+ Faculty prep session October 20, 2009 Beyond the Health Care Proxy: Advance Care Planning for Patients with Serious Illness.

+

Faculty prep sessionOctober 20, 2009

Beyond the Health Care Proxy: Advance Care Planning for Patients with Serious Illness

+Review in this Session

Objectives for small group sessions 1 and 2

Behavior Change Model as it applies to physicians and patients approaching advance care planning

Principles of reflective listening

Use of nominal process

+Objectives: Small group 1

This is session is devoted to developing personal awareness around the issue of ACP and by its conclusion, participants:

will be able to describe circumstances under which they have personally found ACP discussions challenging, and

will, with the help of colleagues, revisit and reframe these challenges

+Objectives Small Group 2

This small group session is devoted to skills practice, and by its conclusion, participants:

will be able to describe an 8 step protocol * useful in guiding advance care directive conversations

will know, and be more comfortable using, phrases that can operationalize those steps in guiding the patient and/or family through this decision making process

will be able to identify prognostic clues in a patient’s clinical presentation

+Behavior Change

Behavior change is the foundational principle underlying both small group sessions, and it applies equally to: what motivates physicians to change

their behavior relative to ACP what motivates patients to engage in

ACP

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Our tasks As clinicians

identify our patient’s readiness to change (in this case, to engage in ACP)

use what tools and interventions are stage appropriate to help them to move forward

As educators help our learners’ to identify their impediments

to moving forward with ACP help them develop the personal awareness and

skills that will enable them to move forward

+Stages of change Precontemplation

Not yet acknowledging that there is a need for ACP or that they are seriously ill; not interested in discussing, see no need, are in “denial”

Contemplation   Acknowledging that they may indeed by seriously ill, but ambivalent,

on a teeter-totter, but not yet ready or sure of  what might be the right choices to make; may be more receptive to discussion

Preparation/Determination Getting ready to change; active gathering of information, trying to

decide what is best

Action Actively making decisions; open to support, help, guidance from

others

Maintenance, Relapse,Transcendence

+Listening and Thinking Reflectively

Thinking reflectively is inherently part of good reflective listening and includes

interest in what the person has to say

respect for the person's inner wisdom

key element is a hypothesis testing, using phrases like “So you feel...” “It sounds like you...” “You're wondering if...”

+Levels of Reflective Listening and Responding Repeating or rephrasing – listener repeats or

substitutes synonyms or phrases; stays close to what the speaker has said

Paraphrasing – listener makes a major restatement in which the speaker’s meaning is inferred

Reflection of feeling – listener emphasizes emotional aspects of communication through feeling statements – deepest form of listening

+Nominal Process

Allows everyone present to contribute to discussion

Levels the playing field

Enables those who are quiet and have difficulty “getting in” or “finding a place at the table” to have space and time automatically allotted to them

Facilitator starts discussion by inviting the most junior, youngest, or newest person to speak first, moving through the group by age/experience etc, to the last person

+Nominal Process

In nominal process, there is no discussion of ideas to begin with.

Participants are asked to contribute a single idea or thought as concisely as possible. The facilitator turns to each participant and continues to do that until all ideas have been solicited. Only then does discussion begin.

This is useful in groups of 6 or more, or even in a smaller group if you know, or discover, there is someone who does all the work for the entire group, of if you have one person who dominates discussion.

You may, or may not, choose to use this technique

+In your small groups, please do

Help participants to identify key phrases in patient discussion that represent Clues to assessing readiness stage Opportunities to move readiness to another

level