How do we have conversations about pain that are in and of themselves healing? Often, clinicians dread having conversations about pain. This session will introduce a map of how to have healing conversations about this challenging topic. Empathy and responding to emotion are key in healing conversations

Marchand, Lucille, MD, BSN, FAAHPM

Western Washington University

Having Healing ConversationsLucille Marchand MD, BSN, FAAHPMMedical Director of University of Washington Hospital Inpatient Palliative Care Service, SeattleFarber Endowed Professor in Palliative Care EducationProfessor and Section Chief of Palliative Care, University of WA Department of Family Medicine, SeattleExecutive Director of the Osher Center for Integrative Medicine at the University of Washingtonlrm19@uw.eduMay 11, 2018Powered by VitalTalk © What are some of your most challenging communication situations with patients and families and with other clinicians around pain management?How do these Innate Qualities affect our Communications with Others?CompassionHopeResiliency CompassionEmpathy: emotional and cognitive process of being able to take the perspective of anotherShared Presence: willingness and skill to enter the intimacy of relationship with another – a state of being with anotherCompassion: desire and actions to relieve suffering of another – Being of Service Practices to nurture compassionFernando AT and Consedine NS. “Beyond compassion fatigue: the transactional model of physician compassion. Journal of Pain and Symptom Management. 2014; 48(2): 289-298.Being Present Tuning into the pause and stillness after the outbreath.   Being still.  Able to be silent yet attentive. Generous listening (Rachel Remen, MD) Listening to what is inside you and what is coming from the other person both verbal and nonverbal – connection.  Breathing ConsciouslyBasic practice of many contemplative traditionsDeep relaxed belly breathing – activating the parasympathetic response.Well-being, relaxation, and presence. Hope “Hope does not lie in a way out, but in a way through.” Robert FrostQuestions to Explore Hope and Pain What is your understanding about your situation? What is important and meaningful to you right now? What worries or concerns you right now and in the future? Miracle question: acknowledge, and what are other hopes? By listening intently to the answers, the health professional explores possibility, optimism, and connectedness, hope, and what is getting in the way of hope. Marchand L. The healing power of hope. AAHPM Quarterly. Summer 2010:13. ResiliencyThe urge to move forward despite great uncertainty and challenge.Back AL, Steinhauser KE, Kamal AH, Jackson VA. Building resilienc for palliative care clinicians: an approach to burnout prevention based on individual skills and workplace factors.  J Pain Symptom Manage 2016;52:284-291.Challenging Situations Bring Up Emotions!Emotions are information!How do we work with our emotions? What is the story behind our emotion?Contemplative practices can help us….Debriefing:  Writing and storytelling can help us…Back AL, et al. “Why are we doing this?”: Clinician Helplessness in the Face of Suffering. J Pall Med 2015; 18(1): 26-30Back AL, et al. “Why are we doing this?”: Clinician Helplessness in the Face of Suffering. J Pall Med 2015; 18(1): 26-30Emotions as informationUsing physical and emotional clinician responses to help understand one’s reaction to a situation to respond rather than distance from a patient –Cues that Can Signal HelplessnessBack AL, et al. “Why are we doing this?”: Clinician Helplessness in the Face of Suffering. J Pall Med 2015; 18(1): 26-30 Hypo-engagement Somatic Lifeless limbs Numbness in the chest Heaviness in the stomach Emotional Apathy  Disconnected Hopeless Cognitive “Nothing ever changes” “Why bother?” Hyper-engagement Somatic Tense muscles Increased heart rate Churning stomach Emotional Irritability Anxiety Hyper-vigilance  Cognitive “We have to do something to fix this!” “Why are we doing this?”Back AL, et al. “Why are we doing this?”: Clinician Helplessness in the Face of Suffering. J Pall Med 2015; 18(1): 26-30 Dynamic process – “zone of constructive engagement”RENEWRecognize helplessness Embrace your first reactionNourish self Embody constructive engagementWeave a new responseFast Facts and Concepts:#203Managing One’s Emotions as a Clinician Posluszny D and Arnold, R.PCNOW.org or CAPC.org/fast facts Reflect on your emotions before you go in Prepare: Goals?  