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Lost in Translation #3/4
Lost in Translation #3/4
Lost in Translation #3/4
Lost in Translation #3/4
Lost in Translation #3/4
Lost in Translation #3/4
Lost in Translation #3/4
Lost in Translation #3/4
Lost in Translation #3/4
Lost in Translation #3/4
Lost in Translation #3/4
Lost in Translation #3/4
Lost in Translation #3/4
Lost in Translation #3/4
Lost in Translation #3/4
Lost in Translation #3/4
Lost in Translation #3/4
Lost in Translation #3/4
Lost in Translation #3/4
Lost in Translation #3/4
Lost in Translation #3/4
Lost in Translation #3/4
Lost in Translation #3/4
Lost in Translation #3/4
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Lost in Translation #3/4

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Third in a series of presentations focused on interprofessional research related to medical communication. Looks at barriers and catalysts to successful medical communication of emotional news. …

Third in a series of presentations focused on interprofessional research related to medical communication. Looks at barriers and catalysts to successful medical communication of emotional news. Particular attention is paid to the emotional state of the physician.

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  • Obstacles and catalysis to successful communicationElements to be negotiated within the shared spaceThe complex nature of “hope”
  • Behavioral economics. MINDSPACE mnemonic: Messenger. Incentives. Norms. Defaults. Salience. Priming. Affect. Commitments. Ego.Image: http://www.scribd.com/doc/42975012/2/Executive-summary
  • Physician statements on the y and surrogate interpretation on the x. 50% chanceRange suddenly 50 to ~70%Median 50% but mean 63%Definitely notRange 0-50%Median 10%Mean 28%No difference between qualitative & quantitative formulationsUsing your scary words will only take you so far.
  • NEJM. …in the world of palliative chemotherapy.“After talking with your providers about chemotherapy, how likely did you think it was that chemotherapy would…cure your cancer.”“…disclosure alone may not lead to sustained understanding among patients.”“In other words, a focus on chemotherapy was the instrument that facilitated prognostic misunderstanding. This phenomenon may help explain our finding that patients with colorectal cancer, a more chemotherapy- responsive disease than lung cancer, were more likely to report that chemotherapy could be curative.”
  • Adapted from a white paper developed from the British Institute for Government and Cabinet OfficeAbout how we target our efforts  changing minds versus changing context of decisionsWho is speaking with usWhat other people are doingAnd what we’ve always done.How we think and the short-cuts that we take in our thinkingAbout things that seem new or important.
  • How do we feelAnd how is the environment influencing those feelings and thoughts;Seeking out things that make us look good to others and feel good about ourselves.
  • Impacted also by the style of communication between pts and families: “1) avoidance of psychological distress,2) desire for mutual protection,and 3) a belief in positive thinking.” (Waldrop et al., 2012.) and by timing, “84% wanted to discuss treatment goals and options when first diagnosed. 59%wanted to discuss survival, but only a third wanted to discuss dying and palliative care at the diagnosis.” (Parker et al., 2007.)**Questions?**
  • Norton’s “Reconciling Decisions Near the End of Life” theory: “From the providers' perspective, the big picture was a gestalt of the patient's condition constructed from information about the diagnosis,test results,prognosis,general assessment findings (including physical, emotional, and spiritual factors),treatment options,treatment efficacy,treatment burdens,and patient goals. This information, filtered through providers' knowledge,insights,and experience…” (Norton & Bower, 2001.)sense of ambivalence and level of comfort. **Questions?**
  • Meaningful communication cannot occur without leaving both avoidance and ambiguity outside of the shared space. Providers do and don’t want do pronounce a death sentence and patients to and don’t want to hear one. The outcome of this is that it becomes easy to glance off those feeling of ambiguity and never explicitly arrive at the core truths. This process of leaving the bubble of ambiguity intact is the most comfortable route for patient and provider Weeks article (Weeks et al., 2012.) (The et al., 2000.)
  • How emotionally numb do you feel about your illness?Adapted from Prolonged Grief Disorder ScaleAssociated withDisbeliefBitternessYearningPTSD related to initial diagnosisThe more emotionally numbThe more likely that EOL discussions would lead to more aggressive care(9-fold increased odds with each increase in the score)(EOL discussions would be expected to be of questionable benefit to a small subset (9.3%) of patients who were either quite a bit or overwhelmingly emotionally numb. Indeed, EOL discussions for a small minority (2.4%) of patients who were overwhelmingly numb may actually heighten rather than protect patients from the risk of receipt of aggressive, expensive, burdensome EOL care.)
  • Adapted from Joan Halifax’s work as a Distinguished Visiting Scholar in the Kluge Center of the Library of Congress on Compassion’s Edge States.EventEmpathy = affective attunement (no separation between self and other)Perspective taking = cognitive attunementMemory = personal experienceArousal levelEmpathic overloadThis is the key point, how the provider reacts at this point can determine the entire course of the patient’s illness experience.EmotionPersonal distressBehaviorSelf-centeredSelfish prosocial behavior (“doing something” to help self)Moral outrageAvoidanceNumbing/freeze responseThis response is neurologically hard-wired; let’s look at it in another way.--EmpathyAffective stateStems from the perception of another’s emotional state/conditionCongruent with that emotionSympathyAffective stateStems from the perception of another’s emotional state/conditionNot identical to that emotionColored by feelings of sorrow/concernSympathy + selfless prosocial behavior = compassion
  • “The Russian doll model of multilayered empathy.The doll's inner core consists of the perception-action mechanism (PAM) (‘mirror-neurons’)that underlies state-matching and emotional contagion (15). Hard-wired socioaffective systemThe doll's outer layers include sympathetic concern (‘empathy  sympathy’) and targeted helping. The complexity of empathy grows with increasing perspective-taking capacities…”…need the training & the tools to be able to successfully move toward effective targeted helping…
  • EventEmpathy = affective attunement (no separation between self and other)Perspective taking = cognitive attunementMemory = personal experienceArousal levelEmotional regulationEmotionSympathyBehaviorOther-centered = selfless prosocial behavior (“doing something” to help other person)EmpathyAffective stateStems from the perception of another’s emotional state/conditionCongruent with that emotionSympathyAffective stateStems from the perception of another’s emotional state/conditionNot identical to that emotionColored by feelings of sorrow/concernSympathy + selfless prosocial behavior = compassionPhysicians are more likely to constructively address patient’s emotional states if they incorporate reflective self-awareness exercises into their practice (Halpern & Arnold, 2008)
  • The provider’s partA willingness to accept the patient’s anxiety around difficult topics and the ability to sit with that discomfort. To accept that she has caused that distress and to reframe it for herself and for the patient. Image credit: http://www.securitycatalyst.com/wp-content/uploads/2011/10/curated_catalyst_540.jpg
  • Compassion isAn emergent processArising out of the interaction of multiple processesSomaticAffectiveCognitiveAttentionalEmbodiedTherefore, it cannot be trained in directly, only primed.
  • The process of building trustTakes time, often a long timeBegins with the building of rapportDoes not take a long timeIs based in mutual understanding of and respect for each other’s world-viewsImage credit: http://businessmarketingsuccess.com/wp-content/uploads/June-19th-Trust-thumb.jpg
  • Successful communication requires:An understanding of the patient’s world-viewAn understanding of the provider’s world-viewA willingness to negotiateAs well as an understanding that…The most important thing to remember is that both parties share the ability, the desire, the natural inclination to prognosticate though they come to the process with different skill sets.Coming to use the same language regarding the patient’s status is a key process.The majority of surrogates in one study (51%) relied solely on their own formulation of prognosis that included…physical appearance (64%),previous fitness (37%),surrogate’s personal optimism (36%),pt’s previous illness experience (28%),intrinsic qualities (27%),faith in God (20%),intuition (19%),family’s bedside presence (13%),rallying of community (5%),miracles (4%)and reciprocity/karma (2%).
  • Cognitive interventionstarget clearly conveying prognostic informationvisual aidschecking behaviorsteach-backs, andmultiple conversations. Emotional and psychological interventions foster rapport (or trust) between clinicians and family, andprovide emotional support to family membersDivergent viewsSeek to speak common languageSpiritual or religious basisphysicians may avoid using more strident attempts at scientific explanations to convince surrogates of the prognosis instead enlist the help of a chaplain or a representative of the surrogate’s religion to help mediate the conflict. Data interpretationSeeking the input of multiple senior clinicians to help patient triangulate. Focus patient on and defineprognostic significance of the physical data(Lee Char et al., 2010.)(Zieret al., 2009.)
  • Transcript

