5.2 () Practical considerations including difficult conversations Flashcards
Name SIX strategies for building the clinical relationship.
(That may help pt tolerate anxiety that arises from serious illness convo)
◆ Take time to PREPARE yourself for the encounter
◆ Create a ‘FRAME’ or set of expectations for the convo (ie. time, topics)
◆ Seek PERMISSION to proceed
◆ Speak gently, honestly, and DIRECTLY
- speak simply, focus on pt concerns, not med details
◆ Affirm patient STRENGTHS
◆ EMPATHIZE with emotions
◆ INCLUDE/EXCLUDE family members as pt prefers
◆ Share OBSERVATIONS about pt’s state of mind (w/ permission)
◆ FOLLOW UP on emotional topics
◆ Ask directly about SOURCES of worry/concern
◆ Offer to REVISIT the conversation later
◆ Affirm ‘TOGETHERNESS’
Table 5.2.1
FS: SPIKE and NEGOP
Name THREE strategies for dealing with denial
◆ Listen for fragments of ambivalence/GAPS in denial
◆ Approach denial w/ CURIOSITY
◆ Align and shift focus to ACHIEVABLE goals
◆ Sometimes being VAGUE allows space for hope
◆ Focus on what MATTERS MOST to pt to identify meaningful and achievable goals
Table 5.2.2
FS: curiosity, 3Ws, NEGOP
Name FOUR strategies for responding to anger
◆ Recognize anger is often about the MESSAGE/SITUATION and not clinician
◆ Respond empathically & NON-DEFENSIVELY
◆ NAME the impact of the mistake on the pt and apologize simply, without justifying
◆ INVITE the pt to share ideas about how to re-establish trust and comfort
◆ ALIGN with pt by sharing the wish that things were different
◆ Do not tolerate ABUSE or intimidation.
- set gentle and firm limits on angry behavior
Table 5.2.3
Name TWO strategies for dealing with grief & sadness
◆ Recognize discussions about loss are also about LOVE & MEANING
◆ Explore ONGOING losses
◆ Although CRYING is distressing, its a healthy expression of sorrow
- don’t fight it/shut it down
Table 5.2.4
Name TWO strategies for dealing with protective feelings
◆ Ask pt specifically about what FAMILY understands about med situation & pt’s preferences and concerns
◆ Acknowledge the pt’s wish to PROTECT loved ones & focus on benefits of prepping fam
◆ Acknowledge and explore family preferences to WITHHOLD info
- emphasize that info belongs to pt if they want
Table 5.2.5
Name FIVE strategies to clarify unrealistic expectations
◆ Recognize that it takes TIME for people to change their expectations
◆ Understand what the family UNDESTANDS & has been told about the pt’s medical situation
◆ Acknowledge an UNEXPECTED change in the pt’s med status
- and how hard that can be for family to process
◆ In acute crisis, provide simply ‘BIG PICTURE’ info
- and give fam time to process
◆ LEARN about the pt
◆ Address GRIEF directly when unrealistic expectations emerge
◆ If med decisions are urgent, empathize w/ difficulty of making BIG DECISIONS quickly
◆ Recognize the challenges of SURROGATE decision making
◆ When the fam is not ready, emergent decisions are needed, pt cannot speak and temporization is not possible -> learn as much as possible about what the pt wanted and make a STRONG RECOMMENDATION
◆ When family EQUATES aggressive care w/ expression of love and respect
- reframe decision to stop life sustaining care as loving decisions/honoring pt
Table 5.2.6
Name ONE strategy to navigate attachment and grief of the clinician (WP: you!)
◆ Initiate serious illness convo EARLY and revisit regularly
◆ Remember that you, as the clinician, are MORE THAN THE TREATMENTS you have to offer
- if chemo does not work, you haven’t failed, the chemo failed
◆ Find a way to GRIEVE
Table 5.2.7
Name SEVEN strategies to discuss prognosis
Essentially SICG guide in full. Chapter written by Block.
◆ Explore illness understanding
◆ Explore info preferences
◆ When pts are particularly anxious/not wanting info, ask questions about the future
◆ If pt’s want “all the information,” clarify what that means to pt
◆ Three types of prog disclosure:
- time, function, unpredictable
◆ Allow silence and check in w/ pt
◆ Finish (serious illness) convo w/ discussion about a recommendation/plan and affirm ongoing commitment
Table 5.2.8
