Eric: Welcome to the GeriPal podcast. This is Eric Widera.
Alex: This is Alex Smith.
Eric: And Alex, who is our guest today?
Alex: Today our guest is you, and you, and you, and you, and you.
Eric: Great. You mean our listeners are our guests?
Alex: No, you are our guest, Eric!
Eric: Oh. I’m your guest.
Alex: …for your New England Journal of Medicine publication and video. Why don’t you introduce yourself.
Eric: So, hello, everybody. This is Eric Widera, I have the luck to work with some really amazing people over the last, well, many, many years on a project for a New England Journal of Medicine clinical video on family meetings. All of the other videos around procedures, and the goal of this was to highlight that communication skills are just as important and should be considered procedures. And it’s really cool, because everybody else on this call, including a couple of people not on this call really helped put this together.
Eric: Alex, do you want to start calling on names? We’ll start talking about who’s with us today.
Alex: Yes. We’re going to start with James Frank. Go ahead, James.
James: Hey. Thank you both for having me on. I’m really excited to be here and so happy to have this project completed. I’m James Frank. I’m a pulmonary and critical care attending physician at UCSF, and program director for the fellowship in Pulmonary Critical Care Medicine.
Alex: Terrific. Next is Lekshmi.
Lekshmi: Hey, everyone. Awesome to be on the famed GeriPal podcast. I’m Lekshmi Santhosh. I started my involvement in this project, as we’ll talk about, back in the day during fellowship, because an amazing mentor and sponsor named James Frank brought me on. So thanks to James, now, several years later, I’m also on faculty at UCSF in pulmonary critical care and hospital medicine, and I’m the associate program director of the fellowship. So, thanks again, James, and thanks to all of you.
Alex: Welcome to GeriPal podcast, Lekshmi. Welcome back, Wendy. You want introduce yourself?
Wendy: I’m Wendy Anderson. I’m a palliative care physician at San Francisco General Hospital and UCSF. Really nice to see everyone.
Alex: Great. And Anne Kelly, who’s returning for the, I don’t know, 30th time, 50th?
Anne: I keep elbowing my way back in.
Eric: Also the voice of the GeriPal introduction.
Anne: Well, I’m a social worker with the palliative care team at the San Francisco VA. And as James was just saying, I was very honored to play a supporting actress role…by debut.
Alex: Oscar nomination. I think these are eligible for Oscars.
Eric: And two other people not on the call, Kathleen Turner from nursing at UCSF, she’s dealing with a code blue right now in the hospital, so we’re going to miss her. And also Kana McKee from the San Francisco VA, one of our palliative care doctors there. She’s out sick this evening. So we’re going to miss her too.
Alex: Well, I got to say it now, because you got to do the song. So, before we get into the topic, we need a song request, Eric. Last time you requested a song. It was Milkshake Brings All the Boys to the Yard – pure torture. What have you got for us this time?
Eric: Well, I was going to do Rockstar,I think it’s DaBaby, but I decided that we weren’t going to do that for Alex. Alex, any song from The Descendants, not the Disney one, but the George Clooney movie.
Wendy: It was what I asked for.
Alex: Right. Right. So why The Descendants George Clooney movie?
Eric: I think, A, I really loved the soundtrack and the setting of the movie is amazing, but more importantly, the movie is based on you have this family that’s living in Hawaii. There is an accident with the wife. She is in an irreversible coma. The advance directors says that she would not want to be kept alive on it. And a final decision … I don’t want to give away the whole movie, but a decision is made around this.
Eric: But I think the really interesting thing is the movie also highlights just everything else that’s going around, what’s happening with this family around, and the decision’s not the major thrust. It just reminds me of when we’re having these discussions, is that we see a snapshot of what’s going on with the family and how they’re coping with this, and everything, all the other dynamics that are happening, and just a lovely reminder to be aware that, again, we’re just seeing this snapshot.
Eric: So that’s why. I thought it fit in perfectly with this idea of family meetings.
Alex: Great choice, and thank you, and I brought the band with me, so I’m going to have my kids introduce themselves.
Kai: Hi, I’m Kai Smith.
Renn: And I’m Renn Smith.
Alex: All right. And how old are you?
Kai: I’m 15.
