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Faculty prep session October 20, 2009

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

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Faculty prep session October 20, 2009

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  1. Beyond the Health Care Proxy: Advance Care Planning for Patients with Serious Illness Faculty prep sessionOctober 20, 2009

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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...”

  9. 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

  10. 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

  11. 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

  12. 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

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