E LL N EE C Geriatric Curriculum · 2011. 4. 5. · 4 Culture influences… • How people view...

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CCEENNLLEEEndEnd--ofof--Life Nursing Education ConsortiumLife Nursing Education Consortium

Geriatric CurriculumGeriatric Curriculum

Module 6:Module 6:Communication at Communication at the End of Lifethe End of Life

Part I: Basic CommunicationPart I: Basic Communication

ObjectivesObjectives::•• Describe basic principles of Describe basic principles of

communicationcommunication

EE LL NN EE CC Geriatric CurriculumGeriatric Curriculum

communication communication •• Explore individual communication Explore individual communication

styles and communication within the styles and communication within the interdisciplinary teaminterdisciplinary team

Basic Principles of CommunicationBasic Principles of Communication

•• Communication is a constant Communication is a constant twotwo--wayway

•• Words and actions are Words and actions are interpreted by the receiverinterpreted by the receiver


interpreted by the receiver interpreted by the receiver •• Much communicationMuch communication

is nonverbalis nonverbal•• Listening is the mostListening is the most

important part of important part of communicationcommunication

Hospice Education Network - ELNEC: Geriatrics - Communication Module 6

Hospice Education Network (c) 2010

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Listening StepsListening Steps

Helping Others/Active

Empathizing

t


Analyzing & EvaluatingInformation

RetainingInformation

Understanding

Ene

rgy

& I

nvol

vem

ent

Hearing

Ray, 1992Ray, 1992

““Nature gave us Nature gave us one tongue and two one tongue and two

ears so we could ears so we could hear twice as much hear twice as much

k ” k ”


as we speak.”as we speak.”

Epictetus, 55 A.D. Epictetus, 55 A.D. –– 135 A.D.135 A.D.

PresencePresence

•• Knowing and being Knowing and being comfortable with oneselfcomfortable with oneself

•• Knowing the other Knowing the other


ggpersonperson

•• ConnectingConnecting•• Affirming and valuingAffirming and valuing•• Acknowledging Acknowledging

vulnerabilityvulnerability



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PresencePresence

•• Using intuitionUsing intuition•• Being Being

th tith ti


empathetic empathetic •• Being in the Being in the

momentmoment•• Serenity and Serenity and

silencesilence

Factors that Influence Factors that Influence Communication at EOLCommunication at EOL

•• CultureCultureAA


•• AgeAge•• GenderGender•• Personal & family Personal & family

experiencesexperiences

Culture influences…Culture influences…•• The rules for The rules for

communication (e.g., is eye communication (e.g., is eye contact okay?)contact okay?)

•• How direct theHow direct the


•• How direct the How direct the communication around communication around illness and death is allowed illness and death is allowed to beto be

•• How openly emotions are How openly emotions are expressedexpressed



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Culture influences…Culture influences…

•• How people view illness How people view illness and deathand death

•• The meanings of words The meanings of words


gg(e.g., family, faith)(e.g., family, faith)

•• How decisions are made How decisions are made and who speaks for the and who speaks for the older adult/residentolder adult/resident

AgeAge

•• Consider the developmental stage of the Consider the developmental stage of the patient when determining how to talk patient when determining how to talk with him/her about dying.with him/her about dying.


•• Ask the person what they prefer to be Ask the person what they prefer to be called.called.

•• Be aware of ageBe aware of age--related factors, such as related factors, such as poor hearing and eyesight, that may poor hearing and eyesight, that may impair communication.impair communication.

GenderGender

•• Men and women tend to Men and women tend to communicate differentlycommunicate differently

•• Culture and religion may affect Culture and religion may affect


g yg ythe social status of men and women, whichthe social status of men and women, whichin turn influences how they interact with in turn influences how they interact with othersothers

•• Older women may prefer their husband or Older women may prefer their husband or son to make decisions or talk with the son to make decisions or talk with the healthcare teamhealthcare team



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Life ExperiencesLife Experiences

•• People who have never or People who have never or rarely had the experience ofrarely had the experience of

People tend to die the way they have lived, for People tend to die the way they have lived, for example:example:


rarely had the experience of rarely had the experience of trust probably won’t trust trust probably won’t trust youyou

•• People who have gotten their People who have gotten their way most of their lives will way most of their lives will expect to get their way expect to get their way during the dying phaseduring the dying phase

SummarySummary

•• EOL care depends on effective EOL care depends on effective communication skillscommunication skills

