Cultivating Prognostic Awareness: Understanding the patient’s experience of serious illness
Explore and reflect on how patients adapt to serious illness
- Identify ways in which patients express prognostic awareness
- Understand how patient’s hope oscillates between less and more realistic
- Identify healthy patient adaptation
Understanding the patient’s story: The curiosity approach
Practice and develop a mindset that allows the clinician to learn more about the patient
- Understand the importance of building rapport and being affectively connected
- Understand that patients’ priorities and decisions are often affected by factors that we do not yet know
- Strong rapport and affective connection is critical to this work
- Approach conversations with curiosity, minimizing assumptions
- Explore ideas or topics that are important to the patient.
- Engage in dialog that is responsive to and connected with what the patient is saying.
Identifying and responding to emotions: Using NURSE
- Learn and practice how to respond to patient emotions
- Identify how clinician emotional responses are coded in the communication literature
- Responding to emotion enables deeper conversations with patients.
- NURSE skills for responding to emotion
Working with patient ambivalence: How to focus on living
- Recognize that patients give mixed messages about how much information they want to know
- Create a framework to focus on living while recognizing the possibility of dying
- Focus on living by promoting adaptive coping
- Clinicians need to understand and empathize with patients’ hopefulness in order to lessen the intensity of the ambivalence and engage in more difficult discussions.
- Strong adaptive coping skills enable patients to better engage in difficult discussions.
- Create a framework to focus on living and acknowledge the possibility of dying
- Align with patient hopes
- Identify and reinforce adaptive coping behaviors
- Engage in practical problem solving
Working with stable patients to slowly integrate prognostic information: How to help patients tolerate the possibility of dying
- Assess how patients are integrating their hopes for the future with the possibility of dying
- Practice skills that invite discussion about the possibility of dying without overwhelming the patient
- Patients need practice thinking about dying in order to prepare for medical decision making.
- Thinking about dying, in small but steady doses, enables patients to build distress tolerance and manage the strong emotions that accompany these discussions.
- Provide safety and containment with ‘The box’
- Prepare for discussions with ‘Talk about talking about it’
- Help patients imagine a hypothetical health state
Retreat: Sitting with suffering
- Recognize suffering
- Use active listening to inhabit the patient’s position as best you can, see how it might feel to be there, and make sounds to let the patient know you are there
- Reflect on the therapeutic benefits of active listening
Calibrating the discussion of prognosis
- Learn how to help the patient discern what he/she wants to know about prognosis
- Discuss prognosis while supporting hope
- Patients may not be aware of what they want to know and may need help formulating their information preferences.
- How to work with patient to decide what information would be helpful and tolerable to the patient (Ask/Ask/Ask/Tell/Ask).
- Use hope/worry to deliver prognostic information that the patient wants to know.
Approaching discussions of prognosis in a medically unstable patient who is struggling to discuss
- Identify when patients have an urgent medical problems that requires discussion of prognosis
- Reflect on the benefit and risks of discussing prognosis when a patient is reluctant to talk
- Learn communication techniques to approach patients who do not want to talk about prognosis but need to make urgent medical decisions
- Become more comfortable with the limited choices presented at end of life
- Some patients may need to discuss prognosis even when they do not want to in order to make medical decisions
- Offer a partnered approach to problem solving with ‘Name the dilemma’
Making a recommendation about goals of care
- Recognize the importance of giving medical recommendations about goals of care
- Understand how to solicit patient goals and values within a defined range of choice that is prognosis dependent
- Identify how negative and positive rights influence patient treatment options
- Part of the physician’s role is to give medical recommendations to patients.
- Determine when recommendations are needed and offer them.
Understanding cultural nuances of communication
- Reflect on the role of culture in communication and medical decision making
- Reflect on how different cultures manage medical information and make decisions
- Culture may impact decision making
- Patients do not need to be told the prognosis in order to make appropriate medical decisions
- How to determine how medical decision making is approached in their family unit.
- How to establish with a patient that they do or do not want prognostic information