Involving the inner circle: Emily Largent, Anne Rohlfing, Lynn Flint & Anne Kelly

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GeriPal - A Geriatrics and Palliative Medicine Podcast 46 min 5 speakers 5 chapters transcribed 8 hours ago

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Why should clinicians explore a patient’s “no” instead of accepting it?

Eric Widera 0:02

Hi JerryPal listeners. Just wanna do a special shout out in the beginning to all of the recent donors to the JerryPal podcast. If you're interested in donating, go to the JerryPal website and just click that big blue button.

Alex Smith 0:14

Special thank you to Margaret Leoung, Huey Lin, Ken Longa, Susan McFadden, Carrie Rubinstein, Marissa Galicia Castillo, Kara Bischoff, Kate Mesrich, James Tulsky, Louise Aronson, Asher Edwards, Mark Apfel, Michael Bordowski, and Meg Wallhagen. Thank you very much.

Eric Widera 0:34

And on with the show. Mm-hmm. Welcome to the JerryPow podcast. This is Eric Quadera. This is Alex Smith. And Alex, I think this may be one of our uh I don't think it's our max number of guests we've had, but it's getting pretty close.

Alex Smith 0:50

Yeah, this is a full house. We're excited to welcome a full slate of guests today. We're gonna start with Emily Largent, who's uh I think they're all returning to the Jerry Powell Podcast podcast. Emily is a bioethicist in the Department of Medical Ethics and Health Policy at the University of Pennsylvania. Welcome back to the Jerry Powell podcast, Emily.

Emily Largent 1:11

Glad to be here.

Alex Smith 1:12

And we're delighted to welcome back um Ann Rolfing, who is a palliative care physician at the VA Palo Alto. Welcome back, Anne. And uh of course Lynn Flint, who's a palliative care physician at the San Francisco VA. Welcome back, Lynn.

Lynn Flint 1:27

Thank you.

Alex Smith 1:28

And a voice that will be very familiar to our listeners, a dynamic and enthusiastic social worker in palliative care at the San Francisco VA and Kelly.

Eric Widera 1:38

Hi there. Nice to be here. So we are gonna be talking about the importance of engaging family members and caregivers into the the care of our patients. But before we get into that topic, I think Lynn Flint has a song request.

Lynn Flint 1:54

I do. Alex, can you play Send the Sun by Nikki Lane?

Eric Widera 2:00

Who who is Nikki Lane and why did you pick this song?

Lynn Flint 2:03

Nikki Lane is a country singer and I was introduced to her by my seventeen year old daughter. So It makes me feel cool to listen to the same music as the

Alex Smith 2:15

teenagers. And you're gonna see her next month?

Lynn Flint 2:18

And we're going to see her next month. Yeah. Exactly.

Alex Smith 2:21

Great. All right. Here's a little bit.

Unknown 2:29

Well it's hard to be apart so many miles in between laying here in the dark are you thinking of me out in the west? Darling, I swear I love you best. And I'm gonna send the sun your way, wake you up. With a dark golden rays I want you around. Don't let the darkness get you down.

Alex Smith 3:21

Lovely. Nice, fun song. Thank you for introducing me to Nikki Haley.

Eric Widera 3:26

All right. I'm I'm gonna start off so somebody else.

Lynn Flint 3:32

I was like,

Eric Widera 3:38

We all looked each other way. Wait.

Lynn Flint 3:42

That was a good moment.

Eric Widera 3:45

All right. I'm gonna start off with a great Jim Jim Jim paper called Make the Call Engaging Family as a Critical Intervention. Done by our two Anns and Lynn Flint, who are on the call with us right now. And Rolfing. Why did you decide to write a paper about the importance of engaging family members? In the work that we do.

