Instructor Resource ManualModule 6 – Relating

Table of Contents

Lecture content outline 2Post-lecture knowledge assessment items 7Answer key and rationale for knowledge assessment items 8Observation assessment form and scoring rubric 9Sample Case 11Sample case group debrief questions and instructor guide 12Sample case role-play activity 13Reflective writing assignment and instructor guide 16

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Content Outline for Lecture

I. Introduction to COMFORTa. COMFORT is an acronym that stands for 7 basic principles designed to be taught in

early palliative care communication, care provided for individuals with a life-threatening or serious illness

b. The curriculum is based on empirical research in hospice and palliative care, including observations of interprofessional teams, team meetings, team member collaboration, and interviews with team members across a range of healthcare professions.

c. This lecture will provide an overview of module 6 – Relating, and more specifically team meetings. This module is an introduction to advanced-level communication skills.

II. Objectivesa. The objectives of this session are to learn about the multiple goals people have when

they communicate and to consider the ways that we can adapt to patient and family perspectives.

b. Relating to patients and families is centered on engaging in critical turning points to advance patient /family understanding.

c. The focus is on relational communication and sharing meaning in order to facilitate instrumental goals (providing physical care).

III. Adapting to Patient and Familya. This communication skill is aimed at two important turning points:

i. patient/family acceptance of a diagnosis/prognosisii. patient/family understanding of new information within the illness journey

b. Bad news is defined by the patient/family. What you consider bad news may not be bad news to the patient/family.

c. Talking and communicating in a way that is radically adaptive assumes that you cannot know the reaction or perspective of the patient/family without first receiving it. It requires putting the “other person” first.

i. Diversified approaches and responses to a topic can be referred to as diffusion of topics.

IV. Understanding the Quest (Frank, 1995)a. To accept news or change is to acknowledge that it is real and assent to that

information in planning, behavior, and communication.b. To find something useful from the experience is called a quest narrative.c. Patient/family acceptability requires them to acknowledge significant changes

following an illnessd. Acceptability and discovery is gained from an event or critical turning point and

brings a sense of identity related to the illness.e. To help patient/family, focus on the turning points in the illness journey and what

they mean.

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V. Engaging Uncertaintya. As patient/family experience uncertainty over the meaning of disease progression,

symptom, and impact of treatment, clinical communication involves helping them process uncertainty.

b. This may be very different for patient and family members.c. Quality of life and what they understand as “normal” are threatened by the unknown

future.

VI. Problematic Integration (Babrow, 1992)a. Changing probabilities about the disease and changing values about acceptable

quality of life create uncertainty for the patient and family.b. Especially in a team-based health care system, there can be variances of

communication among team members with patient/family as well as variance in communication messages that contribute to feelings of uncertainty.

c. There are two concepts for how we process uncertainty.i. Probability

ii. Evaluationd. Common questions from patients as they explore their uncertainty include:

i. Why is this happening to me? Why is this happening now?ii. How long do I have to live?

iii. Do you think I am dying?

VII. Uncertainty arises when….a. When probability and evaluation do not compliment one another, then

communication and decision-making become difficult.b. Here are four ways that patient/family communicate when there is uncertainty:

i. Divergence – patient doesn’t express understanding of impact to routine lifeii. Ambiguity – patient identity is changing and difficult

iii. Ambivalence – patient expresses understanding of future but makes choices that deny or conflict with reality

iv. Impossibility - patient maintains hope for better outcome despite certainty that the outcome will not happen

VIII. Rationalizations in decision-makinga. Recognizing statements revealing problematic integration invites clinicians to

recognize indicators of low acceptability from patients and families.b. Here are some examples from patients.

IX. Speech Acts (Austin, 1962; Searle, 1969)a. Identifying acceptability also involves considering what is actually being said (and

done) when words are spoken.b. When people convey information, often times they communicate much more than

their words encode.c. Words are often received in a way that is NOT intended to be received.

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OPTIONAL: Ask the audience if they have ever miscommunicated with someone and it turned out to be that they misinterpreted the message. For additional demonstration of this, find a cartoon strip that shows the inner thoughts of a character and how they may differ from the meaning of the interaction being depicted. Cartoon strips establish effective humor by playing on this connection or disconnection between words and meanings by placing them in context.

