Navigate Tough Patient Conversations: The PARTNERS© Framework
Did you know that the risk for aspiration pneumonia in a patient with a feeding tube can be as high as 95% in certain patient populations? I recently saw a 104-year-old patient, let's call him Fred, who was being considered for a feeding tube because of his intermittent lethargy. Why? To reduce the risk of aspiration pneumonia, of course. You can change the course of a patient's life by educating the patient, their family, and the interdisciplinary team (IDT). But this can be tricky. Thankfully, the PARTNERS© framework exists to help you. It was created by Marta Kazandjian MA CCC-SLP BCS-S, FASHA and has proven to be a valuable tool across any setting.
Have you ever felt your team wasn't on the same page regarding communicating recommendations to the patient and family? Like you're pulling on one end of the rope, and the rest of the IDT is pulling on the other? This miscommunication often happens when navigating complex medical situations, but regardless, it's our responsibility to make decisions that respect and reflect the patient's wishes and values. So… How can you help?
It's… Complicated
Managing medical conditions involves assessing dynamic variables, utilizing the expertise of multiple specialties, and juggling several perspectives, insights, and opinions. The situation is only amplified when there is a high level of medical complexity. It can be easy to get lost with all this complexity and multiple moving parts and lose sight of what's important. The PARTNERS© framework, a reliable compass, can guide your team through this unfamiliar territory. The acronym creates a simple road map to guide you through difficult medical conversations and focuses on core, indisputable priorities: compassion, respect, and shared decision-making.
What is the PARTNERS© framework?
PARTNERS© is an acronym that stands for:
Prognosis
Advance Directives
Risk
Talk
Nonoral Feedings
Expectations
Recommendations
Summary and Support
Each element supports effective communication and collaboration among the medical team, patient, and family.
Breaking Down the PARTNERS© framework
Prognosis
Prognosis, the first element of the PARTNERS© framework, is a crucial starting point for patient conversations. It can be tricky to nail down because it's theoretical and elusive. Because it can be so abstract, it's often not discussed with the patient or family in detail. This is a disservice. Talking about the prognosis using clinical experience and insights supported by the available literature is essential. You can still be candid about what you do and don't know, but having the conversation is a starting point that needs to be initiated to get the patient and family on the same page as the rest of the IDT.
Without a clear and agreed-upon prognosis, you leave the patient and family in the dark when making decisions. It's like telling somebody you should turn left or right without telling them where these paths lead. They'll make a random choice and be totally surprised when they get to wherever they end up. And nobody wants to be surprised when we're talking about the outcomes of healthcare decisions.
Advance Directives
Advance directives, such as living wills and healthcare proxies, allow patients to express their healthcare wishes in advance, especially regarding end-of-life care. These documents can be invaluable in guiding decision-making when your patient cannot communicate their preferences due to cognitive limitations or a medically complex condition. They are like insurance policies that pay out handsomely in the form of receiving the care your patient wants and deserves.
Risk
Patients and families should be fully informed about the risks and benefits of various treatment options, including swallowing and feeding. However, like prognosis, risk is incredibly intangible and abstract. Nevertheless, you need to discuss it. Every decision carries risk. Yes, even those decisions where you think you're doing the safest thing, like making the patient NPO and recommending a feeding tube. As noted in the introduction, even feeding tubes can and often do cause complications, including aspiration pneumonia. Yup, feeding tubes can cause the very thing you're trying to prevent. You can serve as a resource to help the patient make sense of the many variables at play so they can understand how these variables contribute to the overall risk of a decision and how that risk compares to the alternatives. It's like providing a guiding light in the tunnel of indecisiveness that so many people with medical complexity get lost in.
Talk
Of course, assessing and analyzing the risk isn't very effective if you don't bring the results of that work to the patient to help them interpret the findings in the context of their wishes. This discussion can take time. But trust me, it's worth it if your patient and family can sleep at night knowing they made the best decision.
These conversations can be emotionally charged, so employing conversation tools like SPIKES, NURSE, and the "Serious Illness Conversation Guide" can be helpful. Using one or more of these tools is a great way to ensure you're structuring your conversations appropriately and touching upon all the most important points without talking over the family or missing key pieces of information. It can be easy to think that these conversations should be easy and come naturally, but they aren't, and they don't. We must push back against the instinct to go into the room without a plan. TALK was also created to represent communication and the role of the SLP in facilitating communication for patients who cannot communicate verbally.
