Doctor: well your blood pressure is fine, and her are the repeat tablets for you.
Patient: thank you
Doctor: and that was easy today so we’ve got a bit of time, and there is something that I would like to talk to you about which was precipitated for me because I was talking to my father. My dad is 84, he’s very fit and well. He plays tennis, but he was talking to me able very difficult things that have happened to his friends and what could, how things could be different. And some of his friends have had awful experiences with illness, and he’s scared about that. I just wondered if you had any fears about that sort of thing?
Patient: Yes. As a matter of fact I have.
Commentary (Karen): I think this is a really good way of introducing it. The doctor’s put it in a situation and clearly he’s got good engagement with the patient.
Commentary (Bill): Yes.
Commentary (Karen): He has put in a way that he can relate to.
Commentary (Bill): and he’s normalising it so, he’s saying this is something I would do. In fact, my father’s done and asks some questions about so, it puts her at ease with the fact that he is raising it. So, it’s okay. It’s sort of like giving it permission I suppose.
Commentary (Karen): yes.
Patient: and I do think that in my age group and (pause), lots of people in my age are not as well as I am, and you are aware of other people having bad experiences and having to go into care or even into hospital and I do think about that.
Doctor: so Elizabeth, tell me about what’s important to you for your health and quality of life at the moment.
Patient: I think the most important thing is independence.
Patient: and being able to get out by myself and engage with other people socially and in organisations.
Doctor: ahh (nodding).
Patient: and generally being able to do everything by myself.
Commentary (Karen): That was a really good question because he clearly got the conversation going and now he’s just sitting there and listening to what she has to say.
Commentary (Bill): Yeah. She’s sort of. She’s cottoned onto it straight away hasn’t she?
Commentary (Karen): Yes. And he’s just listening which is really good.
Doctor: any other things you can think of like intellect, or….
Patient: I very much hope that I will be able to manage cognitively until the end of my life.
Commentary (Bill): It’s interesting that he used the word “intellect” and she then responded with “cognitively”. That’s great that it works here, and he obviously knows his patient to know the sort of terminology, but obviously wouldn’t work for everyone one would it?
Commentary (Karen): No.
Commentary (Bill): Often you’d talk more about ability to think or do the crossword or, or you know but I don’t mean that in a sort of simplistic way, but the sort of activities that you already know your patients would be involved in or interested in.
Commentary (Karen): Yes, and clearly here, as you say, he knows this patient really well and so he’s, presumably you know using his past experience to know what level to pitch the conversation which is really important.
Doctor: have you had any particular experiences with people close to you who have had a difficult time with illness or death?
Patient: Yes as a matter of fact I have. I don’t know whether you know about my husband who died last year but we had a really unfortunate experience with him. He badly wanted to stay at home, and he had a terminal illness, and in the event he went to hospital and this caused a lot of discord in my family. Some members of my family wanted him to go to hospital others wanted him to stay at home, and it made the whole situation much worse then it might have been.
Commentary (Bill): It’s great the way the doctors asks about her past experience and how that experience might inform or influence how she feels about illness and problems for herself. Clearly it helps her to relate to how she sees it.
Commentary (Karen): I agree, and he’s also a really good listener and he’s using the right body language which just keeps the conversation going. He isn’t interrupting her either which is really, really good.
Commentary (Bill): Yes.
Patient: and in the end he didn’t have his wish.
Doctor: he didn’t have his wish?
Doctor: did you know what his wishes were?
Patient: Well I didn’t really but, I knew that he didn’t want to go to hospital. I didn’t really know his complete wishes.
Doctor: okay. If that was to happen to you, what would you want to happen?
Patient: I wouldn’t want the discord amongst my family members. Especially I wouldn’t want it amongst my children.
Doctor: so what your saying is that the process he went through caused you stress, your children stress and he didn’t get what he wanted. Is that what your saying?
Patient: That’s exactly what I’m saying.
Doctor: I’m glad we’ve had this……
Commentary (Karen): So here it’s really good the way he used what she was saying about her husband to then turn it into what she would want for herself. So bring the conversation back to her which is well done.
Commentary (Bill): Yes. And by asking about the wishes and she declared that he didn’t get his wish and then also talked about the discord within the family is really seamlessly linking what happened previously with what he wants her thinking about now.
Commentary (Karen): Yes, and he also picked up that the situation with the husband was really stressful and talking about that has got her really engaged in this conversation.
Commentary (Bill): Yes.
