BTK_PC.E3_Clinical Challenges in Surgical Palliative Care - Communication Skills for Difficult Conversations_Recording

Hi everyone, welcome back to another episode of Behind the Knife, the palliative care team from the University of Washington. I'm Allie, joined by Dr. O'Connell, Lindsay, and Virginia. Today we have a special episode where we'll be talking about some specific skills for serious illness communication. We'll be demonstrating these skills through a simulated scenario and identify some common sticking or challenge points we encounter.

Then talk about tips for how to navigate them. To help us today, we have two guests who will be playing out a doctor patient scenario. We have surgery resident Dr. Grace Pak playing our surgeon, and an SP playing Brenda Lewis, the mother of an ICU patient. Now, as we go through the role play, we will be periodically timing out, pausing the scenario so we can talk about what's going on, game plan next steps, and then replay the scenario utilizing these new skills.

Grace, if you're feeling stuck at any point, feel free to time yourself out too. Okay, let's start. Virginia, why don't you read the case to our listeners?

Sure. This case is about patient Robert Lewis, and you'll be speaking with his mother, Brenda. Robert is a 23 year old man who was rock climbing when he fell about 50 feet and sustained a TBI and a C5 fracture with associated cord injury and resulting quadriplegia.

He was taken urgently to the OR for spine stabilization but since has not been seen to move his arms or legs. He was admitted to the trauma surgery ICU where he remains intubated. His propofol was stopped yesterday and he has continued to be unresponsive. You are part of the surgery team and you were asked by the ICU to speak with Robert's mother, Brenda.

Your task is to talk to her about her understanding of the situation and to share your concerns about his future. This is a situation we commonly encounter as the trauma team. Before we get started with the role play, Grace, do you have any questions? No, I guess so. It's just myself. The ICU team is not available.

Yes, it's just you without the ICU team meeting with Brenda. What do you think is going to be challenging about this case for

you? I think there's possibility of a lot of emotion, which would be appropriate on her end, given it's a young guy, it's her son. Also, you know, I think there's the uncertainty in the air of what could happen for him in terms of his mental status, his overall prognosis.

So bringing that to the table from my end will be difficult too, I think. Excellent. Yeah. So really being able to acknowledge the uncertainty so early on after a traumatic injury like this in terms of his prognosis and then responding to emotions. Both really great palliative care skills. Okay. Let's see how I do.

So before we jump in, I just want to name two skills we'll be using and talking about to address these concerns that Grace, you're already thinking about. The first thing you mentioned was there might be a lot of emotion. So what do we do with

that? As we go through this role play, we'll be looking for emotional cues from Brenda, right?

You're already expecting them. And our goal isn't to prevent her from feeling emotion, but it's to recognize when she is so we can address any emotional cues instead of blowing past them. There's different ways to respond to emotion, and today we'll be talking about one of them, which is using what we call nurse statements to provide empathic responses.

This allows us to take a pause and just be with the patient and family in that moment. The second skill is being able to acknowledge uncertainty while also being clear and confident in the information we give Brenda. To accomplish this, we can use a headline statement, which is a clear, concise sentence that conveys the take home message upfront before we dive into providing more information.

We'll talk more about specifics as things come up in this scenario. All right. So, Dr. Pack, go ahead and take it away. Hi, I'm Dr. Pack. I'm with the surgery team. I'm the resident on the team.

Hello. Hi. And what's your name? I'm Brenda. Brenda. And you're Robert's mother? Yes. Okay. So, I just wanted to come sit down with you and get a conversation going about.

What your understanding is, give you an update and then hopefully talk more about this feature. Is there anything that you want to specifically hit on or add to our plan here? Well, I mean, I just want to make sure that, you know, everybody's doing everything they can for him. Yeah, of course. And that's one thing, you know, I can promise is that everybody's doing our best.

Okay. So, you know, this is the first time meeting you in this situation. Can you just tell me what you're understanding so far about what's happening? Well, I I mean, I know that, that he's, you know, hit his head and he broke his spine and that he's not doing well right now, but it's still really early.

So, yeah, yeah, definitely. So I think you got, I'm hearing you

say that you understand that he hit his head and spine not doing. Terrific, but also early in the course. Okay, gotcha. The update that I got from the ICU is that we stopped the sedation medications yesterday to see how he would respond.

And so far he hasn't been seen to move any of his arms or legs, and has not been responsive. So hasn't been opening his eyes or answering questions for us. Well, but I did see him blink. I mean, I did, and I told the nurse who was in there, and they, I don't know if they didn't believe me, or they just didn't think that was important, but I'm sure that he like heard me and responded as best he could.

