Richard Leiter, MD, MA, presents on patients with Covid-19 and how to communicate with their families and how to have difficult conversations.
Hi, My name is Richard Leader, and I am a palliative care physician and researcher at the Dana Farber Cancer Institute, Brigham Women's Hospital and Harvard Medical School. And today I'm gonna be talking about having serious, honest conversations with patients with Covid and their families. So I think now more than ever, empathic and clear communication with patients and families is absolutely critical. And even though I'm a palliative care physician and I've received specialist communication training, I think all clinicians can and should adopt evidence based skills that will not only help facilitate difficult conversations with patients and families, but also may ease. Uh, some of the patients and the families distress when they're having these conversations. So my objective today is to briefly review some of these key skills to better equip you for these emotionally laid in challenging conversations with patients with covid and indeed, their families. So just to start off, I think Covid presents some unique communication challenges for all of us. And I'll say that my experience is colored by my work as an embedded palliative care clinician in our hospitals. Covid I see you so dealing with some of the sickest of the sick patients throughout this pandemic. And I think for for many clinicians were unable these days to physically be with our patients in their and their families. You know, um, we're limiting. The number of clinicians were going into the room to preserve PPE. Um, even when we do go into the room, you know, many of our patients in the ICU are intubated and sedated, and families aren't able to visit. And so this leads to a number of challenges for us. I think first, when we're working over the phone, um, we lose the visual cues we rely on to gauge emotion and understanding. And I think what we found is we rely on these more than we ever thought that we did, because now we're realizing their absence. So So that's that's challenging for for all of us, just get the logistics and then sort of working through how to have these conversations over the phone, I think, also in the ICU. But across the hospital, families aren't able to see their loved ones, and so they can't actually see necessarily the gravity of the situation. They can't see what their loved one looks like when They're intubated and sedated, maybe prone and paralyzed. They can't have that regular sort of, in the moment, communication with the bedside nurse about what's going on. So we're all in a way operating. One of my colleagues talks about this operating in a vacuum, and it's far different than what we're used to. Also, the level of emotion is extremely high, so patients and their families read the news. They know what covid means both for individual patients and also for society. They're anxious, they're scared. And it's worth saying that we're anxious and scared to, um, so that adds the complexity of these conversations. Yeah, I think also that the nature of the patients getting hospitalized with covid is different than what we're used to seeing. You know many of these patients on all of them, but many of them have maybe some minor health issues hypertension, early chronic kidney disease, for example. But they're not necessarily people who have extensive experience with the medical system or hospitals. They and their families aren't used to having these tough conversations about about a serious illness, so it's all new to them. And what we're finding is that you know, Covid doesn't just affect individuals. It strikes whole families and communities often at the same time. So family members themselves are sick there and quarantined. There are isolated, all of which heightens the emotion of these conversations and makes them more difficult for us. I think it's also important to say that clinicians on the front lines are busier than we've ever been before. Our patient loads are up. We're running around. We're dealing with new, logistical, practical and clinical challenges. Communication with patients, families is a critical part of what we do, and it really can't be an afterthought. And at the same time we need to ensure that our conversations are not only effective but also efficient. And I think by using some key skills, we can ensure both. So before getting into the skills, I think it's important to sort of think about who are the patients who need these conversations. And, you know, all patients and their families need regular updates on on their care, and these should be delivered. Updates should be delivered clearly and and with empathy, I think then we also need to identify the patients who are at high risk. So who needs more in depth, serious illness for goals of care conversations on the patient side. So we thought a lot in our group about about triggers, what might trigger a palliative care consultation or might trigger a serious illness conversation here in the hospital. And so in the ICU, I can say we thought about triggers such as the severity of illness, using the things like the sofa score, um, and higher sofas course indicating the severity of higher severity of acute illness. Um, things like frailty. We thought about using either the frail scale or a very, very, uh, crude measures such as things like like age and again. This is not about how we're making decisions for these patients, but