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Advanced Directives

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The transtheoretical model, relapse prevention model and motivational interviewing to facilitate end-of-life discussions.

The transtheoretical model, relapse prevention model and motivational interviewing to facilitate end-of-life discussions.

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  • <number>Metro Medical Direct
  • Metro Medical Direct<number>
  • Metro Medical Direct<number>
  • Metro Medical Direct<number>
  • <number>Metro Medical Direct
  • <number>Metro Medical Direct
  • <number>Metro Medical Direct
  • Metro Medical Direct<number>
  • Metro Medical Direct<number>
  • Metro Medical Direct<number>
  • Metro Medical Direct<number>
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  • Metro Medical Direct<number>
  • Metro Medical Direct<number>
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  • <number>Metro Medical Direct
  • <number>Metro Medical Direct
  • <number>Metro Medical Direct
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  • Metro Medical Direct<number>
  • Metro Medical Direct<number>
  • <number>Metro Medical Direct
  • <number>Metro Medical Direct
  • <number>Metro Medical Direct
  • <number>Metro Medical Direct
  • Metro Medical Direct<number>
  • <number>Metro Medical Direct
  • <number>Metro Medical Direct
  • <number>Metro Medical Direct
  • <number>Metro Medical Direct
  • <number>Metro Medical Direct

