Scripting the Conversation, Part 2: The provider-patient dialogue

My last post —  Scripting “the Conversation” — discussed scripted dialogue at the national level.  It demonstrated how a few academics, so-called health policy experts, special interest groups, and foundations can stage a national dialogue — frame a conversation — with the help of their media allies.

The same group of academics and foundations have been at work on the micro level, generating scripts — literally word-for-word scripts — to be used by providers when they encounter difficult situations with patients and families, mostly in the context of patients and families who want life-sustaining treatment.

If you doubt me, look at this array of scripts from the Medical College of Wisconsin, devised over the past decade or two with funding from RWJF and George Soros.  The little pocket guide of “Communication Phrases [for use] Near End of Life” features ready-made scripts to help the provider communicate to a patient that the patient’s quality of life is really pretty dismal.  Note that the questions assume, and therefore communicate, that the quality of life is not good:

• How has your disease interfered with your daily activities; your family and friends?
• Have you been feeling worried or sad about your illness?
• What symptoms bother you the most? What concerns you the most?
• How have your religious beliefs been affected by your illness?
• Many patients wonder about the meaning of all this—do you?

Here’s another, from the same guide, on “artificial feeding”:

Discussing Artificial Feeding/Hydration
• What do you know about artificial ways to provide food?
• All dying patients lose their interest in eating in the days to weeks leading up to death, this is the body’s signal that death is coming.
• I am recommending that the (tube feedings, hydration) be discontinued (or not started) as these will not improve his/her living; these treatments, if used, may only prolong his/her dying.
• Your (relation) will not suffer; we will do everything necessary to ensure comfort.
• Your (relation) is dying from (disease); he/she is not dying from dehydration or starvation.

The guide includes a few lines to use on a patient who has indicated via advance directives that he wants CPR (note that the monologue ignores the patient’s wishes):

We have discussed your current illness, have you given any thought to how you would like to be cared for at the time of death? Sometimes when people die, or are near death, especially from a sudden illness, life support measures are used to try and ‘bring them back’, alternatively, we could focus solely on keeping you comfortable.  How do you feel about this?

Anticipating that the patient’s response to “how do you feel about this” might possibly be “Pretty irritated that you have ignored my wishes”, the little pocket guide helpfully offers a few lines to use when the patient or his family is angry.  The physician/nurse/social worker should recite one of these lines:

• It sounds/appears that you are angry?
• You appear angry, can you tell me what is upsetting you?
• So, you are telling me that you are angry about ____, is that correct?
• I wish things were different, how can we move forward? How can I help?

These conversation aids from the Medical College of Wisconsin are offered in conjunction with Project ECHO — the national training program headquartered at the University of New Mexico.  You will find a link to these tools at Project ECHO’s Palliative Care site (here); look for the link to the “End of Life / Palliative Education Resource Center.