X. Words exert actiona. Context determines what words mean.b. The act of saying something is the verbal word.c. What a person is doing in saying something is the performance, or contextual

function of the word. For example, “How is your pain?”d. A speech act is the action that takes place by saying something. For example, when

you say ‘I quit’ you are actually quitting. There is a secondary effect on the listener that cannot be predicted.

e. Giving bad news is a good example of how words have action in a specific context.

XI. The Effects of Wordsa. Here is an example of the three actions of words. b. Typically, following a terminal diagnosis, the focus of discussion is on curative

treatment and decision-making.c. Rather than discussing the meaning of the prognosis, the prognosis itself is not

discussed because the language is threatening --- the thing itself is discussed, remade, enlarged.

d. As a clinician, your role is to engage in these constrained topics to aid patient/family acceptability.

XII. What someone is doing in saying somethinga. A direct speech act presents one action, but in actuality is acting on two or possibly

more matters of action with one statement.b. A direct speech act unpacks the content of what someone does in saying something.c. Indirect speech acts present possible actions exerted through spoken words.d. Here are some examples of how a statement can have two meanings.

OPTIONAL: Have the audience recall a time when someone said something special to them. Ask them to write down that statement, who said it, where they were, and what it meant to them. Then ask them to reflect on the statement. The statement likely has little or different meaning without understanding the context and the meaning behind the statement has special meaning to them, given the context in which it was said or the relational history between the two speakers.

XIII. Multiple Goals at Playa. Task level communication is the content of the message and includes what the

message intends to do. For example, task communication involves teaching and educating patient/family members.

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b. While the content level of a message is conveyed by the words themselves (task communication), the relational level generally is manifested by nonverbal communication. Relational level demonstrates how we relate to patient/family through the nonverbal messages we convey.

c. Because clinicians pursue multiple goals (e.g., you are trying to check blood pressure and get a pain rating at the same time), problems can be common in interaction.

d. As we interact with patient/family, new goals emerge from indirect speech acts. Relating is a necessary communication strategy as goals change throughout the interaction and as you recognize indirect speech acts and interpret their meaning.

XIV. In Practice…a. New goals emerge as each speaker makes certain conversational moves in the

interaction.b. Turning points for a patient or family sometimes are identified in the way that they

are communicated. c. Adaptive communication can be used when a patient becomes agitated or cannot

reach acceptability.d. Diffusion of topics can be used if patient/family stray from topic or avoid speaking

about topic. Diffusion of topics involves repeating and inserting the topic continually throughout the conversation. Suspend the need to achieve your goals in work and focusing on relating in order to achieve patient/family acceptability.

XV. Team-based Relatinga. Rather than focusing on prescribed checklist of information to provide or instructions

to give, we advocate that you are adaptive. While each team member has specific care tasks to accomplish, the relational level of communication should be emphasized. Allow patient and family to guide the order of your checklist.

b. Multiple goals need to be recognized. Listen to what the patient/family have to say and the questions they ask. Think about the meaning behind the question – the meaning to them and their family.

c. Don’t forget to use other members of the team! Team members are there for more than simply a referral for a specialize service or care need. Use team members to help relate to patient and family. There may be someone on the team that relates to the patient and family because of similarities (e.g., grew up in similar location, share family history of occupation, similar age/race/ethnicity, etc.).

References

Austin, J. L. (1962). How to do things with words. Oxford: Oxford University Press.

Babrow, A. S. (1992). Communication and problematic integration: Understanding diverging probability and value, ambivalence, and impossibility. Communication Theory, 2, 95-130.

Frank, A. (1995). The Wounded Storyteller. Chicago: University of Chicago Press.Searle, J. (1969). Speech acts: An essay in the philosophy of language. Cambridge: Cambridge

University Press.

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Wittenberg-Lyles, E., Goldsmith, J., Ferrell, B., & Ragan, S. (2012). Communication and palliative nursing. New York: Oxford Press.