Okay, so that's important information that I know you're at his bedside, so these things can be intermittent and not consistent, which makes things obviously more confusing, but it's good to hear from you about that. I think from our side of things, we haven't seen that just to be on the same page with you.

Right, but I mean, I think, I mean, you guys are sort of assuming that things are going to stay the way they are. And I just, I really need for, I really believe in the power of positive energy. And I'd like to know that the people taking care of him believe that, that He can recover from this.

Time out. Okay. So, Dr. Pack, how is it going? I don't know if it's going great. I think she's definitely expressing frustrations to have had in the past couple days where I haven't been present or aware of. So I think I'm stuck in a place of trying to make sure she understands we're doing our best, but also, Like, defending the team, which is a weird thing to do.

Also, perhaps I came in with it too much of a assumption that things are going to stay serious for too long. Maybe she caught that as a, like, that I don't expect things to happen things to get better. Great. So, I want to acknowledge what you've said

initially about feeling like you have to defend the team because, oftentimes we're meeting someone for the first time and they're frustrated with the care that has taken place. And you're sort of bearing the brunt of that. And how do we deal with that gracefully? Let's pull the group and see if anyone has any ideas. Yeah, I. Can I also just share some other things that I think you did really well before we get into that?

First of all, you started by introducing yourself and meeting Brenda. You set a very clear agenda for the meeting and you asked her if there are other things besides that that she wanted to talk about. So I thought you started out by being very clear and setting a very safe space, which is really important.

And sometimes when we're so busy, we forget to do that. So that was great. Now, sorry, back to what? Dr. O'Connell was asking about. It is a tricky spot. Because you want to acknowledge the frustration Brenda's feeling without

validating the idea that the other doctors are doing something wrong. Or you want to acknowledge her observations about the blinking without making her think that means he's recovering miraculously.

Grace, you're doing a great job recognizing this tension. So, what do we do? If I can jump into just for a second, when you're feeling this sort of, it's almost like a firing squad, right? Like you're talking and she's kind of coming at you and that is a red flag in my mind, like, okay, I need to figure out how to align with this family member.

Okay. And one way you can do that is respond to. The emotional cues that she's giving with empathic statements, and that's going to really help you align with her and be on the same page and start building rapport. Seems like a good time to use a NURSE statement, which maybe Lindsay can tell us more about.

Sure. NURSE is a tool to respond to emotion, and it stands for Name,

Understand, Respect, Support, and Explore, which empathic responses. It might sound funny at first to practice saying these phrases out loud, but having a couple of them in your pocket that you feel comfortable saying will make it so much easier in the moment to authentically express empathy rather than fumbling over the words.

Exactly. So why do we need to respond to emotion at all? Is it just a nice thing to do? I mean, yes, but also no. It's not just an extra thing. It's actually really important to having an efficient and effective conversation. Virginia, did you notice what was happening before the timeout? I did. It seemed like Brenda was starting to get upset.

She was really focused on the blinking and asking if the nurses told us about the blinking and how she had seen him respond. Great. And after Dr. Pack gave more information that we weren't seeing that, what did Brenda do? You know, it didn't seem like she was really listening to Dr. Pack anymore, and she started talking about her belief in positive energy, and she was starting to

escalate a little bit.

Yeah, that's what I was sensing too. So, this is why we address the emotional response, to interrupt this escalation. I think we can frame this as the brain generally having two pathways to process emotions. Although our neuroscience friends out there would be correct in saying this is an oversimplification.

But for our purposes, the fast pathway in the brain is that fight or flight, immediate amygdala based response. And it overwhelms the other pathway, which is the slow pathway that goes to the cortex for higher level processing. Responding to a patient or family member's emotion gives the slow pathway a chance to catch up, so the person can get back to a place mentally where they are ready to hear and process more information.

If we don't allow for this sort of recalibration by responding appropriately to emotions, you can see that more information just isn't going to be heard, and it's going to be hard to get the conversation back on track. Grace, was that helpful? Do you want to jump back into

the scenario or do you want to maybe brainstorm as a group what your next sentence might be?

I think I can try jumping out there and then time out again if needed. That sounds great. Okay, so let's go back to the point where Brenda is You know, asking about what he's seen. I've seen him blinking. You know, I don't know if the nurses didn't tell you or didn't think it was important. We'll go from there.

But I saw him blink. I mean, I'm sure that he heard me and was responding to me when I told the nurses. And, and I don't know if they just didn't think it was important or they didn't believe me. But it's like they're ignoring that. So I'm hearing and seeing you feel frustrated, maybe, and also concerned that, you know, we're not hearing you or listening to you or paying attention closely.