Transcript

  • 1. It’s not what you say, but how and when you say it End-of-life Care Raymond Zakhari, NP MetroMedicalDirect.com Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC New York Presbyterian- Weill Cornell Medical Center Metro Medical Direct
  • 2. Sigy getting ready for Bourbon St. Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Medical Direct
  • 3. Sigy after Bourbon St. Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Medical Direct
  • 4. Sigy sleeps it off Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Medical Direct
  • 5. Objectives  The Transtheoretical Model  Relapse Prevention Model  Motivational Interviewing  Group Practice  Summary/ Questions Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Medical Direct
  • 6. In the 21st century, health is increasingly about long-term condition/ chronic symptom management— First, do no harm, and then do good, but if you can’t do good, at least do no further harm. Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Medical Direct
  • 7. Transtheoretical Model “That which I want to do, I do not do, and that which I do not want to do, I do.”  Intention to change  Willingness to change  Barriers to change  Process of change Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Medical Direct
  • 8. TTM: Core Constructs • Stages of Change • Process of Change • Decisional Balance • Self-Efficacy Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC
  • 9. TTM: Process of Change,  Consciousness Raising [increasing awareness]  Dramatic Relief [emotional arousal]  Environmental Reevaluation [social reappraisal] Social Liberation [environmental opportunities]  Self Reevaluation [self reappraisal] Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Medical Direct
  • 10. TTM: Process of Change, Behavioral  • Stimulus control [re-engineering]  • Helping Relationships [supporting]  • Counter conditioning [substituting]  • Reinforcement management [rewarding]  • Self Liberation [committing Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Medical Direct
  • 11. Decisional Balance– Pro’s & Con’s  • Ambivalence is normal  • Listening is crucial  • Tipping the decisional balance  Self-Efficacy: the belief that the  individual has in one self that they  can do a particular behavior. Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Medical Direct
  • 12. TTM: Process of Change, Experiential • Consciousness Raising [increasing awareness] • Dramatic Relief [emotional arousal] • Environmental Reevaluation [social reappraisal] • Social Liberation [environmental opportunities] • Self Reevaluation [self reappraisal]
  • 13. TTM: Stages of Change Precontemplation No intention No problem Contemplation Preparation Action Maintenance to take Problem Action Doing something Trying to keep Pro’s & Con’s about problem the action going I need to do something
  • 14. Precontemplation (no problem identified)  • “The doctor’s will do what they think is  best”  • When it’s there time it’s there time.  • II just want to be around  • “She’s looking around more”  • “They seem more responsive”  • “Is she going to get better?” Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Medical Direct
  • 15. Contemplator— acknowledges problem • “They can’t go on like this forever” “S/he doesn’t look comfortable”  “They didn’t want live with assist devices”  “This was supposed to be a short term  bridge to recovery” Listen for cues that identify the individual is not happy with the status quo.
  • 16. Preparing to take Action (wanting to fix problem) • “ I want them to be comfortable” • “I want to do what they would have wanted, or what we discussed” • “How can I promote quality of life?” • “I want to know that the right thing was done” Listen for cue that convey a desire to take action.
  • 17. Action Stage doing the intended behavior • “I would like to speak to you about my mothers care” • “If my family member winds up taking a turn for the worse I don’t want to use heroic measures” • “I just want you to promote the quality of there last days on earth” • “I don’t want them on a respirator or feeding tube.” Doing the value the aspired to.
  • 18. Maintenance Stage (> 6 months of Action) • “Mom seems very peaceful” • “She’s involved in many activities” • “She looks comfortable” • “I’m glad we addressed those issues before we got to this point” Listen for cues that the person is satisfied with their decision and would do it again if confronted with the same thing.
  • 19. SOC in which the Change Processes are most emphasized Stages of Change Precontemplation Contemplation Preparation Action Maintenance Consciousness Raising Self-liberation Dramatic Relief Reinforcement Management Helping Environmental Reevaluation Relationships Counter conditioning Self-reevaluation Stimulus Control Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Medical Direct
  • 20. Relapse Prevention Model Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Medical Direct
  • 21. Relapse Prevention  High Risk Situations  Self-Efficacy  Abstinence Violation Effect (AVE) Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Medical Direct
  • 22. Craving mediated Lifestyle imbalance by (Shoulds> wants) Desire for Expectancies indulgence or For immediate immediate effect gratification (I owe myself) Rationalization , Denial, and apparently irrelevant decisions Precursors to High Risk Situations
  • 23. Increased Self- Decreased Efficacy probability of Coping relapse Response Cognitive Behavior Model of the relapse process High Risk Situation Relapse No Coping Response Decreased Abstinence Self-Efficacy Violation Effect Lapse
  • 24. High Rates of Relapse: • Negative Emotional State (35%) • Interpersonal Conflict (16%) • Social Pressure (20%) Cummings, Gordon, & Marlatt 1980; Marlatt & Gordon 1980
  • 25. What might this sound like in terms of end-of-life care?
  • 26. Life style imbalance (Should > Wants) • I ought to visit more • I need to take care of my family here • I have a big project at work • I have to make funeral arrangements • I’ll have to sell the estate
  • 27. Desire for indulgence, I owe myself • I’m not going to answer the phone when the hospital calls, I need some alone time • I have taken care of her, so she needs to be around for my kids • I deserve to live in this apartment, if she dies I’ll have to move • People really seem to talk to me more now that she’s on the ventilator
  • 28. Craving Mediated by expected effect • We can finally feel like a family again • If she just gets through this ____ all will be better • If he would just give me a sign, squeeze my hand etc.
  • 29. Rationalization & Denial, • She has to eat and then she’ll get strong enough to pull through • Everyone keeps telling me how bad the situation is, they don’t know her like I do. • Lots of people are on dialysis, this will help her dementia if we clean her blood
  • 30. It’s not what you say but how you say it: Motivational Interviewing as your counseling style
  • 31. The Spirit of MI vs. Treatment As Usual (TAU) • Collaboration • Confrontation • Evocation • Education • Autonomy • Authority
  • 32. Motivational Interviewing (MI) • A client’s discomfort with cognitive dissonance can be a spring board for change. • MI works by activating patients’ own motivation for change
  • 33. Develop Discrepancy  The client/ family should present the arguments for change (rather than the provider)  Change is motivated by a perceived discrepancy between present behavior and important personal goals and values. Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Medical Direct
  • 34. Express Empathy  Acceptance facilitates change  Skillful reflective listening is fundamental • Desire • Ability • Reasons • Needs  Ambivalence is normal Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Medical Direct
  • 35. Values vs. Reality  Advantages/disadvantages of status quo  Advantages/ Disadvantages of change  Optimism for change  Intention to change Listen for change talk in the individual, Where are they are along the SOC? Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Medical Direct
  • 36. Roll With Resistance  Avoid arguing for change  Resistance is not directly opposed  New perspectives are invited but not imposed  The client is the primary resource for finding answers and solutions  Resistance is a signal to respond differently Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Medical Direct
  • 37. R.U.L.E.  Resist the righting reflex • Psychological reactivity & Therapeutic Paradox  Understand your patient’s motivation • Why would they want to?  Listen to your patient • Equal parts of listening & informing  Empower your patient • Help in contemplating the how and why Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Medical Direct
  • 38. Four Guiding Principles  Resist the righting reflex  Understand the patients motives  Listen with empathy  Empower the patient Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Medical Direct
  • 39. Three Communication Styles— Three Core Communication Skills  Guide-- Asking  Open Ended Questions  Direct-- Informing  Affirm the Person  Follow-- Listening  Reflect back Elicit ---  Summarize Provide --- perspective on change Elicit Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Medical Direct
  • 40. Listen for and try to do these things: Resist the Righting Reflex Set an Ask permission Readiness to Agenda Change? Validate & Affirm Reflective Use Rulers Listening Empathy What is the Create Explore the motivation Discrepancy Pro’s and Con’s Consider life balance Ambivalence Explore a Menu High Risk Situations is Normal of Options Promote Self- What’s Abstinence Efficacy Next? Violation Where are they on the SOC continuum? Effect Explore Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Coping Metro Medical Direct
  • 41. References  Curry, S. J., & Kim, E.L., (1999). Public health perspective on addictive behavior change interventions: Conceptual frameworks and guiding principles. In Tucker, J.A., Donavan, D.M., & Marlatt, G.A. (1st ed.), Changing addictive behavior: Bridging clinical and public health strategies (pp. 221-246). NY: The Guilford press.  Larimer, M., Palmer, R., & Marlatt, A. (1999). Relapse prevention: An overview of Marlatt’s cognitive-behavioral model. Alcohol, Research & Health 23(2), 151-160.  Marlatt, G.A. (1985). Situational Determinants of Relapse and Skill-Training Interventions. In Marlatt, G. A. & Gordon, J. R. (1st ed.), Relapse prevention (pp. 77-81). NY: The Guilford press.  Marlatt, G.A., & Witkiewitz, K., (2005). Relapse prevention for alcohol and drug problems. In Marlatt, G.A., & Donovan, D.M. (2nd ed.), Relapse prevention: Maintenance strategies in the treatment of addictive behaviors (pp. 1-24). NY: The Guilford press.  Miller, W., and Mount, K. (2001). A small study of training in motivational interviewing: Does one workshop change clinician and client behavior? Behavioral and Cognitive Psychotherapy 29, 457-471.  Miller, W., Yahne, C., Moyers, T., Martinez, J., & Pirritano, M. (2004). A randomized trial of methods to help clinicians learn motivational interviewing. Journal of Consulting and Clinical Psychology 72(6), 1050-1062.  Miller, W.R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change: The Guilford press. Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Medical Direct
  • 42. My Contact Information Raymond.Zakhari@gmail.com RZakhariNP Rzakhari Raymond Zakhari Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Medical Direct