Instructor Resource Manual

Module 5–Openings

Table of Contents

Lecture content outline2

Post-lecture knowledge assessment items6

Answer key and rationale for knowledge assessment items7

Observation assessment form and scoring rubric8

Sample Case10

Sample case group debrief questions and instructor guide11

Sample case role-play activity12

Reflective writing assignment and instructor guide14
Content Outline for Lecture

  1. Introduction to COMFORT
  2. 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
  3. 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.
  4. This lecture will provide an overview of module 5 – Openings, and more specifically team meetings. This module is an introduction to advanced-level communication skills.
  1. Objectives overview
  2. The objectives of this session are to highlight transitions in care for patient/family members, to recognize communication privacy and self-disclosure as two strategies that can be used to help patient/family members recognize transitions in their own care, and how to effectively engage in these pivotal moments so that they are useful and supportive to patient/family.
  1. Junctures of Care
  2. Just as a disease does not travel the path of a script, neither does the unfolding/timing of conversations between a patient, family, andclinician.
  3. Specific junctures of care provide openings for discussion about care from a global perspective.
  1. Pivotal Communication Points
  2. Difficult conversations with patients and families coincide with transitions in care, and truly require intimate exchanges between patient/family and clinicians.
  3. Pivotal points in communication extend beyond breaking bad news. Depending on your clinical role, you may have more influence after the bad news has been disclosed.
  4. Discussing spiritual concerns with patient and family, talking about cultural needs and concerns at the end of life, processing suffering with patient and family, considering decisions about advanced directives, DNR orders, withholding or withdrawing support, and sharing in the news of recurrence or fear of recurrence with patients and/or family are some of the pivotal points that present themselves in intimate conversations with clinicians.
  1. Role of a Clinician: Openings
  2. Patient/family acceptability is dependent upon your ability to share in conversation with them about challenging decisions.
  3. Clinicians must adapt to where the patient and family are at in terms of acceptability. Some will want to discuss a particular feature of bad news and others will chose not to engage in conversation about it. Some patients would prefer for clinicians to speak to their primary caregiver instead of them.
  4. Clinical communication shared with patient and family at pivotal moments in illness can create openings for positive change.
  1. Quality of Life Domains (Ferrell & Coyle, 2008)
  2. Intimate conversations that facilitate openings for patient and family can profoundly and positively impact the quality of life domains.
  1. Quality of Life Domains and Openings
  2. Here is a table that shows a list of potential tension or avoidance triggers and the quality of life domain impact areas.
  3. Patient/family have a desire to disengage from these tensions, which reproduces more tension the longer it is avoided.
  4. For example, limited prognosis is a basic trigger communication addressing palliative or hospice care.
  5. Each team member contributes to specialized care service in one or more quality of life areas, making collaboration essential and the need for all team members to communicate about these tensions.
  1. Communication Privacy Management
  2. Each team member must make decisions about how, when and if information should be communicated to other family members as well as team members.
  3. Communication Privacy Management outlines how individuals become owners of private information and how this ownership gives them control of private disclosures (HelftPetronio, 2007).
  4. In early palliative care, clinicians have ownership of prognosis information, hospice and palliative services, and the burden experienced by patients/family.
  1. Communication Privacy Management
  2. Clinicians are often in a privacy triangle that consists of clinician, patient, and family member.
  3. When private information is shared between clinician and patient/family, the disclosure comes with communicative responsibilities.
  4. Intimate relationships are established as patient/family disclose private information to you.
  5. The give and take of disclosures can facilitate task and relational communication processes.
  1. Aspects of Privacy Management
  2. As a clinician you are in the position of receiving and delivering private information and thus have private information ownership.
  3. The decision to reveal private information, such as information about disease or prognosis, can create a privacy dilemma. You must decide to communicate vaguely or directly.
  4. Boundaries can become linked as people form alliances with information and include additional parties as recipients of certain pieces of news.Boundary turbulence occurs when the coordination of a boundary is unclear, or when privacy expectations clash.
  5. Boundary coordination is based on the complexity of co-owning or sharing private information that belongs to people collectively (Petronio, 2002).Boundaries are managed through rule management processes that are negotiated between individuals (Petronio, 2002).
  1. Self-Disclosure
  2. Self-disclosure is the core process for relational development between you and the patient/family.
  3. Through self-disclosure individuals move from a superficial to more intimate relationship.
  4. Breadth refers to the number of topics discussed in a relationship while depth refers to the level of intimacy guiding a discussion topic.
  5. Reciprocity is the return of openness from one person to another. An individual’s willingness often leads to the other individual’s willingness.
  1. Tensions, Boundaries, Disclosures
  2. In order to recognize openings when talking to patient/family, consider the following:
  3. Tension
  4. Boundary understanding
  5. Depth of Disclosure
  1. Dispelling Myths
  2. Here are some common myths about dying and the communication realities. Communication realities point to specific openings for communication about dying and information that can be highlighted by all members of the care team.
  1. Clinician Relationship
  2. Complementary behaviors demonstrate interest in a speaker (patient/family) as they disclose information. These behaviors maintain the focus on the patient or family.
  3. Reciprocal communication equals and even surpasses the other’s conversational content in terms of breadth and depth of disclosure.
  4. To position the clinician in the meaning-making process with the patient/family, rather than separate out a clinician’s meaningful experiences from the patient/family.
  1. Communication Tensions
  2. Determining the amount of private information that has or has not been shared with a patient and family, as well as identifying the kind of boundaries that are upheld in a family is important as a clinician plans for an intimate conversation about illness.
  3. Here are two examples of openings and the connections that can be made between patient and family communication needs in transition and potentially useful strategies.
  1. Prompts for Engaging Family Learning
  2. Patient/family can be surprised when asked for their opinions and advice on care.
  3. Here are some prompts that can be adjusted for a particular context and engage patient/family in the learning process.
  1. Team-based Openings
  2. Use team meetings to share and debrief about challenging communication events. Share with colleagues about the tension and potential opening. If you weren’t able to act, then perhaps a team member will be able to capitalize on an opening during their clinical visit. Recognizing openings and ensuring that someone on the team communicates with the patient/family is part of the team responsibility.
  3. Ask colleagues to share how they would have handled the interaction, what has worked well for them in the past or with this particular patient/family, and what you can do to improve your interaction.
  4. Peer support and discussions about points of tension for the patient/family will help develop plans of care that address communication needs and quality of life domains.
    Post-Lecture Knowledge Assessment Items
  1. The family’s desire to keep the patient from knowing that they are dying is an example of:

