During reviews of advance directives, physicians should note which preferences stay the same and which change. Preferences that change indicate that the physician needs to investigate the basis for the change. 5. Apply the patient’s desires to actual circumstances. Conflicts sometimes arise during discussions about end-of-life decision-making. If patients desire non-beneficial treatments or refused beneficial treatments, most physicians state that they would negotiate with them and try to educate and convince them to either forgo a non-beneficial treatment or to accept a beneficial treatment. 16 If the treatment was not harmful, expensive, or complicated, about one-third of physicians would allow the patient to receive a non-beneficial treatment. Physicians stated that they would also enlist the family’s help or seek a second opinion from another physician. Many patients do not lose their decision making capacity at the end of life. Physicians and family members can continue discussing treatment preferences with these patients as their condition changes. However, physicians and families may encounter the difficulty of knowing when an advance directive should become applicable for patients who are extremely sick and have lost their decision making capacity but are not necessarily dying. There is no easy answer to this dilemma. Even if patients require a decision for a situation that was not anticipated and addressed in their advance directive, physicians and surrogates still can make an educated determination based on the knowledge they have about the patients’ values, goals, and thresholds for treatment. Legalities of the Advance Directive & POLST: An advance directive in general is not a legally binding document. While a succinct advance directive can be a description of a patient’s wishes, the patient’s family is not legally bound to follow it in case of the patient’s incapacitation. A Physicians Orders for Life Sustaining Treatment (POLST) which has various names in various states, is in general designed as a legally binding series of medical orders that the patients primary healthcare provider puts in writing after discussion with the patient. This allows for the patient’s wishes to be more easily accepted by putting the wishes into a simple to read, standardized for the state form, that carries the weight of physician orders. Each state’s rules vary, however generally speaking the POLST can be amended by the signatory or other legally authorized individuals. If planning for a patient’s end of life wishes a POLST or similar document is likely a better choice than a typical advance directive. While data about the POLST is generally limited, and focused mostly on Oregon, it is suggested from the current data that there is likely benefit to using a structured form like the POLST. 109 The importance of shared decision making Effective patient-provider communication and shared decision making is achieved in part through active listening, facilitation, and empathetic comments . 17 These skills lead to an engaged, dynamic relationship between patients, their families, and health care
providers. This partnership should be grounded in mutuality, which includes the sharing of information, creation of consensus, and other components of the shared decision making paradigm. 18 Reflective listening An effective communication strategy in any patient- physician relationship is reflective listening . This means listening carefully and non-judgmentally to what your patient is saying, then reflecting it back in a slightly modified or re-framed manner. 19 This lets the clinician confirm the accuracy of their understanding of the patient and gives the patient both the indication that they are being heard (an all-too-rare experience for many patients with chronic illness) and a chance to correct mistaken beliefs or perceptions that could affect their care. Using a reflective listening strategy can take practice. If a patient says something at odds with the evidence, for example, or uses threatening or hostile language, one’s natural reaction is to immediately defend oneself, rebut the charges, or deny the underlying assumptions. This can quickly create confrontation or a power- struggle that can be difficult to reverse. In these situations it’s important to pause before speaking, and then to consciously try to simply re-state what the patient just said. For example, a patient may say, “Doctor, those pills you gave me don’t work—I told you before that I need something stronger.” A directly confrontational response will probably be ineffective. A better response would be something like “You seem to be irritated with me because you don’t think the medications I prescribed are working for you.” In summary, reflective listening techniques provide several advantages: 19 ● They are less likely to evoke or exacerbate patient defensiveness ● They encourage the patient to keep talking and reveal more about their true feelings ● They communicate respect and caring, and encourage a therapeutic alliance ● They open an opportunity for the patient to clarify exactly what he or she means
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Book Code: CA23CME
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