#207: Withdrawal of dialysis: decision-making

FAST FACTS AND CONCEPTS #207

WITHDRAWAL OF DIALYSIS: DECISION-MAKING

Sara N Davison MD and Drew A Rosielle MD

Background   Historically, stopping dialysis was considered by many to be a form of suicide.  However, it is now a widely accepted practice in most countries, with broad ethical and legal consensus that dialysis can be stopped when it is no longer achieving a meaningful goal for the patient. In fact, ~25% of deaths of dialysis patients in North America occur after its cessation.  This Fast Fact reviews key issues pertaining to the decision to stop chronic dialysis; Fast Fact #208 will discuss the care of patients after it is stopped.

 

Why dialysis is stopped   The goal of dialysis is not only to prolong life by providing renal replacement therapy, but to maintain a patient’s quality of life at an acceptable level (see Fast Fact #163).  Discussions to stop dialysis usually occur when:

·   Dialysis is no longer serving to substantially prolong life or is only prolonging a patient’s death (e.g., a patient dying from advanced cancer or sepsis with multiorgan system failure).

·   The burdens of dialysis and its complications outweigh its life-prolonging benefits to a patient (e.g., a patient with progressive frailty who is becoming bedbound, a patient with severe cognitive failure).  In these scenarios dialysis is likely to prolong life but is not helping to restore a patient to an acceptable level of quality of life as assessed by the patient or her/his surrogate decision maker.

 

Demographics   The demographics of dialysis withdrawal have been studied at length.  Patient characteristics associated with withdrawal are older age, female, white race, longer duration of dialysis, higher educational level, living alone, severe pain, and comorbidity (with chronic or progressive diseases).  Ethnic differences have been observed, with African Americans and Hispanics being less likely to stop dialysis than European Americans.  Reported prevalence levels of patient decision-making capacity at the time of withdrawal vary considerably with estimates ranging from 37% to 80%, suggesting cognitive failure drives many of these decisions. Nephrologists rate cognitive and physical functional status as the most important factors for their decision-making around stopping dialysis, and 93% of North American nephrologists report a willingness to honor a patient’s request to stop, even if they have a personal preference to continue.  Internationally, practices vary tremendously, with much lower rates of dialysis cessation in Japan compared to North America, for instance.

 

Responding to a request to stop dialysis   For patients who are otherwise dying, counsel about terminal care issues surrounding dialysis withdrawal (see Fast Fact #208).  For patients not otherwise close to death, explore reasons for withdrawal, especially for treatable factors that might contribute to the desire to withdraw dialysis.  For patients whose desire to stop dialysis is being driven by factors that are potentially ameliorable, clinicians should make sure that the decision to stop dialysis is fully informed, including the possibility that some concerns could be addressed.  These include:

·   Inadequately treated depression, anxiety, pain, and other physical or psychological symptoms (including spiritual and existential suffering)

·   Dissatisfaction or difficulties with dialysis itself (e.g., modality, time commitment, or setting of treatment)

·   Inadequate social support, or concerns with being a burden to loved ones. 

Offer to evaluate and treat these concerns; consider a time-limited trial to see if a patient’s quality of life can be improved.  However, once a clinician feels a patient or surrogate is making a fully informed choice that is consistent with a patient’s values and goals, that decision should be honored.  Proactively address any concerns patients may voice about the ethics of withdrawal.

 

Broaching dialysis withdrawal   Clinicians who are concerned continuing dialysis is no longer benefitting a patient due the reasons described above should broach discontinuation with the patient and family.  This discussion should occur as part of a larger goals-of-care conversation which addresses prognosis (see Fast Fact #191), patient/family assessment of quality of life, and establishes realistic care goals.  Dialysis should be discussed as part of an overall medical plan and framed as how it can or cannot address the care goals.  “Dialysis will likely make your mother live longer.  However – given everything that has been happening – it is not going to improve her strength, memory, or ability to take care of herself.  Based on what you’ve told me about your mother and what is important for her, I would recommend stopping the dialysis as it is only serving to maintain her in a state she would find unacceptable.” 

