The initial interview in palliative care consultation
- Timothy E Quill, MD
Timothy E Quill, MD
- Professor of Medicine, Psychiatry and Medical Humanities
- University of Rochester School of Medicine
The clinical interview in palliative care is not only central to the information gathering process, and to understanding and being able to address patient and family suffering, but it is also a fundamental therapeutic method. Good communication skills, while always important in clinical medicine, are especially indispensable in the context of a life-threatening illness, where fear, anxiety, existential terror, and terrible sadness can make for a challenging clinician-patient relationship. A key task for the palliative care consultant is to establish a personal connection with the patient that can not only tolerate but also integrate the affect that is typically associated with profound worries about the future and with repeatedly receiving bad news. The palliative care interview aims to collect both routine medical data and, as described below, additional personal information not regularly included in a medical history. (See "Overview of comprehensive patient assessment in palliative care".)
This topic will focus on the initial interview that is conducted during a palliative care consultation for an adult, which includes identifying specialized aspects of information gathering and of developing an intimate, trusting clinician-patient relationship that can address a broad range of biopsychosocial and existential/spiritual issues. An overview of the domains of a comprehensive palliative care assessment and a number of related topics in medical consultation and palliative care are covered elsewhere. (See "Overview of comprehensive patient assessment in palliative care" and "Overview of the principles of medical consultation and perioperative medicine" and "Benefits, services, and models of subspecialty palliative care" and "Communication of prognosis in palliative care" and "Survival estimates in advanced terminal cancer" and "Communication in the ICU: Holding a family meeting" and "Discussing serious news" and "Overview of spirituality in palliative care" and "Approach to symptom assessment in palliative care" and "Pediatric palliative care" and "Ethical issues in palliative care" and "Assessment of decision-making capacity in adults".)
GOALS OF BOTH PATIENTS AND CLINICIANS
When patients and families facing a serious and/or life-threatening illness are asked what matters most to them, comfort is often a foremost concern. However, issues that extend beyond the usual biomedical goals of clinical care are also cited [1-4]:
●Avoiding inappropriate prolongation of dying
●Relieving the burden on the familyTo continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Singer PA, Martin DK, Kelner M. Quality end-of-life care: patients' perspectives. JAMA 1999; 281:163.
- Steinhauser KE, Christakis NA, Clipp EC, et al. Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA 2000; 284:2476.
- Steinhauser KE, Clipp EC, McNeilly M, et al. In search of a good death: observations of patients, families, and providers. Ann Intern Med 2000; 132:825.
- Heyland DK, Dodek P, Rocker G, et al. What matters most in end-of-life care: perceptions of seriously ill patients and their family members. CMAJ 2006; 174:627.
- Jagosh J, Donald Boudreau J, Steinert Y, et al. The importance of physician listening from the patients' perspective: enhancing diagnosis, healing, and the doctor-patient relationship. Patient Educ Couns 2011; 85:369.
- The AM, Hak T, Koëter G, van Der Wal G. Collusion in doctor-patient communication about imminent death: an ethnographic study. BMJ 2000; 321:1376.
- Steinhauser KE, Christakis NA, Clipp EC, et al. Preparing for the end of life: preferences of patients, families, physicians, and other care providers. J Pain Symptom Manage 2001; 22:727.
- Huskamp HA, Keating NL, Malin JL, et al. Discussions with physicians about hospice among patients with metastatic lung cancer. Arch Intern Med 2009; 169:954.
- Alexander SC, Sullivan AM, Back AL, et al. Information giving and receiving in hematological malignancy consultations. Psychooncology 2012; 21:297.
- Heyland DK, Rocker GM, O'Callaghan CJ, et al. Dying in the ICU: perspectives of family members. Chest 2003; 124:392.
- Teno JM, Clarridge BR, Casey V, et al. Family perspectives on end-of-life care at the last place of care. JAMA 2004; 291:88.
- McDonagh JR, Elliott TB, Engelberg RA, et al. Family satisfaction with family conferences about end-of-life care in the intensive care unit: increased proportion of family speech is associated with increased satisfaction. Crit Care Med 2004; 32:1484.
- Anderson WG, Alexander SC, Rodriguez KL, et al. "What concerns me is..." Expression of emotion by advanced cancer patients during outpatient visits. Support Care Cancer 2008; 16:803.
- Pollak KI, Arnold RM, Jeffreys AS, et al. Oncologist communication about emotion during visits with patients with advanced cancer. J Clin Oncol 2007; 25:5748.
- Curtis JR, Engelberg RA, Wenrich MD, et al. Missed opportunities during family conferences about end-of-life care in the intensive care unit. Am J Respir Crit Care Med 2005; 171:844.
- Hancock K, Clayton JM, Parker SM, et al. Discrepant perceptions about end-of-life communication: a systematic review. J Pain Symptom Manage 2007; 34:190.
- Anderson WG, Chase R, Pantilat SZ, et al. Code status discussions between attending hospitalist physicians and medical patients at hospital admission. J Gen Intern Med 2011; 26:359.
- Jenkins V, Solis-Trapala I, Langridge C, et al. What oncologists believe they said and what patients believe they heard: an analysis of phase I trial discussions. J Clin Oncol 2011; 29:61.
- Peigne V, Chaize M, Falissard B, et al. Important questions asked by family members of intensive care unit patients. Crit Care Med 2011; 39:1365.
- Mack JW, Cronin A, Taback N, et al. End-of-life care discussions among patients with advanced cancer: a cohort study. Ann Intern Med 2012; 156:204.
