1 Goals of Care Conversations – Part 3 Aligning with Patient Values FACILITATOR NOTES: Before the Training •Familiarize yourself with the content and flow of your session / run through your complete slide deck •Practice for timing and transitions •Have hand-outs ready for distribution •Have white board (or flip chart) and markers available •Test your access to the slides and video functionality in advance •Arrive at the room early When You Arrive •Watch the Time: Make sure you have a clock in your line of vision that displays time visibly •Arrange the room: If you have a large room and few attendees, ask people to move to the front •Keep in mind: •Speak up - make sure the whole room can hear •Look up - keep focus on the audience; not your notes Get Started •Introduce yourself •Base your introduction on the one you created and refined in the VA Facilitator preparation training •State the vision and purpose of this training initiative, and how this training relates •Tell a short (3-4 sentence) personal story about the challenges of discussing goals of care, what you’ve learned, and why this motivates you to train others Aligning With Patient Values Aligning Module • Serious Illness Communication Skills Training •Delivering Serious News • •Conducting Goals of Care Conversations •Part 1 - Reframing: We’re in a Different Place •Part 2 - Mapping the Future: Clarifying Priorities •Part 3 - Aligning with Patient Values •Part 4 - Discussing Life-Sustaining Treatments FACILITATOR NOTES: “Today’s session is the third in a series designed to teach the skills required to conduct a goals of care conversation with high-risk patients and their families. Today we will talking about how to align with the patient’s values and priorities for their care.” * Reframe * Expect emotion * Map out what’s important * Aligning with patient values * Plan treatment to match patient values • REMAP: Discussing Goals of Care FACILITATOR NOTES: Over the last two sessions, we’ve introduced you to REMAP, a talking map for discussing goals of care. At those sessions, we spoke about the first three steps, “Reframe,” “Expect Emotion,” and Map out what’s important. Today, we’re going to cover the last two steps, “Align with patient values,” and Plan treatment to match patient values * “Given where you are in your illness, it seems like a good time to talk about where to go from here” * * “We’re in a different place than we were [x] months ago” Review: Reframe FACILITATOR NOTES: Who remembers what reframing is? Can you give some examples? Facilitator should lead discussion of different kinds of statements that might work, and click through them: •“Given where you are in your illness, it seems like a good time to talk about where to go from here” •“We’re in a different place than we were [X] months ago” * “Are you sure we’ve tried everything?” * * “There has always been another treatment that’s worked!” * * “Are you saying we’re giving up?” Review: Expect Emotion FACILITATOR NOTES: •Practice responding to emotion with the group using these statements in a “Call and Response” format, where you say these things while looking directly at a learner and encourage them to respond. Once you get a response (good or bad) move on to another person and do the same. •An important teaching point to reinforce is the difference between cognitive and emotional data. When patients appear to be asking about information, they may be actually making an emotional statement, and they need an empathic response, not more facts. * “Given this situation, what’s most important?” * * “Knowing that time may be limited, are there things you want to do?” * * “As you think about the future, what are you worried about?” Review: Map Out What’s Important FACILITATOR NOTES: •Ask how participants might move the conversation forward after responding to emotion. Emphasize the need to ask permission to continue, and to “signpost” the next part of the conversation. •Then, ask them to suggest some “Mapping out” phrases. Review: How’s it Gone? üWhat’s worked? üWhat has been challenging? üHave you gotten stuck? FACILITATOR NOTES: •Lead a discussion about what the participants have put into practice since the last session. •“Thinking back over your clinical experiences since the last Module, have you had a chance to try these skills?” Ask: 1.What went well? (Explore this with participants – encourage them to tell the stories of how any of these tools have made conversations easier) 1.Where did they got stuck? (Explore the stuck places participants have encountered and help them deconstruct where the challenges lie. It will usually be about addressing the emotion, instead of the facts.) 2.What was most surprising? Stay positive! What We Will Learn üReframe üExpect emotion üMap out what’s important üAlign with patient values üPlan treatment to match values FACILITATOR NOTES: •Today, we’re going to talk about how to take the patient’s goals, and craft them into a treatment plan that is consistent with what they want. How We Will Learn üDefine skills (lecture) üObserve skills in action (videos) üPractice FACILITATOR NOTES: This session will take less than an hour. We will start with with an outline of the skills that we’ll learn. I’ll then show you some videos that give you examples of what these look like in action. However, learning communication is like learning to improve at a sport, or a musical instrument. You only get better with practice and we’ll have a chance to do that, in a very easy and not-scary way. * Repeating what patient has just told you is most important * Makes sure you’ve got it right, and the patient feels understood • * * * REMAP: Aligning with Patient Values FACILITATOR NOTES: Once you have mapped out what a patient/surrogate’s goals and values for treatment are – it is important to first align with those goals before making a recommendation. Clinician Patient Aligning with Patient Values (Example) “As I listen, it sounds like what’s most important to you is that you stay out of pain and spend more time with your family. It also sounds like you would not be willing to go through things that will cause you a lot of pain and suffering, like being on a breathing machine again. Does that sounds right?” “This has all been so hard