 

References

1.       Galla JH and the Renal Physicians Association/American Society of Nephrology Working Group. Clinical Practice Guideline on Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis.  J Am Soc Nephrol. 2000; 11:1340-1342.

2.       Murtagh F, Cohen LM, Germain MJ. Dialysis Discontinuation: Quo Vadis?  Advances  Chronic Kid Dis. 2007; 14(4):379-401.

3.       Holley JL, Davison SN, Moss AH. Nephrologists’ Changing Practices in Reported End-of-Life Decision-Making.  Clin J Am Soc Nephrol. 2007; 2:107-111.

4.       White Y, Fitzpatrick G.  Dialysis: prolonging life or prolonging dying? Ethical, legal and professional considerations for end of life decision making.  EDTNA ERCA J. 2006; 32:99-103.

5.       Cohen LM, Germain MJ, Poppel DM.  Practical considerations in dialysis withdrawal.  “To have that option is a blessing.”  JAMA. 2003; 289:2113-2119.

 

Author Affiliations:  The University of Alberta, Edmonton, Alberta (SND), and the Medical College of Wisconsin, Milwaukee, Wisconsin (DAR). 

This Fast Fact is also available at EPERC.  

#206: Genetic screening and DNA banking at the end of life

fast facts and concepts #206

Genetic Screening and DNA Banking at the End of Life

John M. Quillin PhD, Joann N. Bodurtha MD, and Thomas J. Smith MD

Background    Many dying patients voice concern for the health of surviving family members.^{1, 2}  The most common causes of death can cluster in families, and this clustering can reflect shared family genes. About 5% to 10% of cancers are strongly hereditary,³ and a family history of heart disease is well established as a risk factor for the disease.^4-6  Family members may benefit from knowing their genetic risk, and offering testing can be a generative act for a dying patient.  Today’s genetic tests can identify known markers of disease for only some families, so testing is most helpful if it includes the affected patient (otherwise ‘negative’ test results are less informative). In addition, more informative genetic tests will likely be available in the future. Once patients die, however, their DNA is no longer readily available for this future testing. On the other hand, decisions about genetic testing are complex and can have profound emotional, familial, and financial impacts on those affected and should not be pursued hastily. 

 

Possible Genetic Conditions    If a patient or family member asks if survivors could be affected by the patient’s disease, consider recommending genetic testing or banking for known genetic disorders (e.g. hemochromatosis, cystic fibrosis) and in the following settings:

·     Earlier-than-expected age at diagnosis (e.g. breast cancer before age 50)

·     Multiple primary cancers (e.g. a history of both colon and ovarian cancer)

·     A major birth defect (e.g. spina bifida, congenital heart defect) or multiple minor physical anomalies

·     Profound hearing or vision loss without an environmental explanation

·     Developmental disability or autism

·     Disorders of sexual development

·     Unusually tall or short stature compared to relatives

·     Unusual skin pigmentation, such as ≥6 café-au-lait spots, or lumps (e.g., multiple lipomas)

·     Congenital myopathy or muscular dystrophy

·     Cardiomyopathy or arrhythmia without clear cut cause, or at an age earlier than expected

·     Suspected connective tissue disease (e.g. hyperflexibility)

·     Excessive bleeding or clotting tendencies not associated with medication or comorbidity

·     Seizures without an identifiable etiology

 

Talking to Patients and Families   There is no consensus on who should be approached for discussion of familial risk, and to date no studies on effective communication strategies for genetic screening at the end of life are available, despite acknowledgment of a practice gap.^7-9   In practice, a straightforward invitation for discussion of the topic may be effective: “I’d like to talk with you about your family health history. Some health conditions tend to run in families and knowing your health history and seeing if it is connected to your illness could help others in your family to stay healthy. Most diseases are not strongly genetic, but sometimes it is helpful to have a genetic test or store a blood sample for testing later.” 

 

Genetic counselors, medical geneticists, and genetic nurses can facilitate comprehensive genetics evaluation, assist in test selection, provide informed consent, and educate patients and family members about indications for and costs of testing and banking. Genetic consultation is usually covered by major insurers and Medicare, especially for patients with active disease such as cancer.

