Doctor: okay Ian, now that we’ve reviewed all your results, I’m just wondering if it would be alright for us to talk about your future health choices if ever a situation came up where you might not be able to make those decisions for yourself.
Patient: Yes. That would be fine.
Doctor: So Ian tell me then how you are feeling about your health at the moment?
Commentary (Karen): That’s a really good, safe way to introduce the topic and to check that it’s okay to talk about it and then to get going. So that was really good.
Commentary (Bill): Yes, and then immediately as soon as she has engaged him, she’s asking him about his own health. It’s a good way of ensuring that he has a good understanding of what’s going on before she then talks about other things.
Commentary (Karen): It’s the more traditional way that we teach doctors to do advanced care planning.
Commentary (Bill): You mean rather than talk about having done it yourself (Karen: yourself), or with your father or another family member.
Commentary (Karen): Yes.
Commentary (Bill): But both ways are equally valid.
Commentary (Karen): They are and I think there is no right way to do it. The same person won’t necessarily always do it the same way either because it needs to match the situation.
Commentary (Bill): And in fact I think rather than telling people they need to do advance care planning or introduce it in a particular way, they should do it in a way that they are comfortable with, that they can relate to because it will come across naturally rather than feeling forced. So, where as the first GP related to it in his own way, and we know in fact that he is very good at doing advanced care planning, this doctor does it in her own way and it comes across naturally.
Commentary (Karen): It does. They’re both really good ways to do it.
Patient: Well, I’m really not enjoying life as I used to. I, I’ve always enjoyed my golf and now I find I can’t walk around the golf course anymore which is a worry to me. The other thing is I don’t want to be a burden to my family.
Doctor: can you tell me more what you mean by that?
Patient: I’ve been independent all my life and active all my life and I just feel I would be a burden to my family and my wife if I was laid up in bed for a lengthy period of time with no likelihood of any good outcome coming out of it.
Doctor: What do you mean by good outcome and what are the things that are really, I guess are so important to you that you wouldn’t want to lose in your life if you felt that…..
Patient: Well I think my independence is, is the main factor. I still like to be active, and I certainly wouldn’t want to finish up in a nursing home.
Commentary (Karen): It was really good as she was going through when the patient was making statements that she actually asked him to clarify what he meant by being a burden or what he meant by outcomes. It was very clear to her what he was actually talking about.
Commentary (Bill): Yes, and the way she is drawing him out so that he explains to her what and explains for himself what are actually the important outcomes that would make a difference for him.
Commentary (Karen): and now she’s moving onto what it means to live well now, so that’s really good as well.
Commentary (Bill): And I like the way she’s leaning forward and she’s really engaged with the patient. She‘s got a smile. She’s coming across as very relaxed and probably putting him at ease in having this sort of discussion.
Patient: the worst thing that could ever happen to me. I just want to want to fall off the twig when the last putt drops in on the 18th hole at the golf course. Oh man, I would be the happiest man dead.
Doctor: So that’s, that’s, I can, I can understand what you are saying there but I guess it doesn’t always happen that way, that there’s a sudden event and we die. I mean it might be that there’s a process of illness, and significant illness before that happened. Have you thought about what you might like done, if you were say, say if you were to have another really significant heart attack, or a stroke or something where you really couldn’t do those things that you said are so important to you?
Commentary (Bill): It’s good the way she’s brought him back on track. It’s helped to dispel his thinking that it’s just going to be fine for ever and that he’s just going to drop dead and she’s pointing out, I think, in a nice way that that’s not the way it happens and so she’s really making sure he thinks about what if another event occurs like the event he’s already had before like a heart attack or something like that.
Commentary (Karen): Yes. I agree. Again she’s using what he’s saying to make sure that she can clarify anything.
Commentary (Bill): Yes.
Commentary (Karen): Which is good.
Commentary (Bill): reflecting it back on him.
Commentary (Karen): Yes.
Patient: well I have mapped it out in my mind that if I’m incapacitated to the extent where I am a liability on carers and high care situation, I don’t want to be hooked up to a whole heap of pipes and things and just kept alive for the sake of being alive. I would like to die like my grandfather died. He never went into hospital in his life. He fell of his bike at 88 and we went to visit him in the hospital on the Monday night. I said we would come out on Wednesday night and he said I won’t be here. He said he was going to his maker and he did on Wednesday morning the happiest man alive.
Doctor: Yes. It seems to me, and let me know, tell me if you think I’ve got it wrong but it seems to me that you have thought about this for quite a long time, and quite, quite deeply about it and if it was to happen that you had a very big heart attack and you weren’t able to do those things that you value highly and you weren’t independent because it comes across again that your independence is very important to you..
Patient: it is.
Doctor:.. so if you weren’t able to make those decisions for yourself, it comes across very strongly that you wouldn’t want any life or you know, heroic life saving measures..
