Top Six Tips to Start "The Talk"

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End-of-life planning is gaining increased attention in the care coordination arena, in part because of Medicare’s recent decision to allow for end-of-life counseling reimbursements. But initiating “the talk” can be daunting for both physicians and patients. The Telligen QIN-QIO care coordination teams work with community members in Colorado, Illinois and Iowa that have these conversations every day. Here are their top six tips:

1. Get the conversation started.

Anyone can have a conversation about end of life care, says Kate LaFollette, RN, Telligen senior quality improvement facilitator for care coordination in Iowa. Many times, doctors are waiting for the patient to bring up the subject, the patient is waiting for the doctor, and the nurse and family members are waiting for someone to talk about it. Stop waiting for someone else to start this conversation. 

2. Arm yourself with compassion.

You don’t have to be a medical professional to ask someone about his or her values and wishes for end of life, LaFollette says.  The most important skill you need is compassion. Starting a conversation about end-of-life care informs patients and families of their options and helps them make choices that align with their wishes and beliefs.

That said, Peggy Budai, RN, MS, NP-C, CNS, founder of the Sharing the Care Campaign in Fort Collins, Colo., and a geriatric clinical nurse specialist at the University of Colorado Health Northern Colorado, says, “you must be willing to do the work yourself first.” Budai advises people to think about their own preferences, talk with their family and friends about their preferences, and then put their decisions in writing through advance care directives. “Only after you’ve done it for yourself should you have the conversation with the aging parent,” Budai says.

3. Don’t wait until it’s too late.

No planning or poor planning plays a major role in readmission rates. Through her care coordination work for Cass County Health System, a 25-bed critical access hospital with a network of 10 outpatient clinics in Atlantic, Iowa, Danielle Staiert, RN, talks about goals of care with patients who have had multiple readmissions for end-stage diseases. Staiert also counsels the frail elderly and those with end-stage diseases who are in declining health, as well as patients with terminal illnesses who have chosen to stop treatment.

4. Inquire about quality of life.

Staiert starts with open-ended questions: How are you feeling? How has your disease affected your life recently? Then she discusses their options for care that support them in their current environment. These options may include palliative care or hospice.

5. Engage family or caregivers in the discussion.

Staiert includes family members in end-of-life conversations. “This allows the patient to be able to state their wishes with family present,” Staiert says. “This also helps the family hear the patient’s wishes and concerns as well as give the family peace of mind.”

6. Know where advance directives are kept.

Budai says that health care providers not only need to learn how to have these crucial conversations with their patients, but they must take the next step and learn how to find advance directives in their electronic health records (EHRs). “Patients are spending a lot of time and effort to complete these documents, and we need all providers to learn where to find them so that we can do a better job of honoring people’s wishes,” Budai says.

Penny Cook, MSW, Telligen senior quality improvement facilitator for care coordination in Colorado, emphasizes that  “having end-of-life conversations before a time of crisis empowers people to have a voice in their care no matter where they are receiving it. It also ensures that providers understand what people want—and what they don’t want—as they transition between various care settings.”

To learn more about Telligen’s work with communities in Colorado, Illinois, and Iowa that have incorporated end-of-life care planning into their care coordination initiatives, contact Penny Cook in Colorado, Tasha Gill in Illinois, or Kate LaFollette in Iowa.