Answering Difficult Questions…
…Some thoughts
Ciara Savage, Palliative Care Social Worker.
18th September, 2014
Why is it so hard…?
…personal feelings
…helplessness
…fears we hold
…awkwardness
…the environment
…bearing witness to pain
Palliative Care and End of Life Care…
“…touches, pervades and
provokes primeval fears and
feelings.”
(McSherry, 2013)
Our Fears…
What energises them?
unknown
uncertainty
WISE FEAR ~ it is scary
LEARNING ‘how to notice’ (in our
patients and ourselves)
DIGNITY
Actioning Dignity…
… otherwise it remains rhetorical
(Magee et al, 2008)
Dignity
PHYSICAL
CULTURE
SOCIAL
SPIRITUAL
ENVIRONMENT
PSYCHOLOGICAL
Dignity of Personal Identity
Integrity, Autonomy, Inclusion…
… shapes and preserves us.
Our actions, attitudes and behaviours
can either preserve or compromise our
patients Dignity.
DIGNITY
Disease, illness can strip Dignity away,
Leaving patients vulnerable & exposed.
Our Role; to safeguard and preserve
Dignity
ABCD of Dignity Conserving Care
(Cochinov,2002)
Attitudes
Behaviours
Compassion
Dialogue
EMPATHY
‘Einfuhlung’ (Lipps, 1880’s)
‘…consideration of another persons feelings and
readiness to respond to his/her needs… without
making his/her burden one’s own’ (Szalita, 1976)
‘a balanced curiosity leading to a deeper
understanding of another human being (Bellet & Maloney,
1991)
EMPATHY
Recognising presence of strong feeling
Pausing to reflect on this
Stating your perceptions on what has been
described
Legitimising these feelings
Respecting effort to cope with difficulty
Offer of support
Emotional Attunement
The point of Empathy…
… to focus attention on the patient (not on
introspection)
Need not be awkward or exhausting
Skillful Attunement;
… reading non-verbal cues, tone of
voice, body language.
… use in ordinary clinical and nonclinical interactions
When the question is asked…
… our patients take a chance on us.
How we respond is critical.
Ground our response; honouring the patient’s
personal dignity, using skills of empathy and
emotional attunement.
Simple Ideas
Take a breath – don’t rush it
Avoid the temptation to placate
Really listen – what is actually being asked?
why is it happening now?
why am I being asked?
Communicating in stressful circumstances
HOW?
Use natural strengths; but have awareness of limitations
KNOWLEDGE
(translate)
STYLE – using repetoire, skills
GRACE – feel, generosity of spirit
Using Questions Effectively
Broad, Open: Encourages story/ narrative
(How, what, Tell me…)
Open Directive: Targeting specific issue/point
(How did you feel when you heard that?)
Directive: Important when seeking factual
information. (Where is the pain?)
Closed: When you need a YES/NO ‘Are you
sleeping?
Pitfalls to Avoid…
Leading Questions:
Can assume an answer, or restrict expression. (I expect
you were worried)
Multiple Questions:
Without pause for response
Premature/False reassurance:
Need to explore fully
Normalising:
Be careful in use
Responding to Anger
Speak to FEAR & not to ANGER
(Cancer Tales, 2002)
Diffusing Anger
o Acknowledge
o Invite explanation of cause
o LISTEN to story
o Focus on THEIR stress/feelings
o Apologise if appropriate
o Clarify if appropriate
o Negotiate a solution
Family Focus
Helping families understand End of Life
Symptoms.
Specific Information
Reduces Anxiety and potential
misunderstanding
becoming a,
‘Fellow Traveller’
(Holloway, 2010)
References
McSherry, Wilf, Dignity in end of life care,in Spirituality and
End of Life Care, Gilbert, P (ed.)2014 Pavillion
Cancer Tales, (2002) also online learning resource
www.cancertales.org
http://realbalance.com/the-role-of-empathy-inhealthcare/Print
Charon, Rita Narrative Medicine: AModel for Empathy,
Reflection, Profession, and Trust, JAMA,
2001;286(15):1897-1902
Moss, Bernard, The Caring Professions (Ths Social Worker)in
Spirituality and End of Life Care, Gilbert, P (ed.)2014
Pavillion