a)Self-disclosure

b)A quality of Life domain

c)Boundary Turbulence

d)A private family

  1. Pivotal communication points that are opportunities for openings with patients and families include:

a)Transporting a patient to a care setting

b)Discussing DNR orders

c)Ordering meals or a meal plan

d)Arranging for medical tests

  1. A patient who is in the final stages of advanced cancer is visited by her physician. The physician overshares about her own children and Thanksgiving plans in response to her the patient’s polite inquiry. In this example, reciprocal disclosure:

a)Diminishes and dismisses the difficulty imparted by the patient

b)Creates hope for the patient

c)Reiterates that her prognosis is terminal

d)Confuses the patient

  1. If Chloe is in the last stages of cancer and is in intractable pain concealed from her husband Bob, this would be Chloe’s:

a)Boundary turbulence

b)Opening

c)Control of private information

d)Self-disclosure

  1. ______impact communication tensions or avoidance triggers in illness, creating openings for clinicians.

a)Depths of disclosures

b)Self-disclosures

c)Engaging family learning

d)Quality of life domains

ANSWER KEY - Post-Lecture Knowledge Assessment Items

1. Answer: B

Rationale: Turbulence can emerge as family members try to protect the patient from his/her private information. Especially when physicians do not adequately disclose terminal prognosis, family members attempt to create their own private information.

2. Answer: B

Rationale:Difficult conversations with patients and families coincide with transitions in care, and truly require intimate and private disclosures between patient/family and clinicians.

3. Answer: A

Rationale: Intimacy in the clinical setting involves the meaning-making process with the patient or family, rather than separating out the clinician’s meaningful experiences from the patient/family. In this case, reciprocal communication surpasses the other’s conversational content in terms of depth of disclosure.

4. Answer: C

Rationale: We own our private information until we share it with others. Once private information is self-disclosed to another individual, that individual assumes co-ownership of the information. Boundaries are then managed through a rule management process between individuals.

  1. Answer: D

Rationale: Quality of life domains represent tension points when pivotal communication points such as DNR orders need to be discussed. Patient/family have a desire to disengage from these tensions, which reproduces more tension the longer it is avoided.

