Delivering Bad News

1. Delivering Bad News Mom never said that it would be like this

2. A fantasy Once upon a time, there were two families who lived next door to each other. At 110 First Avenue, lived Bob and Barbara Bluster and their two children, Morgan and Fran. At 112 First Avenue lived Larry and Lori Luster, their son Henry, Larry’s mother, Sadie and Sadie’s beloved cat Fabula. Bob and Larry had been friends since college. They married classmates. Each frequently asked each other to take care of their homes while they would go on vacations. As happens with long-term friendships and families, over the years they had grown to tolerate each other’s annoying habits. Bob had a very blunt and direct way of giving bad news. Larry, on the other hand, preferred, in his words, to “sugar” it up a bit. Fortunately, this difference had never been tested until this day.

3. A fantasy (continued) Larry, Lori, Ruth and Henry were going on their annual vacation. Originally Sadie was going to go as well, but she developed a cold the night before the family was to leave and was unable to go with them. So, Larry asked Bob to keep an eye on “my mom” and Fabula while they were gone. Bob said, “Sure thing.” Three days after Larry and his family arrived at their destination, Larry called Bob to see how things were going. “How’s Fabula?” Larry asked. “She died.” “What! How can you say that. That’s terrible. What happened?” Bob proceeded to explain that the cat had crawled out an open window in Sadie’s room, tried to jump to the tree next to the house, couldn’t grab on to the tree because she had been declawed, and fell to her death. Larry was furious at Bob because he was so blunt. “Bob, why couldn’t you give it to me gently. You know, tell me about the tree next to the house, the window being open and the cat getting out and my mom called the fire department and they came and they couldn’t save Fabula. Why must you always be so darn blunt!” Well, tell me how did my mom take it?” After a long silence, Bob says, “Well Larry, you know the tree next to the house, the window was open . . . .”

4. Bad news Bad news: telling others you don’t want to tell them about something they don’t want to hear • In the Bob and Larry story, there are two choices: both are not always appropriate • Where to get guidance: from survey procedures; and from psychology • We’ll be spending time today on both, more on the psychology of giving bad news.

5. What do S&C Procedures have to say? • State Operations Manual • Exit Conference

6. Hospital, Appendix A Exit Conference • Purpose: “preliminary findings” • Team consistency and organization • Boundaries • If provider is represented by counsel, may refuse to conduct the conference if counsel tries to turn exit into evidentiary hearing • If provider creates an environment that is hostile, intimidating, or inconsistent with exit as informal and preliminary

7. Appendix P: Nursing Homes Team communication throughout survey Task 7 - Exit Conference Purpose: “preliminary findings” Who: personnel; ombudsman and officer of resident’s group, if one • Provide opportunity for discussion/additional information • “Ongoing dialogue”  rare surprises

8. Appendix M: Hospice • Exit conference: to inform the hospice of observations and preliminary findings of the survey. • “ongoing dialogue”  rarely surprises Implement the following guidelines during the conference:

9. Appendix J: ICFs/MR • Pre-exit: Team discusses findings/make conclusions, subject to additional information provided by facility officials • Determine need for more information • Ask for and consider additional information or clarification if necessary • If, per facility, “acceptable practice,” request supporting references

10. Summary: survey procedures • Preliminary • Respectful, open to change and to listen for more information • Factual • Context is informational exchange • Boundaries are

11. How Can Psychology Help?

12. Cognitive Therapy • What is it? • Where did it come from? • How does it apply to this task?

13. BeliefsIrrational v Rational What is Cognitive Therapy? • Thinking  Feeling  Behaving Where it came from: • Research based: Most research based of any therapy • Viktor Frankl Man’s Search for Meaning • The young girl dying of Typhoid and CHEERFUL

14. How Does Cognitive Therapy Apply to giving “Bad News”? • Thinking makes it so: Irrational v Rational • Irrational thoughts – makes bad news worse

15. Distorted Beliefs • Personalization (no connection to requirements) • Defensiveness • Entitlement Seeking -- “I deserve it” • Perfectionism – No mistakes • Approval Seeking • Over-responsibility D. Burns (2000). Feeling Good. NY: HarperCollins Publishers.

16. Beliefs  Thoughts

17. Thoughts that get you into trouble • All-or-Nothing Thinking. Black and white. • Overgeneralization. “Always” and “Never” fallacy • Mental Filter. Facility’s history: in and out of compliance. New ownership. Doesn’t matter • Disqualifying the Positive. “My positives don’t count” • Jumping to Conclusions. a. Mind reading. You conclude that someone is reacting to you in a negative way, but you don't check it out to see if it's true. b. Fortune Teller Error. Based on observations you “know” facility is out of compliance D. Burns

18. Thoughts that get you into trouble • Magnification or Minimization. Either make things way out of proportion or you shrink their importance. Binocular effect. “Facility isn’t so bad. These are poor people anyway so it’s better than what they have at home.” • Emotional reasoning. If I feel it, it must be true. “I feel inadequate to the rest of the team, so I must be.” • Should Statements. You motivate yourself or others with shoulds and shouldn'ts, or musts and oughts, or wills and won'ts, that have no basis in law. • Labeling. Extreme overgeneralization. “This team member is “a loser" • Personalization. You see yourself as causing some negative external event, which you have no control over. D. Burns

19. The Negative Triads The 3 R’s of Negative Living Resistance Revenge Resentment

20. Negative Triads (continued) Rescuer Victim Persecutor

21. Solution • Speak from within your framework – the requirements • Attack the distorted thoughts with “EVIDENCE” -- Sunshine • Examples: • Personalization: LD: No trace left • “Shoulds”: My should or the Law? • Perfectionism: Impossibility

22. Change Thinking Practice Sheet Antecedents or Triggers. Next to the words that come closest to capturing what you experienced, put a number from 1 to 10. • Angry • Anxious • Depressed • Guilty • Other. Specify __________ • Other. Specify __________ • Other. Specify __________ What were your automatic thoughts? (Thoughts you have without thinking, which just come into your head) What distorted thinking was behind each automatic thought? [See previous slide] What’s the evidence that disclaims your automatic thought? What words do you use to talk back to your automatic thought? After talking back, what changes, if any, do you see in the feelings you identified above? Look back at the feelings you rated at the top of this page and rate how you feel now. You should feel at least somewhat better. If you don’t, then repeat the exercise.

23. Change Outwardly: Accurate Empathy • A skill. You know and express the other person’s thoughts and motivations in such a way that the response is, “Yes, that’s exactly what I mean.”

24. Build Team • Consistency • Practice – who will say what • Cohesiveness • Comfortable enough to disagree • Recognize the psychological strengths / challenges of each team member and emphasize the strengths

25. Overall Suggestions • Know the Requirements/Procedures • If you survey facilities whose procedures omit exit conference, ask supervisor if your group may adapt current procedures: preliminary, mutual, respectful, rare surprises • Practice Self-awareness – Know and minimize distortions • Focus on “fact gathering and presenting” not friendship forming • Reinforce your strengths and positives individually and as a team