really just identifying who is in need of more, more in depth discussion. We also looked at things like duration of ICU admission or duration of intubation. If we're starting to think about harder conversations around prolonged mechanical ventilation where we go from here, what we've also found is that clinicians are developing good sense of who's sick. And so in working with ICU clinicians, one of the things I asked them regularly is, Who are you worried about, and we don't have data on this, But I suspect that that's actually a fairly sensitive marker for which patients need need conversations in the literature. They describe something. There's the surprise question, which we've asked of, um, oncologist, primary care clinicians, various other specialists. And the question is, would you be surprised if you're patient died within the next year? And if the answer is no to that question, that necessitates further conversations. And so, in some ways that there can be a similar question asked of clinicians in the hospital. Would you be surprised if you're patient? Got much sicker from Covid and died on on this admission? And that may be a useful trigger to have these conversations. So once we've identified who the patients are, we need to think a little bit about logistics and technology, and various hospitals are doing this thing in different ways, and it's important to know what the local landscape is. So what platforms are available? Is there a local telehealth platform or people using Zoom or Skype? Or now, with the HIPAA laws have kind of been relaxed a little bit in the setting of the pandemic things even like like facetime. So it's important to know what be what you're using in the hospital and get to know that platform a little bit, the ins and outs of mhm and then considerable logistics and infrastructure. So how are we communicating with families? Is it on the computer? Is so do we have the Web camps set up due? We have ipads where those ipads coming from. If we're going into the room with the iPad's who's bringing them in? Who's getting these things ready? All of these things are are challenges that we didn't necessarily anticipate. But we've had to figure out on the fly as we're setting up our first meeting. So I think the more planning that can be done around this d the better and easier these conversations will will be so moving on to the conversations. These are difficult. These are difficult conversations. And as I mentioned before, there's a high level of anxiety and fear. And so one of the things that we found is incredibly important is whoever is making the call is to start with a headline for the purpose of the call. So I'm calling with a regular update today and in those when we are calling with updates, they ease the family members anxiety some of our early conversations, family members. If we didn't start with that, we could tell they were waiting for us to deliver bad news, and we didn't necessarily have that bad news. But that's what they worried. The purpose of the call would be so to start with the clear headline about the purpose of the of the car, what we've heard from families is that some of them are traumatized, waiting for these phone calls to to happen. Every time the phone rings, they worry it will be bad. So whatever we can do to when it's appropriate to ease that anxiety, I think it will go a long way with families. I think it's also important to name the emotion and lead with it. One thing that I have found incredibly effective in starting my conversations is to say, right off the bat after my headline, I can't imagine how hard this must be for you with your mother so sick and you're unable to visit to get it out there and then we can talk about the emotion a little bit It's tricky because I've heard from our social workers to If we think about this as a trauma for families, there's only so much emotion that they can take in. At some point, we need to pivot to giving them the information, because it can be incredibly hard and and distressing for them to sit in that emotion for too long. At the same time, we need to acknowledge it. So what I recommend whenever possible is to partner with the psychosocial clinician partner with the social worker on on the case to help with these conversations because they're adding another layer and another expertise that we often don't have as the as the primary clinicians. So some strategies to manage emotions are things in the literature called nurse statements, and you are S E and that stands for name, understand, respect, support and Explorer. And I'll give examples of all five. So to name is to name the emotion that you're sensing from the patients. So this must be so scary or it seems like you're really worried. It sounds like you're frustrated. It's important to move the conversation forward. To acknowledge the emotion understand is to align with them, and we can never truly understand what they're going through. But we can make statements that show how much we care. So I can only imagine what you're going through. Help me understand what you've been going through respect. As next, it's clear how much you love your father and want the best for him. Families are feeling so disconnected from their loved ones in the hospital, and they do very much want the best for them. They want to be there, and we know that they're doing all they can, so it's important to acknowledge that support. We'll be here with you throughout all of this and