Difficult Families or Difficult Conversations?

Transcription

1 Difficult Families or Difficult Conversations? N. Joel Fry, MSW, LISW President / Therapist, TEAM Restoration Ministries State Representative Associate Consultant, Weatherbee Resources MDP Educator, National Hospice and Palliative Care Association Lecture Faculty, Simpson College Adjunct Faculty, University of Iowa 1 Objectives Review common questioning techniques used in family therapy. Explore the Family Focused Grief Therapy Model as a preventive intervention for high-risk families during meetings focused on palliative care and bereavement. Through case studies and role play, practice questioning styles useful in family meetings involving palliative and hospice care issues. 2 1

2 Assumptions 3 Assumptions in Palliative Communication Interdisciplinary care is straightforward, clear, and always successful Patient preferences should be the governing consideration in all decisions Interactions with families are a basic extension of interactions with patients - Hauser,

3 Assumption 1 Case Example 50 y/o male Gleoblastoma Paralyzed on right side Loss of vision Incontinent Can eat and drink Independent in thinking Dependent in cares 5 Case Example con t. Identifies self as one who takes control of life Widower and raising two teenage daughters Increasing moments of confusion and extreme bone pain controlled by intravenous methadone 40 mg/hr Panic attacks at times Spiritual practice is key with visits from his pastor weekly Desires all treatment due to his fatherly duties Care team consists of private hire care, neurological team, oncology team, hospice team, numerous other consultants 6 3

4 Challenge the Assumptions What are the advantages of teams? What are the disadvantages of teams? How do teams improve care? How do teams not improve care? - Hauser, Advantages Resource availability Diversity in solutions Professional learning environment Creative solution making - Hauser,

5 Barriers to Teams Complexity of health care provider relationships Professional education that adopts discipline based vision Collaboration versus competition - Hauser, Disadvantages Inefficient Speak different professional languages Different communication styles and with unclear lines of authority and accountability - Hauser,

6 Assumption 2 Risk or Certainty Low risk decisions High risk decisions - Hauser, Models of Decision Making Parentalism/paternalism Informed Shared - Hauser,

7 Your Thoughts? In your agency, what decisions fall into the low risk and how are they handled? In your agency, what decisions fall into high risk and how are they handled? 13 Assumption 3 10 Steps for Communication with Patient and Family Premeeting planning Medical review Medical appropriateness Environment Introductions Reactions/questions Care options Set goals and planning Patient/family knowledge Conclusion - Hauser,

8 Application of the 10 Steps Utilize previous case example and work through the 10 steps of laying out how this patient/family meeting would look. Share thoughts with the larger group Team Communication Questions What do we know so far? What do we want to know? What are our goals and next steps now? - Hauser,

9 Stages of Family Therapy an overview The initial phone call The first interview Early phase of treatment Middle phase of treatment Termination - Nichols & Schwartz 17 Family Therapy 18 9

10 The Initial Phone Call Assess who is making the call Gather minimal amount of information Arrange for referral meeting Time Date Location Invite the family - Nichols & Schwartz 19 The First Interview Introductions Assess the emotion Build rapport Assess current knowledge and expectations of care Assess current knowledge of illness Allow all parties to ask questions Assess future needs Assessment of family strengths and successes Set care plan goals - Nichols & Schwartz 20 10

11 First Session Checklist Acknowledge each person s point of view Establish leadership (structure and pace) Balance warmth and professionalism Recognize family strengths Maintain empathy and respect Focus on specific problems and attempted solutions Identify unhelpful interactions and explore how they developed Not all players may be present Always ask about questions - Nichols & Schwartz 21 The Early Phase of Treatment Refine the hypothesis of what is needed from the care team Assessment of safety Assessment of needs Assessment of goals and outcomes Focus shifts from alliance building to challenging towards change Direct or indirect confrontation of the issues Addressing interpersonal conflict Identification of interactions patterns that are keeping people stuck Continue to listen all members feelings Homework assignments - Nichols & Schwartz 22 11

