Challenging conversations in the Emergency Department

Transcription

1 Challenging conversations in the Emergency Department ED Teaching Day, 27 th April 2017 Renton Perry Specialty Doctor in Emergency Medicine The Plan 1. SHORT INTRO Dying matters -Communications at the End of Life course 2. COMMUNICATION Feelings matter - Give space for the other s feelings 3. STRATEGY You matter - Know your limits; your emotions matter too 4. ROLE PLAY 1

2 Challenging Conversations at the end of life - Communication Skills 2-day course St Christopher s Hospice, Sydenham, London SE22 Challenging Conversations at the end of life - Communication Skills 2-day course St Christopher s Hospice, Sydenham, London SE22 Who is it for? Specialist palliative and end of life care practitioners Any NHS, allied health or social care professionals who regularly work with life-limiting illness of uncertain prognosis Social workers, care home managers or social care managers 2

3 The Plan 1. SHORT INTRO Dying matters -Communications at the End of Life course 2. COMMUNICATION Feelings matter - Give space for the other s feelings 3. STRATEGY You matter - Know your limits; your emotions matter too 4. ROLE PLAY Understanding Communication The Communication ICEBERG Is key to improved relational skills Is key to relating well to patient & their relatives But especially important for Challenging Conversations e.g. End of Life, breaking bad news or with frustrated, angry or anxious patients. 3

4 Understanding Communication The Communication ICEBERG Words, tone, volume, silence, body language feelings, expectations, assumptions, attitudes, beliefs and values Understanding Communication This is a more dynamic picture The Communication HOTSPRING A hot spring that bubbles up helps illustrate Outbursts Being emotional An iceberg better illustrates: Silence Being withdrawn 4

5 Uncomfortable Conversations Conversations The inside pressure in an unseen world below the surface is what triggers visible/audible responses at the surface set off by: - Life changing bad news - Frustration over blocked goals - Anxiety over possible outcomes - Etc. The response may be massive or subdued, immediate or delayed and may recur at intervals Understanding Communication Communication INDIRECT RESPONSE The response to bad news or events is often not spoken out directly. WHAT TO SAY NEXT? When a response isgiven, we often do not know how to interpret it and respond. How do we react to the words or silence? UNCOMFORTABLE! We easily jump to wrong or unkind conclusions about any uncomfortable, angry or even accusing responses. Words, tone, volume, silence, body language feelings, expectations, assumptions, attitudes, beliefs and values 5

6 Uncomfortable Conversations Conversations The Communication ICEBERG Silencecan be the most uncomfortable of all responses. Just being silent in response to silence (as a technique) is unhelpful. Why? Although your mouth is shut, the whole of you is communicating nonverbally as much as the other person. Therefore how& whyyouremain silent is important. Consider it positively as the gift of someone (you)being present in that moment. The other person is not alone as he/she silently explores below the surface. WHY COMMUNICATION CRASHES The Communication ICEBERG This CANbe known by practised& focused observation and listening Words, tone, volume, silence, body language This CAN ONLYbe known if the other tells you Anything you think otherwise will always be guesswork & assumption feelings, expectations, assumptions, attitudes, beliefs and values 6

7 WHY COMMUNICATION CRASHES The Communication ICEBERG Words, tone, volume, silence, body language What CAN ONLYbe known if the other tells you Anything you think otherwise will always be guesswork& assumption BEWARE! YOU HAVE BEEN WARNED! feelings, expectations, assumptions, attitudes, beliefs and values THIS FREQUENTLY CATCHES US OUT The other person may not be wanting to communicate in the way it comes out But would be helped by communicating something, somehow to someone about this (as it is driving what we see & hear) The problem: doesn t know how/ where to start Words, tone, volume, silence, body language feelings, expectations, assumptions, attitudes, beliefs and values 7

8 Example: a patient hears from you he or she has advanced breast cancer There follows an inner gut reaction that is sensing threat to important things that need protecting The anxious question How long have I got? (and you can t give an answer) may turn out to be arising from a deeper, unspoken question: Who is going to look after my children when I die? Empathy is about connecting on the level of what is going on inside. The Plan 1. SHORT INTRO Dying matters -Communications at the End of Life course 2. COMMUNICATION Feelings matter - Give space for the other s feelings 3. STRATEGY You matter - Know your limits; your emotions matter too 4. ROLE PLAY 8

9 St Catherine s Education 5Ps Framework PERSON My understanding of what I learnt about the 5Ps strategy for challenging conversations at the End of Life, expressed in my own words PURPOSE PREPARATION PROCESS PRODUCT Disclaimer Please attend a St Catherine s Education course or read their material for a better understanding of their 5Ps Framework. 9

10 St Catherine s 5Ps Framework PERSON PATIENT Or RELATIVE My understanding of what I learnt about this strategy for challenging conversations at the End of Life, expressed in my own words Understand who are you talking to (beforehand/ask on arrival) Be sure to keep your eyes and ears open to receive all the communication available (words, tone, silence, body language). Give the person time to speak /resist interrupting YOU Continually recognise what is going on in you If it was emotionally demanding, consider a short debrief afterwards with a senior or colleague PURPOSE PREPARATION PROCESS PRODUCT St Catherine s 5Ps Framework PERSON PURPOSE YOURS PATIENT Or RELATIVE S My understanding of what I learnt about this strategy expressed in my own words Clarify for yourself the purpose of the conversation (beforehand if possible) Communicate your purpose early on in the conversation for the other person sake e.g. I would like to give you an update on The purpose of conversation includes listening. If the primary purpose was to give a message, after ask: Is there anything you would like to ask me? After responding to a question or complaint, ask: Do you have any other questions? PROCESS PRODUCT 10