Anne Rohlfing 4:12

Yeah, so I think um this this started I'll just say the paper we had to sort of have a de-identified case, but the inspiration was actually um a patient that we saw. I was on a team with Lynn and Ann. I think it was my last week of fellowship. Um And we were on at the San Francisco VA and just had a very powerful case. Um, I think a lot of a very strong emotional reaction, I think, from our whole team at seeing the consequences of not having Family involvement ideally a lot earlier in the patient's care and how that impacted the family, how that impacted the patient, and wanting to make a case for including family much earlier and to disseminate that to our internists, to the folks who are doing a majority of the communication with families when patients are hospitalized and and facing.

Anne Rohlfing 5:07

you know, serious illness diagnoses. Lynner Ann?

Lynn Flint 5:10

I was just gonna say I think it felt really um Uh first of all I'll add to the list of the impacts and this is could be the least of it, but there was an impact on us as a team too. It it really made um the The end of life decision making. Challenging, really challenging. And I think we really when we looked back.

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Chapters

5 chapters

1 Why should clinicians explore a patient’s “no” instead of accepting it? 0:02–7:40 2 What motivated the JGIM paper on early family engagement? 7:40–19:56 3 How does the “burden” reasoning affect patients’ refusal to involve family? 19:56–31:27 4 What is relational autonomy and how does it expand consent? 31:27–43:08 5 How can clinicians move from a simple “no” to a deeper conversation? 43:08–46:16

Speakers

5 identified

Eric Widera 7 min Alex Smith 7 min Anne Kelly 6 min Lynn Flint 4 min Bruno Satin

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Topics in this episode

Alex Smith 1 Nikki Haley 1 Elizabeth Chung 1 Harry Hahn 1 Susan Nelson 1 Eric Quadera 1 Christopher Heck 1 Daryl Owens 1 Asher Edwards 2 Meg Wallhagen 2 James Tulsky 2 Kate Mesrich 2

Source

Recorded23 Feb 2023

Publisherrss.libsyn.com ↗

Transcriptspeaker-named · 100+ languages

Handlerec:20524610

Show notes

You know when you walk out of a patient's room and have that sense, "This isn't going to go well." The patient is sick and getting sicker, and refuses to let you talk with family or other members of her inner circle. Should you stop at "no?" Today we talk with Anne Rohlfing, Lynn Flint, and Anne Kelly, authors of a JGIM article on the reasons we shouldn't stop at "no." We owe it to the patient to explore the reasons behind the "no," commonly not wanting to be a burden to their family. In such cases, we owe it to the patient to use persuasion, for example, "I hear that you don't want to be a burden. And I'm worried that there may come a time when you have trouble making decisions for yourself. We will have to reach out to your daughter then to help with decisions. Imagine her hearing for the first time that you're sick, that you're hospitalized, that you're in the ICU, and that you can't make your own decisions? That's a huge amount of news all at once. It would help her to prepare if we could start talking with her now." We also talk with Emily Largent, a bioethicist and former ICU nurse, who argues in a Hastings Center Report for an expanded vision of patient consent. Consent is often viewed as "all or nothing" for any specific decision. Emily and colleagues have argued for a wider view of consent that continues to involve patients whose consent may fall in the gray zone - able to express some goals and values, hopes and fears - but not able to think through the complexities of a major decision. I'd hazard that maybe half the patients I care for at the intersection of geriatrics and palliative care fall in the gray zone. Emily's expanded notion of consent is grounded in the concept of "relational autonomy." Relational autonomy was was first introduced to bioethics by feminist scholars, who observed that most people do not make decisions as isolated islands. Rather, most of us live and make decisions in relationship to one another. Emily's notion also borrows from pediatric bioethics, in which parents can look to young children for assent and input on decisions, empowering them to some extent. Invoking this principle, Emily argues for an expanded role for patients in the gray area and their inner circle working together along a spectrum of cooperative decision-making. My favorite line from Emily's paper: "Geriatric assent has not been widely adopted in clinical care, but bioethicists should advocate for this, as adoption of partial-involvement strategies can prolong the period in which individuals are (appropriately) engaged in decisions about their health care." Enjoy! -@AlexSmithMD

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