12 Early Phase Checklist Identify conflicts for all to understand Form hypothesis of the issues and how it is perpetuated (consider processes, structure, family rules, triangles, and boundaries) Keep focus of treatment on primary issues Identify family member s role in the issues Push for change Utilize the IDG - Nichols & Schwartz 23 Middle Phase of Treatment Expression of self and achievement of mutual understanding Heavy encouragement of direct interaction among members Assess and assist with anxiety Encouragement of family members relying on own resources Continued encouragement of family members owning their part of unproductive patterns of interaction - Nichols & Schwartz 24 12

13 Middle Phase Checklist Use intensity to challenge Therapist avoids being destructive and controlling Foster individual responsibility and mutual understanding Efforts to improve relationships need to have a positive impact on initial issue Remember the entire family picture and don t avoid those deemed as difficult Assess for being stuck on a plateau - Nichols & Schwartz 25 Termination Happens when the issue is resolved Review all growth as related to initial care plan goals Review techniques learned Identify points in the future that might cause upsets or setbacks - Nichols & Schwartz 26 13

14 Termination Checklist Is the initial issue resolved or improved? Is the family satisfied with their achievements? Is their understanding of what was not working and how each individual contributed to the issue? What do minor recurrences represent? Have relationships improved both in and out of the family context? Is care plan resolved? - Nichols & Schwartz 27 Family Focused Grief Therapy 28 14

15 Family Focused Grief Therapy (FFGT) Family functioning determined on three domains: Cohesiveness Expressiveness Capacity to deal with conflict - Kissane, et.al, Differentiation of Families Well functioning Intermediate functioning Dysfunctional functioning - Kissane, et.al,

16 Key Aspects of FFGT Treatment of the whole Time limited therapy Goals are to minimize complications of bereavement - Kissane, et.al, FFGT 3 Phases Assessment Intervention Termination - Kissane, et.al,

17 Four Questioning Styles Information Questions Linear questions Circular questions Influencing Questions Reflexive questions Strategic questions - Dumont & Kissane, Group Work Read case study alone. Form a question from each of the four styles. Using the FFGT 3 phases, determine questions to ask. Select the one best question to share with the group

18 Complicated Grief Case Study The family is an 80 y/o African American female, her daughter (the patient) and 2 adult sons and wives. Her husband died at your hospice inpatient facility about 5 years ago. The 80 y/o s daughter is currently receiving care at your inpatient facility. Her daughter s illness has spurred the pain of her husband s death 5 years ago. He died of Alzheimer s disease and she was his primary caregiver for 5 years. After her husband s death she was never contacted by the bereavement counselor. Shortly after her husband s death, she moved in with her daughter and became her primary caregiver. 35 Case Study con t. The daughter suffers with Chronic Obstructive Pulmonary Disease (COPD) and is unable to care for herself. Due to the intensity of her cares, the decision was made to move the daughter to the inpatient facility, somewhat against the mother s wishes. She wanted to care for both her husband and her daughter in their homes, but in the end was unable to provide the level of care needed. She is frustrated and in deep pain because she desired to be present at her husband s death. He died in the night somewhat unexpectedly while she was at home

19 Case Study con t. It was made clear to the facility staff that she expected to be there at his death. Since she doesn t drive, she was assured that a volunteer would be able to pick her up and get her there. The facility night staff were unable to find a volunteer to transport her. This has left her wandering about the care provided, not to mention the guilt she lives with because of not being present at his death. At this time she is hurt, angry, and guilt ridden. She is angry at the hospice but reluctantly scheduled a session with her family and the hospice care team. She has been informing other families at the facility about her experience with her husband s death. 37 Questions/Comments 38 19

20 Key Points Contact Information N. Joel Fry, MSW, LISW

21 Sources Dumont, I., & Kissane, D. (2008). Techniques for Framing Questions in Conducting Family Meetings in Palliative Care. Hauser, Joshua. (2007). Palliative Care: Expanding the Boundaries of Communication. Kissane, D., et.al. (2006). Family Focused Grief Therapy: A Randomized Controlled Trial in Palliative Care and Bereavement. Nichols, M., & Schwartz, R. (1998). Family Therapy Concepts and Methods. Allyn and Bacon, Boston. 41 Difficult Families or Difficult Conversations? N. Joel Fry, MSW, LISW President, TEAM Restoration Ministries Associate Consultant, Weatherbee Resources MDP Educator, National Hospice and Palliative Care Association Lecture Faculty, Simpson College Adjunct Faculty, University of Iowa 42 21