 

DNA Banking   Banking involves drawing blood for long-term storage at a DNA banking facility.  DNA banking is typically not covered by insurance; costs vary from one to a few hundred dollars. Facilities offering DNA banking vary in their informed consent requirements and documentation for ownership of samples (e.g. who is authorized to submit a sample to a laboratory for genetic testing).  Banking can be particularly helpful considering turn-around-time for genetic test results can be long and more informative tests may become available in the future.  In addition, given the complex and emotional decision making that can be involved in genetic testing, banking gives family members time to seek counseling and to carefully consider such decisions, without feeling pressure to pursue testing before a loved one dies. 

 

Resources    Clinical laboratories that currently offer DNA banking can be found at http://www.genetests.org. Providers can search for nearby genetic counselors and geneticists at http://www.nsgc.org and http://www.acmg.net. General resources for clinicians about genetic counseling and testing can be found in references 10-13. 

References

1. Duggleby W, Wright K. Elderly palliative care cancer patients' descriptions of hope-fostering strategies. Int J Palliat Nurs. 2004;10:352-359.
2. Skirton H, Frazier LQ, Calvin AO, Cohen MZ. A legacy for the children--attitudes of older adults in the united kingdom to genetic testing. J Clin Nurs. 2006;15:565-573.
3. Offit K. Clinical Cancer Genetics. New York: Wiley-Liss, Inc.; 1998.
4. Hunt SC, Gwinn M, Adams TD. Family history assessment: Strategies for prevention of cardiovascular disease. Am J Prev Med. 2003;24:136-142.
5. Murabito JM, Pencina MJ, Nam BH, et al. Sibling cardiovascular disease as a risk factor for cardiovascular disease in middle-aged adults. JAMA. 2005;294:3117-3123.
6. Lloyd-Jones DM, Nam BH, D'Agostino RB S, et al. Parental cardiovascular disease as a risk factor for cardiovascular disease in middle-aged adults: A prospective study of parents and offspring. JAMA. 2004;291:2204-2211.
7. Kirk J. The family history of cancer - a common concern in palliative care. Progress in Palliative Care. 2004;12:59-65.
8. Lillie AK. Exploring cancer genetics and care of the family: An evolving challenge for palliative care. Int J Palliat Nurs. 2006;12:70-74.
9. Quillin JM, Bodurtha JN, Smith TJ. Genetics assessment at the end of life: Suggestions for implementation in clinic and future research. J Palliat Med. 2008;11:451-458.
10. Pletcher BA, Toriello HV, Noblin SJ, et al. Indications for genetic referral: A guide for healthcare providers. Genet Med. 2007;9:385-389.
11. American Society of Clinical Oncology. American society of clinical oncology policy statement update: Genetic testing for cancer susceptibility. J Clin Oncol. 2003;21:2397-2406.
12. Genetics and Your Practice. March of Dimes.  Available at: http://marchofdimes.com/gyponline/index.bm2.  Accessed July 10, 2008.
13. National Office of Public Health Genomics.  Centers for Disease Control and Prevention.  Available at: http://www.cdc.gov/genomics/.  Accessed July 10, 2008.

 

Author Affiliations:  Massey Cancer Center, Virginia Commonwealth University.

This Fast Fact is available at EPERC.

#205: Destination Ventricular Assist Devices for Heart Failure

FAST FACTS AND CONCEPTS #205

Destination Ventricular Assist Devices for heart failure

Heather Ferris MD, PhD and Susan Hunt MD

Introduction   About 250,000 Americans have end-stage heart failure (‘Class IV’ by the New York Heart Association criteria, meaning patients cannot carry out any physical activities without discomfort and experience dyspnea or angina at rest).  Fewer than 1% of patients, however, will receive a heart transplant. The left ventricular assist device (LVAD) was initially designed as an implanted mechanical circulatory support to extend the life of patients awaiting heart transplants (“bridge therapy”).  In 2002, the FDA approved the LVAD not only as “bridge therapy”, but also as an alternative to transplantation, or “destination therapy.”

