

Communication is the brush bioethics are painted with

Is it always necessary to use MI in equipoise in palliative care?