    • 1. Kyle P. Edmonds, MD Institute for Palliative Medicine San Diego Hospice
    • 2. Elements to Negotiate Patient Perspective Provider Perspective
    • 3. Zier et al., 2012.
    • 4. Weeks et al., 2012.
    • 5. Messenger • Who communicates Incentives • Mental shortcuts (avoiding loss) Norms • What others do Defaults • We “go with the flow” Salience • What is novel and relevant Dolan et al., 2009.
    • 6. Priming Affect Commitments Ego • Sub-conscious cues • Emotional associations • Public promises / reciprocated acts • Act in ways that make us feel better Dolan et al., 2009.
    • 7. Data Chosen Role Trust in Provider Cues Patient Framing Ambivalence Coping Style Beliefs History
    • 8. Experiences Assumptions Education Population Data Provider Professional Norms Chosen Role Patient Data Ambivalence Beliefs
    • 9. Patient Defenses Avoidance Reality Provider Discomfort Ambiguity
    • 10. Maciejewski & Prigerson, 2013.
    • 11. Event Arousal Emotion Behavior • Empathy • Perspective • Memory • Overload • Ambivalence • Personal distress • Selfish Prosocial • Avoidance • Freeze Adapted from: Halifax, 2011.
    • 12. de Waal, 2012.
    • 13. Event Arousal Emotion Behavior • Empathy • Perspective • Memory • Emotional regulation • Sympathy • Selfless Prosocial • Othercentered Adapted from: Halifax, 2011.
    • 14. • Mutual understanding • Willingness to engage • Reframing anxiety
    • 15. Halifax, 2012.
    • 16. • Rapport • vs. Trust
    • 17. Location of Hope Power of Optimism Meaning Making Control Needs
    • 18. Actions Experiences Defining Hope Ambivalence Framing Assumptions Tailoring Outcome Affective Cues Avoidance Lack of Trust Confidence Interval
    • 19. Kyle P. Edmonds, MD kyle.p.edmonds@gmail.com kylepedmonds.com
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