Simple But Profound Conversations

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.

1 The Siebens Domain Management Model has 3 sets of terminology for the four domains. The four listed above – Body, Mind, Activities, and Surroundings – are the simplest. See Siebens H., "Proposing a practical clinical model," Topics in Stroke Rehabilitation 2011;18:60-65.
 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.