Page 173 - Hospital Authority Convention 2018

Masterclasses

M15 Difficult Conversation – Interactive Case Discussion 14:30 Theatre 1
and Use of Applied Mediation Skills to Resolve
Conflicts in End-of-life Care

Difficult Conversation – Interactive Case Discussion and Use of Applied Mediation Skills to Resolve Conflicts in
End-of-life Care HOSPITAL AUTHORITY CONVENTION 2018
Lui SF
Jockey Club Institute of Ageing, The Chinese University of Hong Kong, Hong Kong
Yuen J
Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
Kng C
Department of Geriatrics, Ruttonjee and Tang Shiu Kin Hospitals, Hong Kong
Yang N
ADR International Limited, Hong Kong

End-of-life Care
Despite advances in medicine and enhanced care for patients, it is inevitable that there comes a time when end-of-life is
reached when all appropriate curative therapies have been exhausted. This may not be a simple situation, regarding the
timing and the decision on the appropriate end-of-life care. When is the beginning of the “end-of-life”? When is the end of
“end-of-life” – the final weeks or days? It is important to provide appropriate and good end-of-life care, based on what is
appropriate, feasible, and what matters most to the patient and family. End-of-life care is a continuous process, from the
earlier stage to the final days. It may be a difficult and challenging process for healthcare professionals and patients and their
family members.
Feeding
Of the many elements of end-of-life care, feeding challenges arise when oral intake becomes inadequate, or swallowing is
unsafe. The usual options are to modify dietary texture or consider artificial nutrition and hydration. A competent patient can
make an informed decision to refuse or consent to tube feeding. For those with advanced dementia, and lack of an advance
directive, the decision burden falls on relatives and healthcare professionals to act in the best interests of the individual.
In Hong Kong, tube feeding is commonly chosen despite lack of evidence it confers benefits for survival or quality of life
compared to oral feeding. It may relate to the widely held belief that providing nutrition is synonymous with caregiving and
filial piety. To forego this is perceived as neglect and inducing suffering from hunger and thirst.
An alternative option is to provide comfort feeding through careful hand feeding. Comfort feeding means that oral feeding is
only up to the point where it is not distressing to the patient. It also refers to a comfort-focused goal of care where the least
invasive means of providing nutrition may be the most comfortable option. It avoids restraint use to prevent the feeding tube
from being removed and allows tasting of favourite foods. Moreover, the act of feeding enhances the touch and bonding
process between carer and patient. The quantity of food taken is not the prime focus.

Reframing the end-of-life discussion from foregoing actions such as “do not feed” or “do not resuscitate” to a positive
framework for what can be done to improve quality of care not only broadens the conversation, but also aligns the goals of
care, helps resolve conflicts and ethical dilemmas.
End-of-life Conversation
The conversation on end-of-life care is difficult – for healthcare professionals to initiate with the patient/family member and
also between the patient and family members themselves. Often, the conversation is not conducted, and if conducted, it may
not be timely, nor the contents are adequately covered. Tuesday, 8 May 2018
End-of-life conversation should not occur just once but should be a continuous conversation with the patient and family to be
revisited whenever the patient’s condition or preferences change.
There is a need to enhance how healthcare professionals conduct end-of-life conversations with patients/family members
and to assist patients/ families to come to terms with and to reach an agreement on appropriate end-of-life care.
Apply Mediation Skills
One can apply mediation skills to resolve conflicts that may arise when making end-of-life care decisions. The skill set
includes nine elements under five key components:
Manage emotion: Empathy, anger management
Clarify issues: Active listening, questioning
Refocus issues: Reframe, paraphrase, summarise
Understand issues: Position and interest
Options on issues: Explore acceptable options by the parties.

Session content/format
Using a case scenario of a family with different views on “tube-feeding” for their father, the session will include (1) an
interactive panel discussion on “End-of-Life Care and Conversation” including decisions about feeding problems and (2) a
role play to introduce “apply mediation” skill to resolve conflicts.

171