Nonoral Feedings
Nonoral feeding options, such as nasogastric or gastrostomy tubes, may be considered when swallowing safety and efficiency are compromised. The decision to pursue nonoral feeding should be made collaboratively with the patient, family, and medical team, considering the patient's overall health, prognosis, and quality of life. It's a BIG decision and should never be made lightly. Some patients may want to continue to eat and drink no matter the cost, some may opt for short-term solutions until their status improves, and others may opt for more long-term solutions to reduce the discomfort and pressure of sustaining themselves via PO nutrition only. The steps you've taken leading up to this consideration should help you navigate if and how to move forward with nonoral feedings.
Expectations
Understanding the patient's and family's expectations for treatment and recovery is a prerequisite for appropriate goal setting and ensuring everyone is on the same page. Think about it: if your patient expects they will be discharged home and will start living independently after a week of rehab, and the doctor expects them to spend at least 2 months in a subacute facility to recover, someone is going to be disappointed by the final decision. You can help guide the patient toward a more realistic expectation and maintain their excitement to work towards their ultimate goal through your discussions with them.
Recommendations
What core message are you trying to deliver to patients and their families? Can they receive and understand it? Making sure the patient understands the recommendations by having her tell them back to you, writing them down, and answering any questions she has are great options for closing a successful discussion.
Summary and Support
Of course, the journey doesn't end there. Is your patient likely to follow your recommendations? Flip a coin. About 50% of patients don't understand medical recommendations and cannot carry over key instructions. Summarizing and writing down the key points while offering ongoing support is a great way to ensure all the work you've put into assessing and educating doesn't go to waste. It would be like running a marathon and bailing at the last mile to eat a pile of pancakes at the diner.
This step was designed to provide the patient and family with an opportunity to review what the clinician understood and to summarize a plan for the future. It demonstrates that they were “heard” while allowing them to clarify any unclear points. Learning how to use supportive serious illness language is key to the process.
Providing ongoing support to the patient is similar to providing a roadmap for the journey ahead, with your business card clipped to the edge in case they have questions about that journey. Patients should feel they have a clear plan and know there is someone to contact if circumstances change.
The PARTNERS© framework in Action
Let's go back to Fred. We bring all relevant interdisciplinary team members together to discuss with him and his daughter. The attending helps establish a prognosis, which does not appear to be very good given his age and medical complexity, and while he doesn't nail down a specific number of months, he makes it clear that it would be unlikely if Fred lives for much more than a year. While Fred had no advance directives, he was occasionally alert enough to discuss his preferences and values with his daughter and the rest of the team. While he was not hungry and did not feel he could eat enough to sustain himself, he did not want to go through another uncomfortable procedure.
We discuss the risks involved with placing a feeding tube and the risks involved with proceeding with PO intake. A modified barium swallow study was completed and showed that he could safely take puree, mildly thick liquids, and even small amounts of thin liquids if he were alert enough to follow strategies. By discussing these variables, it becomes clear that nonoral feeding may not reduce the risk of aspiration pneumonia and will likely not extend his life enough to be worth the risk of discomfort and complications.
By going through our P, A, R, T, and N, Fred and his daughter are beginning to develop realistic expectations of how the coming months of living with his conditions will go. We conclude by clearly explaining the medical recommendations, which include the diet, compensatory strategies, and exercises, and we leave time to summarize what was discussed. We then support Fred and his daughter as they ask questions and seek guidance in the future.
Conclusion
The PARTNERS© framework is valuable for promoting patient-centered care and achieving patient outcomes. By emphasizing the importance of early discussions of goals of care, the integration of conversation guides, and a structured approach to communication and shared decision-making, the framework ensures that patients and their families are actively involved in care and that their preferences are honored. It sounds easy. It isn't. It takes time, effort, and often multiple attempts to get it right. Like any instrument, you usually hit the wrong notes and miss some entirely the first few times you use it. But with practice, you'll get to the point where you can harmonize with the patient and family and reach the goals they strive for.
I hope this blog post has been helpful. If you have any questions or comments, please feel free to leave feedback below.
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This blog post was inspired by Marta Kazandjian and Dr. Martin B. Brodsky's MedBridge course "PARTNERS: Inclusive Framework for Multidisciplinary Team Conversations," which introduced me to this concept. I especially enjoyed the interview at the end, where the two seasoned pros discuss tough clinical scenarios and how the PARTNERS© framework can be used. Medical SLPs can access this course and other resources with a $101 discount. Check it out with this link.
Reference: Kazandjian, M. & Dikeman, K. (2022). Communication and Swallowing Management for Tracheostomized and Ventilator Dependent Individuals, Eat, Speak Breathe Publishing Inc., New York.