- Momen NC, Barclay SI. Addressing 'the elephant on the table': barriers to end of life care conversations in heart failure - a literature review and narrative synthesis. Curr Opin Support Palliat Care 2011; 5:312.
- Nelson JE, Gay EB, Berman AR, et al. Patients rate physician communication about lung cancer. Cancer 2011; 117:5212.
- Reinke LF, Slatore CG, Uman J, et al. Patient-clinician communication about end-of-life care topics: is anyone talking to patients with chronic obstructive pulmonary disease? J Palliat Med 2011; 14:923.
- Tulsky JA, Fischer GS, Rose MR, Arnold RM. Opening the black box: how do physicians communicate about advance directives? Ann Intern Med 1998; 129:441.
- Heyland DK, Frank C, Groll D, et al. Understanding cardiopulmonary resuscitation decision making: perspectives of seriously ill hospitalized patients and family members. Chest 2006; 130:419.
- Weeks JC, Cook EF, O'Day SJ, et al. Relationship between cancer patients' predictions of prognosis and their treatment preferences. JAMA 1998; 279:1709.
- Murphy DJ, Burrows D, Santilli S, et al. The influence of the probability of survival on patients' preferences regarding cardiopulmonary resuscitation. N Engl J Med 1994; 330:545.
- Lautrette A, Darmon M, Megarbane B, et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med 2007; 356:469.
- Norton SA, Hogan LA, Holloway RG, et al. Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients. Crit Care Med 2007; 35:1530.
- Billings JA. The end-of-life family meeting in intensive care part I: Indications, outcomes, and family needs. J Palliat Med 2011; 14:1042.
- Billings JA. The end-of-life family meeting in intensive care part II: Family-centered decision making. J Palliat Med 2011; 14:1051.
- Billings JA, Block SD. The end-of-life family meeting in intensive care part III: A guide for structured discussions. J Palliat Med 2011; 14:1058.
- Back AL, Arnold RM, Baile WF, et al. Efficacy of communication skills training for giving bad news and discussing transitions to palliative care. Arch Intern Med 2007; 167:453.
- Goelz T, Wuensch A, Stubenrauch S, et al. Specific training program improves oncologists' palliative care communication skills in a randomized controlled trial. J Clin Oncol 2011; 29:3402.
- Baile WF. Training oncology practitioners in communication skills. J Pediatr Hematol Oncol 2011; 33 Suppl 2:S115.
- Kissane DW, Bylund CL, Banerjee SC, et al. Communication skills training for oncology professionals. J Clin Oncol 2012; 30:1242.
- Tulsky JA, Arnold RM, Alexander SC, et al. Enhancing communication between oncologists and patients with a computer-based training program: a randomized trial. Ann Intern Med 2011; 155:593.
- Hospice and Palliative Medicine Competencies Phase 3 Workgroup. The SECURE Framework - Palliative Care. www.aahpm.org/pdf/toolkit/icsa.doc.
- Quill TE, Cassel CK. Nonabandonment: a central obligation for physicians. Ann Intern Med 1995; 122:368.
- Beckman HB, Frankel RM. The effect of physician behavior on the collection of data. Ann Intern Med 1984; 101:692.
- Lo B, Quill T, Tulsky J. Discussing palliative care with patients. ACP-ASIM End-of-Life Care Consensus Panel. American College of Physicians-American Society of Internal Medicine. Ann Intern Med 1999; 130:744.
- Back AL, Arnold RM, Baile WF, et al. Approaching difficult communication tasks in oncology. CA Cancer J Clin 2005; 55:164.
- Learning Module 1: Introduction to Oncotalk Teach. Developing skills for teaching communication to oncologists. https://depts.washington.edu/oncotalk/learn/modules.html (Accessed on June 26, 2015).
- Clayton JM, Hancock KM, Butow PN, et al. Clinical practice guidelines for communicating prognosis and end-of-life issues with adults in the advanced stages of a life-limiting illness, and their caregivers. Med J Aust 2007; 186:S77, S79, S83.
- Back AL, Arnold RM, Quill TE. Hope for the best, and prepare for the worst. Ann Intern Med 2003; 138:439.
- Quill TE, Arnold RM, Platt F. "I wish things were different": expressing wishes in response to loss, futility, and unrealistic hopes. Ann Intern Med 2001; 135:551.
- Quill TE, Brody H. Physician recommendations and patient autonomy: finding a balance between physician power and patient choice. Ann Intern Med 1996; 125:763.
- Billings JA, Krakauer EL. On patient autonomy and physician responsibility in end-of-life care. Arch Intern Med 2011; 171:849.
- Bernacki RE, Block SD, American College of Physicians High Value Care Task Force. Communication about serious illness care goals: a review and synthesis of best practices. JAMA Intern Med 2014; 174:1994.
- Quill TE, Williamson PR. Healthy approaches to physician stress. Arch Intern Med 1990; 150:1857.
- Meier DE, Back AL, Morrison RS. The inner life of physicians and care of the seriously ill. JAMA 2001; 286:3007.
- GOALS OF BOTH PATIENTS AND CLINICIANS
- PROBLEMS COMMUNICATING WITH PATIENTS WHO HAVE A SERIOUS ILLNESS
- PREPARING FOR THE CONSULTATION
- Getting started
- - Greeting
- Patient-centered interview: Process
- Patient-centered interview: Content
- Patient-centered interview: Responding to emotions
- CLINICIAN-CENTERED INTERVIEW
- Patient and family education
- Care planning: Establishing goals of care and making a recommendation
- Arranging follow-up
- COMMUNICATING WITH THE CARE TEAM
- CLINICIAN SELF-CARE