https://choosingwiselycanada.org/events/past/

Link to Time to Talk: Encouraging Serious Illness Conversations https://choosingwiselycanada.org/serious-illness-conversations/

Please feel free to enter any questions or comments in the Chat box.

I thought that the term living will was no longer used ??

@Aileen - it's not something used in Canada.

We use different terminology provincially. In BC it would be an Advance Care Plan or Written Expression of Wishes.

My experience (as a patient partner in various end of life, palliative care and end of life communication initiatives) is the the general public does not (yet) know the change in terminology - eg that Living Will is now called Advance Directives

How to get the horse to drink? "Better communication" a fundamental, SIC useful, but how to help busy clinicians take it up when other exhortations to communicate haven't succeeded?

Yes! Dr Sanders - thank you for acknowledging lack of resources oft prevent dying at home.

I have to leave early for another meeting so wonder about the response to my question/ comment. But here it is, the assumptions about why some expect LST are typically culture specific and do not consider the contexts of variations in global bioethics where sanctity of life impacts most values and wishes for (even) aggressive treatment.

Unless someone has a very quick death/ short end of life period , lots of insurance , a big family or support system and or lots of money dying at home just not realistic in many cases

In Alberta we have hospitalists. They interrupt the flow and trust with your family physician. How do we get rid of them?

Hi @Esha - what is LST?

@Richard Edwards: such a key point. The PCORI initiative I’m involved with is developing scaling up/sustainable strategies for incorporating SICP

@Kathy what I find discouraging is in QC due to acute staff shortages, people at EOL requiring either MAiD or palliative care must now go to the hospital instead of receiving this care at home.

It is also time now to share with patients and families about the unusual cruel clinical practice of Unilateral DNR ORDER in cases where clinicians do NOT agree with even conscious well informed adult patients' wishes despite recods of SIPP or ACP

is there a link to the tool kit thank u

https://choosingwiselycanada.org/serious-illness-conversations/

This is the link to the toolkit

thank u!

There are also important protocols of the Due Process which do protect patienyts and families in dispute settings and it is critical that all SIPP conversations inform patients and families about these.

can you put the qr code up again? thank you for a great presentation

In Alberta proxy /agent legal paper work includes a advance care plan which is legally enforced by the Personal directive act

Here is the link to the Choosing Wisely tools for serious illness conversations, this was what Dr. Sanders QR code linked to @Bhooma Bhayana https://choosingwiselycanada.org/serious-illness-conversations/

Thank you for the great lecture!

Yes!!! What to expect when you are expecting - what to expect when you are diagnosed with a chronic illness!!!

Absolutely!

Maybe we need to change the term Advanced Health Care Planning. I teach this , work in long term care , do palliative care , the medical team get the term but the lay public don't get it. This came home to me recently doing a volunteer talk in the community to seniors on ACP and they had no clue as to what it was ? financial , life , health etc

Except we rather look forward to a birth more than the other end of things...

I often say - people deserve as much attention, love and education at end of life that they get a beginning of life

@Nicole absolutely!

Patient-centred care along with co-design creates informed patients who are much better prepared for all sorts of events - and have the courage to speak up.

We all need death plans! Everyone plans their life; school, weddings, babies, careers, etc. but we never plan for our death. Detah is something that we will all have the opportunity to experience.

Death*

Definitely! We need to change the culture to accept death. Change the death phobia.

it's a realtionship

Both ACP and SIPP need to be inclusive to resonate with diversities and dynamism of patients and families in addition to their contexts of soecific illness

@Richard: couldn’t agree more about birth being a joyous anticipation, vs end of life - not so much. I always push back against that comparison (with all due respect @Leah Steinberg)

and exceptional situations such as the pandemic

Agree! The relationship is key to the experience/ journey

The role of the SDM is to interpret the previous expressed wishes of the patient, whether written or verbal, and apply it to the decision to be made. Therefore any information ACP, Advance Directives, informal conversations and SIC is all important to support future decisions needing to be made on behalf of an incapable person.

Public need to know what their options are

Absolutely !

Early education might be a place to start. My children changed my role in recycling with education...What has the panel seen in regards to early education advocacy?

