Convening Difficult Conversations October 27, 2017 Presenter-Lores Vlaminck, MA, BSN, RN, CHPN Grandmother of 10 wonderful grandkids! Nurse Consultant for: Hospice Palliative Care Assisted Living Home Care Educator ELNEC HPNA EPEC Objectives Define the need, challenges and opportunities in facilitating difficult conversations Identify the 2-3 researched based tools helpful in convening the conversations 1
Four Issues Affecting The Health Of Older Persons Lack of resources Scarcity of providers Financial barriers Cultural barriers and biases Seeing the World Through the Resident s Eyes Patient s Openness to Talk About Prognosis Uses term, Accepts fact Avoids term, Accepts fact Uses term, Avoids fact Avoid term, Avoids fact 2
Intimate Listening in Thin Places Celtic traditions describe the concept of a "thin place," an in-between place that merges the natural and sacred worlds, where the ordinary and non ordinary mingle, where the seen and the unseen share common ground. Gomes suggests that these thin places are likely to be found where there is greatest suffering, among the marginalized and excluded. (Gomes, 1996). Intimate Listening in Thin Places Celtic traditions describe the concept of a "thin place," an in-between place that merges the natural and sacred worlds, where the ordinary and non ordinary mingle, where the seen and the unseen share common ground. Gomes suggests that these thin places are likely to be found where there is greatest suffering, among the marginalized and excluded. (Gomes, 1996). LITERATURE SUPPORT FOR DISCUSSIONS Patients with have conversations about their wishes are more likely to receive care consistent with their wishes End of life discussions associated with fewer deaths in ICU Aggressive care is associated with worse quality of life Mack JW, Weeks JC, Wright AA, Block SD, Prigerson HG, 2010 3
GOVERNMENT SUPPORT FOR DISCUSSIONS CA Right to Know End of Life Options Act -2009 Requires MD s and NP s provide terminally ill residents Full disclosure Right to refuse or withdraw treatment, etc NY Palliative Care Information Act 2011 Requires MD and NP s with 6 months prognosis counseling in EOL options Care the reflects the goals, values and beliefs CMS- Voluntary Advance Care Planning January 2016 Medicare Part A and Medicare Part B Consider the Conversation SPECIAL RELATIONSHIP WITH PATIENTS Who is the constant with the resident? Who has the responsibility to recognize the need for communication? What are the values, wishes and goals of the resident? Who has the resident shared this with? Has anyone asked? 4
BARRIERS TO FACILITATION OF DISCUSSIONS Lack of comfortableness' of the professionals with whom the resident has the most trust Lack of education Lack of personal/professional experience with death and dying THE ART OF COMMUNICATION Transactional process Verbal and non-verbal messages Core element of palliative care Listening in thin places Requires putting own biases aside THREE LEVELS OF COMMUNICATION Day-to-day interaction Assessment of treatments Existential Disclosure Search for meaning Suffering 5
Words Have Meaning Hospice Giving up Palliative care Giving up SNF A place to live until one dies TRANSITIONS: OPPORTUNITIES TO REVISIT GOALS OF CARE Points of possibilities Initial diagnosis Disease progression Functional decline When disease-focused treatments are likely to cause greater harm than benefit SIX COMMONLY ARTICULATED GOALS OF CARE (1) Be cured (2) Live longer (3) Improve or maintain function/quality of life/independence (4) Be comfortable (5) Achieve life goals (6) Provide support for family/caregiver. Kaldjian LC, Curtis AE, Shinkunas LA, Cannon KT, 2008 6
THINGS TO THINK ABOUT Have conversations early and often Consider a script Role-play and rehearsal THINGS TO THINK ABOUT Consider your resources Print material On-line Team members Other Develop collaborative relationship with palliative care and/or hospice staff Debrief to increase confidence and knowledge CONVERSATION STARTERS Reflective re-phrasing of the conversation Some useful expressions: Thank you for trusting me with this information. Thank you for you asking this difficult question. How can I help? I wish things were different for you right now. What do you need at this time? 7
CONVERSATION STARTERS Have you had a conversation with your doctor? Would you like more information? Have you talked with anyone about this? What would you most like to happen? What has been the most helpful about what your church/pastor has done? IMPORTANT MESSAGES TO COMMUNICATE THROUGHOUT I will listen to you. I will be honest with you. I will not abandon you. I value you as a person. I will respect you. Patient s Narrative A study about spontaneous talking time of residents in general practice points out that two minutes of listening is enough for 80% of the residents to recount their concerns. 8
