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