Alex: As of today, it’s Kai’s birthday.
Eric: Happy birthday, Kai.
Renn: And I’m 12.
Alex: All right. And we’re going to play Hi’ilawe, which is a classic coined tune from The Descendants’ soundtrack.
Eric: That was awesome. Can we get a full extended version at the end, Alex?
Alex: We’ll get the ending at the end. That was subtly extended so we can make sure they had time to do a little solo. Good job, kids.
Eric: That was awesome. I really encourage all of our listeners, if you haven’t watched The Descendants, great movie, especially if you’re interested in this topic, which is the topic at hand, family meetings for individuals with serious illness. And, man, I’m trying to think back. I remember the first time … Alex, do you remember this? When we got the idea for the video?
Alex: I think you were looking up an email. When was it?
Eric: It was actually before the email.
Alex: Oh, it was Ken walking into our office and saying, “Hey all those New England Journal papers about procedures like how to insert the central venous catheter. You should do one on your procedure, which is family meetings.” And we’re like, “That is brilliant.” Right?
Eric: So this all started off with Ken Covinsky. So we have Ken Covinsky to blame. I think it also highlights the importance of amazing mentorship, because Ken is one of those people, just gives us an idea and …
Anne: Somehow all grand stories begin with Ken Covinsky.
Eric: With Ken Covinsky. And, Wendy, you look back. When was the first discussions with New England Journal on this?
Wendy: I believe spring of 2014, six long years ago.
Alex: Six long years, several videos later.
James: This is the second full length video of it now.
Eric: I also want to acknowledge, for anybody who’s interested in putting something like this together, the importance of working as a team, I also want to acknowledge Lekshmi, because the idea of managing up, the amount of times I got emails from Lekshmi saying, “Hey, Eric, just wanted to check. Where are we with the video?” And it served as an excellent reminder for me to go on, push ahead and move things forward for it.
Lekshmi: Thank you. Sorry, not sorry.
James: I remember when, Eric, you first asked me if I wanted to be involved in this project in the early status where we’re recruiting. Originally, it was going to be family members of patients in the ICU, and people to be in the video. The very first person I thought of was Lekshmi, who was a Fellow at the time, but we had done some family meetings and I knew she could really have some great ideas and great input for this project.
Eric: So, to all of our listeners too, please check out the video. It’s on the new England journal website. We’ll have links to it from our GeriPal webpage on the video. A big shout out … So we initially did first videos with a real life family meeting. To increase production quality, we moved to actors. A big thank you to MOPED Production, Maureen Isern who really helped us put this together. And we had Wendy Anderson, Anne Kelly, Kathleen Turner as our actresses too for this, with some actors as well. Really, it was a amazing time to put this together and see how it all works.
Alex: Yeah. The other lesson is start early. It could take six years.
Eric: Yeah, the logistics behind it.
Wendy: And where did we film it? Do you remember where we were?
James: At the JCC. Yeah, absolutely, with that monkey fireplace behind us there.
Anne: Back when we could gather 30 people in a room.
Eric: Yeah. Good times. So, in the video, we do a structured layout of how to have a family meeting, starting with preparation and working ourselves through it. We’re not going to cover all of those steps, right, Alex, in this podcast?
Alex: No. No.
Eric: What do we want to do?
Alex: I think we should go around, and we’ll do a popcorn style. So, Eric, you can start off, and you could say one key pointer that you would want everybody to remember about family meetings in the setting of serious illness. And then you pass it on to somebody else and they go. And we’ll just keep going around until we hit time, because I’m sure we all have at least one, if not three, if not five different pointers we want to get across. But we’ll see how many we can get across. And we’ll also feel free to riff off of each other’s pointers.
Eric: Yeah. I’m going to go back to The Descendants, because that was my first point, is I think we were working with family members, even other healthcare providers is to recognize that we are seeing a slice of their life right now. And they may be dealing with so many other issues, especially in time of COVID and everything else that’s happening, Black Lives Matter … The world is just crazy right now. And when we’re dealing this with family members of their loved one in an ICU, it is yet another thing, but it’s unlikely to be the only thing that they’re dealing with, and to recognize that we’re seeing that sliver, it’s a really important sliver, but there’s probably so many other things that’s going on with their lives to just have a moment of gratitude that they’re with us and they’re with us for this patient, and empathy for everything that they’re going in to this meeting with. I have to remind myself, too, at this time. It’s so hard right now was just dealing with everything, and I come from a very privileged place. So that is my one take home.