Tool Box COMMUNICATION STRATEGIES Tell Ask Tell STRATEGIES FOR PURPOSEFUL COMMUNICATION WITH THE PATIENT/FAMILY Buckman Protocol Adapted from: Buckman, R., M.D., Breaking Bad News: A Six-Step Protocol. How to Break Bad News: A guide for Health Care Professionals. John Hopkins, 1992. EPEC Six-Step Approach:Setting the Stage The Palliative Response (Modified for BCBSRI/Brown University project) 9
STRATEGIES FOR PURPOSEFUL COMMUNICATION WITH THE PATIENT/FAMILY SOLER Squarely face the resident Open body posture Lean forward Eye contact Relaxed posture Egan G., 2009 SERIOUS ILLNESS GUIDE Set up the conversation Assess understanding and preferences Share prognosis Explore key topics Close the conversation Document your conversation Communicate with key clinicians https://www.ariadnelabs.org SET UP Thinking in advance Is this okay? Hope for best, prepare for worst Benefit for resident/family No decisions necessary today https://www.ariadnelabs.org 10
SERIOUS ILLNESS CONVERSATION GUIDE What is your understanding now of where you are with your illness? How much information about what is likely to be ahead with your illness would you like from me? If your health situation worsens, what are your most important goals? What are your biggest fears and worries about the future with your health? https://www.ariadnelabs.org https://www.ariadnelabs.org SERIOUS ILLNESS CONVERSATION GUIDE What abilities are so critical to you life that you can t imagine living without them? If you become sicker, how much are you willing to go through for the possibility of gaining more time? How much does your family know about your priorities and wishes? https://www.ariadnelabs.org ACT Affirm commitment Make recommendations about next steps Acknowledge medical realities Summarize key goals/priorities Describe treatment options that reflect both https://www.ariadnelabs.org 11
What about Family? What are you hoping for? What are you afraid of? What matters most to you? What do you value? Avoiding Family Feuds Invite participation Share the power Share in the powerlessness Allow time to pass Let the client call the game Allow for unpredictability Rational Way to Resolve Conflicts Identify the problem (pain, lack of communication, fear, anger, hurt, etc.) 12
Rational Way to Resolve Conflicts Brainstorm for Solutions Share with the your supervisor Share with your team (not your SO) Create a list of solutions Evaluate Solutions Agree on the Solution Implement the Solution Evaluate the Solution ADOBE Acknowledge Relationship Difficulty Discover Meaning Opportunities for Compassion Adjusting Boundaries Extend the System Ethical Relationships Appropriate boundaries Caring Fairness Integrity Respect Trust Cameron, M.E. & Moch, S.D. (2000).; Ethical relationships among nurses. Journal of Nursing Law, 7(1), 13-20. 13
Appropriate Boundaries A boundary violation is a process rather than a line that should not be crossed Well-intended actions can become boundary violations when HCW* meet their personal needs at the expense of colleagues or clients HCW- Health Care Worker Caring Excessive caring can lead to violating appropriate boundaries HCW can serve as advocates by treating one another with compassion and protecting individuals who are vulnerable 14
Fairness or Justice When HCW have unequal power, they need to be aware of the potential for exploitation Treat each other according to an individual s merits, needs, and abilities Integrity Develop a clear sense of self and act in a manner consistent with that self Remain true to own values 15
Respect Recognize a person s worth, abilities, and dignity Understand and accept each other s differences and competencies Trust Rely on the character, strength, and truth of the other person Place confidence in each other s integrity and abilities The ultimate measure of a man is not where he stands in the moments of comfort and convenience but where he stands in the times of challenge and controversy. Our lives begin to end the day we become silent about things that matter. Martin Luther King, JR 16
Summary Define the need, challenges and opportunities in facilitating difficult conversations Identify the 2-3 researched based tools helpful in convening the conversations Lores Vlaminck, RN, BSN, MA,CHPN Lores Consulting, LLC 3063 Darcy Drive NE Rochester, MN 55906 lores@loresconsulting.com 507-288-6050 507-358-4301 17