 

The Technology   The LVAD is a surgically implanted pump with two conduits, one of which is implanted in the left ventricle, the other into the aorta.   Blood is pulled from the left ventricle, and pumped into the aorta, increasing cardiac output and reducing heart failure symptoms.  A third conduit passes from the pump through the abdominal wall, and attaches to the LVAD’s battery and control system.  Right and bi-ventricular assist devices also exist, but are not currently approved for destination therapy.  Patients can go home on most types of assist devices.  [CB1] LVAD patients may use a wearable battery system for several hours, which allows them more maneuverability. To qualify for destination LVAD therapy, a patient must have refractory Class IV heart failure, severe systolic dysfunction (ejection fraction <25%),>

 

Outcomes

·   LVADs can prolong life.  REMATCH, a randomized controlled trial, compared destination LVAD therapy to medical therapy.   LVAD patients had 1-year and 2-year survivals of 52% and 29% respectively, compared to 25% and 13% for medically managed patients.  The mean survival for LVAD patients was 14 months, compared to 9 months for medically managed patients.  Depression and health-related quality of life were improved in LVAD recipients.

·   Shorter survival is predicted by poor nutritional status, low serum albumin, coagulation abnormalities, impaired renal function, and signs of right heart failure. A pre-operative risk model has been developed using these factors (Lietz 2005); using this model, the 90-day and 1-year survival for low-risk patients is 93% and 81% respectively, compared to 18% and 11% for high-risk patients.

·   Complications of LVAD therapy include stroke, multi-organ failure, bleeding, thromboembolic disease, and sepsis.  Peri-operative mortality is very high (33%).  Patients generally spend 20% of their survival time in the hospital.  Some patients can perform all activities of daily living, but anxiety among patients and caregivers may be significant.  LVAD alarms, which occur an average of 6.7 times daily, are particularly distressing.

 

Discontinuing LVADs and Care Planning   LVADs may be implanted as a bridge to transplantation, but later become destination therapy when patients are no longer transplantation candidates.  In the rare instance of left ventricular recovery, LVADs can be explanted.  More often, LVADs are removed at cardiac transplantation or, in the case of destination therapy, when severe complications arise.  When the LVAD is turned off, not only does support to the damaged heart stop, but the non-functioning device causes impediment to the pumping of the native heart, thus in a small way hastening death.  Patients usually die rapidly after device discontinuation.  Discussions leading to a decision to discontinue the LVAD should focus on its inability to continue to fulfill its intended goals, and the importance of providing comfort care for a dying patient. 

 

LVAD therapy is a surgical therapy which can prolong life and improve function in selected patients, but is associated with very high mortality and treatment burden.  Discussions with patients and surrogates to clarify prognosis, goals, and endpoints for LVAD therapy should take place before implantation.  These discussions should address the quality of life below which a patient would no longer want to continue mechanical circulatory support, and would want to initiate comfort-only care. Palliative care physicians may be involved in these discussions, and involved in evaluating patients who have suffered complications or request LVAD discontinuation.     

 

References

1. Lietz K et al.  Outcomes of Left Ventricular Assist Device Implantation as Destination Therapy in the Post-REMATCH Era; Implications for Patient Selection.  Circulation.  2007; 116:497-505.
2. Park SJ et al. Left Ventricular Assist Devices as Destination Therapy: A New Look at Survival.  J Thorac Cardiovasc Surg.  2005;129:9-17.
3. Rose EA et al. Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) Study Group: Long-term Use of a Left Ventricular Assist Device for End-stage Heart Failure.  N Engl J Med.  2001;345:1435-1443.
4. Bramstedt KA, Wenger NS.  When Withdrawal of Life-Sustaining Care Does More Than Allow Death to Take Its Course: The Dilemma of Left Ventricular Assist Devices.  J Heart Lung Transplant.  2001;20:544-548.
5. Slaughter MS et al.  Home Discharge Experience With the Thoratec TLC-II Portable Driver.  ASAIO Journal.  2007;53:132-135.

Author Affiliations:  University of Pittsburgh Medical Center.

This Fast Fact is available at EPERC here.  