Alex: So this is more of an attitudinal rather than a words to say.
Eric: Attitudinal. When we talk about the video, we go through seven different steps. The very first step is preparation. And this is the preparation. Just pause. Pause before you go into this family meeting. Pause before you talk to the other providers. And just acknowledge that, again, there may be a lot of other things going on with our lives right now, and to give people a little bit of slack and space.
Alex: That’s great. And I think it helps refocus people from the, “I got a family meeting here. So I could make this decision because I have to decide whether to do this with the ventilator or that with the ventilator, make this decision or that decision.” This puts it back into putting yourselves in the patients and in the family’s shoes as they’re coming in here and having empathy for their larger experience and all the challenges they may be going through. Eric, you got to pass it on somebody else.
Eric: I am going to pass it off to the physician in the video, Wendy Anderson. I think she got an Oscar on this one. So, Wendy.
Wendy: Hey, so am I allowed to read Kathleen Turner’s? Because she did email what hers-
Eric: Yeah. Read Kathleen’s in Kathleen’s voice.
Wendy: Look. I cannot do that, and everyone knows that, speaking of Oscar winning performances.
Wendy: So Kathleen says that the thing that she’s trying to remember is prioritizing attending to emotion. “We have little to no in-person contact with families these days, families have not had the opportunity to get our trust or know the clinicians caring for their loved ones. Clinicians haven’t seen family members day-to-day to get a sense of their emotional bandwidth and styles. And then we lose all of this emotional data on Zoom compared to face-to-face.
Wendy: “Our current situation tasks us with pausing our information channel to check in with how family members are doing first. We know that this is a best practice anyway, so our COVID area constraints can be an opportunity to deepen these skills.”
Eric: Couldn’t have said it better. That was really lovely.
Alex: Anything anyone else wants to say about attending to emotion? I’ll say that when I’m evaluating trainees in particular about their facilitation of serious illness family meetings, the point where they tend to have the most room for improvement is around attending to emotion. And so to remind everyone, and trainees in particular, that if somebody is demonstrating strong emotions in family meetings, that it doesn’t mean it’s time to pass them the tissues, just to get them to stop or to move on to the next topic, that this is an opportunity to acknowledge what they’re going through, and do we have any techniques, Wendy, for acknowledging emotion?
Wendy: Why, yes. I believe that there may be, even something that was discussed in the video, that there’s a mnemonic called nurse. So naming, understanding, respecting, supporting, exploring emotion, and I think, really, the key piece being a lot of space. So Eric was talking about pausing, and so naming this must be really hard, and then pausing.
Eric: Great pause, everybody, right there.
Wendy: Yeah. The pause. That’s really interesting with the videos is I think we’re used to being able to see strong emotion, but if it’s video or phone, we have to just assume, checking in with people. What is it like to hear this? Is this what you were expecting?
Alex: Yeah. And we did a podcast with you, Wendy, and Tony Bach, and he was talking about this very issue is when he takes a drink and nearly brings it back up. It’s like, yes, how hard it is to have these conversations via Zoom when there’s that little disconnect in time, when they’re like Eric is staring down at the screen right now. He’s not looking at me. I’m not making eye contact. He’s looking at this image of me on the screen. Now he’s looking at the camera, but so many issues get in the way.
Alex: James, you were going to say something.
James: Well, I work with medical students a lot, and I wanted to know what Eric brought up. For people who are new to doing family meetings, I think acknowledging emotion can be difficult, and Wendy really said this nicely, and this is highlighted in the writeup, in the video, that beginning a first step is really just naming the emotions that you are seeing happening will be your entry. So naming and pausing, I like, because it’s a very specific tip, skill, tactic, that you can use even in the setting of feeling anxious in your stomach and not really sure what the next thing’s going to be as a newer person coming to leading a family meeting. So I think that’s a great, great one.
