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Drs Simon and Dunne

Making Hard Conversations Easier: The Serious Illness Care Program

Edwin Ocran, PhD Candidate, Translational Medicine

The Department of Medicine was privileged to have Dr. Jessica Simon and Dr. Fiona Dunne, two seasoned palliative care physicians at the University of Calgary at last week’s grand rounds to share their experiences and insight on the value of serious illness conversations in clinical practice.
 

Dr. Dunne began the talk by stating that the Serious Illness Conversation Guide (SICG) is one of the most practical and practice changing tools that have been developed in medicine. The guide is at the center of the Serious Illness Care Program (SICP) developed by palliative care experts at Ariadne Labs and tested at the Dana-Farber Cancer Institute.[1]  Dr. Dunne stated that the program is designed to provide a clear path for making serious illness conversations easier. She discussed some of the major barriers to its adoption and implementation including time and competing priorities and patient and family preparedness. The initial step in having these conversations is identifying patients. Dr. Dunne mentioned that there are existing validated prognostication tools such as the Hospitalized-patient One-year Mortality Risk (HOMR) score, that can be used. As discussed, these goals of end of life conversations are important because they capture what patients truly want as patients may have other priorities besides living long such as improving family relationships.
 

Dr. Dunne also highlighted that the conversation guide allows for consistency, ensures that all tasks are covered, and provides patient-tested phraseology that gives the user a good lead-in. Additionally, it provides strategies for common scenarios such as managing intense emotions, as well as the “wish/worry/wonder” framework which makes conversations easier.  Dr. Dunne also mentioned that an initial challenge following these conversations was communication of patients’ goals. These goals are not always easily accessible by other facilities and paramedics in emergency situations. In Alberta, patients receive a Green Sleeve which serves as a “health care passport” that communicates their goals of care in various situations.  

 

Dr. Simon discussed the progress that has been made in integrating the SICP in acute care units across Canada, stating that the major challenge was the time and space for these conversations. Initial work on this project involved one on one engagement with stakeholders and embedding the program into the existing work-flow process in order to use the existing systems to the full.  Preliminary data from these programs suggest that high quality conversations are being had. Patients have expressed that these conversations are worthwhile, have increased their understanding of future health, and provided a sense of peace, hopefulness, and control. Overall, the programs have had positive feedback from patients as well as physicians and supporting staff. Dr. Simon pointed out however, that there were a few concerns about conversation durations. Although conversations typically take between 12 to 20 minutes, at least 30 minutes is set aside for each patient. She concluded by saying that the SICP is a simple process that is “good medicine”.
 

During our post round discussion, Drs. Simon and Dunne reemphasized the fact that ideally palliative care should start soon after the diagnoses of serious illnesses. Dr. Simon sighted the PaCES Project in Alberta which tries to provide early palliative care for patients with advanced colorectal cancer. She mentioned that the goal of these early discussions is illness comprehension, provision of support and letting patients know that it is okay to talk about their fears and worries. Drs. Simon and Dunne mentioned that the general perception and misconception in the lay media and the public is that these conversations are about hard choices when in fact they are discussions on what one wants to look forward to as they approach the end of life. As discussed, there is the need to rephrase existing terminologies and engage the lay public on these issues and social media is a valuable platform for this. Toward the end of our discussions, our speakers mentioned that “every day is ethics in palliative care” and stated that a controversial area that will need to be thoroughly debated in the near future is the concept of Medical Assistance in Dying (MAiD) in advanced care planning. 
 

Finally, Drs. Simon and Dunne shared their journeys into Palliative Medicine, which was relatively latter on in their medical careers. They encouraged us to work hard in our various areas of research and be open-minded about pursuing our interests.  It was a pleasure to have Dr. Simon and Dr. Dunne present at our Medical Grand Rounds discussion. On behalf of the Translational Medicine program, thank you for sharing your time and experiences with us.

 

References:

1            Bernacki R, Hutchings M, Vick J, Smith G, Paladino J, Lipsitz S, Gawande AA, Block SD. Development of the Serious Illness Care Program: A randomised controlled trial of a palliative care communication intervention. BMJ Open 2015; 5.

Related Links:

  1. Ariadne Labs- Serious Illness Care: https://www.ariadnelabs.org/areas-of-work/serious-illness-care/
  2. Green Sleeve: https://myhealth.alberta.ca/Alberta/Pages/advance-care-planning-green-sleeve.aspx
  3. (PaCES): Project https://cumming.ucalgary.ca/research/paces-project

 

Comments

Name
Madison

Mon, 02/03/2020 - 14:17

Excellent summary, Edwin! The SICG seems to be having a very positive effect on the communication skills of those physicians who frequently deal with serious illness or death (such as palliative care or oncology). I was thinking, and would be curious on others opinions on this, should the SICG be taught to all healthcare professionals? Or at least the principles and strategies of phraseology, using silence, listening etc. that Drs. Simon and Dunne mentioned be taught? Obviously not all healthcare workers deal with serious or life-threatening illness, but I think at least the basic principles mentioned during these rounds could apply to all healthcare professional as just a way to simply improve their communication skills with patients!

Name
Madison

I think you make a great point and I completely agree with you. I think it's incredibly important that all physicians be taught the SICG, not only to communicate to their patients about their need of palliative care and what's to come, but also to help the physicians build their empathy and communication skills. Like you mentioned, not all specialities deal with life-threatening illnesses but physicians still often deal with having to communicate serious and distressing diagnoses, whether life-threatening or not. I know for instance, patients with epilepsy, which is not always life-threatening, often don't handle their diagnoses well because they believe there's a stigma that comes with epilepsy. I believe in instances like these, having physicians that know the SICG, would be extremely beneficial because it might allow them to sit and listen to the concerns of the patient and help them this of strategies to handle this diagnosis.