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Post-Lecture Knowledge Assessment Items

1. What is involved in adapting to patient and family?a) Determining what the patient considers bad newsb) Diffusing topics by discussing sportsc) Recognizing that patient/family define what is bad newsd) Engaging in radically adaptive care interventions

2. Patient/family members attempt to manage and process their uncertainty bya) Considering probabilities and evaluating outcomesb) Considering the background of their healthcare teamc) Considering where they live and where the hospital is locatedd) Considering what college their physician attended

3. A woman suffering from stage IV cancer with metastasis to the liver, bone, and lymph nodes explained to her social worker: “After these treatments, I will be right back at work and returning to my role as Head Girl Scout Leader for my daughter’s troop.”Her statement is an example of:

a) Ambiguityb) Divergencec) Ambivalenced) Impossibility

4. At the airport, travel partner Jo asks travel partner Bill, “Are you sure this is the right gate for us?” as they await an outbound flight. What indirect speech act could Jo be implying?

a) Jo is admitting she doesn’t know what time the plane leaves.b) That Jo and Bill are at the wrong gate.c) That Jo doesn’t trust Bill’s navigation.d) Either A or C.

5. Multiple goals are at play during interactions and are produced by:a) Task and Relational level of messagesb) Adaptive communication strategiesc) The discovery of illnessd) Problematic Integration

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ANSWER KEY - Post-Lecture Knowledge Assessment Items

1. Answer: CRationale: Bad news is defined by the patient/family. What you consider bad news may not be bad news to the patient/family. To accept news or change is to acknowledge that it is real and assent to that information in planning, behavior, and communication.

2. Answer: ARationale: Uncertainty results from the problematic integration of the way a person feels about something (positive or negative emotional value) and their perceived probability that something will occur.

3. Answer: BRationale: Patients and families attempt to manage uncertainty when what they want (cure) is not likely to happen, and they perceive a declining status. Divergence is the discrepancy between what we want (evaluative) and what is likely (probabilistic).

4. Answer: DRationale: There are indirect meanings at work in Jo’s question. When a speaker says something, the force or action of their speech carries more meaning. In this case, Jo’s indirect speech act could be implying that the gate is wrong or that she doesn’t trust Bill’s navigation. Indirect speech acts are the implied meaning behind the words themselves.

5. Answer: ARationale: Every person accomplishes, or attempts to accomplish multiple goals in interactions. Sometimes these goals are emergent, and sometimes people enter in interaction knowing very clearly what they need/want to achieve. The instrumental goal is the basic purpose of the interaction, and the relational level is how individuals present themselves and the impact of the goal pursuit on their relationship with the person.

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The COMFORT Communication Assessment ScaleModule 6 – Relating

Student:_______________________

Element Unacceptable(1)

Poor(2)

Acceptable(3)

Good(4)

Adaptive response to the patient/family perspective on illness

Patient/family perspective on illness is not explored

Patient/family perspective on illness is mentioned but not engaged

Patient/family perspective on illness is included often in encounter

Patient/family perspective on illness is explored in conversation and developed by patient/family

Communication is guided by patient/family acceptability: Diffusion of Topics

Neglects to adapt to patient/family acceptability in light of clinician agenda

Acknowledges acceptability level but neglects to converge with this level

Responsive to acceptability level of patient/family within the interaction

Inquires about acceptability level and integrates knowledge into current meeting and plan of care

Acknowledgement of significant changes in health status

No inquiry into health status

Changes in health status noted once during interaction

Changes in health status are discussed by clinicians

Changes in health status are explored with scenarios, stories, reflections, and incorporate all members present

Explore turning point in the illness trajectory and its impact on the quality of life domains

No inquiry into critical turning point in health

Clinician prioritizes task (conveying information) over relational (conveying support/empathy) content

Clinician recognizes patient/family concerns, and attempts to relate to patient/family

Clinician is highly responsive to patient and family concerns and discusses quality of life domains as patient/family are able

New life and care options are explored

No inclusion of new opportunities in illness

Clinician includes task goals that present new opportunities

Clinician incorporates task and relational content in discussing new opportunities

Clinician is highly responsive to patient/family goals (task and relational) in discussing quality of life domains

Uncertainty is included as an important aspect of illness trajectory

Provides no opportunity for patient/family feelings and descriptions of uncertainty

Recognizes patient/family feelings and descriptions of uncertainty

Demonstrates empathy for patient/family feelings and descriptions of uncertainty

Creates opportunities for patient/family to explore and understand their own feelings and descriptions of uncertainty

Recognition of multiple and competing goals expressed by patient/family

Remains biomedical in focus

Minimal acknowledgement of patient/family identity (e.g.. occupation, name, hometown)

Inquires about patient/family identity factors in illness.

