As part of our mission to seek simple, scalable solutions to health care, Ariadne Labs holds regular innovation meetings to bring together our community of researchers and innovators seeking to produce discoveries that make care better. Earlier this year Amelia M. Cullinan, MD, a Palliative Care physician in Lebanon, New Hampshire, spoke virtually to the Ariadne research community about her work implementing the Serious Illness Conversation Guide in the Norris Cotton Cancer Center at Dartmouth-Hitchcock Medical Center. Dr. Cullinan is the director of Outpatient Palliative Care Services and Co-Director of the Serious Illness Care Program at Dartmouth.
During her virtual presentation, Dr. Cullinan described instituting the Serious Illness Conversation Guide at Dartmouth-Hitchcock Medical Center, and how the tool was gradually expanded as the value manifested itself.
We caught up with Dr. Cullinan for an interview after her Ariadne Labs talk. The following Q & A has been edited and condensed.
Q: What first motivated you to institute the Serious Illness Conversation?
A: I was in the early cohort of those taking the national Serious Illness Conversation Guide training in 2015. My reaction was, “This is genius.” And I wanted it to be part of our palliative care practice. But before long, a colleague and I realized that this was also a brilliant tool for teaching other clinicians. We wanted to disseminate it as a primary palliative care tool within the institution. So we started using it as an educational tool; we thought we could educate the different learners that come through our palliative care service.
Q: You obviously were very moved by it back in 2015. Why did it grab you?
A: In the training, I went through something that I see a lot of people go through. At first, I thought, ‘I’m really good at this, I don’t need someone to tell me how to have this conversation right.’ But I realized pretty quickly the value of having a common language among clinicians for the things that we’re doing.
Q: You also found that it’s been a powerful connection between the patient and families. When did that become apparent to you?
A: I’ve been using the Serious Illness Conversation Guide myself in my outpatient palliative care practice since I learned it. What I have seen over and over again is that patients and families feel more connected after being part of the conversation than before. One of the things I care most about in my work is helping patients and families have healthier relationships as they are dealing with serious illness. Patients and families are now talking about these really important things and they view this as a loving act. When I open this conversation and invite a patient to have their family present, I’m basically creating a space for people to be loving with one another.
Q: In your hospital’s Palliative Care Clinic, you use a pre-interview menu that patients can see. Why is this important?
A: I think I think there’s a fair bit of literature to suggest that patients and families want to talk about serious illness issues, but they think that they’re not supposed to bring it up. On the other side, physicians and clinicians may think that they shouldn’t talk about it, either. We received grant funding to develop a Pre-Visit Questionnaire (PVQ) and Dashboard for our clinic to improve the quality of the care we provide. What I like about the PVQ, or agenda setting tool, is that it basically says, “Hey, this is the gamut of stuff that we talk about here. It’s all OK to talk about this.” I think that gives people permission to discuss things and it shows that we can handle the conversation. Specifically for Serious Illness Conversations, having those on the PVQ can increase people’s willingness to raise their hand when they’re ready themselves.
Q: Why do you say that the Serious Illness Conversation Guide should be done sooner rather than later?
A: The earlier you start, the better job you can do to get someone to a place of acceptance or at least a feeling of relative peace near the end as opposed to being frantic and terrified.
I also heard from my oncology colleagues, after taking part in our implementation in the Cancer Center, that they liked knowing their patients’ priorities before critical treatment decisions needed to be made: they could anticipate what the patient might choose and they would not feel caught off guard. I think clinicians felt more confident, more secure, and more able to make recommendations when they had had a conversation earlier.