Therapeutic Communications; Compassion, Death & Dying; MAD

1. Therapeutic Communications; Compassion, Death & Dying; MAD Condell Medical Center EMS System October 2010 CE Site Code # 107200-E-1210 Objectives by: Debbie Semenek, RN, EMS System Coordinator Packet prepared by: Sharon Hopkins, RN, BSN, EMT-Paramedic

2. Objectives • Upon successful completion of this module, the EMS provider will be able to: 1. Define the communication process. 2. List components of the communication process. 3. List obstructions to the communication process. 4. Identify strategies for developing trust and rapport with patients. 5. Define interpersonal zones. 6. Identify strategies used during the interview process with patients.

3. Objectives cont’d 7. Describe elements of patient caring. 8. Describe the unique challenges for EMS personnel in dealing with themselves, adults, children and special populations related to death and dying. 9. List the 5 predictable stages of loss by Elizabeth Kubler Ross. 10. State the components of the State of Illinois Advanced Directives.

4. Objectives cont’d 11. Review the Region X SOP “Withdrawing Resuscitative Effort”. 12. Review the MAD usage. 13. Review documentation components for discussed conditions. 14. Actively participate in case scenario discussions. 15. Successfully complete the post quiz with a score of 80% or better. 16. Given the equipment, demonstrate use of the MAD device.

5. Communication • Just an exchange of symbols: • Written, spoken, gestured

6. Components of Communication • A sender – creates the message • The message is sent • A receiver – interprets the message sent • Feedback – response is given to the message received

7. Failed Communications • Prejudice – toward patient or situation • Lack of empathy – identifying with and understanding another’s situation, feelings, motives • Lack of privacy – may inhibit responses • External distractions – TV, traffic, crowds • Internal distractions – thinking about other things

8. Key Point • Improve communication skills with: • PATIENCE • FLEXIBILITY • RESPECTFULNESS • EVIDENCE OF COMPASSION • Once trust is established, rapport follows • Avoid false promises – they violate your patient’s trust

9. Building Trust & Rapport • Use the patient’s name • Breaks down some barriers • Ask the patient how they want to be addressed • To remember names: • Say the name out loud three times in the 1st minute • “See” the name in your head • “Feel” yourself writing the name in your imagination

10. Trust and Rapport • Voice • Watch your volume, speak quietly in low tones • Check your pitch – high voices are harder to hear • Watch your rate of speaking • Use a professional, compassionate tone • Avoid sarcasm, irritation, anger

11. Trust & Rapport • Explanations • Explain what you are doing • Explain why you must do something • Eases patient’s anxiety • Often best to give a short explanation immediately prior to the procedure • Less time for the patient to dwell on what will be done • Less time for the imagination to roam

12. Trust & Rapport • Facial expressions • Keep a kind, calm facial expression • Keep a “poker” face • Convinces the patient you can handle the situation • Smiling when speaking puts a more pleasant tone in your voice

13. Interpersonal Zones • Intimate zone – 0 – 1.5 feet • Visual distortions • Best for assessing breath & body odors • Personal space – 1.5 – 4 feet • Used for much of patient interview and assessment • No visual distortion • Voice is moderate • Social distance – 4 – 12 feet • Impersonal business transactions • Personal interview in dangerous situations

14. Interviewing Techniques • Goal: • Identify chief complaint • Determine circumstances causing the emergency • Determine the patient’s condition • Achieving the goal: • Asking questions • Observational skills • Effective listening skills

15. Interviewing Techniques • Open-ended questions • Questions that permit unguided, spontaneous answers • “What happened that you needed to call 911?” • “What seems to be the problem?” • Benefit • Patient responds in an unguided way • May include information that indicates additional assessment of patient • Chief complaint can drive direction of rest of the interview

16. Interviewing Techniques • Leading questions • Question framed to guide the direction of the patient’s answer • “Are you having chest pain?” • Problem – • Could miss a serious problem by refocusing the patient away from their true chief complaint

17. Interviewing Techniques • Direct or closed questions • Requests specific information • “Are you nauseated?” • Answers fill in information generated from open-ended questions • Answers crucial questions when time is limited • Helps control overly talkative patients

18. Interviewing Techniques • Ask one question at a time • Allows patient to finish answering one question and to complete their thought • Designate one person to ask questions • Confuses patient when multiple people ask questions • May not be clear which person/which question the patient is responding to • Listen to the responses • Do not interrupt

19. Interviewing Techniques • Use of language • Use words the patient understands • “pee” instead of “urinate” • Avoid slang or jargon • May need to phrase the words multiple ways for the patient to understand the question • Remember that children are literal, concrete minded • You say “I’m taking your blood pressure” and the child wonders where you are taking it to

20. Patient Caring • “People will seldom remember what you did or what you said. But they will almost always remember how you made them feel.” Cab Driver, Boston

21. What EMS does… • We fix problems • Technical stuff • Splint • Bandage • IV’s • Drugs • Etc.

22. What else we do…. • We fix people • Family concerns • Non-medical needs • Emotions • Comfort • Being a friend / advocate

23. EM“S” • Service • Must have a natural ability to like people • We encounter people at their worst – they are in crisis • If you don’t want to be there and you don’t want to take care of them…they will sense that, so… …consider a different profession!