Eric: Yeah. I would also add, going back, and this is going to be my second point. So, to be generous to yourself, too. I always think back to … There was this one time I was leading a family meeting. I forget what it was, but Anne was with me, and I think he brought up death or something, and then both me and the rest of the doctors, we just glanced right over it. Do you remember this, Anne? Do you remember the specifics? Tell me the specifics. Remind me.
Anne: Well, actually, I think it was a patient where you and a trainee were seeing him in the ICU. And he was someone who was really struggling with how sick he was, and I think ambivalent around whether or not he wanted to keep living. And he said something to that effect. And I think he asked what seems a cognitive question, and you guys responded cognitively-
Eric: Do you remember what the question was?
Anne: Yeah. “Because you won’t kill me. Will you?” And you said, “No. We won’t.” And I said, “Hold on a minute.” [laughter]
Eric: I think that’s the great thing about working as a team, is that there are times, again, so many other things going on, you’re trying to attend to a lot of things, and it’s easy … And I am embarrassed talking about this on this podcast. I should know. I’m on their fellowship. You should know these things, and yet there are times where you miss an emotional cue, and even potentially a quite blatant one.
Anne: But I think that really adds to what you were saying earlier, Eric, about not only do we need attitudinal preparation, but part of preparation is really, “Do I have the luxury to have access to a team right now? Are there other people who should be in this room that I have access to?” Not everyone will always have access to others, but if they do, not only does it help get all the right experts in the room, but it helps share the responsibility of being able to catch those moments when they happen. It doesn’t have to fall on one person’s shoulders. It’s really nice to be able to rely on the team.
Alex: Wendy, you got to pass it on.
Wendy: Oh, yeah. Lekshmi.
Lekshmi: Yeah. I was just going to add to what Anne said, and building off of what Eric said in terms of setting up that pre-meet. It’s not just about making sure that box of tissues is there and ready, and that we’re in a lovely circle or semicircle shape, if at all possible, not a conference room style table. It’s really about figuring out who’s here in the room, who should be here in the room, who’s not in the room, whose voices are input we should make sure is heard? And above all, I think talking to the family about imagining if their loved one would be able to be in the room with us, because we talk in the video and the write up about talking about how it’s a complicated to talk about decision making from a surg perspective. And I think that’s one of the things in the pre-meeting that comes up as well. Not only are we thinking about bringing all the teams together, bringing all the team members together, but again, remembering if that patient was in the room with us, what would they want?
James: Don’t forget the water and the tissues. We heard feedback on one of the original versions of the video, that said that we must acknowledge that you would provide water and tissues. Yeah.
Alex: So we were good authors and put it in because the reviewers asked us to. But Lekshmi, so many great points in there. When I’m teaching family meetings setting a serious illness, I tell people, “If you remember nothing else from this teaching session about a structured approach to family meetings, remember that the pre-meeting is as important, or potentially even more important, than the meeting itself. Make sure you have a pre-meeting to get everybody on the same page.”
Alex: And the other thing I love about what you said is bringing people into the room, and that would also include, as you allude to the patient who’s sick and can’t be there, bringing them into the room in some way. When Eric and I, I know several of you were doing video consults with folks in New York at the height of COVID there, the conversations were so much richer when we could start with, “Tell us about so-and-so,” because we’re not there to be with them and to get to meet them and get to know them.
Alex: And even in the ICU, often, when you see them, they’re intubated. You don’t get to know them either. But if you can bring them into the room, if you can get that family to talk about them and who they are, and bring them alive, this is a person who loved dancing and was a DJ, struggled with depression, and this and that, it really humanizes the discussion you’re having in a remarkable way.
Eric: Yeah, yeah. If you look at qualitative data around ICU family members, what’s distressing often is they feel sometimes like the physicians never took time to understand their loved one as a person. So they feel like people are making decisions maybe for the system standpoint or not particularly for this patient. And a lot of Doug White’s work, who we’ve had on multiple times to this podcast, is really bringing it down to understanding the patient as a person, as an important part of this family meeting process.
Eric: All right. Lekshmi, are you going to pass it on?
Lekshmi: Pass it on to Anne.