Creates opportunities for patient/family to articulate their own personal needs and goals

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Comments to be filled out by students following viewing of videotaped encounter:1. Regarding (relating) communication skills, what did you think went well?

2. Regarding communication with this patient/family member (role play), what, if anything, would you do differently?

3. What are the barriers and pathways you see in communicating with the patient/family? The team?

4. Any other observations or comments about this particular patient/family encounter?

NOTE: Feel free to refer to R-Relating and O-Openings of COMFORT when reflecting on which tasks you accomplished, as well as the way in which you accomplished them.

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Sample Case

Sue Lanz, 33, and her family believed that she was enduring either the strange after effects of a laparoscopy surgery or some complication from her diabetic pump. A mass on her rectus abdominal muscle had been steadily growing since an oophorectomy three months previous. At this same time, Sue had been offered a promotion as an Associate Pastor to a church across the country. Feeling fine, though losing weight, Sue and her husband Phil moved. In her second week in a new place, Sue made a doctor’s appointment concerning her growing mass. She was referred to an infectious disease specialist who pursued it as infection. After two weeks of an antibiotic therapy, the physician ordered an x-ray, revealing profuse bilateral tumor activity in her lungs. An open biopsy was ordered. Her tumor, as well as several lymph nodes, was read by pathology as poorly differentiated adenocarcinoma.

Sue and Phil met with a local oncologist for care. After finding his communication with them unclear and void of empathy, they pursued treatment at a comprehensive cancer center. Once arriving there, the diagnosis became graver, as further tests revealed advanced metastatic spread. Still though, Sue and Phil were offered treatment. The cancer center coordinated the chemotherapeutic components of the care at a small local cancer clinic near their home, while they commuted across the country for specialized radiation treatments at the comprehensive cancer center.

Over the next few months, Sue endured profound side effects from her treatments. Her quality of life was markedly diminished. Despite the grim outlook of her diagnosis and diffuse spread of disease, Sue and her family waded further into a dizzying carousel of clinicians, side-effects, appointments, and travel.

Sue continues to remain in place as the Associate Pastor in her new job, despite the fact that she is heavily medicated, in pain, and weak. Her brother has moved in and travels to and from work each day with Sue to oversee her physical well-being and facilitate her work efforts.

Phil’s Profile: Finishing doctoral work at a nearby university, Phil tries to juggle his life outside of his wife’s illness with his professional hopes. He continues to pursue his degree and is gone from the home and Sue half of the week to accommodate his commute. As a result, Phil leaves the door open for his brother-in-law to move in and become Sue’s constant companion and caretaker.

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Sample Case Group Debrief Questions

1. When encountering Sue in the clinical setting, how might you explore issues of uncertainty and illness with her?

Instructor Guide: This patient is focused heavily on her work. There is no clear indication that Sue has discussed prognosis or sought out resources to deal with an incurable cancer. The team might not know Sue’s understanding of her disease or her level of uncertainty about this grave diagnosis. Example:

“Sue, can you describe what you are thinking about your diagnosis?”

2. What might the team want to find out about concerning Sue, her brother, and her husband?

Instructor Guide: Learning about the family’s understanding of the Sue’s illness is important in informing a team about how the family is coping. Also, each person’s goals might be aligning, or perhaps diverging, based the level of disease understanding.

3. How could an effective conversation about Sue’s illness trajectory inform her husband’s goals? Her brother’s? Sue’s?

Instructor Guide: Each member of this family appears to be on a different path, though they all are living in the same life---Sue’s. Sharing in and being exposed to information about Sue’s illness will inform all of them, allowing a better opportunity to prioritize.

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Role Play Activity

Objectives:

1. Practice identifying patient/family goals.2. Identify specific opportunities to explore patient/family goals and their differentiation. 3. Engage in role-play activities informed by patient/family uncertainty.4. Extend the relating module to actual communication application.

How to Proceed-Introduction & Discussion: (20 minutes)

Review objectives for group activity and facilitate introductions of group members to one another.