24. Remember, an emergency is defined by its owner – not by us • Don’t underestimate the patient • People are easily overwhelmed • They don’t know where to turn, so they turn to us • It does not make them stupid • It is not a waste of our time…

25. ...it's our JOB!

26. Who Do We Serve? • Define who all of our customers are • In-house, department members • Vendors supplying the department • Other village/city/governmental departments • Hospital staff • Our patients • Our patient’s families • Who else???

27. What’s the message??? • Regard everyoneas a customer.

28. Be Effective • To be effective with your technical skills you must: • See the patient as more than the problem, complaint, that they present • They are customers that reach out to you in the worst moment of their lives

29. Be Effective • Explain every phase of treatment to your patient • Let them know what to expect • Ask permission before a procedure • When you can accept a ‘yes’ or ‘no’ answer • When there shouldn’t be a choice (ie: necessary IV), avoid phrases like “Can I start this IV” • Give the choice, instead, possibly to the IV site • Give them an opportunity to report changes

30. Patients are highly aware of a caregiver’s attitude – whether positive or negative. • If you show honest concern, the patient will sense it. What's your attitude?

31. Caring… • We must be people who can enjoy serving others for 30 years and sell them the real deal • Not every call is dramatic • Burnout is a possibility • What are your expectations? • Our role in a patient’s life is more than just a moment

32. Caring… • Habitually use peoples’ names • Hi. What is your name? • Introduce yourself • Ask how the patient wants to be addressed • Connect with the person – not the problem • Smile • Be respectful • Maintain eye contact • Immediately puts you in touch with their emotional state and mental status

33. Caring… • Remember people have families / significant others • Families are important to us • Healing • Informative • Supportive • DO NOT toss a family member/significant others aside so we can do our work • May be the last time the patient is seen in a comfortable setting

34. Understand that physical comfort, fear and embarrassment are important to our patient • Need to be vigorously addressed • Pain control • Keeping a patient warm / cool • Providing emotional comfort • Maintaining modesty / dignity

35. Families and Death • The reality of death is: • It’s traumatic • It’s stressful • For us, too • It’s a situation that is permanently imprinted • Everything that is heard and seen and will be remembered

36. Delivering the News of Death • EMS often in the position to have to deliver news of a death • No script can cover all situations • Each scene must be assessed as well as the persons involved • Then determine safest and most compassionate way to deliver sad news • Provide a private area for sharing information

37. Deaths – Phrases to avoid… • “I know how you feel” • “I understand” • “You’re so strong” • “Get on with your life” • “It was God’s will” • “They led a good life” • “It could have been worse”

38. Caring…Two roads to take • The high road • Compassionate • To each other • Conveying caring / offering condolences • Explaining actions / inactions • Giving permission to grieve • Denial, anger, bargaining, depression, acceptance • Offering continuing support • Clergy • CISM (CISD # 1-800-225-2473) • Counselors • Friends

39. The low road… • Tough / abrasive • Don’t talk to anyone, keeping them away • “Death does not phase me” attitude • Being cold • Being distant • Tough is not professional

40. Dealing with the difficult situation • Families who are able to spend time with the body or dying person do better emotionally in the long run “There is an image of the loved one looking worse than they really are when the body can’t be seen.” • If the image is bad, give family the option

41. What to say & do… • It’s OK to share that it’s hard for you • Let touch convey caring • “I wish so much you had them back” • “I see how painful this is for you” • Ask to hear about their loved one • Be a good listener

42. Stages of Loss • Experienced in any loss • Death • Relationships • Jobs • EMS is exposed to a multitude of emotional responses • We don’t always see people at their best is why we always need to function at our best

43. Stages of Loss • 5 predictable stages • Denial – “not me” • Anger – “why me” • Bargaining – “okay, but first” • Depression – “okay, but I haven’t” • Acceptance – “okay, I’m not afraid” • Stages can progress in any order and time frame for each is individualized

44. Denial • Inability or refusal to believe the reality of the event • Used as a defense mechanism • Person can put off dealing with the inevitable • If death is discussed, use the terms “dying, died, death, dead” • Use of “passed on, left us, gone away” can be misinterpreted • Avoid statement’s of “God’s way” or relief of pain or other subjective assumptions

45. Anger • Really a frustration over inability to control situation • Anger can be focused on anyone or anything in their pathway • Watch for safety issues

46. Bargaining • Patients may try to “make deals” to put off or change the inevitable • “I promise to …(go to church, be kinder, donate my money…) if…(the diagnosis is wrong, the disease isn’t so bad, it was mistaken identity)

47. Depression • Patient experiences a variety of feelings • Sadness • Mourning • Retreats into self/private world • May lose interest in self care • Bathing issues • Non-compliance with medical care

48. Acceptance • Patient may or may not reach this stage • May achieve a reasonable level of comfort with situation • Family may need more support at this point in time

49. EMS and Patient Resources • Department peers • Department chaplain • Family members • Religious affiliation • Hospital services patient is connected to • Hospice if patient is enrolled • Others?

50. DNR FORM