Doctor:..talk today. I’ve been through this myself where I’ve had exactly those fears that you’ve had, and there is a solution for that. I’ve done this myself and I’ll tell you about it and you can decide whether it’s the right sort of thing for you. What I’ve done I’ve created a document. It’s called an advance care directive or advance care plan (pause) that (pause) gives me a sense of security. There are four important points to it.
Commentary (Karen): Here he’s actually used the words advance directive and advance care plan and that’s okay but he could have also have this conversation without mentioning those terms at all by just describing what they are. I think that for many patients that would be a better way to do it because clearly using that sort of jargon may potentially create problems, misunderstanding and..
Commentary (Bill): or alienate
Commentary (Karen): alienate the patient.
Commentary (Bill): yes, so he could simply say you know, that is important to think about these things and we could even write them down on a piece of paper.
Commentary (Karen): Yes.
Commentary (Bill): And if later she wants to know what, how we refer to the piece of paper or if he talks about that later that’s fine, but to bring in terms she may not have an understanding of at this time. Look it may be fine for some patients but, not necessarily for all.
Doctor: The first part is it provoked me to have clear discussions with my family about what my wishes are so that in the event of something bad happening to me and I was incapable of determining or communicating what I wanted to have happen, they would know in advance what my wishes were. The second part was that I had to appoint someone to be my agent to act for me if that dreadful thing was to happen. Now, people can choose either a family member or a friend. I chose a friend because the people in my family, I didn’t think were tough enough. I chose someone tough, and someone who knows my wishes and is prepared to argue on my behalf. And the last thing is...
Commentary (Bill): it’s good how he’s done a couple of things there. He’s emphasised to the patient that it’s important to talk about this with the family and obviously to reflect upon it about what he would and wouldn’t want if things went badly. But then he’s also talked about why it’s important to choose a particular person to be substitute decision maker and then he’s elaborated on why its, or the qualities of that person about being tough and knowing what he wants and so on. He’s really getting that message across.
Commentary (Karen)(not visible): Yes, he is.
Doctor: …writing down your wishes very clearly. Now it’s quite a task. It involves a lot of thought, but I found it uplifting to go through. It is a terrific thing to do and it does give me a sense of security.
Commentary (Karen): I think it’s good here that he’s actually explained why it’s so important and what it’s actually done for him. That’s been quite positive.
Doctor: Here’s a booklet which you can read through when you get home, and if you decide this is the right process for you, you can come back and talk to me about it and we can get the things rolling.
Patient: it sounds like a really good idea.
Doctor: an when you read this booklet you will find there are questions in there which will help you to go through the other steps of talking to your family and talking to your medical power of attorney. They help tease out what your clear wishes are so that everyone is clear what you want. After you’ve done that, if you can bring that back to me, then we will go through the process of getting that put in writing, formally, and then send it to the institutions, the hospitals and other places that might be involved in your care in the future.
Commentary (Bill): Initially he’s said that there are four things and it seems liked he has only gone through three, but in fact the fourth one is filling out the document. So it’s talking to the family, it’s appointing a person, its writing or thinking about their wishes and then it’s documenting and then sending the document off.
Commentary (Karen): The other thing that’s really good here is he’s given the brochure to the patient but he’s left it up to her a little bit to take the next step which means she’s not been forced into doing something. So if she really doesn’t want to be involved, then she won’t feel forced into doing something extra. He’s also opened the door so it is very easy for her to continue on if she would like too.
Commentary (Bill): Yes. That’s very important isn’t it?
Commentary (Karen): Yes it is.
Doctor: And hopefully that will give you a sense of security and safety and make things better for you. I’m really please we have had this discussion. This is something that I think is really important but often quite difficult. I’m hopeful that we haven’t upset or distress you by doing this.
Patient: not at all. In fact I was thinking about it myself but, it is so confronting that I probably would not have raised it myself, so thank you very much.
Doctor: it’s a pleasure.
Commentary (Karen): it’s a common misconception that talking about these things will actually upset patients, but as we’ve seen here it’s often the opposite and patients actually want to talk about these things and don’t get upset, or if they get upset they still want to do it. They also expect health professionals, doctors and others to actually raise the topic in the first place, and I think all of those points have been illustrated here.
Commentary (Bill): Yes. In fact she’s saying she’s pleased it’s been brought it up even though she felt it was difficult, she felt it was difficult to think about or bought up herself. I suppose he reflected that in his own way when he said having done this was uplifting which I interpreted to mean it’s a burden off his shoulders which is quite a common response isn’t it, that people feel having had the discussion even though it may not have been an easy discussion.
Commentary (Karen): That’s right. That’s certainly been my experience as well.