Thinking Ahead – End of Life
Communications in Advance
Care Planning Workshop
Aims of workshop
Raise awareness of what an Advance
Care Plan is
Develop an understanding about the
positive aspects of Advance Care
Promote insight into the issues around
communication and the confidence to start
the Advance Care Planning process with
Recap AIMS of the workshop
Raise awareness of what an Advance Care Plan is:
Tool to encourage pre planning of care
About patient wishes/ preferences
Promoting knowledge of process
Links with Mental Capacity Act
Develop an understanding about the positive aspects of Advance Care
Enables better provision of service related to patient need
Gives hope & empowerment
Promotes patients best interests & honest communication
Promote insight into issues around communication and the confidence to
start the Advance Care Planning process with patients/clients:
Encourages deeper conversations at an important time
Need for empathy
Patient/client led so they remain in control
Identify and link into patient’s communication style/develop rapport
Arthur Dent is a 65 year old gentleman who has diabetes
and smokes between 10 -20 cigarettes a day. He lives
on his own since his wife died 2 years ago from cancer
but he has a 25 year old daughter who lives near by. He
has a history of ischaemic heart disease which was first
diagnosed 10 years ago and he underwent a coronary
artery bypass operation 5 years ago. He was recently
admitted to hospital suffering severe chest pain and was
diagnosed as having had a large anterior myocardial
infarction (heart attack). He has been treated with
intravenous inotropic drugs and nitrates during his
admission. 5 days into his admission his condition is
deteriorating and his echocardiogram still shows severe
heart weakness. The team have reviewed his condition
and his Doctor is planning to talk to him about his care
because his chances of coming through
cardiopulmonary resuscitation successfully are very
White hat (factual)
Dr. Hello Mr Dent. I would like to talk to you about your treatment
options, is that ok with you?
Pt. Yes, that’s ok Doctor.
Dr. OK. If your heart goes into a fast rhythm would you want us to re
Pt. Oh! My goodness is it likely to do that?
Dr. Well it could go into a fast rhythm which we could treat with
defibrillation and intravenous drugs. Otherwise the electrical activity
in your heart could just stop.
Pt. What does that mean? Would I be dead then?
Dr. Yes, technically but there are things that we could do to try to
revive you. In your case though, this may not be the best option.
Would you like me to explain to you what could happen in detail?
Pt. If there are things that you could do I want you to do them!
Red hat (intuition, hunches, feelings)
Dr. Hello Arthur.
Pt. Hello Doctor.
Dr. How do you feel about your condition?
Pt. Well I’m feeling better today because I was able to have a good wash
this morning and I feel as though I have a little more energy. I also had a
little breakfast so that’s bound to help isn’t it?
Dr. Yes, that sounds good. But how do you feel that you are progressing
Pt. I suppose not that well really. I know that my heart isn’t working properly
and I worry that it won’t get any better, I don’t know if I have any hope now?
Dr. What would give you hope?
Pt. My wife died 2 years ago and I worry about my daughter and how she
feels about my condition with it deteriorating. I would like to know how my
daughter feels but I’m afraid to talk to her about it.
Dr. Would it help you if we talked to you and your daughter about possible
courses of action that we can take when we are caring for you, so that you
are both more prepared for if you don’t get better?
Dr. We can talk about the possible next steps in your treatment and we can
help you and your daughter to make some decisions about how you want to
be treated. This may help you and your daughter to discuss the possibility
of your death and how she would cope with that.
Pt. Yes, I think that I would like that.
Green hat (possibilities, alternatives,
Dr. Hello Mr Dent.
Dr. I would like to discuss with you your options for your care with
us. As you know we are treating your heart with drugs to help your
heart to work better and we will continue to do that. I would like to
let you know though that you have some options for if your condition
should change or if you should become more ill, would you like to
hear what these are?
Pt. Yes please.
Dr. Ok. There is a possibility that your heart could stop suddenly, if
this happens there is a chance that we could revive you but the risk
is that your brain could be damaged when you wake up.
Pt. I really wouldn’t want that for myself or for my daughter. But if
you don’t resuscitate me it doesn’t mean that you are not doing
everything to get me well again does it?
Dr. No definitely not. We are doing everything that we can to
strengthen your heart. Maybe you would like to talk to your
daughter about it and then we can record your wishes in your notes
about how you would wish to be treated if your heart stops.
Communication skills – being
P – prepare for the discussion
R – relate to the person
E – elicit patient & carer preferences
P – provide information
A – acknowledge emotions & concerns
R – realistic hopes
E – encourage questions
D - document
Case Study Analysis
Facts are necessary but not as an opening statement unless it is initiated by the
This is Doctor driven without rapport with the patient.
The patient is not ready for the information.
This perpetuates the patient’s lack of control over the situation.
Open questioning about feelings lack direction. Good opening chat to establish
Leading question needed to get back on track.
Patient gives a clue that he wants information by saying ‘I know that my heart isn’t
working properly and I worry that it won’t get any better, I don’t know if I have any
Although the conversation is steered to Advance Care Planning, the patient is left
with a plan to pick this up in the future with his daughter.
The patient is more ready for information.
It encourages patient control.
The patient has the power and controls and the Doctor is steering the conversation.
A bit of each hat is appropriate to use at
different times. It is important to
accommodate the patient’s communication
style and agenda and to obtain and
maintain rapport and honesty in
communication. If this is achieved it is
easier to address these issues effectively.
Advance Care Planning is a key part of the
solution to improving end of life care.