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The COMFORT Communication Assessment Scale

Module 5 - Openings

Student:______

Element / Unacceptable
(1) / Poor
(2) / Acceptable
(3) / Good
(4)
Essential transition in illness is identified / Avoids tension in communication; does not explore tension / Recognizes tension in communication; does not explore tension / Asks patient/family about tension in communication / Explores patient/family tension using talk, silence, and nonverbal immediacy
Understanding of disease process is explored / Avoids patient/family understanding of disease process / Recognizes patient/family understanding of disease process / Asks patient/family about their understanding of disease process / Explores patient/family understanding of disease process using talk, silence, and nonverbal immediacy
Spiritual concerns are included in interaction / No inquiry of spiritual concerns in interaction / Recognizes spiritual concerns / Asks about patient/family spiritual concerns / Explores patient/family spiritual concerns using talk, silence, and nonverbal immediacy
Cultural concerns are included in interaction / No inquiry about cultural concerns in interaction / Recognizes cultural concerns / Inquires about patient/family cultural concerns / Explores patient/family cultural concerns using talk, silence, and nonverbal immediacy
Awareness of information ownership and privacy boundaries / No recognition of privacy boundaries for patient/family / Recognition of privacy boundaries for patient/family / Inquires about patient/family privacy boundaries / Explores patient/family privacy boundaries and their impact on quality of life domains and care planning
Complementary communication: disclosure strategies / Insensitive to patient disclosure and self-disclosure / Allows patient/family disclosure / Inquires about patient’s/family’s feelings and descriptions / Facilitates patient’s/family’sunderstanding of the illness experience by exploring concerns of quality of life in all four domains

Comments to be filled out by students following recorded encounter:

  1. Regarding opening communication skills, what did you think went well?
  1. Regarding communication with this patient/ family member role play, what, if anything, would you do differently?
  1. What are the barriers and pathways you see in communicating with this patient/family? With a team?
  1. 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

Meg, a 16-year old girl, has just been admitted to the Pediatric Unit with sudden onset of intractable head pain, rapid eye movement, and balance disturbance. Her headaches have increased over the last two weeks especially in the morning. An MRI reveals a large tumor in the base of the brain with a likely diagnosis of medulloblastoma.

Meg is a sophomore in high school, dating a long-time boyfriend, is on the cheerleading squad, and was preparing for her school’s homecoming events when this tumor was identified. She has a younger and older sibling.

After assessing Meg and her tests, Dr. Coone as well as Krystal, the pediatric unit’s social worker, has come to talk with Meg and her mother about the likely diagnosis of medulloblastoma and their goals of care. It is regular practice for the physician on this unit to be joined by the social worker to lend support to the entire team as challenging news is shared and future plans are considered. Meg, like most teenagers, does not have an advanced directive, but is potentially facing very challenging and risky treatments including a brain resection, radiation, and chemotherapy. Meg is minimally responsive due to pain and pressure from the tumor.

Dr. Coonefeels an urgency that decisions need to be made now regarding do-not-resuscitate/allow-natural-death and status. She is concerned and honest with Meg and her mom that Meg, should she have cancer or not, may not survive the brain resection and hospitalization. The brain surgery is scheduled for the next day. She recommends that palliative care be included in all plans of now.

Krystal Forts was called by Dr. Coone to meet with her and Meg and Sandra to discuss the DNR and goals of care. Krystal describes the advantages of early palliative care and shares ways that this care can assist with preventing suffering, manage symptoms, and support the family. Krystal also wants to try and consider goals of care with Sandra and Meg to the best of their ability at this point in their illness journey.

Sandra’s Profile:As a single parent, Sandra copes by managing every detail of her and her childrens’ lives. Facing this terrible prospect of cancer, which does not fit in with any of her imagined hopes for Meg, she worries that the clinicians and staff are being too negative without definitive information about the tumor. She is also is concerned that Meg will not be able to attend next week’s Homecoming activities, and that she herself will have difficulty finding a way out of work as she works as a mail carrier and has used several of her six family sick days allotted per her contract year.

Sample Case Group Debrief Questions

  1. Presented with an opportunity for an opening about goals of care, what tensions in this family might be good for the health professional to explore?

Instructor Guide: Narrative clinical practice, the guiding force of COMFORT, advocates for understanding experiences and relationships. If health care professionals avail themselves to this approach, families will more readily cultivate a sense of trust and, likely, more readily engage in decision-making with the team instead of apart from them. In short, if Sandra’s experience and relationship with Melanie is privileged, she will feel more connected to those offering her daughter help. Example:

“Sandra, tell us about your daughter.”

2.When meeting with Sandra for the first time to broach weighty subjects such as brain tumors, cancer, and possible sudden death in surgery, what might be an appropriate way to begin this interaction?

Instructor Guide: The tension for Sandra is clear; she is at the threshold losing many aspects of life that have previously been known and understood. Her awareness of what could be directly in Melanie’s path is the point of tension. This is the subject that must be engaged by the team. Once the reality of Melanie’s health is shared, Sandra can locate resilience. Without effective communication about what is ahead, Sandra faces compounded burden. Example: