ARNOLD, Robert. End of Life Difficult Conversations, Jonathan King Lecture, Pitt, Sept 27, 2016
<p class="MsoNormal" >ARNOLD, Robert. End of Life Difficult Conversations, Jonathan King Lecture, Sept 27, 2016
This is a <b>memorial lecture in Berg Hall (Stanford </b>in LKS.) Prof. Arnold is from U of Pitt.</p>
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video of Jonathan King (my former grad student colleague from 40 years ago in CSD at Stanford.
Jonathan died in 1991 of cancer, leaving a widow and a 6 yo and a 12 yo.
(I worked down the hall from Jonathan for about a decade in the CSD.)</p>
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In his video, as he is dying, Jonathan emphasizes the importance of control and hope!</p>
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(filed under Psychiatry Grand Rounds (but this was a separate event),
Oncology, and Jonathan King)</p>
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Prof. Bob Arnold is a prof. at U. of Pittsburgh.</p>
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past pres. of Bioethics (society)</p>
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he is from Univ of Pitt... integrated palliative service.</p>
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The King family sponsors this event (yearly)
(Note about this lecture: This lecturer totally won me over. (My usual stance is...
bioethics... who cares! Just bring on the science. But... he addresses an important topic and really addresses it well.
Families just don't get it when you (the MD) ask them "Do you want us to do everything?" or "Do you want us to stop?")
he begins....</p>
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why do you think families say they can't communicate with the MD and vice versa?
(in regard to hospitalized dying patients.)
...</p>
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myth... better not to talk about this conflict...(between the doctor and the family of the dying patient)</p>
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famly thinks... why is MD treating me like a dummy?</p>
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(Why can't (the almighty, all powerful) Stanford cure my loved one? They claim they can cure everything!)</p>
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Futility... when to quit...
why might this caring family be making a decision that is unreasonable? (thinks the MD)
(to continue to try for a cure despite the futility of the case.)
He polls our SRO audience of a few hundred... why does the family refuse to give up?
(many, many excellent justifications provided by our audience)</p>
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also this approach will help in talking with your teenagers...</p>
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he cites the big debate (Hillary vs Donald) just last night...</p>
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naive realism...</p>
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can't (the Trump supporters get it and vice versa for the Hillary supporters)</p>
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why is this politically involved person thinking as they do (he analogyzes)</p>
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why would the family insist on keeping going?...</p>
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a million great reasons from the audience..here are a few...</p>
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(they're guilty, they're waiting for a miracle; want to avoid remiss (regrets)) or they want to max. <b>quantity </b>of life...</p>
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Douglas Stone... <b>Difficult Conversations</b>... he recom. this book. (despite being by a lawyer!)</p>
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the more the family talks, the more THEY are satisfied.</p>
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French study... after 15 mins. of discussion by the MD,
the family still does NOT even get the diagnosis or the prognosis.
Family asks "why did my loved one get cancer?"
The (stupid) doctor says "oncogenes!"</p>
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doctors say well, he's "really, really sick" will never just come and out and say... he's gonna die!</p>
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MDs don't like to make people sad.</p>
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everybody's in blue scrubs (same as the cleaning person) (espec at the University...
residents, fellows, attending and from specialty services...</p>
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MDs call it "renal failure" or metastases... incomprehensible!</p>
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waiting for a miracle; big diff. among difft cultures;</p>
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one cannot process more than 3 to 7 pieces of info...</p>
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think of talking to your kids (talking is NOT efficient)</p>
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family does NOT want to hear bad news.</p>
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Lake Wobegan effect (how many of your are good drivers.? everybody raises their hand;
and are your children beautiful? everybody says so.)</p>
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"My Mom is strong" she will beat the odds. (thinks the family)</p>
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do not try to convince them... try to understand...</p>
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Ask; then tell then ask again...</p>
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ask permission... would it be ok if I talked about this... (same approach with your kids)</p>
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(is this a good time to talk about your grades ? (to your kids))</p>
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what's the headline? that's what to give the family...</p>
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what questions do you have? and keep asking until they stop.</p>
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the FEELING conversation (ASK before you tell)</p>
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emotion shuts down cognition.</p>
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when emotions get hot... the cortex shuts down...</p>
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(from neuroeconomics world)</p>
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what really mattersr! (when emotional we talk about what we really care about)</p>
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(why do I have cancer... (<b>oncologist answers by talking about oncogenes</b>)</p>
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when you hear bad new, you first react emotionally.</p>
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what you want... I can't imagine working so hard and not being appreciated
(when you tell spouse that your boss was terrible to you)</p>
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I wish I had a better treatment option;
This must be really frustrating.</p>
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wait with your answer and just be empathic (for 40 seconds)</p>
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Denial... a psych defense mechanism... it's too painful to hear.</p>
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don't quit before your miracle.. (an ad run by by a cancer center)</p>
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False hope... he says the data says that false hope is ok... fine to hope for a miracle.</p>
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(but diversify your hope potfolio!)</p>
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our own feelings are really important (as clincians... a rich source of data...)</p>
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<b>when he is frustrated or upset...he becomes super polite</b>;</p>
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identity conversation...</p>
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best spouse... advocates for her husband and never leaves the bedside... gets everyone involved...</p>
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in contrast... a "good" intern just gets the DNR order in the bag.</p>
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family.. sons do not give up on their dad.</p>
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he cares for HIV patient with pain. he doesnt mind addicts.
(unlike his next door colleague who takes care of CEOs)</p>
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"do you want us to do everything for your dad?" (MD stupidly asks)</p>
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intead, ask... what would your dad want?</p>
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offer a plan...</p>
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family... what ARE you going to do...</p>
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a time limited trial... be clear about what counts and how long...</p>
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find things that you can agree on (with the family)
(but don't continue to have the same conversation over and over again)</p>
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conclusiion: we must up our game with this.
(filed under psychiatry, oncology, jonathan king)
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