#204: African Americans and End-of-Life Care

FAST FACT AND CONCEPT #204

AFRICAN AMERICANS AND END-OF-LIFE CARE

Mythili Raghavan, Alexander Smith MD, MS, and Robert Arnold MD

Background   The care African Americans receive at the end-of-life, as well as African Americans’ attitudes towards end-of-life care, differ in some ways from the general US population.   Clinicians’ poor understanding of these differences may lead to ineffectual communication and patient dissatisfaction. This Fast Fact outlines research findings on differences in end-of-life care and values between African Americans and the population as a whole. Note:  the differences discussed here represent broad trends and the full spectrum of values and practices within African American communities is diverse and not captured by the following discussion.  Clinicians are advised not to make assumptions about individual patients based on population data, and to always explore each patient’s values and wishes.

 

End-of-Life Practices   With respect to European American cohorts, African Americans are:

·   Less likely to complete advance directives (14, 19), enroll in hospice (15), receive appropriate symptom management at the end-of-life (3, 9), or be satisfied with the quality of end-of-life care and communication (20).   

·   More likely to receive aggressive treatment at the end-of-life (including artificial nutrition and hospitalization) (2, 4, 5, 16), to stop hospice care to seek life-prolonging treatment (11), and to die in a hospital (6, 13).  Over recent decades, while there have been more opportunities for patients to die outside of hospitals, rates of in-hospital deaths have declined for European Americans; a similar decrease has not been observed for African Americans (8).

 

Reasons for these differences have been researched extensively and likely include:

·   Preferences/Values – In general African Americans are more likely to want life-prolonging and aggressive treatments; to associate treatment limitations and hospice care with ‘giving up;’ and have less interest in completing advance directives (relying more on verbal communication of their wishes with family) (6, 9, 10, 18).  These differences are not solely due to mistrust or educational and economic status (similar trends are seen with African American physicians) (3), although they can be attenuated by explicit advance care planning in some instances (19). They likely also reflect deep cultural values stemming in part from the strong religious faith of many African Americans; for instance a trust that ‘death is in God’s hands’ may underlie a reluctance to discuss or plan for terminal care needs (3, 10, 12).

·   Health Care Disparities and Trust – Historic and current racism and health care inequalities, and the resultant mistrust of health care providers and institutions, likely drive these differences as well (3). African Americans are less likely to be offered hospice care and pharmacies in minority neighborhoods are less likely to stock opioid analgesics (1, 3). There is some evidence that differences in end-of-life care are attenuated where health care is distributed more equitably (such as in the Veterans Health Administration) (7).

 

Recommendations for Communication

·   Ask the patient and family about their perspectives about end-of-life care and decision-making prior to making recommendations. Have you thought about getting sicker? What happened when your dad got sick and died? Are you the kind of person who makes decisions on your own or do you want your family to be involved?   This allows you to understand the patient’s/family’s beliefs about end-of-life care and make suggestions that are consistent with their values (see also Fast Facts #17 and 26). 

·   Ask about spirituality and religious beliefs (see Fast Fact #19).  Offer to involve a chaplain or the patient’s personal spiritual advisor.

·   Frame the discussion positively.  Focus on meeting shared goals, not on what you are not going to do.  I want to help you live as best you can, given how sick you are becoming.

·   Look for issues of trust and address them openly.  Seek to understand any mistrust, avoid labeling the patient (e.g. as ‘irrational’), and redress any grievances within your power.  Build trust through offering time, careful communication, and close follow-up.

·   If there is conflict, recognize that we all bring our own values and culture to the bedside, and our conception of what constitutes a ‘good death’ may genuinely differ from our patients’.  Seek shared goals and values, focused on the needs of the patient, and recommend what you feel is the best medical care for a patient given their prognosis, options, and goals.

 

References     

1)       Bernabei R, Gambassi G, Lapane K, Landi F, Gatsonis C, Dunlop R, Lipsitz L, Steel K, Mor V. Management of pain in elderly patients with cancer. SAGE Study Group. Systematic Assessment of Geriatric Drug Use via Epidemiology.  JAMA. Jun 1998; 279 (23): 1877-82.

