Hospice and Palliative Nurses Association (HPNA) E Learning

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1 Nurse Communication: Goals of Care and Transitions in Care Joy Goldsmith, PhD University of Memphis Department of Communication Elaine Wittenberg-Lyles, PhD City of Hope Division of Nursing Research and Education Disclosures Joy Goldsmith and Elaine Wittenberg-Lyles have no real or perceived conflicts of interest that relate to this presentation. An Overview of Objectives 1. Recognize communication needs of patients and families while engaging goals of care 2. Identify needs of patients and families while engaging transitions in care communication 3. Apply strategies to impact patient/family self disclosure 4. Apply strategies to explore patient/family uncertainties 1

2 COMFORT* Communication (story) Orientation and options Mindful presence Family Relating Team * Wittenberg Lyles, E., Goldsmith, J., Ferrell, B., & Ragan, S. (2012). Communication and palliative nursing. New York: Oxford. An Overview of Key Reports Institute of Medicine The Future of Nursing Communicating with physicians, professionals, patients, and families promotes open communication with other professionals. Cancer Care for the Whole Patient Psychosocial cancer care should provide psychosocial services by facilitating communication between patients and providers, identifying patient needs to design appropriate individualized care plans. The Palliative Nurse Standards of Palliative Nursing (ANA and HPNA, 2013) Standard 11: Communication Standard 12: Leadership Standard 13: Collaboration Institute of Medicine (2013) Delivering High-Quality Cancer Care Coordinated work force, with nurses as full partners Comprehensive interprofessional education 2

3 COMFORT* Communication (story) Orientation and options Mindful presence Family Relating Team * Wittenberg-Lyles, E., Goldsmith, J., Ferrell, B., & Ragan, S. (2012). Communication and palliative nursing. New York: Oxford. : Communicating about Goals of Care What is an Opening? An opportunity provided by the intentional or unintentional communication of patient/family A topic that is introduced by patient/family The topic can lead to conversation about goals of care These can be moments of tension that are avoided by clinicians An opening involves three steps: Common Ground + Self- Disclose on Topic + Connect to Quality of Life = OPENING 3

4 Question and Answer What is an Opening? A topic presented or avoided by patient/family which can lead to a conversation about goals of care Common Ground can be found once a patient/family reveals something, however small, about their feelings concerning illness (Petronio & Sargent, 2011) A safe zone for further discussion is offered How is a safe zone presented? A patient/family shares feelings during an appointment or meeting A patient/family member confides; they feel trust in you A patient/family shares about illness and who can know about it (Helft & Petronio, 2007) 4

5 Family asks you to hide something from patient Patient asks you to hide something from family Patient/Family asks about information concerning treatment, side effects, or dying (Helft & Petronio, 2007) The power of LISTENING Observe the opening Do not direct the opening or manage it Listening is purposeful Listening establishes and grows a relationship (King et al, 2012) Question and Answer If a patient asks you to hide information from family, is this a potential opening? Yes or No? YES 5

6 Listening Pearls Acknowledge the story you are listening to includes reason and sense Acknowledge that the story needs to be told Demonstrate that the story reveals strengths (King et al, 2012) The Role of Self Disclosure Reciprocating disclosure creates trust Sharing common ground demonstrates care (Altman and Taylor, 1973) Self Disclosure Pearls Once Common Ground is shared, you can share. Identify your own similarities/commonalities with the patient/family. But your sharing MUST maintain and privilege the patient/family not eclipse them. (Wittenberg Lyles, Goldsmith, Ferrell, & Ragan, 2012) 6

7 So Far.. Common Ground + Self- Disclose on Topic + Connect to Quality of Life = OPENING and Quality of Life The final step in engaging an opening Connecting the common ground and self disclosure to a quality of life domain. Spiritual Psychological Physical Social and Quality of Life Topic Initiated by Patient/Family Self disclosure topic Quality of Life Domain Patient asks for detailed information about dying Meaning of illness, anxiety about suffering, loss Spiritual Family shares information during healthcare interview about their depression Fear, anxiety, functioning concerns, caregiver burden Psychological 7

8 and Quality of Life Join the topic you share with patient/family to a quality of life domain. Common Ground + Self- Disclose on Topic + Connect to Quality of Life = OPENING Goals of Care Communication Reached through You are positioned to connect your conversation about Quality of Life with Goals of Care. (Ferrell & Coyle, 2008) Question and Answer If a family member shares with you about their marital difficulties in the midst of the pressures of caregiving, you have an opportunity to connect this disclosure with what Quality of Life domain? Any Domain 8

9 Relating: Communicating about Transitions in Care What is Relating? Understanding what the competing or unrealized goals are for patients/families Learning about patient/family priorities Journeying with patient/family during points of transition in care Attending to the role of uncertainty in the goals of patient/family Relating and Uncertainty Talking with patient and family about uncertainty Reviewing known and unrealized goals Tracking progress toward goals.. Is the work of relating. Relating and Uncertainty Uncertainty compromises decision-making Palliative and end-of-life care is full of uncertainties that cut across every quality of life domain People/we are inconsistent in what we want and how we pursue it People/we are inconsistent in how we process information (Babrow, 1992) 9

10 Question and Answer People are consistent in knowing what they want and acting on what they want. True or False? False Relating and Multiple Goals Our own goals are heavily based on relationships Our own goals are compromised by uncertainty Goals can be created by our need to reduce uncertainty Goals are complex, competing, and changing (Tracy & Copeland, 1990) Relating to Uncertainty Conversations with patients/families that include goal processing provide a place for reflection Key questions can help elicit areas of uncertainty Key questions can help elicit competing or unrealized goals 10

11 Question and Answer Goals can be competing, and/or unrealized, and/or multiple. True or False? True Relating and Communication Strategies Possible Source of Uncertainty Communication Prompt Health event changes loss of function What are you thinking about since the change in your? Change in diagnosis What are your hesitations about this news? Relating Uncertainty to Transitions in Care Empower patient/family with some goals that are achievable Assure patient/family that every person experiences competing goals Consider achievable goals in the the quality of life domains (psychological, physical, spiritual, social) 11

12 Relating Uncertainty to Transitions in Care Listen to multiple and competing goals Listen to their questions Strive to understand the meaning of their goals in the context of their family and life Establish a time frame for reviewing transition in care ideas Communication Pearls and Multiple Goals What do you hope for the most? What could you complete that would give you comfort? What is the best possible outcome? What do you want to achieve most right now? What fears are holding you back? Question and Answer People almost always make decisions based on competing goals. True or False True 12

13 Additional Resources Health Communication app in itunes 13