Once the palliative care discussion is effectively initiated, an individualized plan of palliative care should be developed for those patients and families interested in this approach. The plan should be congruent with values and goals expressed by the patient and family and the clinician’s abilities to apply complex knowledge and skills. Successful implementation of an individualized palliative plan of care depends upon the integration of patient and family values and goals with technical medical skills (e.g., pain and symptom management), family resources (e.g., financial, social, emotional, spiritual, and community), understanding of health care delivery systems (e.g., hospice, home health, long-term care, and insurance benefits), and general community resources (e.g., availability of hired caregivers, social programs for bereavement and support groups). A competent application and integration of these multiple skills requires a high degree of experience and expertise. Research by Farber et al. indicates that mastery of these skills in our present educational environment requires a minimum of 10-15 years of clinical experience.
Having integrated as common story as possible from the patient and family the clinician now has the challenge of developing an individualized palliative care plan congruent with patient/family values and goals. The ability to develop such a plan requires complex attitudes, knowledge and skills on several levels including:
• Medical/technical competence . You need to be able to diagnose and treat physical symptoms especially pain to promote comfort and quality of life. Additionally you need to be able to diagnose and treat medical conditions including life-threatening conditions that are consistent with the patient/family values/goals and the medical context. In short you need to be a knowledgeable and skilled clinician.
• Analytical and problem solving skills that allow you to bridge the gap between the patient/family story and what they hope to achieve and your professional understanding as a physician. Often there will be major differences between your understanding of what is possible or desirable and what the patient and family think is possible with medical treatment. Being able to integrate patient, family and physician perspectives into an individualized plan of care consistent with patient and family goals and values requires great creativity and flexibility.
• Communication/Relationship Skills that allow you to forge a collaborative relationship with the patient and family to develop a shared plan of care are essential. Assuring the family you understand what is important to them a fundamental skill. Simultaneously informing them from your professional perspective what the consequences of their decisions are likely to be and what is realistic given the medical context is important. When a treatment will no longer help the patient and family live a life consistent with their goals and values communicating to them in a way they can understand this reality within the context of their story is essential. Additionally demonstrating your commitment to guiding them through this frightening and challenging time in their lives builds a relationship of trust.
• Humanistic Attitudes and Skills that include : It is the physician’s responsibility to develop a plan of care consistent with the patient’s and family’s story and it is your professional role to gain the needed attitudes, knowledge and skills in palliative care to benefit your patients, families and yourself.
Again having a framework upon which to accomplish the complex task of developing an individualized palliative care plan can be helpful. We suggest the following framework once you have solicited the patient/family story:
• Assist the patient and family in clarifying their values and goals for living the best life possible and helping them understand what medical care can support these goals. It is important that you confirm with the patient and family you correctly understand their values and goals.
• Assist the patient and family in understanding what values and goals are shared by everyone patient, family and physician to live the best life possible. Stress what medical treatments are consistent with supporting these shared goals and which treatments are inconsistent with these shared goals. Patients rarely choose medical treatments as an end in themselves. They choose them as a way to live a meaningful life.
• Assist the patient and family in understanding differences in values and goals among the patient, family and physician in how to live the best life possible and the use of medical treatments to support these differing values and goals. Patients and families are usually novices at living with serious illness while physicians have an in depth understanding of what the risks and benefits of medical treatments might be. Code status and resuscitation is an example of where patients and physicians can differ significantly on the advisability and benefits of such heroic treatments. Instead of sharing statistics on survival helping the patient and family understand how the resuscitation helps them meet or not meet their goals is a more effective way of assuring medical care that provides the desired benefit is provided.
• Assist everyone, patient, family and physician in integrating shared and differing values and goals into a common understanding of how to live the best life possible within the context of available medical and social resources.
• Based upon as common an understanding as possible develop an individualized plan of care that supports:
• Mind : psychosocial/emotional issues of patient and family congruent with their values and goals within the context of their story and medical situation
• Body : biomedical concerns especially pain and other distressing symptoms congruent with their values and goals within the context of their story and medical situation
• Spirit : spiritual concerns of patient and family congruent with their values and goals within the context of their story and medical situation
Developed an individualized Palliative Plan of Care
- Clarified pt/family values and goals
In the course of the interview the clinician assisted the patient and family in clarifying their values and goals for living the best life possible and how medical care can support these values and goals.
- Asked clarifying questions
- Asked probing questions
- Asked for specific examples/stories
- Made summarizing/reflective statements
- Confirmed pt/family/MD Shared values
In the course of the interview the clinician assisted the patient and family in recognizing what values and goals they shared in living the best life possible and how medical care can support these values and goals
- Asked probing questions
- Asked clarifying questions
- Asked for specific examples/stories
- Made summarizing statements
- Made reflective statements
- Acknowledged differences in Pt/Family/MD values
In the course of the interview the clinician assisted the patient and family to be aware of differences in values and goals among the pt/family/clinician in how to live the best life possible and use medical treatments
- Asked probing questions
- Asked clarifying questions
- Asked for specific examples/stories
- Made summarizing statements
- Made reflective statements
- Made declarative statements
- Clinician Integrated Pt/Family/Medical Perspectives
In the course of the interview the clinician used her/his expertise in caring for a seriously ill pt/family to integrate a common understanding of how to live the best life possible within the context of available medical and social resources.
- Made summarizing statements
- Made reflective statements
- Made declarative statements
- Provided specific examples/stories
- Asked probing questions
- Asked clarifying questions
- Asked for specific examples/stories
- Plan Supports Mind
- Supports psychosocial/emotional issues of patient/family congruent with their values and goals and within the context of their story
- Plan Supports Body
- Supports biomedical concerns of pt/family especially control of pain and other distressing symptoms congruent with their values and within the context of their story
- Plan Supports Spirit
- Supports spiritual concerns of pt/family congruent with their values and within the context of their story