•• Many factors influence how peopleMany factors influence how people


Many factors influence how people Many factors influence how people communicate and we need to be communicate and we need to be sensitive to these differencessensitive to these differences

•• Listening is one of the most Listening is one of the most important parts of communicatingimportant parts of communicating



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Module 6Module 6

Part IIPart II::Therapeutic Communication at theTherapeutic Communication at the


End of LifeEnd of Life

Challenges in Communicating with Challenges in Communicating with Dying Patients and Their FamiliesDying Patients and Their Families

•• Societal denial of deathSocietal denial of death•• Lack of direct experienceLack of direct experience

with deathwith death


with deathwith death

•• Older adults’ and families’Older adults’ and families’fears and emotionsfears and emotions

•• Dementia and other conditions that Dementia and other conditions that make conversations about the future make conversations about the future and other abstract ideas difficultand other abstract ideas difficult

Challenges in Communicating with Challenges in Communicating with Dying Older Adults and Their FamiliesDying Older Adults and Their Families

Caregiver fears:Caregiver fears:•• Not having “the answers”Not having “the answers”


•• Feeling helpless/Feeling helpless/inadequateinadequate

•• Upsetting the patient/familyUpsetting the patient/family

•• Fear of showing emotionsFear of showing emotions•• Caregiver’s personal fear of dying Caregiver’s personal fear of dying



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Basic ConceptsBasic Concepts

•• Use active listening Use active listening •• Being present, rather than what you say, is Being present, rather than what you say, is

most important most important •• Let the patient and the family lead you Let the patient and the family lead you –– join join


p y yp y y jjin their journey; but emphasize that they are in their journey; but emphasize that they are in chargein charge

•• Encourage reminiscing; let the older person Encourage reminiscing; let the older person and families tell their storiesand families tell their stories

•• Let the patient know that their lives have Let the patient know that their lives have meaningmeaning

Active Listening is Demonstrated By:Active Listening is Demonstrated By:

•• Body languageBody language•• Eye contactEye contact•• Echoing wordsEchoing words


Echoing wordsEchoing words•• Head noddingHead nodding•• Leaning towards the speakerLeaning towards the speaker•• Not interruptingNot interrupting•• Paraphrasing facts and feelingsParaphrasing facts and feelings

TimingTiming•• Make sure the patient/ Make sure the patient/

resident and/or family is resident and/or family is physically comfortable physically comfortable


before starting a before starting a conversation.conversation.

•• Whenever possible, use the Whenever possible, use the older adults/resident’s and older adults/resident’s and family’s timetable, not family’s timetable, not yours.yours.



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Asking QuestionsAsking Questions

•• Ask only necessary questionsAsk only necessary questions

•• Focus questions on the patient and Focus questions on the patient and family’s concernsfamily’s concerns


yy

•• Respect privacy, including the privacy of Respect privacy, including the privacy of the patient and family’s emotionsthe patient and family’s emotions

•• If you need to ask a sensitive question, If you need to ask a sensitive question, explain first why you need to ask itexplain first why you need to ask it

Important Messages to Important Messages to Communicate to Someone at EOLCommunicate to Someone at EOL

•• ListenListen•• RespectRespect


•• RespectRespect•• Hopes, values, Hopes, values,

and goalsand goals•• Encourage Encourage

questionsquestions

Ways Dementia Can Impact the Ways Dementia Can Impact the Person’s CommunicationPerson’s Communication

•• AphasiaAphasia•• AgnosiaAgnosia•• AnomiaAnomia

•• PerseverationPerseveration•• ParaphrasiaParaphrasia•• Using curse wordsUsing curse words


•• AnomiaAnomia•• ApraxiaApraxia•• Losing train of thoughtLosing train of thought•• Word saladWord salad•• WithdrawalWithdrawal

•• Using curse wordsUsing curse words•• Speaking lessSpeaking less•• Reliance on nonverbal Reliance on nonverbal

gesturesgestures•• Reverting to a foreign Reverting to a foreign

languagelanguage



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Tips for Communicating with Tips for Communicating with Patients with Dementia Patients with Dementia

•• EnvironmentEnvironment•• Treat person/resident as an adultTreat person/resident as an adult


•• Treat person/resident as an adultTreat person/resident as an adult•• Respond to emotions rather than Respond to emotions rather than

wordswords

Behaviors When Talking with Behaviors When Talking with Patients With DementiaPatients With Dementia

•• SmileSmile•• Use humorUse humor•• Do not argue or confrontDo not argue or confront


•• Do not argue or confrontDo not argue or confront•• Be positiveBe positive•• Know the person/residentKnow the person/resident•• YOUYOU do most of the work in do most of the work in

communicating!communicating!