How’s about determining what language we (patients/fam) use rather than trying to get us to understand your jargon

Its usually the clinician making an excuse for their lack of skill blaming the patient that the patient just doesn't understand

Values and contexts of life and death are typically culture specific and it is critical to integrtae these cultural variations in both public awareness raisng and healthcare providers'education

The relational component: one outcome of this that I have never heard discussed is clinician reward (avoidance of burnout). I am an intensivist so spend much of my work day with patients with whom I cannot communicate. The time that I spend sitting with a patient on the ward, prior to ICU admission, discussing their options, is one of the most emotionally rewarding parts of my job, and I think protects me from burnout because of the connection that we develop. Just to make the point that the value of these conversations is not just one-way to the patients.

I also push back on ‘values’ (I know, politically incorrect ) but..- too obtuse, and oft requires too much explanation to get to the questions that I think more easily accessable: hopes and worries.

My worry with COVID is reinforcement that a person could know what they would and would not want as far as specific medical interventions in the absence of context

There is a bit of disconnect for me. Choosing wisely is about not offering tests and treatments that are not wanted or valued. This means treatment decisions need to be made congruent with patient values. If SIC is about ‘preparing’ the patient and relationship building, there seems to be a gap in improving medical decision-making. seems like there needs to be more work done on improving shared decision-making in the context of serious illness if we are going to realize the CW goal.

Have to leave now but thank you for organizing this very important conversation ! Look forward to many more !

@Daren: Yes! Shared Decision-Making in end of life. Hard, IMHO because oft we don’t know as much as you (doctors etc) about what (may be) ahead and consequences of decision.

Thanks for a fantastic presentation!

Perhaps change the pcp payment to an annual panel payment. Stop the fee for service

with the serious illness charts maybe including all the possible billing codes attached to help folks with the billing

Indications too that effective conversations are time-saving longer term.

Agree, Leah! Sometimes it might be one question from the guide that is relevant to the situation that helps us to ascertain goals, values, wishes. I have gleaned great information by using parts of the guide (especially in time-pressed situations) in the moment.

wondering about the intent of "green sleeves" in family praxtice..I worked in alberta which i have seen more prevalence of this conversation, now in nova scotia...I find not as prevalent

process of discussions all along the course of the serious illness

normalize these conversations not just at the time of crisis ?

@Janet Reynolds: Yesss! Built into annual, with a Q ‘prompt’. Also SO critical to prepare us for convo: give us time to think bout what we do or don’t know

pcps must have these conversations. prevention is way cheaper and more effective with outcomes than treatment later

Different conversations at different stages in the disease and whether it's learning values or at a time when a treatment decision needed

@ Ailee: Totally agree. These conversations should be normalized. Regularly "touching base" with patients regarding these discussions are so helpful.

Thanks for your great work everyone

How many of us on this call are patients? I hope lots are here .

Thanks Justin, Leah et al for this great sessions. A group of us nationally are working with Pallium to create nationally accessible SIC workshops for clinicians and to train facilitators.

Fantastic conversation! Thanks, Justin and Leah!!

Normalize from the get go

Surely "communication skills" are integrated into medical training?

Thanks Justin and Leah

Thank you great discussion .

Oh please, can I be (a patient partner) on continued convos?

There are "official" patient groups who might be happy to receive guidance on how to start such conversations with their clinicians.

Wendy, Choosing Wisely could lobby medical schools to begin an understanding of these issues with medical students before they begin their careers.

I believe the patient must be part of this whole conversation. I am a PaCER trained volunteer and a patient.

Thank you for the session, good conversation

Excellent conversations, thank you.

Most def patient partners needed in convo to make it most effective for all stakeholders

Thank you Leah and Justin for this stimulating conversation!

Survey Link (English): https://www.surveymonkey.com/r/72MT89ZSurvey Link (French): https://fr.surveymonkey.com/r/72XSPM2

Excellent presentation!

Thank you for a great presentation and discussion - from Nova Scotia

Thanks so much!

Please email your questions to: info@choosingwiselycanada.org

https://choosingwiselycanada.org/event/cwtalks-jan13/

Thank you, Justin. So happy to have you and your wisdom on this side of the border! :)

Abstract Submissions: https://choosingwiselycanada.org/perspective/abstracts-2022/