Ask group participants to read case. Facilitate discussion of speech acts and relating.

How to Proceed-Role Play: (20 minutes)

Roles: There are several roles to be played in this case; remaining participants can observe

Facilitator: Keep time (20 minutes MAX for this part of group activity, as divided below): 5 minutes for role players to read roles and arrange seating for conversation 10 minutes for role play 5 minutes for de-brief and discussion.

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Family Meeting Role Play

Situation: This morning, Sue, meets with her care team. She has been briefly hospitalized for a blood transfusion and skin biopsies that tested positive for cancer on the dermis directly overlaying a tumor site.

Sue no longer walks without the support of her brother or husband, showers in a seated position, and is constantly accompanied by others regardless of the context. She has recently fallen and has a sprained right ankle, but has little sensation; this injury has caused profuse bruising and swelling in the area. Her chart indicates that Sue cannot lift herself up and down off of the toilet. Additionally, there are descriptions of her advanced cancer spread with metastases to the eye, liver, spine, shoulders, hips, femurs, and lungs.

In asking questions about pain, Sue describes frequent intractable pain. She is eager to move forward on planning regular therapy and also describes upcoming chemotherapy and radiation treatments.

Upon entering the hospital room, Sue, is packing up for their drive home. Sue has made the request to see a physical therapist as she would like to begin on a strengthening and balancing program.

Just then, Sue’s husband, Phil, enters the room to carry down more luggage to their car. He walks in as the consulting PT asks about a walker for Sue. Phil scoffs and says “over my dead body,” quickly rushing about the room to gather more of their things. Suddenly, without warning, he drops the load in his arms on the floor and yells to the clinicians present, “Just get the hell out of here!”

Present: Sue (patient), Phil (Sue’s husband), Dr. Bell (PT), Dr. Jill Lundquist (oncologist), and Cheryl Ross (social worker)

Sue, received a diagnosis of cancer 6 months ago. She still maintains a thriving social work practice and has no children. Her sister is the primary caregiver for her.

Phil, is Sue’s husband. He is a graduate student in a nearby PhD program and continues with his studies and teaching during Sue’s illness. They have been married for six years.

Dr. Steve Bell, has just completed her Doctorate in Physical Therapy and is working on an oncology floor.

Dr. Jill Lundquist, is Sue’s oncologist of 9 months. She has mentioned hospice in one previous conversation but wants Sue to seriously consider other care options that would be less toxic than chemotherapy and radiation.

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Cheryl Ross, social worker, talked independently with Sue and Sue’s sister the previous day. She quickly picked up on cues from the sister that the family’s current management plan for Sue was stressed to the limit.

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Reflective Writing Activity

Elena Marquez is a 12-year old girl with end-stage sarcoma who has been seen by the pediatric

palliative care service in the Children’s Hospital for the last three years. Elena’s cancer is

metastatic with protracted bone pain. Elena’s mother, her only parent, has two younger children

and also cares for her own mother with Alzheimer’s disease. Both the nurse and social worker

have observed that while Elena is generally open in describing her pain or other symptoms, when

her mother is present she does not complain and minimizes any symptoms. She tells the nurse

later, after her mother has gone, that it is easier to bear the pain than to see her mother’s distress,

which Elena believes increases when she reports symptoms or takes medications. Seeing the

clinician’s concerns Elena becomes very withdrawn, saying “Do not talk to my mother about my

pain and upset her. Actually it’s much better now.”

Questions:

1. What could each team member do to contribute to a solution for Elena?

2. What indirect speech acts are associated with Elena’s request? What multiple

goals do you interpret?

3. How is Elena managing her uncertainty?

Instructor Debrief

Physical pain management is most effectively practiced when clinicians employ the best

evidence and skills to support patients and families. Elena’s reluctance to discuss pain

management is challenging and has the potential to become fully debilitating not only for Elena,

but also for her mother. Responding to patient and family needs involves recognizing that

statements have multiple meanings and goals. Practicing clinical communication includes an

awareness of these multiple goals to better support patient care. The clinician can move beyond

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what is said to interpret multiple meanings between patients and families, often dependent upon

relational history, and explore and address more truthful and complex statements. For Elena, the

goal driving most of her communication is the protection of her mother and siblings.

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