I just finished reading Dr. Atul Gawande's book Being
Mortal. He explores how we fail to talk about death - those important
and uncomfortable conversations between doctors and patients. Dr. Gawande
provides multiple examples where treatments continue while healthcare
professionals miss the forest for the trees. The patient is dying but no one
talks about it.
As an example, I became responsible for the
care of a middle-aged patient with metastatic cancer in our rehabilitation
unit. He and his wife had been told that we would get him
better. He would be going home. After reviewing the
records, examining and talking with him, I realized the man was actively dying. He
was in the last weeks of life when death is unequivocally near. No medical
professional had told him the facts.
It fell to us, admittedly late in the situation, to
have the conversations as described by Dr. Gawande. We began to
review the patient’s understanding of his illness and what was most important
to him at the moment. We shared the cancer's reality and how it was
affecting his body. These conversations involved his family and the
treatment team. But before the discussions could be completed, he died suddenly.
Tragically for his family, we had not resolved all the issues. It was also
profoundly painful to me as his doctor, trying to do the right thing.
Talking honestly with patients is crucial to the
quality of our work, whether in crisis or in basic care. But how to
structure those conversations in the crazy pace of patient care? I
have come to a framework based on my own experiences with rehabilitation and
geriatric patients. It is a simple 4-domain outline, easy to
remember. Each domain addresses a different area of the patient’s
health: body, mind, activities, surroundings. Identifying issues within
the domains can be key to providing quality care (1).
Called the Siebens Domain Management Model
(SDMM), this framework is gradually being applied by others because it works. Here
are three examples from clinicians who have used it during their patient
conversations:
1. A physician in a rehabilitation unit reported,
"I would have normally not considered asking Mr. A. about his future
employment just a week after his bilateral below-the-knee amputations.
However the SDMM cue card (2) prompted me to ask about his
work. It required driving. We set him up with our
vocational rehabilitation services to start right after he left the
hospital. From there, he was set up with a training program for
drivers with amputations. Had I not started the ball rolling, there
may have been some real delays in getting these services started. The
patient may not have returned to work as soon as he did, leading to possible significant
loss of income."
2. Another physician had an inpatient, wheelchair-user, heading for discharge. He was returning
to his "previous living arrangements, which was with his wife in a first
floor apartment with wheelchair ramp access and no stairs." The plan
seemed appropriate. However, using the SDMM framework, the physician
knew to ask about his surroundings. He revealed that he
was not on good terms with this wife. She had moved out two days
earlier. She would no longer care for him. She would no longer drive him
thus leaving the patient without transportation.
The physician added, "This information greatly
changed his discharge plan." Had she not inquired
systematically about his living situation, the patient's new circumstances
might not have been discovered as quickly. Bringing his major non-medical
concern to light better informed the treatment plan for his life
post-hospital.
3. A seasoned primary care physician had a patient
with multiple sclerosis. He was losing his ability to walk. During
an out-patient visit, and using the SDMM cue card, she inquired about his
spirituality. She learned that he had a strong faith that
helped him live day-to-day. She told me, "I had had no idea and it
was remarkable. I really learned something important about how he
managed. This helped me connect with him much better."
Conversations with patients provide us a deeper
appreciation for them. They need not always lead to immediate medical
decisions, as in the discussion with the patient suffering with
MS. Other times, the resulting connections often improve our
diagnoses and care plans. Either way, the connections are at the core of
what we doctors love most: providing quality care that
includes conversations about strengths and solutions in the midst of
adversity. Conversations that save us from missing the forest for the
trees. Conversations that are simple but profound.
2 The SDMM Cue Card (also called SDMM Communication Card), downloadable at no charge from the Resources on this website's home page. Please note Guidelines for SDMM Use as well.