Bring someone with you. Breathe. Cultivate presence and being in the moment. While you are there: be aware of your emotions Naming intense emotions. Take a break if needed. Debrief after visitExperiencing Grief and Loss and Being in Shared Presence Understanding our “hot buttons” Being able to be present and actively listen without needing to fix and cure when that is not possible.Namaste: Respect for the other. Every encounter with a patient is a cultural oneThe heart is needed to balance the mind.     Heart and mind working together, open, in presence, is Mindfulness.MindfulnessBringing intention, presence, awareness, curiosity, being and doing, reflection to your life and work. Inner self inquiry. Mindfulness Based Stress Reduction Program (MBSRP) available widely to public and clinicians. Kabat-Zinn, Jon.  Wherever You Go There You Are: Mindfulness Meditation in Everyday Life.  New York: Hyperion, 1994. Kabat-Zinn, Jon. Whole Catastrophe Living: using the wisdom of the body and mind to face stress, pain and illness.  Revised edition: 2013.  Santorelli, Saki. Heal thy Self: lessons on mindfulness in medicine. New York: Bell Tower, 1999. Krasner MS, Epstein R et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA 2009; 302(12):1284-1293. Narrative MedicineCharon, Rita.  “Narrative Medicine: a model for empathy, reflection, professionalism and trustworthiness.  JAMA 2001; 286(15): 1897-1902.Narrative competence: importance of story To be able to listen to, absorb, interpret meaning, and act on stories of others: patients, families, colleagues  Need for teller and listener of story – communication between at least 2 people – shared presence  Listening to stories “requires generosity and courage to tolerate and bear witness” - Witnessing Authenticity; trust building with others: relationship  Skills and competencies: self reflection and listeningValues: Narrative Medicine It is only through a clear understanding of the patient’s values and priorities that an appropriate plan of care can be built.  Therefore, eliciting the patient’s perspective or story represents the core of our work with patients and families.Story-listening Allowing ourselves to hear the story of another without interruption or advise giving (fixing and problem-solving), but with generous listening, presence, silence, witnessing, mindfulness and compassion.   Telling our stories to others- finding our voice- usually with co-workers. SPIKES method for breaking bad news and family conferencesØ Setting- Appropriate and without interruption, have plenty of seating, involve patient if possible.Ø Perception- What do you know/understand of the condition?Ø Invitation- Is everyone present, and how much information at this time does pt/family want?Ø Knowledge- Deliver the information as appropriateØ Empathize- And explore emotionØ Strategy- Summarize and make a planØ Include preparation, briefing with team, and debriefing for family conference(Baile, Buckman, et al, 2000)VitalTalk© Communication Roadmap. Reframe of situation; why now is different Expect and respond to emotion – NURSE statements Map out big picture and what is important now Align yourself with the patient’s values Plan for care that is in alignment with patient valuesNURSE: Responding to Emotion (powered by VitalTalk©)When you notice an emotional cue, respond! Naming: “it looks like this is frustrating” Understanding: “this can be hard” Respecting: ”you have had to cope with so much” Supporting: ”I wish it wasn’t so frustrating for you”  Exploring: “tell me more about what is frustrating for you right now”  “The Precious Necessity for Compassion”Joan Halifax  Journal of Pain and Symptom Management 2011;41:146-153 Our spiritual resources support our work “caregivers should have a spiritual practice such as compassion meditation to have the strength and perspective to acknowledge the pain and suffering in others and ourselves and develop an appropriate and transformative relationship to suffering through insight and the regulation of our emotions.”Contemplative Practices for Self and Others: Turning Inward Prayer/meditation/ spiritual practices/ breathing consciously Meditative movement Art  Retreat Reflective writing/storytellingWhat to do in challenging situations?Dr Bob Arnold said in a lecture:Be curiousBe kindBe loving (compassionate)What will you bring home with you as a learning?I plan on…. Thank you!

Having Healing Conversations

https://cedar.wwu.edu/cgi/viewcontent.cgi?article=1051&context=pci

Having Healing Conversations

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