We accept We accept you and you and

we will not we will not abandon youabandon you


abandon youabandon you



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Messages to Give to the DyingMessages to Give to the Dying

•• I love youI love you•• I forgive youI forgive you

Pl f iPl f i


•• Please forgive mePlease forgive me•• Thank youThank you•• GoodbyeGoodbye

Byock, 1997Byock, 1997

Communicating Hope Communicating Hope at the End of Lifeat the End of Life


Dimensions of HopeDimensions of Hope

•• Accepting and moving beyond Accepting and moving beyond current sufferingcurrent sufferingS tti l d i t i iS tti l d i t i i


•• Setting goals and maintaining Setting goals and maintaining controlcontrol

•• Connectedness to other peopleConnectedness to other people

•• Connectedness to God, something Connectedness to God, something “bigger” than oneself“bigger” than oneself



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Accepting and Moving Beyond Accepting and Moving Beyond Current SufferingCurrent Suffering

•• Prevent and manage Prevent and manage symptomssymptoms


symptomssymptoms

•• Use lightheartedness and Use lightheartedness and humor skillfullyhumor skillfully

•• Support older patients and Support older patients and families in positive self talkfamilies in positive self talk

Accepting and Moving Beyond Accepting and Moving Beyond Current Suffering (cont.)Current Suffering (cont.)

•• Engage the older adult in creative, Engage the older adult in creative, joyous, aesthetic activitiesjoyous, aesthetic activities


•• Encourage reminiscingEncourage reminiscing

•• Focus on past and present joysFocus on past and present joys•• Share positive, hopeShare positive, hope--inspiring inspiring

storiesstories

Setting Goals and Maintaining Setting Goals and Maintaining ControlControl•• Help the older adult/resident and family:Help the older adult/resident and family:

–– Identify, obtain, and revise goalsIdentify, obtain, and revise goals


–– Identify resources to achieve goalsIdentify resources to achieve goals–– Maintain their sense of controlMaintain their sense of control

–– Identify past successesIdentify past successes

•• Provide them with accurate informationProvide them with accurate information



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Connecting with OthersConnecting with Others

•• Provide time for relationshipsProvide time for relationships•• Affirm sense of selfAffirm sense of self--worthworth

E bli h & i iE bli h & i i


•• Establish & maintainEstablish & maintainan open, respectful an open, respectful connectionconnection


“Hope is an act of collaboration. It cannot be “Hope is an act of collaboration. It cannot be achieved alone. We offer grains or fragments of achieved alone. We offer grains or fragments of hope to one another so that everyone’s sense of hope to one another so that everyone’s sense of possibility can grow. In this way we can do possibility can grow. In this way we can do together what might seem impossible alone.”together what might seem impossible alone.”

Fischer, 1998Fischer, 1998

Connecting with One’s SpiritualityConnecting with One’s Spirituality

•• Help the older adult/ resident Help the older adult/ resident participate in religious rituals participate in religious rituals meaningful to him or hermeaningful to him or her


•• Assist in arranging clergy visitsAssist in arranging clergy visits•• Help the older adult/ resident & family Help the older adult/ resident & family

find meaning find meaning in the experiencein the experience



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Symbolic Language:Symbolic Language:“I Want to Go Home”“I Want to Go Home”


Symbolic LanguageSymbolic Language

•• Explore with the Explore with the family the possible family the possible meaningsmeanings


•• Don’t contradict Don’t contradict statementsstatements

•• Don’t assume Don’t assume deliriumdelirium

SummarySummary

•• There are many challenges to There are many challenges to communicating openly at the EOL. We communicating openly at the EOL. We must meet these challenges to provide must meet these challenges to provide

f if i


excellent care for the dying.excellent care for the dying.•• The most important message to The most important message to

communicate to the dying is acceptance communicate to the dying is acceptance and a commitment to being there for and a commitment to being there for them no matter what happens.them no matter what happens.



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Summary (cont.)Summary (cont.)