Anne: Thank you, Lekshmi. I didn’t come prepared to say this, but as I’m listening to this, I think it’s helpful to remember that this is really hard. This kind of work and these meetings are really difficult, and I think about how so much of what we’re describing as pearls really take practice, and for many people, a willingness to practice, a willingness to fight through the discomfort of putting themselves out there and trying different things. And for me, we talked about pre-meetings, but one of the things that really helps with the practice, I think, is a debrief meeting, too, so how did that go? What went well, what do we wish we could have done differently? And those are moments where we can deconstruct what happened. And if something really wonderful happened there, we get to deconstruct what it was that led the meeting to go so successfully, or otherwise.
Eric: Yeah. If the patient says, “Hey, you’re not going to kill me. Right?” Hey, Eric, maybe that’s not a cognitive question he’s asking.
Anne: Yeah. It’s an opportunity to be like, “Oh, yeah. I can learn from that. It doesn’t mean I’m terrible and every time I do this, I’ll never get it right. It’s just an opportunity to reflect and learn from it.”
Eric: And I often think of it as it’s the bookends to the family meeting. You have the preparation and the pre-meeting beforehand, and then in our last step for this video, we have the debriefing. It’s the bookends that puts it together.
Alex: Can we talk about this for a moment? It’s so important to have a debriefing, and on the other hand, I think we’ve changed the way that we debrief. I know, Eric, you went and did VitalTalk, and Wendy Anderson’s a Bay Area lead and heavily involved in VitalTalk. And we used to do these debriefs that landed-
Eric: Yeah. Half an hour long marathons?
Alex: You’re right. They lasted as long as the family meeting itself. And by the time we’re done, the poor primary team’s exhausted, they’re like, “Ugh.”
Eric: Nobody knows what anybody said because it lasted a half an hour.
Wendy: And now we’re going to have another meeting with us again.
Alex: Never. Never. Right? So how should we do this debrief? What is your advice? Wendy, what would you tell people as they’re learning, teaching these meetings, what do they say afterwards get the debrief started?
Wendy: What I love about this is keeping it to one thing, and that it can really be as simple as you can go around to everyone in the meeting and say what’s one thing that you think worked really well? And then what’s one thing that you might want to do differently and next for next time or that you’re thinking about? And people can just say that, and then that can be it.
Eric: And that one thing only goes to the facilitator. Right? You’re not asking everybody, if there’s a group of seven people, what’s one thing you could do different next time. Right?
Wendy: Oh, right. Could be. Or what’s one thing that you want to think about? So it’s not feedback for the facilitator, but just about the meeting in general.
Alex: Well, I do like to go around the people in the room, because this is something that’s also changed in the way I … I used to put it all on the facilitator. The facilitator, you got to do introductions, you’ve got to, you got to find their agenda, you got to address their agenda, you got to attend to emotion, you got to summarize, you got to make sure you talk about prognosis, next steps, set up another meeting, and then we’ll debrief afterwards. It’s all on you. We’ll sit there and watch you and then give you feedback.
Eric: And we’ll all just be silent. So it’s really odd for the patient or family that eight people are listening, but not saying anything.
Alex: Right, right. But now it’s changed. And I think we try to emphasize to the facilitator, “Your role is to be more like a point guard in a basketball game and distribute the ball. ‘I want to bring in so and so here and make sure they have an opportunity to speak.’ ‘We haven’t heard from you yet. I want to make sure we hear from you, because your perspective is important.’ ‘This would be an important opportunity, because you’re an expert in this, to talk about that.'” So we can all debrief as well. It’s not just the facilitator, it’s everybody who is in that room, even if they didn’t say anything.
Eric: Which brings us back to the preparation stage. Now on the preparation stage, we actually, and Anne does a really good job of this, reminds people that if we start talking as a palliative care team, or as a social worker, that doesn’t mean your facilitator job is done. It just means you’re doing a good job of facilitating. Other people are talking.
Alex: Wait, wait, wait. No. If somebody who’s a rank above me speaks, that means I must be silent for the rest of the encounter.
Eric: For the rest of the meeting.
Alex: So, yeah, explicitly saying, “No, that’s not the case, because we laugh about it. But that’s the culture in medicine, is the second somebody a rank above you starts talking, you’re done. Like, okay, tag team-
Wendy: Tap out.
Alex: Right. Anne, anything else to say, then you’ve got to pass it on?
Anne: I’m going to pass it on to James.