2)       Braun UK, Rabeneck L, McCullough LB, et al. Decreasing use of percutaneous endoscopic gastrostomy feeding for veterans with dementia – racial differences remain. J Am Geri Soc. 2005; 53:242-248.

3)       Crawley L, Payne R, et al.  Palliative and end-of-life care in the African American Community.  JAMA. 2000; 284:2518-2521.

4)       Degenholtz HB, Thomas SB, Miller MJ. Race and the intensive care unit: disparities and preferences for end-of-life care. Crit Care Med. 2003; 31(5 Suppl):S373-S378.

5)       Earle CC, Neville BA, Laundrum MB, et al.  Trends in the aggressiveness of cancer care near the end of life. J Clin Oncol. 2004; 22:315-321.

6)       Etienne Phipps, Gala True, Diana Harris, Umi Chong, William Tester, Stephen I. Chavin, Leonard E. Braitman.  Approaching the End of Life: Attitudes, Preferences, and Behaviors of African-American and White Patients and Their Family Caregivers. Journal of Clinical Oncology. Feb 2003; 21(3) : 549-554.

7)       Fischer SM, Kutner JS, et al.  Lack of ethnic differences in end-of-life care in the Veterans Health Administration.  Am J Hospice Palliat Med. 2007; 24:277-283.

8)       Fiory J, Yinong YX, Gurol I, Levinsky N, Ash A, Emanuel E. Place of death: US trends since 1980. Health Aff (Millwood). May-Jun 2004; 23 (3): 194-200.

9)       Hopp FP and Duffy SA. Racial variations in end of life care. J Am Geriatr Soc.  Jun 2000; 48 (6): 658-63.

10)   Jenkins C, Lapelle N, Zapka JG, Kurent JE. End of life care and African Americans: voices from the community. J Palliat Med. Jun 2005; 8 (3): 585-92.

11)   Johnson KS, et al. Racial Differences in Hospice Revocation to Pursue Aggressive Care. Archives of Internal Medicine. 2008; 168(2), 218-224.

12)   Johsnon KS, Elbert-Avila KI, Tulsky JA.  The influence of spiritual beliefs and practices on the treatment preferences of African Americans: a review of the literature.  J Am Geri Soc. 2005; 53:711-719.

13)   Johnson KS, Kuchibhatala M, Sloane RJ, Tanis D, Galanos AN, Tulsky JA. Ethnic differences in the place of death of elderly hospice enrollees. J Am Geriatr Soc. Dec 2005; 53 (12): 2209-15.

14)   Lahn M, Friedman B, Bijur P, Haughey M, Gallagher EJ. Advance directives in skilled nursing facility residents transferred to emergency departments. Acad Emerg Med. Dec 2001; 8(12):1158-62.

15)   Ludke RL and Smucker DR. Racial differences in the willingness to use hospice services. J Palliat Med. Dec 2007; 10 (6): 1329-37.

16)   Mor V, Papandonatos G, Miller SC. End of life hospitalization for African-American and non-Latino white nursing home residents: variations by race and a facility’s racial composition. J Palliat Med. Feb 2005; 8 (1): 58-68.

17)   Sambamoorthi U, Walkup J, McSpiritt E, Warner L, Castle N, Crystal S. Racial differences in end-of-life care for patients with AIDS. AIDS Public Policy.  Fall-Winter 2000; 15 (3-4) 136-48.

18)   Torke AM, Garas NS, Sexson W, Branch WT.  Medical care at the end of life: views of African-American patients in an urban hospital. J Palliat Med.  Jun 2005; 8 (3): 593-602.

19)   Volandes A, Paasche-Orlow M, Gillick M, et al.  Health literacy not race predicts end-of-life care preferences. J Palliat Med. 2008 (in press).

20) Welch LC, Teno JM, Mor V. End of life care in black and white: race matters for medical care for dying patients and their families. J Am Geriatr Soc. Jul 2005; 53 (7): 1145-53.

This Fast Fact is available at EPERC here.  

