working with the challenging family patrick j. dawson, md ‘facing tomorrow’s challenges today’...
TRANSCRIPT
Working With The Challenging Family
Patrick J. Dawson, MD‘Facing Tomorrow’s Challenges Today’
Wroten & Associates Long Term Healthcare Conference
May 13, 2010
Even when life seems easy – it just keeps on getting harder. Deets in “Lonesome Dove”
The Red Queen shook her head. “You may call that nonsense if you like,”
she said “but I’ve heard nonsense, compared with which that would be
as sensible as a dictionary!”
“Through the Looking Glass” Lewis Carroll
Hell is other people. Sarte
Changing the Prevailing View of Long Term Care
Public policy Public expectations and
perceptions Professionalism Personal standards Passion
Cheryl Phillips, CALTCM, 2004
Yet Another Task – Involving the Physician
Areas of Physician Service at End-of-Life provide excellent communication
advance care planning with clear decision-making support discharge and home care planning empathy for family emotions attention to grief and bereavement
Michael Rabow, MD
Communication Is Fundamental
“We stand here confronted by insurmountable opportunities.” Pogo
Trust Is Inextricably Entwined With Communication
Poor Communication And Plaintiff Dissatisfaction
Physician deserted the patient
Physician devalued the patient/family views Physician delivered information poorly Physician failed to understand patient/family perspective
Norcal Mutual Ins, Co.Claims Rx Jan. 2005
Patients Who Sued Physicians Identified Why Communication Failed
Physician did not return phone call promptly
Physician did not answer questions or listen
Physician was too busy to talk or explain
Staff members were not attentive listeners
Staff members did not explain what they were going to do
Communication Components We Own
Medical informationExplaining the nursing home environmentDetection of resident/family concernsUnderstanding resident/family NH experiencesLearning prior caregiver roles
Advance Care Planning
Not just “Code Status”
Resident values, beliefs, preferences
Resident – and family – expectations and goals
Resident instructions and NH realities
Advance Care Planning Can Be…
How power is to be shared in the resident-family-physician-facility relationship
and
How we focus on the resident while facilitating the Family’s adaption.
Family Systems Theory
Maladaptive family structure in LTC – enmeshment
disengagement
hierarchies
triangulations
coalition
The Conflicted Surrogate Syndrome
Complaints made in other than good faith.
Complaints made as a result of psychological problems or mental illness.
Complaints made due to pathological family dysfunction.
Very Few Related Studies With Limited Explanations
Families react more intensely
Families have different expectations Families felt like outsiders Families did not feel trusted
The Meeting
Be prepared – who will attend? do they know?
where? when? length?
who is chair? who is note taker?
what is on the agenda?
Pay attention to time
Introduce and sign-in
State the purpose of the meeting
The Meeting
Remember techniques to facilitate communication: allow one person to speak at a time allow everyone to have the chance to speak avoid interruptions do not bring other work to the meeting avoid side conversations with tangents make it safe to disagree listen
The Meeting
Prime and direct the conversation:
“Tell me what you understand about your dad’s condition.”
“Tell me what you think about NH compared to a hospital.”
“How has your family been handling the physical and emotional
demands of caregiving?”
“When families place a loved one in a NH, it isn’t unusual to
feel guilty. Have you?”
“What are your expectations for your husband’s stay here?”
The Meeting
If there is an agenda, try to cover it.Ask if there are any questions.Summarize issues, promises, questions.It should be clear who is doing what by when.How will we communicate?Who is the contact person?When is the next meeting?
Risk Management
Avoid defensiveness, anger and confrontation, but do not try to avoid the family.Be honest and realistic, but do not make excuses or give false hope.Document and do not alter the record.Organize and nurture a team approach.Try to objectively understand the family
complaints.Who can you call? When should you call?What can you do?
Every morning in Africa a gazelle wakes up.It knows it must run faster than the fastest lion or it will be killed and eaten.Every morning in Africa a lion wakes up.It knows it must run faster than the slowest gazelle or it will starve to the death.It doesn’t matter whether you are gazelle or a lion, when the sun comes up you better start running.