James: Great. All right. Thank you, Anne. I really like the emphasis on this debriefing point last, because, I mean, I guess I don’t want to lose in this … Well, it’s sort of implicit in the whole project of the analogy to procedure. I think that’s familiar to people who do a lot of family meetings, but I think people who are less comfortable doing them may not be thinking about it in that same way that they think about, say, putting in a central line, which I was just doing like an hour ago. And it’s so true. Eric you were talking, if the attending steps in and grabs the needle, then you’re done. Right?
Alex: That’s right.
James: I have so many points that I would love to emphasize, and I’ll start with big picture things. So overarching, think about this like a procedure, and then think about these steps. As you become familiar with the step wise process, it helps you to make the most of all of this energy that you and the family are putting into this meeting. It’s easy to get sidetracked. Sometimes it’s important to explore avenues that come up that you weren’t prepared for, but having this basic structure in your mind will keep you on a focus that will help you to come away from the meeting feeling like something was accomplished, even if it’s not a big decision in the care. So I think that’s great and the tools that and the write up that little point by point card would be a great thing for newer people to look at and become familiar with as you’re learning these skills.
James: So big picture wise, it is a lot like other procedures that one learns, and just like with other procedures, you really benefit from coaching and feedback and you want to make the time to do that every single time you do it. And that’s how you’ll get better.
James: So can we dig into details now? Or should we wait or go back around again?
Eric: No. I want to talk about this idea, because that’s the first line of the video, is that family meetings are a lot like other medical procedures. James, Lekshmi, you guys are involved in fellowship level training of people who do a lot of procedures. Have you noticed the change where communication skills are a greater focus in training of fellows nationally as well? Is something that pulmonary fellowships, critical care fellowships is a major focus?
James: I think it is becoming more so, certainly it is for us. We dedicate time in the first year of fellowship to learning communication skills, relationship centered communication skills, and have multiple sessions that recur through the year, where strategies for communication in different contexts come up, including family meetings and also just working with other interprofessional team members and talking around issues of diversity, equity and inclusion. And so communication is a huge part of the role of being a pulmonary critical care provider.
James: What’s amazing to me is when I was a fellow, we had none of that. Zero time was spent in a concerted way on teaching people how to do, say, a family meeting or talk with a patient in an encounter. And what seems to me to be so strange about that is that’s where I spend most of my time doing now.
James: So we make it a big … I think a lot of other places are beginning to do that, too. So I think that’s a good positive change.
Alex: Lekshmi, from your perspective?
Lekshmi: Absolutely. I think we’re seeing a lot more and more programs around the country doing things like actually having coaching and feedback around these conversations, having observation. And I think just more of the culture that just any other procedure, this is something that is not, automatically I’m bad at this, or I’m good at this. And so just flipping that concept to this is a procedure that we can all get better at with training, with skill, with coaching, with mentorship. I think rather than that fixed mindset of lines aren’t my thing, family meetings aren’t my thing. I’m not good at this, and rather that growth mindset of communication, particularly around difficult conversations in the ICU is something that can be taught, can be coached, we can break it down, we can give you concrete tips.
Lekshmi: And I think that this video and the write up that goes along with it really helps break it down, just like a procedure, a really complex multi step process. It helps break it down into little bite sized chunks that say, Oh, that makes you say, “Oh, I can do that.” Or, “That’s one technique that I can take that I hadn’t thought of before.” Or, “This is something that I want to get better at.” And I will say in terms of coaching and feedback, nothing like watching a video of yourself leading a family meeting, probably 50 to a 100 times cringing, this hard cringe. They’re really quite a humbling experience, really. And, again, a very educational experience in process and learning what could I have done better in that meeting at that moment in time, but again, lessons to take us for the future for family meetings to come, and they’re also learning.
Alex: Just to explain that to our listeners, Lekshmi actually ran the family meeting in one of the first family meeting videos that we took, sent to the New England journal, wasn’t ultimately the one that we published, but it was a terrific learning opportunity all around.
Alex: I wanted to ask on this note of training and practice, what do people think about role plays as a way of training and practice?
Wendy: Well, I can say I learned a lot in the thing that you don’t see in the video is that there would be a pause, and then James or Eric would come over to me and they’re like, “Say this.” And I’m like [crosstalk 00:36:55] say that. And then two lines later, they come over, “Say this.”