#203: Managing One's Emotions As A Clinician

Fast Facts and Concepts #203

Managing one’s emotions as a clinician

Donna Posluszny PhD and Robert Arnold MD

It is normal for clinicians to experience an array of emotions when interacting with ill patients and their families.  Although positive emotions such as joy and satisfaction are rarely problematic, negative emotions such as anger or sadness may interfere with your ability to communicate empathically or even to provide appropriate medical care. This Fast Fact focuses on clinicians’ emotional responses to patient care.  See also Fast Facts #59, 167-170, and 172 for more on responding to anger, clinician burnout, and professional boundaries.      

 

Sources of Emotion   Some of the emotions we experience are direct reactions to what the patient is saying or doing (e.g. an angry patient may trigger our own anger). Difficult emotions may also arise when patients do not act in ways that we like (e.g. feeling frustrated when a patient is not taking medication as prescribed).  We may feel sad, helpless, or even guilty when we cannot prevent a patient from further illness or death. We may also experience emotions triggered by our own past experiences, such as a patient who reminds us of a family member (e.g. grief, longing).

 

Strategies for managing difficult emotions   Dealing with one’s emotions is a learned skill. Like all skills it takes time and practice.  Be patient and keep practicing – look at each experience as a learning opportunity. 

·         Prior to an interaction you anticipate will be difficult specifically identify what is causing your emotional response.  Was it the patient’s health behavior, their behavior towards you, their intense emotions, or your own sadness about their condition?  If your emotional response is based on your past, acknowledge this and put it aside during the upcoming interaction. 

·   Practice the interaction ahead of time. Imagine the most likely ways that the patient will react and how you will respond.  

o  Clarify your goals.  It is unrealistic to expect that you can prevent or control patients from experiencing difficult emotions, especially anger and grief.  Acknowledge this and focus on realistic goals: being empathic, listening, disclosing medical information, talking patients through options, and validating their emotions.

o  Don’t go it alone.  Bring along a colleague or team member who can help if you have trouble controlling your emotions and can give you feedback on what might work better next time.

·   During the interaction recognize when your emotions are impacting your thinking/communicating:

o  Increased heart rate; feeling flushed, sweating; shallow, rapid breathing; increased muscle tension; speaking rapidly or loudly; repeating yourself; or realizing you are not listening.

·   If you are experiencing intense negative emotions:

o  Give yourself and the patient time to allow emotional intensity to subside.  Listen, rather than speak; allow silence.

o  Validate the patient’s experience by naming their emotions (‘You seem frustrated’).  If you are not sure, pose it as a question (’Are you feeling frustrated?’). Besides being empathic, simply naming what is happening may attenuate your own emotional response.

o  Naming your own emotions is appropriate as long as it does not divert attention from the patient’s needs or put blame on the patient.  For example you might say, “I am feeling frustrated that there is not more we can do to help you.” 

·   If you are feeling overwhelmed, it is appropriate to say, “Please excuse me for one moment” and then step outside the room; resume your interaction once composed.

o  Most patients appreciate certain displays of clinician emotion (e.g. tears), if they occur at appropriate times and are consonant with the tenor of the interaction.

o  However, losing control of one’s emotions, including grief (sobbing), is never appropriate in front of patients and clinicians should excuse themselves prior to doing so.

·   Afterwards, debrief with a trusted colleague or team member about what happened, how you responded, and how you might do it differently next time.  A less emotionally involved person can often see things in the interaction that you cannot.  Students and residents might ask faculty to come with them the next time they interact with the patient.  Repeated episodes of emotional instability may be a sign of burnout and/or need for mental health counseling.

 

References

1. Meier D, Back A, Morrison RS. The inner life of physicians and care of the seriously ill.  JAMA. 2001; 286(23):3007-3014.
2. Halpern, J. Empathy and patient-physician conflicts. J Gen Int Med. 2007; 22(5): 696-700.
3. Back A, Arnold R, Baile W, Tulsky J, Fryer-Edwards K. Approaching difficult communication tasks in oncology. CA, A Cancer Journal for Clinicians. 2005; 55:164-177.

This Fast Fact is available at EPERC here.