and I’m tired. I’m really worried that the pain might get worse. I Know I don’t want to end up on a breathing machine like the last time I was in the hospital. I never want to go through that again. And I haven’t been able to really be with my husband and my kids. I’d like to get back to that – maybe go on a vacation, have fun together again.” FACILITATOR NOTES: Read the patient statement, then the clinician statement in response. Emphasize the need to pay attention to the many things the patient brings up. Also, note that the align statement uses simple language and repeats back much of what the patient said. * Ask permission to make a recommendation * Make a treatment recommendation that matches the patient’s goals and helps meet them –focus on what can be achieved –focus on what might be possible –discuss what you will not do because it will not meet the goal * After making recommendation, ask patient or family whether it feels right –Also, check in to make sure they understand the treatments you are recommending, and provide more information if needed REMAP: Plan Treatments that Match Values FACILITATOR NOTES: Stress here that it is the role of the doctor to give a recommendation – as long as it matches the patients stated goals/values. •“Would it be all right if I offered a recommendation?” •“Given what you’ve told me is most important, there’s a lot we can do to help. We’ll focus on keeping you out of pain. We can also get some services into your home to help you stay there and spend more quality time with your family. We’ll work toward that vacation, and have a better idea of how possible that is after we see how you feel on the new medication.” •“In addition to all the things I’ve mentioned we will do, I also recommend that we don’t consider further scans, blood draws, or pursue aggressive life-sustaining treatments like putting you on a ventilator, or if your heart stops, doing CPR, because at this point it won’t help you achieve your goals...” •“What do you think?” REMAP: Plan Treatments (example) FACILITATOR NOTES: Here is an example of how to make the recommendation for the patient whose values we aligned with. •“Would it be all right if I offered a recommendation?” •“Given what you’ve told me is most important, it sounds like you would want to pursue any treatment that would give you a chance of living longer, even if that means your life might be supported by machines. •“Does that sound right?” •“Is there any situation you can imagine when you wouldn’t want your life to be supported by machines?” REMAP: Plan Treatments (example) FACILITATOR NOTES: Here is an example of a recommendation when the patient’s goals clearly support aggressive treatment. * For medical trainees and some clinicians, it may not be possible to immediately formulate a plan * In these situations, map out goals and make an “acknowledge” statement with the patient * Inform your team of the patient’s goal * Return later with the recommendation REMAP: Separate Align from Plan FACILITATOR NOTES: This is a key learning point. Many residents and advance practice providers shouldn’t be making the recommendation without first discussing with their attending and team. Separating Align and Plan in time and space accomplishes this. Recommend a Plan that Aligns with Goals FACILITATOR NOTES: Set up the video carefully: •“Here is an example of a doctor making a recommendation that aligns with the patient’s values.” •“Pay close attention to the words used, and we’ll discuss what you saw at the end.” What specifically did the doctor do that you liked? FACILITATOR NOTES: After the video, turn to the audience and ask: •What did you see? Or… •What did the doctor say? Make sure that they catch all the things that happen here: •Doctor does not dismiss the idea of hope. •Doctor explores what is most important •Doctor stays positive and uses language of hope You may also want to ask: What was the effect of what the doctor said on the patient? Difficult questions “Does this mean you are giving up on me?” “Are you telling me I am going to die?” “Is there any hope?” “Absolutely not. But tell me, what do you mean by giving up?" “Hearing all of this must be really scary. I wish I could tell you something different.” “There is always hope. Tell me about what worries you.” Difficult Questions Clinician Patient Difficult Questions • FACILITATOR NOTES: Listed here are a few typical questions that stump clinicians. Read through the questions, and then ask the group if they have other “dreaded questions” Role-play responses to these with the group using the “Call and Response” technique Is there Any Hope? FACILITATOR NOTES: Set up the video carefully: •“Here is an example of a doctor responding to a patient that asks if there is any hope.” •“Pay close attention to the words used, and we’ll discuss what you saw at the end.” What Did You See? FACILITATOR NOTES: After the video, turn to the audience and ask: •What did you see? Or… •What did the doctor say? Make sure that they catch all the things that happen here: •Doctor does not dismiss the idea of hope •Doctor explores what is most important •Doctor stays positive and uses language of hope You may also want to ask: What was the effect of what the doctor said on the patient? Time to Practice!! FACILITATOR NOTES: Tell the group: “Now that you’ve heard and seen what these skills look like, let’s practice them” If this group has a lot of new learners that weren’t at one of the earlier sessions, then ask the group, “How do athletes or musicians practice?” Facilitate the responses, and then (if they haven’t gotten there on their own), talk about drills. Something like, “Even the world’s best athletes or musicians do drills every day. Basketball players practice shot after shot and pass after pass. Professional musicians play 30-60 minutes of scales every day – even though they know them by heart. Drills build and retain muscle memory, and also allow us to learn new things” We’re going to practice using the words we’ve been talking about, and we’re going to make it really easy for you by giving you exact words to say. It may seem easy, or even silly, but it’s just like a great basketball player practicing layups” (or choose another similar analogy that you’re comfortable