Eric: That was when I was doing VitalTalk, where I would say something and Bob Arnold would say, “Why don’t you try saying this?” I love role play because it gives you the rules.
James: Yeah, nothing worse than having a video of everything you do showing again and again. Oh my gosh.
Wendy: So we got role play, especially if you have someone in real time that can tell you exactly what to say.
Eric: I also love the idea of in real time, even in the pre-meeting or in the debrief, using role play, that split second role play of, “Okay, let’s talk about how would you talk about prognosis? How would you actually say the word that he’s dying?” Because if you don’t do that to somebody who’s never done that before, they’re going to stumble. They’re not going to know how to actually say those types of words, and they may just completely gloss over it or use some type of euphemism that nobody’s going to understand what they’re saying.
James: I’m a huge fan of this. When I first started to have formal training and communication skills that involved role-playing, I was skeptical, and not an early adopter, but I cannot think of another way that you would do it, actually. It’s very inefficient to do it if the only way you do it is in actual meetings. There’s not a really great efficiency there, and there’s a little bit more of a “risk” of having it not go so well and not feel so good. So I’m a big fan of role playing and practice-
Alex: Yeah. Better if the first time you code somebody, it’s a mannequin, one of those highly responsive … I don’t know what you call them. The simulated people that are coding. I don’t know.
James: Yeah, that’s right. That’s what we call them.
Wendy: Mannequins, I think. Right?
Alex: I think I’m last. Do I get to go?
Eric: You got to go, Alex.
Alex: Okay. And this riffs off from something that you were just saying, Eric, it’s really important to talk about prognosis in that pre-meeting, because you may have wildly different ideas. The oncologist may think one thing. The nephrologist may think another. The ICU team may think another thing and the palliative care team may think another thing. It’s really important to get on the same page and do that in the pre-meeting, not during the meeting, because I have been in meetings where, like, “Oops, we forgot to discuss prognosis. Oh!” And it starts to come out that we’re not anywhere near the same page, but it’s the meeting, very awkward, not optimal care for the family. Better if you get on the same page in the pre-meeting.
Alex: And they ask people, “How long do you think she has?” People tend to, this is their bias, I believe, trained in medicine, think of the most optimistic scenario. They pick up the best case. “Well, if they can get to this infection and get off of CVVH, and we can dial down the pressors-
Eric: And we get them to rehab.
Alex: Yeah. “We can extubate them, get them to rehab, it’s going to be a long road, but I think they may have one to two years left.” So that is the most optimistic frame. In order to counter that, because I think that’s our psychological bias, that we had hardwired into us, I like to start this question, “Does anyone think that she’s dying?” Because if you start at the other end of the spectrum, then you’re more likely to counter that bias, that optimistic bias, and then some people start nodding their heads. Like, “Oh, yes.” And sometimes they’re like, “Oh no, I don’t think she’s dying.” And that’s fair. But sometimes they do think that she’s dying. And this is the first time they’ve actually said it out loud and said it to each other, because we know from work about prognosis, that docs tend to formulate a more pessimistic prognosis than they communicate to other physicians, and the prognosis that communicate to patients and family members is even more optimistic than that.
Alex: So we need to fight against these biases. And I like to do that in a pre-meeting by anchoring with, “Are they dying?” And then if we do think that they’re dying, I think it’s important that we encourage people in the meeting to use those words in the family meeting. “We met beforehand, and we talked about how long they might have. Is that something that you would like to discuss? Can we talk about that? Where do you think things stand? We are worried that your loved one is dying. We’re worried that they’re dying.” Processing that, and then moving to, “How do we care for them with this understanding that they’re dying?” And that really shifts the conversation.
Eric: I think that’s really important. I’m just thinking back to my week on service right now, and it’s very easy to go from a discussion of how the patient is currently doing in their health, straight to goals of care and completely avoid the prognosis question. And your goals are completely, not completely, are heavily dependent on your prognosis. I love you guys. I’m doing this podcast with you. If this was my last night on earth, I may be hanging out with my family instead. My goals shift depending on what my prognosis is. And I saw it today. It’s really easy to bypass that critically important discussion about prognosis.
