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ES 06 - Communication Skills in the End of Life/ Symptom Management in Lung Cancer (ID 515)
- Event: WCLC 2017
- Type: Educational Session
- Track: Nursing/Palliative Care/Ethics
- Presentations: 1
ES 06.02 - Discussing Advance Care Plans - What Do You Say? (ID 7606)
15:45 - 17:30 | Presenting Author(s): Florian Strasser
Patients with advanced, incurable cancer, and also their family members, typically struggle between hopes to have long lives or even get cured and the concious, unconcious or denied reality of limited life time due to cancer. This struggle becomes more pronounced in modern oncology, making predictions of response to anticancer treatments or survival increasingly difficult. Adressing existential issues and uncertainties is an often feared theme for cancer clinicians (doctors, nurses, other professionals) in clinical practice: concerns about destroying hope, hesitation about own professional role (e.g., authentic, paternalistic, servant for patients autonomy), doubts about involvement of family members, incertitude about decisional processes on anticancer treatments, or prudence on patients emotional condition (e.g., stress, trauma, anxiety, depression, anger) may constitute real challenges. Adequate communication skills including empathetic communication and concepts of shared decision making are necessary, but often not suffcient to perform as an accountable, understanding, educating, empowering, self-reflective, and competent clinician guiding patients and families to address the reality of limited live time, death, dying and bereavement. Preparation for illness-deterioration and end-of-life encompasses continuous engagement in a) patients illness understanding (e.g., causes and impact of pain, fatigue, or cachexia); b) decisional processes for or against anticancer treatments (e.g., concrete goals, significance of burdens, characterization of patients values and expressed definition of own quality-of-life); c) worst and best time range scenarios of life expectancy (never say a concrete mean estimate !) These communicative, educational and counselling interventions are part of early integrated palliative care, supported by high quality evidence to improve patients quality-of-life and symptoms. To integrate palliative care early services may adapt the name (supportive) but not the content. Advanced care plans (ACP) shall include most relevant elements to prepare for the end-of-life period, but often they are limited to power of attorney and life-sustaining treatment choices (e.g., POLST, Advanced Directives); evidence suggests that such limited processes may not alleviate existential distress, but still are important. ACP shall encompass a structured process delivered in several encounters of patient and family members with cancer clinicians, built on a trustful relationship invigorated in good decisions, patients values and life concept including spiritual aspects and patients and families’ adequate illness- and prognosis understanding. Evidence supports that ACP do not deteriorate hope and that even in cultures not used to ACP patients welcome them. Key elements of ACP encompass patients’ life values, expressed understanding and preferences of management of typical complications and disease deteriorations, concrete professional support (nurses, specialized palliative care nurses, physicians, other professionals, 24/7), timeschedule of family members offering support, preferred place of death, adressing premortal grief with important people, adressing premortal preparation for postmortal roles, preferences for funeral arrangments, legacy work, finish business including legal & financial issues and words of love, excuse, forgiveness and love, use time left conciously, prepare for prolonged live and lazarus effects. To engage in ACP clinicians may self-reflect about own accountability to have an opinion, offered in a humble, reliable, and attentive way. Also clinicians may embrace concepts of healthy denial and the power of the double way: the reality of death and dying together with promises of modern oncology. In summary it is less the issue of what to say, but how to support the process, offer advice and continuous, accountable support.
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