•• Be sensitive to the language and Be sensitive to the language and communication of the dying patient.communication of the dying patient.Th t t i thTh t t i th


•• There are many ways to sustain the There are many ways to sustain the patient and families’ hope at the patient and families’ hope at the EOL.EOL.



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Module 6Module 6

Part IIIPart III::Working with Families and DealingWorking with Families and DealingWi h C fliWi h C fli


With ConflictWith Conflict

Working with Families at the Working with Families at the End of LifeEnd of Life


•• ParticipatingParticipatingL tti /l tti iL tti /l tti i

Needs of the Family withNeeds of the Family withSomeone in LongSomeone in Long--Term CareTerm Care


•• Letting go/letting inLetting go/letting in•• Going through the stages of griefGoing through the stages of grief•• Achieving connectionAchieving connection



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There is the There is the potential for potential for growth and growth and

change change


throughoutthroughoutthe family life the family life

cyclecycle

How can familiesHow can familiesbe angry with usbe angry with us

Older Adult & Family EmotionsOlder Adult & Family Emotionsand Responses to Impending Deathand Responses to Impending Death


be angry with usbe angry with uswhen we haven’twhen we haven’tdone anythingdone anythingwrong?wrong?

Conducting a Family ConferenceConducting a Family Conference

•• Gather the family/the team members/and Gather the family/the team members/and resident (if possible)resident (if possible)

•• Establish purpose and goalsEstablish purpose and goals


•• Use attentive listening/ask openUse attentive listening/ask open--ended ended questionsquestions

•• Be sensitive to silence and nonverbal Be sensitive to silence and nonverbal communicationcommunication

•• Acknowledge your feelingsAcknowledge your feelings



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Conducting a Family Conference Conducting a Family Conference (cont.)(cont.)

•• Avoid misunderstandingsAvoid misunderstandings•• Don't change the subjectDon't change the subject

T k i i i i d iT k i i i i d i


•• Take your time in giving adviceTake your time in giving advice

Dealing with Conflict at the EOLDealing with Conflict at the EOL


If You Get Caught in the Middle of a If You Get Caught in the Middle of a Conflict, Remember:Conflict, Remember:

•• There are many points of view in every There are many points of view in every situationsituation


•• Don’t take sidesDon’t take sides

•• Grief can be expressed as angerGrief can be expressed as anger•• Anger may be directed at people who are Anger may be directed at people who are

“safe” targets (for example, staff)“safe” targets (for example, staff)



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Tips for Managing Your Own Tips for Managing Your Own ResponsesResponses

•• Remove yourself from the situationRemove yourself from the situation


•• Talk with other team membersTalk with other team members

•• Make a plan for dealing with the Make a plan for dealing with the conflictconflict

When You are Communicating When You are Communicating With Someone Who is UpsetWith Someone Who is Upset

•• Treat the person with respectTreat the person with respect•• Answer the person’s questionsAnswer the person’s questions


Answer the person s questions Answer the person s questions •• Stay calm; don’t argueStay calm; don’t argue

•• Use active listening skillsUse active listening skills•• Let the person talkLet the person talk

Nurse/Physician CommunicationNurse/Physician Communication

•• Preparation is essential!Preparation is essential!•• Physician is dependent on Physician is dependent on

i f ti id d b thi f ti id d b th


information provided by the nurseinformation provided by the nurse•• When the nurse and physician do not When the nurse and physician do not

communicate wellcommunicate well——the patient loses!the patient loses!

Dahlin, 2010Dahlin, 2010



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The BASICS ApproachThe BASICS Approach

•• B = BackgroundB = Background•• A = AssessmentA = Assessment

S Si i /S Si i /


•• S = Situation/symptomS = Situation/symptom•• I = InterventionI = Intervention•• C = CommunicationC = Communication•• S = Successful outcomeS = Successful outcome

Berry & Miller, 2006Berry & Miller, 2006

Strengthening Your Strengthening Your Communication SkillsCommunication Skills


Strengthen Your SkillsStrengthen Your Skills

•• Identify your communication Identify your communication style/your team member’sstyle/your team member’s

•• What communication styles What communication styles


yyare easy/ difficult for you to are easy/ difficult for you to deal with?deal with?

•• Do you understand your role Do you understand your role on the team and communicate on the team and communicate it to the team?it to the team?



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Respect, Respect, RespectRespect, Respect, Respect





E LL N EE C Geriatric Curriculum · 2011. 4. 5. · 4 Culture influences… • How people view...

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