Lekshmi: And I think one of the other things that that helps you prevent, is also a situation where you think you’re conveying or painting a picture of how a person is doing. And then when you ask the family member to tell us how that sounds or how that means to you, and then you get an answer that’s totally discordant with what you think you communicated, and you thought you communicated they’re dying. And what they heard is, “Okay, sounds like they just need to be extubated and they’ll be discharged soon.” So I think that prognosis conversation is also really important to avoid going straight from A to C, and really dwelling in that prognosis conversation, though uncomfortable, is often necessary and can avoid big misunderstandings.
Eric: Yeah. I also want to do a shout out to Nathan Gray. He’s a great cartoonist. You’ll see his stuff on Twitter. But he just published a cartoon on are you using vague prognostic language, too? And has pictures of the words “grim,” “guarded,” “limited,” and poor, with a Grim Reaper for each one of them, and the one for “poor” is the Grim Reaper sticking out his pockets like he has no money in them.
Eric: So when we use, “Oh, it’s guarded,” or, “It’s grim,” or, “It’s limited,” or, “It’s poor,” what do people actually take home from that? And again, I love Doug White’s work on this, too, is that there’s usually an over optimism when we use these types of words. Even if we’re using specific words, there’s an over estimate of prognosis.
Eric: So following up is, does that change anything about how you think your prognosis is looking like, or your loved ones prognosis is?
James: I would jump in with one other, I think, really critical point, that’s highlighted in one of the figures for the write up and it’s nicely demonstrated in the video, and that’s maintaining rapport when communicating around discordance between the family’s perception of prognosis and what you need to tell them. And, again, that’s daunting for people, I think, and can make you feel quite anxious, but the wish, worry technique that we highlight is one way to handle that. “I wish that it was true that your loved one loved one was going to have a better prognosis, and I’m worried that this is what’s going to happen.” So that can bridge that space and get you talking about what you want to talk about in terms of prognosis or need to talk about.
Eric: Well, Alex, I wish we could continue on all of these great topics, and I worry if we do, we’re not going to have any time for the second part of the song.
Alex: All right. You guys vamp and keep talking while I get the band back together.
James: That was so well demonstrated, Eric. Thank you.
Alex: I learned something from the video.
James: I’m disappointed. I had some pictures, some still pictures, from the video day of production of the final video, but I don’t have them ready to show here. I’m sad I didn’t think of that until earlier. But there are some great ones of our actors, Dr. Anderson and Kelly and …
Wendy: Did you get the makeup chair? Because my favorite thing was was we had hair and makeup was awesome, but do you know who was in the makeup chair before us? The last person that she had made up?
Wendy: Sentiment brat.
Anne: Stop it now.
Eric: Wait. Who’s that?
Anne: We’re going to have to continue this conversation without you.
Lekshmi: You need to be educated. [laughter]
Eric: By the way, for all of our listeners, if you are on YouTube, you could see Nathan Gray’s tweet about vague prognostic language. We’ll also have a link to this on our GeriPal site, and a link to the New England Journal article and the video on our GeriPal site too. I see right now that the band is being set up right now. So, we’ll give them a second.
Eric: I want to thank all of our guests today for joining us. Thank you all for joining us and for working on this project with us.
Wendy: Thank you, fearless leader, Eric, who … How many hours do you think over the six years, really when you put it together?
Eric: It was a lot, and to the New England Journal editors, they let us know in the beginning that it’s a long and arduous process. So want to send a big thank you to them, too. And again, I always think back to, I would have never had the energy to pursue this any farther if it wasn’t for people like Lekshmi that sent me emails and said, “Hey, Eric, where are we with this?” So, again, for all those junior faculty members, fellows, residents out there, it’s okay to mentor up, because we need it. And that encouragement’s really important. And sometimes it results in a New England Journal publication. So think about that.
Eric: All right, Alex, you ready?
Alex: Here we go. One, two…
Eric: And with that, thank you, Alex, Renn and Kai for that wonderful song. Thank you, all of our guests today for joining us, and fellow coauthors on this video. Big thank you to the New England Journal, our stone foundation for your continued support, and, most importantly, to all of our listeners for continuing to support the GeriPal podcast. If you have a second check out the New England Journal video and share it amongst others. Get the word out.
Alex: Thanks everybody. Good night.
Eric: Good night.