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.

Objectives

• Understand the duality of task and relational communication

• Discover foundations of narrative clinical practice

• Learn to practice person-centered messages

Task CommunicationThe 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)

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)

Narrative Nursing• Being with and relating to others while honoring

their voice & lived experience

Bearing Witness:1. Recognize individuality2. Understand life prior to illness3. Refocus beyond medical information

Kendall, 2007; Hess, 2003

Recognize Individuality

DeconstructionActive listeningUse adjectives to describe patient uniqueness

to others

Your Role: • Listen for vulnerabilities/uniqueness• Identify story structure– Who are the main people involved?

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?”

Understand Life Prior to Illness

ExternalizationSolicit/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?

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?”

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

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?”

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

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

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?”

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?”

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)

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.

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

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?”