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Palliative Care Perspectives : Chapter 10: Palliative Care Consults : Performing Consultations

As suggested above, most consults are not straightforward requests for advice regarding a particular symptom but rather very difficult processes of communication and relationship building in emotionally charged situations. Thus, most critical to performing consults is skill in communication. The GOOD acronym - identifying goals and options, giving one's opinion and then documenting the consult - is a useful way to think about performing a consult. Here, I highlight key tasks within this general structure and indicate how the GOOD structure may be modified to accommodate the consult process.

1. Identify stakeholders.

The people who request the consult are the most obvious stakeholders in the process. Of course, we hope patients and families will also be involved and will benefit from our work. Other consultants, case managers, and discharge coordinators are often other key stakeholders.

2. Identify overt and covert issues in the consult.

Almost always, certain problems are overt in a consult. The team may be requesting transfer, help with a symptom, or assistance with communication. These are usually easy to identify. More difficult to identify are covert issues - unstated, often emotional issues on the part of consult requesters and others. Often, these must be teased out from conversations with key stakeholders. For example, in the case of Mr. C, discussed at the beginning of Chapter 8, I first talked with the ICU team members. When they told me that if something was not done soon they would have to insert a tracheostomy and a feeding tube, I said something like, "My, that must be worrisome" - a form of empathetic mirroring. "You bet it is worrisome! We don't want to do that," was the reply. In consulting on a case of a "simple" hospice referral in which oncologists are involved, I might ask, "What do the oncologists think about the patient going to hospice?" "That's the thing," comes the response. "The oncologists just refuse to recognize that he is dying. They are pushing for an experimental treatment. You know how they are." Oh, so the covert request is for assistance in dealing with the oncologists. The sooner we know this, the better we will be able to respond.

3. Identify the stories.

Different stakeholders often have very different stories - especially when related to an emotionally charged issue of dispute. As highlighted in the GOOD acronym, it is usually helpful to inquire as to stakeholders' understandings of what is going on. In talking with stakeholders and reviewing the chart, the consultant should try to piece together these stories, looking for points of convergence and divergence. In battling with an oncologist, the primary care team's story may be that the patient is dying and that the oncologist cannot see this and is overall too aggressive. Discussion with the oncologist may reveal that she does recognize that the patient is dying, but the patient keeps asking if any experimental therapy is available because she is not ready to give up. Reluctantly, the oncologist feels obliged to offer such therapy. As these examples illustrate, stakeholder stories go beyond that particular person's opinion of the patient's medical status and wishes regarding a preferred option to include their perceptions of other stakeholders' stories. The primary care team's stories incorporates a perception of the oncologist's story. The oncologist's stories incorporates an interpretation of the patient's stories and tries to make sense of a request for experimental therapy.

A chart review, in addition to providing important medical data about the patient, can be very revealing of certain aspects of clinicians' stories. Histories and physicals (H&P), discharge summaries, and progress notes can be notable not only for what they say, but also for what they do not say. Too often, the H&P and initial progress notes make little, if any, reference to a patient's goals of care, or symptomatology. The patient, as a person, is rarely revealed. Often, the only clues to psychosocial issues, goals of care, and subsequent venues of care are to be found in the case manager, social worker, or discharge coordinator notes, not the physician or nursing notes. If the patient's situation is not improving, short references at the end of notes often suggest that clinicians are growing concerned or frustrated. Usually, there is a clear precipitant to the request for a consult, which should be sought by the consultant. The precipitant is usually helpful in understanding the timing of the request and may hint at covert issues. For example, a utilization review note that pushes for discharge may hint at many possible tensions. Why is the patient still in the hospital? Is discharge a reasonable option? Is there some tension among clinicians, patient, and family as to posthospital options? Have care alternatives even been addressed?

4. Clarify roles.

Different stakeholders are likely to have different expectations (overt and covert) about your role as a consultant. In hearing clinician, patient, and family stories, it is often necessary to clarify the consultant's role, especially when the consultant's perception of his or her role differs from that of a stakeholder. If, for example, the primary care team wants the consultant to "do battle" with another consult team, the consultant should clarify that, while the consult team owes the requester an honest opinion, it does not engage in battles. With patients and families it is particularly important to emphasize that our only goal is to be helpful. So often in a conflict, patients and families come to believe that we are there to talk them into something they do not want to do. An explicit statement of "neutrality" is very helpful, although such a statement may not initially be believed. I often say, "I am not here to talk you into anything. My only goal is to be helpful to you, your family, and the care team." In saying this or similar words, the consultant must truly be neutral and not attached to any particular outcome. In giving an opinion to clinicians, patients, or family, one might say something such as, "I owe you my opinion. However, whatever you choose to do with it is entirely up to you." One cannot even become attached to the goal of performing a successful consult, however that might be defined.* Such neutrality, combined with a sincere statement of one's intent to be helpful, often puts people at ease. I have also noticed that consultants who make such statements become calmer, an infectious condition that serves the process well. The words I use, as in the above example, speak more of neutrality, as this is usually easiest for clinicians, patients, and families to understand. Neutrality, as I am using the term, does not mean without passion or commitment. I may care very deeply about what is happening and have a strong opinion as to what might be best to do. What I really mean in talking of neutrality is not investing oneself in particular outcomes. In interacting with others and in offering my opinion, I try to commit myself completely to the process and to be clear in my opinion. However, having done so, I cannot invest in such things as whether the advice is taken.