Name
Spencer Finn

Great point Maddie. I know that as part of their education, health care professionals receive training on professional communication and cultural competency. They are taught basic principles the enable them to effectively communicate with patients in various settings and to manage sensitive conversations such as breaking bad news, which may sometimes have specific guides or protocols. I believe that with some exposure to the unique environment of palliative care and the SICG, health professionals will enhance key aspects of their communication skills and promote a more comprehensive patient-centered approach to care.

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Edwin Ocran

Name
Jessica

Mon, 02/03/2020 - 20:37

Thank you Edwin for your excellent summary of our rounds and visit with you. It's heartening to see our key messages captured in your report and that they resonated with you. I was so impressed by your colleagues in the translational medicine program and your insights. I do agree with Madison that there are communication skills taught within the serious illness care program that are broadly applicable within the practice of medicine. Fortunately both the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada do emphasize communication competencies in their training programs. A number of approaches are already routinely taught that go by the acronyms like "SPIKES" and "FIFE," along with others like "Dignity conserving care" and the "Calgary-Cambridge communication guide to the medical interview". These frameworks help clinicians share bad news, explore emotions or elicit concerns or obtain medical histories. The Serious Illness Care Program complements and builds on the communication skills acquired from these other approaches, by providing patient tested language and a sequence of questions that help clinicians elicit patients own priorities and concerns related to living with serious or life-limiting illnesses. We are now offering the training workshop to all family medicine and internal medicine trainees and I think if the evidence for the SICP in practice continues to show benefits it may well become a future routine part of medical training.

Name
Jessica

Name
Edwin Ocran

Tue, 02/04/2020 - 08:41

In reply to by Jessica Simon (not verified)

Thank you, Dr. Simon, for shedding more light on the communication competencies that pertain to the training of clinicians and the prospects for future trainees. Again, it was a pleasure to have Dr. Simon and Dr. Dunne present at our Medical Grand Rounds discussion.

Name
Edwin Ocran

Name
Joseph Nashed

Tue, 02/04/2020 - 10:46

Great Summary Edwin! I recently finished a the book "Range: why generalist triumph in a specialized world", and it got me thinking about Dr. Simon's and Dr. Dunne's varied careers before palliative care, and I couldn't help but think how much their career paths may have really been an asset in Palliative care. I like to think my heterogeneous background has been an asset in my career path, but maybe people have different opinions on this?

Name
Joseph Nashed

Thanks, Joe. I looked up the book briefly and it is indeed thought-provoking. I believe individuals with diverse backgrounds and experiences in different fields acquire a myriad of skills that are transferrable and applicable to various tasks and situations. Additionally, they have a broader perspective on issues. I think having a heterogeneous background is a great asset.

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Edwin Ocran

Hi Joe! You raise a great point about the value of having a variety of lived experiences. I firmly believe that the more varied the experiences you have, the more well-rounded of an individual you become and that will translate into your career as a clinician-scientist. I think we've seen this play out with most, if not all, of our Grand Rounds speakers. With Dr. Simon, as she described, her experience and expertise in the area of stroke translated into her palliative care career. With Dr. Dunne, her experiences in internal medicine inspired her to become a more well-rounded clinician and pursue palliative care training. Dr. Mark Swain, if you recall from weeks past, used his wet lab expertise to inspire a way to eliminate wait times in GI clinics. The more varied the experience, the more perspectives you can gain, and I think Dr. Simon and Dr. Dunne exemplify this greatly.
Thank you for the great summary Edwin and the great point Joe.

Name
Quentin Tsang

Name
Reem Alzafiri

Wed, 02/05/2020 - 11:31

This is a great post, Edwin! Our discussion with Drs. Simon and Dunne really helped me understand the importance of palliative care. By having more of these types of discussions on social platforms it will better educate people and address any misconceptions associated with receiving palliative care.

Name
Reem Alzafiri

Name
Daniel Rivera

Fri, 02/07/2020 - 15:15

Thank you for the summary, Edwin! I think this was a particularly valuable MGR in terms of being centred on topics that are, while rooted in palliative care, applicable across specialties. I particularly thought fondly of the idea of having these conversations as early as the time of diagnosis of a serious illness. I imagine this would help prepare patients in the case of terminal illnesses. I think, perhaps, there might be some reluctance to having such conversations early on as it can be difficult for both the clinician and the patients who may be more inclined to focus on potential treatments rather than preparation for the worst case. I believe the idea of incorporating this into medical education was brought up, however, was wondering what you think might be an effective way to help change this thinking, assuming it is somewhat prevalent, in both clinicians and patients today?

Name
Daniel Rivera

Good question Daniel. Indeed, around the time of diagnosis of a serious illness, both physicians and patients tend to focus more on possible life-saving treatments. However, as we discussed, the goal of these early discussions is to help patients have a better understanding of their illness, treatment options, and prognosis in order to make informed decisions. Additionally, patients are able to discuss their fears and worries in a safe environment, which in itself is therapeutic. Thus, early conversations are not necessarily about advanced care planning or discussions on "preparations for the worst". I believe that education is the key to changing the existing perceptions and misconceptions about serious illness conversations among health professionals as well as the general public.

Name
Edwin Ocran

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