Answering Difficult Questions… …Some thoughts Ciara Savage, Palliative Care Social Worker. 18 th September, 2014.
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Answering Difficult Answering Difficult Questions…Questions…
…Some thoughts…Some thoughts
Ciara Savage, Palliative Care Social Ciara Savage, Palliative Care Social Worker.Worker.
1818thth September, 2014 September, 2014
Why is it so hard…?Why is it so hard…?
……personal feelingspersonal feelings……helplessnesshelplessness……fears we holdfears we hold……awkwardnessawkwardness……the environmentthe environment
……bearing witness to painbearing witness to pain
Palliative Care and End of Life Palliative Care and End of Life Care…Care…
“…“…touches, pervades and touches, pervades and provokes primeval fears provokes primeval fears and feelings.”and feelings.”
(McSherry, 2013)(McSherry, 2013)
Our Fears…Our Fears…
What energises them?What energises them?
WISE FEAR ~ it is scaryWISE FEAR ~ it is scary
LEARNING ‘how to notice’ (in our LEARNING ‘how to notice’ (in our patients and ourselves)patients and ourselves)
unknown uncertainty
DIGNITYDIGNITY
Actioning Dignity…Actioning Dignity…
… … otherwise it remains otherwise it remains rhetorical rhetorical
(Magee et al, 2008)(Magee et al, 2008)
DignityDignity
PHYSICAL
SPIRITUAL
PSYCHOLOGICAL
SOCIAL
CULTURE
ENVIRONMENT
Dignity of Personal Dignity of Personal IdentityIdentity
Integrity, Autonomy, Inclusion… Integrity, Autonomy, Inclusion…
… … shapes and preserves us.shapes and preserves us.
Our actions, attitudes and Our actions, attitudes and behaviours can either preserve behaviours can either preserve or compromise our patients or compromise our patients Dignity.Dignity.
DIGNITYDIGNITY
Disease, illness can strip Dignity Disease, illness can strip Dignity away, away,
Leaving patients vulnerable & Leaving patients vulnerable & exposed.exposed.
Our Role; to safeguard and preserve Our Role; to safeguard and preserve DignityDignity
ABCD of Dignity ABCD of Dignity Conserving CareConserving Care (Cochinov,2002)(Cochinov,2002)
AAttitudesttitudes
BBehavioursehaviours
CCompassionompassion
DDialogueialogue
EMPATHYEMPATHY
‘‘Einfuhlung’ Einfuhlung’ (Lipps, 1880’s)(Lipps, 1880’s) ‘…‘…consideration of another persons feelings consideration of another persons feelings and readiness to respond to his/her needs… and readiness to respond to his/her needs… without making his/her burden one’s own’ without making his/her burden one’s own’ (Szalita, 1976)(Szalita, 1976)
‘‘a balanced curiosity leading to a deeper a balanced curiosity leading to a deeper understanding of another human being understanding of another human being (Bellet (Bellet & Maloney, 1991)& Maloney, 1991)
EMPATHYEMPATHY
Recognising presence of strong feelingRecognising presence of strong feeling
Pausing to reflect on thisPausing to reflect on this
Stating your perceptions on what has been Stating your perceptions on what has been
describeddescribed
Legitimising these feelings Legitimising these feelings
Respecting effort to cope with difficultyRespecting effort to cope with difficulty
Offer of supportOffer of support
Emotional AttunementEmotional Attunement
The point of Empathy…The point of Empathy…
… … to focus attention on the patient to focus attention on the patient (not on introspection)(not on introspection)
Need not be awkward or exhaustingNeed not be awkward or exhausting
Skillful Attunement;Skillful Attunement;
… … reading non-verbal cues, tone reading non-verbal cues, tone of voice, body language.of voice, body language.
… … use in ordinary clinical and use in ordinary clinical and non-clinical interactions non-clinical interactions
When the question is When the question is asked…asked…
… … our patients take a chance on us.our patients take a chance on us.
How we respond is critical.How we respond is critical.
