The AMEN tool to help health professionals talk to dying patients

Norman Swan: One of the things often missing in modern medicine is attention to or respect for the spiritual life of patients and families, which includes miraculous thinking. And that's why Rhonda Cooper developed the AMEN tool. Reverend Cooper is the Kimmel Cancer Center Chaplain at Johns Hopkins University in Baltimore.

Rhonda Cooper: The AMEN tool was developed in part because I observed the team, not only the physicians but the nurses, being a bit stymied. The doctor says to the family of a very ill patient, 'We've done everything we can and we fear that your loved one will not survive his illness.' The family would listen very respectfully, but after the physician finished they would say, 'Thanks Doctor, but we believe God will heal our husband by a miracle.'

Norman Swan: Even if they didn't say that, a lot of people still hope that something miraculous would occur, even if they don't have any particular religious belief.

Rhonda Cooper: Of course. However, when they say it, the team would often respond in an argumentative way or try to convince them that was not going to happen, which is outside their scope of practice, to talk theologically. Or they would say something that might sound snide. So how do you help them join with the patient and see this kind of comment as an invitation to continue their conversation, not to stop it.

For instance, if someone says, 'Well, Doc, I'm hoping for a miracle,' a way to join them could be, 'I hear that you are hopeful, and we always have hope too.' Instead of saying, 'Well, you can hope that all you want but it's not going to happen,' which I actually heard that once. Respecting, reflecting back what they've said, and to, above all, assure them that no matter what the future brings, that we on the team will accompany you on that journey.

Norman Swan: Which is what palliative care physicians and nurses do all the time, it's just it doesn't happen on the regular ward.

Rhonda Cooper: Yes, right.

Norman Swan: Dealing with the spiritual world, regardless of whether you have a religious belief or not.

Rhonda Cooper: Exactly, and also the concept of non-abandonment. Sometimes a committed medical team, even though they may not say it this way, if they have suggested wonderful treatment and the patient has been compliant and everything has been done, yet that patient's path leads them to death instead of cure, when a caregiver is really invested in that they may have a tendency to take that personally and disengage.

Norman Swan: How does it work?

Rhonda Cooper: So the protocol, which is entitled AMEN, the A is for 'Affirm the patient or the family's belief'. Affirm that does not mean agree with it. When the patient says, 'Well, I am praying or I'm believing there will be a miracle,' a simple response would be, 'I'm hopeful too.' And then the second part would be the M or the 'Meet the patient where they are'.

Then thirdly you can then 'Educate from your own role', this is the E. The provider's role is to give the patient or the family their best medical opinion. And so they might move to, 'I'm hopeful too, and I would like to share some information that I think will be helpful.' But we say throw out the word 'but', which is really hard to do actually. Throw that out and say, 'I'm hopeful and let me also share some information that may be helpful to you from my perspective.'

And finally is the 'No matter what', or the idea of non-abandonment. That is, we are committed to your loved one's care, or as the patient we are committed to your care and we are going to be with you every step of the way. And we don't say I am going to be with you the whole way, because frankly that's probably not true, but someone on the team, your caregivers, we will be with you. And so this allows both the provider and the patient or family to stay in their role with integrity.

Norman Swan: No matter what.

Reverend Rhonda Cooper is a Chaplain at Johns Hopkins University Medical Center in Baltimore.


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