COMFORT*

2. COMFORT* • Communication (narrative) • Orientation and opportunity • Mindful presence • Family • Openings • Relating • Team * Wittenberg-Lyles, E., Goldsmith, J., Ferrell, B., & Ragan, S. (2012). Communication and palliative nursing. New York: Oxford.

3. Objectives • Understand the duality of task and relational communication • Discover foundations of narrative clinical practice • Learn to practice person-centered messages

4. Task Communication The content of the message • Teaching- confirm and explain bad news • Advocating- share information with healthcare team (Price, et al., 2006; Radziewicz & Baile, 2001) • Coordinating- mobilize needed resources (Pavlish & Ceronsky, 2009)

5. Relational Communication The relationship between the people as conveyed by the message • Caring - provide patient/family support • Sharing - emotional reactions and providing opportunities to process the bad news (Warnock, et al., 2010)

6. Narrative Nursing • Being with and relating to others while honoring their voice & lived experience Bearing Witness: • Recognize individuality • Understand life prior to illness • Refocus beyond medical information Kendall, 2007; Hess, 2003

7. Recognize Individuality Deconstruction • Active listening • Use adjectives to describe patient uniqueness to others Your Role: • Listen for vulnerabilities/uniqueness • Identify story structure • Who are the main people involved?

8. Recognizing Individuality • “Tell me about times when you aren’t thinking about illness/your loved one’s disease.” • “How would you describe this illness/the shared experience of illness?” • “Is there anything else that could explain your/his/her illness?” • “I’m wondering if there is more to this than meets the eye.” • “Who else is involved in your/his/her illness?”

9. Understand Life Prior to Illness Externalization • Solicit/employ information • Encourage reflection • Incorporate psychosocial history in diagnostic assessment Your Role: • Encourage sharing to identify and address feelings • Adopt multiple perspectives • What are the relationships between the people involved?

10. Understanding life prior to illness • “How has your illness (or his/her illness) affected your life and your relationships?” • “How do you think ignoring this will affect your life?” • “How does your illness (or his/her illness) reflect on you as a person?” • “How do you see the future?” • “How are you affected by others’ opinions?” • “What do you think influences this experience?”

11. Go Beyond Medical Facts Re-authoring • Help revise and widen narrative lens beyond illness • Solicit history to understand illness • Help patient/family understand and accept current circumstances Your Role: • Consider the mental health of patient/family member • Creative skills (What solutions can be drawn?) • Tolerate uncertainty as you listen to the story

12. Going beyond medical facts • “What people in your life are supporting you?” • “What do you think needs to happen in order for you to be able to care for your loved one/yourself?” • “What needs to change?” • “What does your success in solving problems related to care say about your abilities?” • “How is this experience affecting your life?”

13. Person-Centered Messages (PCM)* • Speaking in a supportive way to validate and affirm patient/family • Support is conveyed with clear language • Be realistic, yet supportive • Focus on the patient’s feelings *Burleson, 1994

14. Practicing Person-Centered Messages • Explicitly recognize and acknowledge the patient/family’s feelings but does not elaborate on those feelings. • Provide an elaborated acknowledgement and explanation of the patient/family’s feelings • Help the patient/family to gain a perspective on his or her feelings

15. Person-centered messages From the following, choose the most person-centered message: (a) “I can see why you are upset. That’s a normal reaction.” (b) “I’m so sorry this has happened. Did you think this was coming?” (c) “Let’s talk about your treatment from this point forward. Can I see you tomorrow?”

16. Examining person-centered messages (a) “I can see why you are upset. That’s a normal reaction.” (b) “I’m so sorry this has happened. Did you think this was coming?” (c) “Let’s talk about your treatment from this point forward. Can I see you tomorrow?”

17. When discussing bad news… • Clearly explain prognosis, elaborate • Respond to impact on life • Show clear respect for feelings • Integrate life/work into decision-making • Address pain, family role in care • Plan, present team structure, hospice/Advance directives (if appropriate)

18. The unique role of the nurse • Presence before, during, and after bad news • Vulnerable to questions from patient/family • provide supplemental information • assess information needs • clarify misunderstanding • educate • Your role is to validate bad news to aid in patient/family acceptance.

19. Challenges for the nurse • Physician assumptions about your role, knowledge • Not being present for bad news delivery • Not knowing all of the patient/family information when confronted • Ambiguity about your role on the team and appropriate communication topics to discuss

20. Breaking Bad News Scenarios for the Nurse • Over the phone “I know this is not ideal, but I can talk to you now over the phone about your health and we can meet together tomorrow to talk more.” • Nurse not present during bad news disclosure “Since I was not here for the news, can you tell me how the conversation with the team went? [response]. Now, as I listened to you these are the questions I think you still have [relay concerns], is that right?”