Ground our response; honouring the Ground our response; honouring the patient’s personal dignity, using skills patient’s personal dignity, using skills of empathy and emotional of empathy and emotional attunement. attunement.
Simple IdeasSimple Ideas
Take a breath – don’t rush itTake a breath – don’t rush it
Avoid the temptation to placateAvoid the temptation to placate
Really listen – Really listen – what is actually being what is actually being asked?asked?
why is it happening now?why is it happening now?
why am I being asked? why am I being asked?
Communicating in stressful Communicating in stressful circumstancescircumstances
HOW? HOW? Use natural strengths; but have awareness of Use natural strengths; but have awareness of
limitationslimitations
KNOWLEDGEKNOWLEDGE
(translate)(translate)
STYLESTYLE – using repetoire, skills – using repetoire, skills
GRACEGRACE – feel, generosity of spirit – feel, generosity of spirit
Using Questions Using Questions EffectivelyEffectively
Broad, Open: Encourages story/ narrativeBroad, Open: Encourages story/ narrative
(How, what, Tell me…)(How, what, Tell me…)
Open Directive: Targeting specific Open Directive: Targeting specific issue/pointissue/point
(How did you feel when you heard that?)(How did you feel when you heard that?)
Directive: Important when seeking factual Directive: Important when seeking factual information. (Where is the pain?)information. (Where is the pain?)
Closed: When you need a YES/NO ‘Are you Closed: When you need a YES/NO ‘Are you sleeping?sleeping?
Pitfalls to Avoid…Pitfalls to Avoid…
Leading QuestionsLeading Questions: : Can assume an answer, or restrict Can assume an answer, or restrict
expression. (I expect you were worried)expression. (I expect you were worried)
Multiple QuestionsMultiple Questions: : Without pause for responseWithout pause for response
Premature/False reassurancePremature/False reassurance: : Need to explore fullyNeed to explore fully
NormalisingNormalising: : Be careful in useBe careful in use
Responding to AngerResponding to Anger
Speak to FEAR & not to Speak to FEAR & not to ANGERANGER
(Cancer Tales, 2002)(Cancer Tales, 2002)
Diffusing AngerDiffusing Anger
o AcknowledgeAcknowledgeo Invite explanation of causeInvite explanation of causeo LISTEN to storyLISTEN to storyo Focus on THEIR stress/feelingsFocus on THEIR stress/feelingso Apologise if appropriateApologise if appropriateo Clarify if appropriateClarify if appropriateo Negotiate a solutionNegotiate a solution
Family FocusFamily Focus
Helping families understand End of Helping families understand End of Life Symptoms.Life Symptoms.
Specific InformationSpecific Information
Reduces Anxiety and potential Reduces Anxiety and potential misunderstandingmisunderstanding
becoming a,becoming a,
‘‘Fellow Traveller’Fellow Traveller’(Holloway, 2010)(Holloway, 2010)
ReferencesReferences
McSherry, Wilf, Dignity in end of life care,McSherry, Wilf, Dignity in end of life care,inin Spirituality and End of Life Care, Gilbert, P Spirituality and End of Life Care, Gilbert, P (ed.)2014 Pavillion(ed.)2014 Pavillion
Cancer Tales, (2002) also online learning resource Cancer Tales, (2002) also online learning resource www.cancertales.orgwww.cancertales.org
http://realbalance.com/the-role-of-empathy-in-healhttp://realbalance.com/the-role-of-empathy-in-healthcare/Printthcare/PrintCharon, Rita Narrative Medicine: AModel for Charon, Rita Narrative Medicine: AModel for
Empathy, Reflection, Profession, and Trust, Empathy, Reflection, Profession, and Trust, JAMA, 2001;286(15):1897-1902JAMA, 2001;286(15):1897-1902
Moss, Bernard, The Caring Professions (Ths Social Moss, Bernard, The Caring Professions (Ths Social Worker)Worker)in in Spirituality and End of Life Care, Spirituality and End of Life Care, Gilbert, P (ed.)2014 PavillionGilbert, P (ed.)2014 Pavillion
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