with) Drill Instructions * Review drill as a group * Divide into pairs to practice the drill * Practice the drill script (person with bigger feet goes first) * Switch roles * Debrief with one another: –How did it feel to say the words? –One thing clinician noticed –One thing patient noticed – – – * Drill Instructions FACILITATOR NOTES: Walk the group through the drill instructions. At the end, ask if there are any questions and make sure there is complete clarity in the room about how to do this. Ask the group to divide into pairs. Read the first three drills out loud – or, better yet – have two learners in the audience read them out loud for you using the power point slides. Then, have the people that just demonstrated, switch roles and do the three drills again. Then, explain that after these two drills, you’ll debrief. Handout the drill sheets to the pairs and have them practice using the drill sheets. Clinician Patient Drill A: Align with Patient’s Values (scripted) I’m sure that’s scary. So, what I hear you saying is that you’re tired of coming to the hospital, but you need a way to deal with your shortness of breath at home. I’m really sick of coming into the hospital all the time, and I know this isn’t going to get any better, but I get really scared when I can’t breathe well. Exactly… FACILITATOR NOTES: These first three drills are for aligning with patient values. Read the drill out loud. Or, better yet, ask two people in the group to read it out loud for the group. “I don’t want to be in pain anymore. And I want to be able to spend more quality time with my family, not feeling so sick.” Improvise by aligning with what you heard… Drill A: Align with Patient’s Values (simple) Clinician Patient FACILITATOR NOTES: Have the two learners read this drill out loud as well. Let the person playing the clinician know they need to improvise their response – this allows them to practice aligning. The goal is that they essentially restate what they heard the patient say. Improvise by aligning with what you heard… “I’m scared. I want to live and I’m worried that I am not getting better. But I don’t want to prolong anything if it just means being stuck on machines or being dependent on my kids. And I don’t want my kids to have to deal with any of these decisions.” Drill A: Align with Patient’s Values (more complex) Clinician Patient FACILITATOR NOTES: Have the two learners read this drill out loud as well. Let the person playing the clinician know they need to improvise their response – this allows them to practice aligning. The goal is that they essentially restate what they heard the patient say. Drill Instructions: Swap Roles Clinician Patient Drill Instructions: Swap Roles • FACILITATOR NOTES: Ask them to switch roles and show again. When done demonstrating the drill, go back to slide 23 (drill instructions) and ask everyone to do the three drills in their groups of two. Walk around the room and observe how they are doing, and when it looks like everyone has completed both drills, call for the switch. – * How did it feel to say the words? * Drill: Debrief Drill: Debrief Drill: Debrief FACILITATOR NOTES: Ask each of the dyads to answer this question just to each other. Give them 1-2 minutes to run through this exercise. Yes, that’s what I want. It sounds like things will be a lot better that way. Based on what you’re saying, it sounds like we should focus more on your symptoms and keeping you home with your family. And, stopping admitting you to the hospital for every chest pain will make it easier to do that. How does that sound? Drill B: Plan Patient Clinician FACILITATOR NOTES: Now demonstrate the next drill by reading it out loud, or having two learners read it out loud. Yes, it’s so hard, but I think it’s what I would want. Based on what you’re saying, it sounds like if you get a lot sicker, it would not make sense to put you on a ventilator, or if your heart stops, to do CPR. I worry if that happens, you will likely not get off the machines, and even if you do, you would be a lot more dependent. That sounds like what you wanted to avoid. Drill B: Plan Patient Clinician FACILITATOR NOTES: Now demonstrate the next drill by reading it out loud, or having two learners read it out loud. Drill Instructions: Swap Roles Clinician Patient Drill Instructions: Swap Roles • FACILITATOR NOTES: Ask them to switch roles and show again. When done demonstrating the drill…..go back to the drill instructions slide and ask everyone to do the drill in their groups of two. Walk around the room and observe how they are doing, and when it looks like everyone has completed the drill, call for the switch. – * How did it feel to say the words? * One thing clinician noticed * One thing patient noticed * Drill: Debrief Drill: Debrief Drill: Debrief FACILITATOR NOTES: Then ask them to talk among themselves answering the three questions: 1.How did it feel to say the words? 2.One thing the clinician noticed 3.One thing the patient noticed Now lead a group discussion about their reactions to practicing these words. What surprised you? What do you want to take forward? Anywhere you might get stuck? FACILITATOR NOTES: This is the debrief where deeper learning takes place. Ask everyone to write about each of these questions for 1-2 minutes. Then, lead a group discussion asking people to volunteer something they wrote in response to one of these questions. * REMAP: a talking map for goals of care * Align with patient values * Plan treatment that matches these values –Check in with patient / family to get their reaction * What’s one thing you’re going to try this week? – – * Summary: REMAP FACILITATOR NOTES: Summarize very quickly and then ask everyone to write down on a piece of paper the one thing they’re going to try out this week, and keep that paper in their wallet/purse/pocket. Then thank the group, express appreciation for their willingness to practice and engage, and close the session. Goals of Care Conversations • •Goals of Care Conversations training materials were developed and made available for public use through U.S. Department of Veterans Affairs contracts with VitalTalk •[Orders VA777-14-P-0400 and VA777-16-C-0015]. • vital talk logo VA National Center for Ethics in Health Care