11 St Catherine s 5Ps Framework PERSON My understanding of what I learnt about this strategy for challenging conversations at the End of Life, expressed in my own words PURPOSE PREPARATION Give yourself enough time before going to see the person, for information gathering YOU for forethought How will I approach this? Are you emotionally prepared? If you don t feel you are, take someone with you, or if it s possible, ask someone else PROCESS PRODUCT St Catherine s 5Ps Framework PERSON My understanding of what I learnt about this strategy for challenging conversations at the End of Life, expressed in my own words PURPOSE PREPARATION PROCESS PATIENT Or RELATIVE Alwaysbegins with establishing where the other person is at. e.g. Ask what they know already. You need to establish the context before supplying the information. Only then proceed to giving the new information. PRODUCT Then respond to the person s response you haven t finished until you have done this. This is about empathy and may include responding to silence with silence or reflecting in question form on what you sense they may be feeling. 11

12 When I give someone bad news, it starts off an inner chain reaction As professionals, we have not finished our communication until we have begun a first step in helping the hearer copewith that inner chain reaction We have a measure of responsibility, as our communication of facts started it. MY 1 FACT THE RESULT St Catherine s 5Ps Framework PERSON My understanding of what I learnt about this strategy for challenging conversations at the End of Life, expressed in my own words PURPOSE PREPARATION PROCESS PRODUCT This final P is a way of saying What is the desired outcome?. YOU What do you hope will happen as a result of this PATIENT conversation? Is it the same as the patient or Or RELATIVE relative hopes for? 12

13 PERSON: What to reflect on prior to the conversation Communication is 2-way These aspects don t just apply to the patient or relative. These are present in ourselves, the professionals. They influence our communication style and our response to the other person. Words, tone, volume, silence, body language feelings, expectations, assumptions, attitudes, beliefs and values We can and do read each other! 13

14 PERSON: Reflection during the conversation Observe the effect of the person s unspoken communication upon you! Is whati am feeling being picking up from the person s unspoken communication to me? The unspoken part of the other person s communication (body language, tone, volume, silence) is telling me something about what is going on inside the other person e.g. tension, frustration, embarrassment, grief If an earthquake is happening next to me I will feel it. and it may disrupt my planned next move! 14

15 PROCESS: Responding to the response Do saying sorry for a bad situation. Promise a solution ifthere is one. Don t offer one if there isn t!! But if you acknowledge the persons feelings, then theyhave (at last) managed to communicate (get through) to you how they feel. And that is important to them, because otherwise the conversation wouldn t have been difficult! Feelings are words put to emotions EMPATHY requires that you can acknowledge and describe the negative feelings that someone else has. Everyone feels better for having their feelings understood SYMPATHY is joining someone in their feelings. But EMPATHY instead seeks to be constructive in the acknowledgement of feeling. 15

16 The Plan 1. SHORT INTRO Dying matters -Communications at the End of Life course 2. COMMUNICATION Feelings matter - Give space for the other s feelings 3. STRATEGY You matter - Know your limits; your emotions matter too 4. ROLE PLAY GROUPS Groups of 3 Alternate between the 3 roles: The Professional The Patient, Relative or Customer The Observerwho gives feedback to the Professional THE POINT OF THIS Role Playing Difficult Conversations enables you to: PRACTICE THE SKILLS in a safe environment RECOGNISE the helpfulness of - Observation - Empathy - acknowledging feelings as a normal & healthy way of improved communication with the patient/ relative /customer. 16

17 Rules for the patient/ relative/ customer Don t make it easy -it is after all, meant to be a Difficult Conversation Everything sorted is not today s goal. Youcan be silent, but not for more than 1 minute. Keep an underlying reason for your reaction hidden don t say unless you feel that the Professional has hit the right button to hear it. The thing that stirs your reaction may be straightforward, or so complex that don t fully understand yourself. In the feedback you can give the actual or a hint of the deeper reason behind the reactions of the person you role-played. Optional action for the role player If you are particularly drawn into role play, after finishing it may be helpful to switch off, by stating: My name is I am not the person I role played just now. 17

18 TIMING The Patient/ Relative/ Customer chooses the scenario SUGGESTIONS Choose a difficult conversation that you have experienced or observed, either as a professional or as a customer. Please don t chose one that affected you deeply as a patient or relative. 2 min. Thinking time 1 min. Explaining the scenario 5 min. Action started by the Professional 2 min. Feedback from Observer 10 min TOTAL per Role Play Examples You role play a relative who needs to be urgently told that your father is exsanguinating from AAA. You role play a patient that is not accepting that the ED doctor is unable to order an MRI for. You role play a customer who has not received an urgent order placed, or the taxi promised for 10 minutes (half an hour ago). PROCESS: Responding to the response Will be the main exploration point in role play If you are the professional seek to be silent and wait, if the patient/ relative is silent, then perhaps verbalise the feelings you sense. if verbalconversation is proving difficult, gently acknowledge the presence of those feelings in words. 18

19 THIS FREQUENTLY CATCHES US OUT The other person may not be wanting to communicate in the way it comes out Words, tone, volume, silence, body language But very often does want to communicate something about this (the underlying stressor) but doesn t know how, or where to start feelings, expectations, assumptions, attitudes, beliefs and values & past experiences The professional s role in a difficult conversation is facilitate this 19