*As palliative care consults become more popular in the hospital because of success with difficult problems or patients, unrealistic expectations can arise as to what the team can do. Showered with praise, consultants may drive themselves toward repeated success. Consultants may judge their work a failure if, for example, a patient rejects all overtures to establishing a relationship. Working for "success" can create a quiet desperation in the consultant, which poisons the consultative process.

5. Identify options.

In hearing clinician and patient stories, certain options become apparent. Very often, consults are precipitated by a clear disagreement about options, such as whether to go to hospice. Just as often, certain options will not be apparent to clinicians or patients. Such options may include where to live under what conditions or may concern management of a particular symptom. If the consultant identifies an option that is either not apparent to a stakeholder or that has already been flatly rejected, attempting to make sense of it in relation to that person's story is a key task. A case may help clarify this point.

At the beginning of this chapter, I mentioned a patient who said to our team, "So you're guys who are going to pull the plug on me!" This was Mr. S. Let me share a little more of his story. Mr. S had advanced small cell carcinoma of the lung. Three rounds of chemotherapy had had no effect on his tumor progression. Although the oncologists were "considering" a fourth round, their hearts were not in it. Mr. S had been a loner for many years and had lived in a trailer. He hated being sick but hated losing control of his situation even more. Communication among the ward team, the oncologists, and the patient had deteriorated to the extent that he ordered them all out of his room whenever they visited. They had mentioned hospice as an option, but that just made him more upset. When the intern called for the consult, she said, "Don't tell him I called you. He already hates me!" In response to the above greeting, I told Mr. S that our only intent was to help and that we were not there to pull the plug or to push for anything. "How do you think you are doing," I asked. "Like shit," he replied. He then needed to tell us of all the ways the doctors and nurses did not listen to him, lied to him, and controlled his life. We sat quietly and listened. "That sounds miserable," I responded. "Where do you think you are headed from here?" "I just want to go home to my trailer and be left alone." It was clear to us that Mr. S had an "external locus of control" - that is, he externalized the causes of his problems. At the same time, he desperately wanted to be in control of everything - a sure-fire recipe for suffering. It was also clear that Mr. S hated being on an acute medical ward, which for him epitomized lack of control. We first explored the possibility of where he might live outside the hospital. He admitted that, for now, the trailer was out, as he needed more help than that would allow. He had a daughter, but she worked and went to school full time. He did not want to impose. His estranged wife had even offered to let him live with her, but he nixed that idea, "That's out." Then we began exploring institutional options other than the acute ward. They were effectively limited to three choices - a regular nursing home (which he refused), a rehab-oriented ward, and our inpatient hospice ward. We explored the advantages and disadvantages of the rehab and the hospice wards. In discussing the hospice option, to which he was initially allergic, I said, "I want you to listen for a moment to what the hospice ward has to offer. Just forget about the H word for a minute...." Mr. S also had a number of distressing physical symptoms. I explained that our staff was more skilled in addressing these symptoms than was the rehab ward. Because self-control was such an important issue to Mr. S, I also highlighted the fact that the hospice ward was less restrictive in terms of letting him live as he wished, including the possibility of allowing passes to visit family. In short, I discussed the two ward options in terms of his story. Only after this did we explicitly discuss hospice philosophy and his goals of care. As it turned out, he was not opposed to a palliative approach, he just wanted to keep his options open, and, as is often the case, he needed reassurance that it was fine not to give up hope. In fact, we told him we wanted him to be hopeful. We did not push hospice as an option. As the consultant, I had to be accepting if he rejected this advice and chose the rehab floor or to be discharged to his trailer, even though I believed both would be very foolish choices. The next day we met with his daughter. She and her father toured the unit, and he decided to be transferred. The day following his admission to our unit, he said, "I should have come here a long time ago!"

