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An Ascending Pathway: Connection, Meaning and Co-creation At Every Stage of Life

Harness the power of positive imagery and the science of branding to co-create personal narratives of health, age, and the end of life.

Photo of Karen Knops
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Who is your idea designed for and how does it reimagine the end-of-life experience?

Health professionals, patients and caregivers. From discussing an initial diagnosis to end-of-life planning and "crisis" conversations, opportunities to improve the end of life begin with communication. The ASCEND approach and materials can be used to refine conversations for those who already have training or a passion for end-of-life discussions. More importantly, ASCEND serves as a "first step" - an approach for clinicians, patients or families who face challenges in discussing illness.

Communication is the most important, rewarding, and challenging aspect of healing and caring for others.  Patients and their families feel the frustration and powerlessness that come with poor communication - even in everyday health care visits. Skilled communication is a final common pathway in creating a meaningful end of life experience.  It is the cornerstone of the process of end-of-life planning, and becomes the foundation of shared resilience in the face of the unplanned. 

The "ASCEND" pathway was developed over ten years ago, building on expert recommendations and research in advanced care planning, breaking bad news, and other clinical communication.  The pathway expanded on existing models by emphasizing universal elements of communication - allowing the techniques to be used in a wide range of discussions.  Simple language was used in the model, intuitive for health care workers and for patients and families faced with serious illness.  The existence of a "patient-centered" version of the pathway allowed it to be posted in a waiting room, supporting both clinician and patient in communication.

The name "ASCEND" is not accidental.  Its connotations of achievement and enlightenment are vital for countering fears of discussing difficult topics, such as illness and death.  Imagery of climbing, navigating a path, and rising above obstacles - images that resonate with the deepest human instincts to persevere - are a part of "ASCEND" materials and training.  Users learn that co-creating a narrative is its own journey, a form of bravery.  The model has been used to facilitate training of clinicians and the community, and has been adapted as an advanced care planning workshop for the public.  To "ASCEND" is to go upstream - the process can be used by a lay person to discuss fears about illness (or even fears about talking about illness) with family, easing the first steps towards meaningful discussion days, months, or years later. 

Far from competing with formal communication training programs, the pathway complements existing, well-established curricula, and creates a scaffold for further education.  Because the techniques can be used to discuss less emotional, "everyday" topics such as informed consent or discharge planning, they can be taught and practiced very early in medical education.  Used in an office or hospital, "ASCEND" patient and clinician materials are designed to trigger recall and use of communication skills.  "ASCEND" encourages both clinicians and patients to start where we are, knowing that the only way to reach our goal is to begin with a first step.

What early, lightweight experiment might you try out in your own community to find out if the idea will meet your expectations?

Select a subgroup of clinicians who are enrolled in communication training through a well-established training program. Integrate the ASCEND tool and concepts (this should not significantly add or subtract from training in terms of content) and provide the subgroup with ASCEND materials to use in the clinical environment, including patient-centered materials. Compare measures of follow-up performance (satisfaction, confidence, documentation) between the subgroup and the control group.

What skills, input or guidance from the OpenIDEO community would be most helpful in building out or refining your idea?

Allowing diverse medical and public organizations to use, adapt, and give feedback on the ASCEND pathway will bring the tool out of the palliative care “box” and into medical community and culture at large. Input on the design of visual tools, technology, and environmental triggers is key to making ASCEND skills easier to remember and a pleasure to use. Communication and narratives are profoundly powerful "medicine" and should have marketing to increase awareness of the public and professionals.

Tell us about your work experience:

As a teen with medical issues, I faced difficult conversations (surgery, quality of life) and became passionate about person-centered care. I founded a palliative care program years ago and educated thousands of clinicians and community members. I learned efficiency principles working at McDonalds!

This idea emerged from

  • A group brainstorm
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Attachments (2)

ASCENDPoster9 11.pptm.pdf

The ASCEND pathway for clinicians received a blue ribbon at the 2008 Academy of Hospice and Palliative Medicine Annual Assembly poster session. It was recently adapted for use by the Hospice and Palliative Medicine Fellowship Program at Memorial Sloan Kettering Cancer Center, in addition to other facilities and training programs. It's been formally presented to surgical, radiology, psychiatry, medical, OB/gyn, ED, pediatric, nursing, social work, pastoral care, and patient advocacy professionals

6-1-2011 KK ASCEND Silde (2).pptx(2).pdf

Sample "pocket cards" - the patient-centered "ASCEND" guide was also embedded in patient education materials for ICU and oncology. A poster of the "ASCEND Guide for Patients and Families" was placed in the ICU family room. In addition to lectures, it has been presented as a teleconference for home-bound elders, and as an advance care planning workshop. The clinician "ASCEND" card is coupled with residents/students education and referenced in preparation for and documentation of discussions.


Join the conversation:

Photo of Bridget Nicholson

I have used this model for teaching clinics a new to palliative care and it is a powerful tool to help clinicians facilitate family conversations. 

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