finally explore. Tell me more about what you mean by that. When you say you want everything done, what does that mean to you? So those are nurse statements can be very, very helpful when the emotion at any point in a conversation, when you want to acknowledge the emotion and and work through that emotion. Another skill and this is particularly helpful for all of us, as were initially getting to know seriously ill patients with covid is pairing hope and worry. So we this is a key palliative care skill that we use all the time. And the idea is that we align with patients or families hopes and then also express or worry about what could happen. So I hope your dad gets better and I worry he could get sicker from this note that I said, I hope and I worry not, I hope, but I worry because both can be true. I do hope my patients get better, and I also worry about them. And that juxtaposition is important again. Headlines can be incredibly helpful too often, particularly in the setting, an uncertain disease. We can get trapped talking about technicalities. Where are the ventilator settings today? What have the lab's been doing and what that allows us to do? It feels more comfortable because we can talk about small improvements or small declines, but it prevents us from talking about the big picture and what families really want to know. At the heart of this is what is the big picture? What is the forest here? They're somewhere interested in the trees, but they really don't want to know about the forest. And so to do that, start with that. You can use a headline I'm worried that your mother may not recover from this is a headline. I am worried she may be dying. If you're worried someone's dying, that can be your headline. And as you leave a headline, as you say, state a headline like that Leave space pause. This is bad news. Take time to acknowledge it. Here's where you can deploy the nurse statements that that I talked about earlier. Uh huh, other key skills, what we call mapping values and a lot of what I'm drawing on here are from the vital talk framework. So vital talk isn't as an American based national nonprofit focused on teaching communication skills for serious illness. Um, and they've created some conversation guides for covid as well, which I highly recommend. So mapping values. So after you've shared the bad news, if your father could be here right now with us, what would he say? What would be most important to him? What were the abilities that you think he couldn't live without really important to get a sense of who the patient is? Because that's what we're gonna do is we're gonna use that along with our medical knowledge, to make recommendations So we've we've given the headline. We've mapped that as we supported their emotion. It's important to make it the end, make it make a recommendation when we have it. So based on what you've told me, it sounds like your father really values is independence and his ability to communicate. I wonder if I could talk, we could talk about my recommendations for how we might move forward and then assuming you get that permission, which most of the time people give because they do want to hear from us. You can say I recommend we continue to do what we're doing now to support your father through this. If his hardware to stop, I'd recommend we protect him from things like CPR, because if that were to happen, it wouldn't get him doing things like CPR wouldn't get him back to that independence that he value. Notice how I'm making a clinical recommendation, but very much rooting it in the patient's goals and values as I understand them from from the family. So making recommendations that align with those values. It's a critical skill throughout all of these conversations. There are many other skills. I think these are some of the key ones, I would encourage you. There are many resources that have been developed, uh, for serious illness, conversations and palliative care in general. In the setting of Covid, our group has created an app called Talackova dot app um, which is incredibly helpful in a repository of symptom management guides and communication tools. Brigham and Women's Hospital has created covid protocols dot org, which is sort of a living encyclopedia of all things covid. Not only palliative care, but there is a palliative care chapter there in a communication chapter. And there you can find links to conversation videos that we've created for how to have these conversations across a variety of settings in the emergency department on the floors, different conversations in the ice used to see these models with trained communicators and also patient actors. As I mentioned before, The vital talk communication guides, which can be found on their website, are incredibly helpful as well, with some very helpful pneumonic for how to have these conversations and then other groups as well. The Serious Illness Conversation program at Ariake Labs that develop some tools, the conversation project all are incredibly valuable resources for how to have these conversations in these challenging times. So my take one point from this would be These conversations are important. They're difficult. But if we if we rely on evidence based fundamental communication skills acknowledging emotions, mapping patients, goals and values, and making concordant recommendations, these conversations will be somewhat easier for us and less distressing for patients or for their families. Thank you very much.