6. Give opinions.

As mentioned in the section on the GOOD acronym, an opinion should be clear regarding what is being recommended and on what basis. To the extent possible, opinions should take into account the stories of the involved stakeholders and the facts as they are understood. They should relate to points of disagreement and should work to bring different story lines together. In the case of Mr. S, I clearly stated that I believed his needs would best be served on our unit. However, I assiduously avoided trying to convince him of this.

As discussed above, in thinking about offering an opinion the consultant must first consider what aspects of the opinion should be given to the patient or family and what aspects should be offered to the ward team or attending physician. In giving an opinion (recommendation) to the ward team or attending physician, make sure the overt questions asked in the consult have been addressed. If the consult says, "Please evaluate patient for appropriateness for hospice," make sure this is commented on. More covert issues are often better responded to informally. Usually, there will also be numerous aspects of care that the consultant thinks could be improved on. The patient may be on an inadequate laxative regimen. The breakthrough opioid dose may be insufficient relative to the basal dose. Artificial saliva might help with the patient's dry mouth, and so on. In addressing such specifics, the consultant should prioritize a few key recommendations, at least initially, regarding such care but should avoid trying to make things "perfect" with a laundry list of suggestions. The reasons for this are threefold. First, too long a list of suggestions risks overload. The ward team or requestor might implement some but might omit the most important suggestions. Second, the subtext to the recommendation may be interpreted by the requestor as, "You do not know what you are doing and are a terrible doctor. That is why I have to give so many recommendations." Third, a cardinal principle for all consults is help more than you hurt. That is, while you may ask the requestor to do certain things, such as change some orders, on balance the requestor should perceive that you are decreasing his or her work rather than increasing it. The help:hurt ratio can be favorably adjusted by offering to do certain recommended tasks yourself. For example, when recommending home hospice you could help by offering to contact the hospice, if this is agreeable to all parties, rather than recommending that the requesting team do so.

Palliative Care Note
Learn more about these clinical issues by reading the sections on constipation and pain management.

Giving recommendations and opinions often involves giving feedback on care that has already been provided. The recommendations we give often involve suggestions that the requesting team do something different, and thus, in effect, feedback is given that earlier care was less than ideal in some way. In giving feedback a simple but effective technique is to use the "sandwich" approach. First, go out of your way to give positive feedback: "Its great that you have him on a laxative while giving morphine. That is so often forgotten about." "I was happy to see you using a long-acting opioid for his pain." "The patient told me how much he appreciates your care." Then, give recommendations and negative feedback: "However, using just a stool softener is usually not enough when someone is on morphine. Most people need a promotility agent, like senna." "However, the Vicodin you have prescribed is at too low a dose relative to the basal opioid dose." "I noticed that nobody on the team addressed the patient's goals of care during the first two weeks he was in hospital. For a patient with advanced disease, I think this is a priority. Perhaps if the goals had been addressed earlier, it would have saved a lot of trouble." Finally, try to end on a positive note: "This was a great consult. Thanks so much for thinking of us." "It's clear the team has been working very hard to try to help this patient. I know it has been a struggle for you. You deserve a lot of credit for hanging in on such a difficult case."

7. Document the consult.

Documenting the consult in the medical record is a necessity but often seems anticlimactic to the consult process. I recommend that the consultant think carefully about what needs to be written and what could better be handled informally. For example, you might recommend adding senna every evening for constipation. You might informally give the feedback that DSS is an inadequate laxative in discussing the case with the intern in order to save face for the intern. Documentation is a useful way both of summarizing what has happened and of giving explicit recommendations. My notes usually summarize in story form my understanding of the current situation, areas of disagreement, overt questions posed in the consult request, and my overall impression. I then list, in ritual consult form, recommendations. You may also provide some education in the chart by explaining, for example, why a certain medication is recommended, taking care not criticize other clinicians. You might even give the team a short handout that discusses the issues at hand. Because it is difficult to express uncomfortable emotions such as anger or frustration in person, it may be tempting for some to try to express such feelings through the chart. This should be avoided. Because we are human, we will sometimes get upset, but it is far better to deal with these emotions, especially as they relate to other clinicians, off-line and in person.

Summary

Performing palliative care consults is challenging and rewarding work. It is amazing to me that the availability of palliative care consults is more the exception than the rule in most hospitals. I believe that in the not distant future palliative care consult teams will become routine. I look forward to a time when palliative care consults and the widespread provision of palliative care are nothing special, just part of a continuum of healing for the patients and families we serve.

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Palliative Care Perspectives

James L. Hallenbeck, M.D.

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Copyright 2003 by Oxford University Press, Inc.

The online version of this book is used with permission of the publisher and author on web sites affiliated with the Inter-Institutional Collaborating Network on End-of-life Care (IICN), sponsored by Growth House, Inc.