Patient: absolutely not.
Doctor: ..yeah, and that perhaps you might like some control over these things before it happened.
Patient: I think it is better to have control now than too late.
Commentary (Karen): It’s really good here that she’s basically talked back exactly what he’s said but you know to make sure she’s really clearly understood exactly what he said which is a really good way to do it as well. It’s clear that the communication has worked and that she understands what he is saying.
Commentary (Bill): Yes. The summary is good for her for clarification and also good for him so if there was any misunderstanding he can, he can think it through and sort it out.
Commentary (Karen): Yes.
Doctor: yeah. Since you have thought about it for such a long time have you discussed it with your family at all?
Patient: yes, I have but not to any great extent. But I have let them know my thoughts in as much as we have previously discussed.
Patient: I don’t want to be left around, lying around.
Patient: some of them are quite receptive to the idea. Others didn’t want to know about it.
Doctor: No. There is a way you can do this. You can actually write down what you would like done. At the moment you are able to make perfectly rational decisions and you said you have thought about it for a long time, you can actually go through a process where you do write this down. Some people like to choose, perhaps, a family member after the discussion and the whole family might be involved in that discussion and decide the who might be the person that’s appointed I guess to follow through with those decision you have made because that’s what they are doing, basically they are sticking to your decisions so its something that you need to discuss very thoroughly with them and make sure they would be able to do that. It is not necessarily an easy thing in that situation.
Patient: it will save a lot of heart ache….
Patient: ..if and when something does happens..
Patient: decisions are made before hand.
Doctor: yes. Whether you decide in the end to..
Commentary (Bill): It’s nice the way she’s introduced a number of concepts here. Firstly, the one about where she asked him whether he has talked about it with anyone. This introduces the concept of talking about it with your family and making sure they understand what your views would be. She’s also seamlessly introduced the idea of a substitute decision maker and ensured that the qualities of that are understood by him about someone who understands what he would want and who would be capable of making those decisions. He has picked up on that by saying “it would actually make it a lot easier for the family” if all that’s sorted out, it’s easier to make decisions, so it’s running quite nicely isn’t it?
Commentary (Karen): it’s going really well, and she’s doing a really good job of taking him through it all.
Commentary (Bill): Yes.
Doctor: ..have a family member or a friend you know following through with your wishes it’s entirely up to you and really the best fit for you and your family. People do often think that my family knows what I want and you might have been quite clear in what you want, but, but often things happen so suddenly and the situation is so distressing for people that they find themselves unable to make decisions, even simple decisions, let alone decisions that are life saving or life ending.
Patient: That’s why if there is an answer to the situation where we’re not going to have family breakups because of a fight over the deathbed for one want of a better word, we want all the decisions made and each one in the family clear in their mind exactly what’s going to happen.
Doctor: yeah right Ian. Well I’m glad we have had this opportunity to talk about this. I’ve got some literature here. This is a form that talks about the issues that we’ve discussed. It’s called advance care planning. It’s really just about decisions that you want to make for your future health.
Doctor: Take your time. Have a good read. Take you time. Discuss it with your family and make an appointment to see me after you’ve had a look, a week or two what ever suits you and we will have a talk about it when you come back next time. Okay?
Commentary (Bill): The way she brought up advance care planning makes sense to mention it now when she’s handing him a document that says advance care planning on it. I remember earlier she just talked about writing things down, so he thought about that at that time and now he understands a little bit more. So, it’s good to only bring up the terms when required. In fact, you can have a whole advance care planning discussion without ever mentioning the term advance care planning can’t you?
Commentary (Karen): You can. The other thing she does a number of times is talk about talking to his family, and now she’s invited him to come back and talk about this further and what would have been really good is if she’d actually asked him whether he’d like to bring any family or whoever he thought would be a good substitute decision maker along to the appointment because that may have helped the whole process, helped him and helped whoever is going to be his substitute decision maker perhaps other members of his family to be involved in the process.
Commentary (Bill): Yes, I completely agree. Although he comes across as very switched on and positive about it, we don’t know what the family are going to be like. In fact he does already alluded to possible disagreement within the family so we don’t know what lies behind that. In fact he might have a family who are going to fight over the death bed as he referred to it.
Patient: Just a cursory look through there this looks like it’s the answer to my prayers. It’s going to save a lot of heart ache from all angles I think. Thank you very much for bringing this up and letting me know about it.
Doctor: Your welcome.
Commentary (Bill): By saying that it’s the answer to his prayers after having a brief conversation, he’s almost too perfect a patient but it helps to illustrate the point that very, very few patients disagree with having this sort of conversation and really welcome it even if it isn’t something they really wanted to face up to earlier.
Commentary (Karen): Yes. That’s right.