Making Hard Conversations Easier: The Serious Illness Care Program

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| 3 February 2020

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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.

Making Hard Conversations Easier: The Serious Illness Care Program

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Making Hard Conversations Easier: The Serious Illness Care Program

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