Yeah, I just You know, I just want to, I don't want anybody to miss anything. Yeah, of course. And, you know, thank you for talking with us frequently

and we are definitely doing our best on our end. I'm sorry if you felt that that wasn't the case, but we're definitely on the same team as you and really trying our best for each time.

Thank you. Time out. How did that feel different? It felt like I didn't have to, like, be on the other side of her, like, trying to defend the team, but just be with her this moment and her emotions right now. Can we try a respecting statement? Mm. So, When you're, when someone's coming at you, you can use a respect statement to kind of bring them down and align with them.

So it's something like, I really appreciate how you've been here every day supporting your son and how strongly you're advocating for him. And let's see if we can start over with the blinking and then try that, try a respecting statement and see how that goes. And respecting

statements. Sorry for me.

Just that means that you're just trying to appreciate what they're doing and recognize their efforts. So, the general exactly. Yep. Yep. You're saying I see you. I see what you're doing, even though it's like, it's coming across at you like, kind of aggressive. You respect what they're doing for their loved one.

Yeah. Thank you. But I saw him blink and I know that, that, that he heard me and was responding to me and I told the nurses on it. I don't know if they, if they just, if they just didn't believe me or they don't think it's important, but it's like they acted like it didn't even happen. Okay. I really appreciate that you've been paying such close attention to your son and they're every step of the way and talking to us about it too.

That's a lot of hard work and dedication on your end. Thank you. I mean, he's just everything to me. Yeah. Time out.

Okay. Did that feel different than the first time we ran through the scenario? Yeah, definitely. Tell me what you saw. How did she respond differently that time? It seemed like her emotion was able to be expressed and then kind of She felt some relief that someone was hearing her and seeing her, and not so much that she had to keep fighting to be heard.

I felt the same thing. Yeah. She really transitioned from kind of pushing really angry, but kind of getting there to okay, now I'm being heard and the sadness was starting to come out. Yeah. And I feel like we're at a better spot now to give information from my end if I need to know that, like, emotionally we're seeing more aligned and she seems more relieved that we're cured.

Exactly. Dr. O'Connell, do you think now is a good time, since Grace has identified that Brenda seems

ready to hear more information maybe now is a good time to talk about how we deliver that information? Yeah, that sounds good. Talk about developing. A headline statement. Yeah. So headline statements are how we deliver the take home message at the beginning of the conversation, like we mentioned earlier, usually it's good to have a previous statement, like I have some serious news or we're in a different place or things are about the same.

Just to tune them into what's coming. Then deliver your headline. Lindsay, tell us about the components of the headline statement. So you can think of this. in a way like a newspaper headline. It comes first and is succinct, setting the tone for the conversation to come. It contains both the overall information and what that means for the patient.

Usually when I give a presentation on Rounds, I start with giving a lot of information up front with this objective data, objective data like vitals, exams, labs, imaging, etc., and then summarize with my assessment at the end, but it sounds like this actually is the opposite

structure. Right. Patients are not trained to listen and interpret medical data like we are.

So if you leave the headline until the end, it usually gets buried, or you're giving them a bunch of information about the overall meaning to add context, so you keep getting interrupted with questions and you never get to the take home message. Maybe it's just me, but I sort of think about it like when I'm hearing about a new consult from someone, I want to know up front, it's for a bowel perforation, the patient's sick, needs an operation.

Then how I listen to the HPI that follows is really different than if the achalasia. Anyway, let's brainstorm what a good headline would be to give Brenda. So Grace, what do you feel like is the medical information that you want to share with her? I think the update that I want to give with her is that we are now off sedation but he remains unresponsive.

And hasn't shown signs of neurologic recovery. Yeah, and so we know as

clinicians that's not a good sign, what we're seeing. What does that mean for Robert and his overall kind of trajectory and care that Brenda could expect from him? Right, so I guess for Robert, that means that he could potentially not recover to the point of being independent or interactive, even with people and then depending on kind of his goals of care if that is something that he would want to live like with those restraints.

Yeah, and so I think you're starting to go into some of the next steps of the conversation, and I just want to pull you back a little bit for the headline statement and let's say, how would you put together that information and what that means into one succinct statement. And can you also add that uncertainty piece?

Right. Highlighting sort of where we are currently in

his trauma course, being very early. And there's still a lot of uncertainty with his prognosis. Okay. So, kind of starting by saying, as you know, there's, he's had a serious head injury, serious spine injury. The change today is that we've been off sedation for about a day, but he hasn't shown that he's talking with us awake or moving anything.

And so at this point, we're not clear how much he'll recover of his function. Yeah, I think you are so close. If maybe we could tweak it just a little bit. I love the medical update part. I think we need to just shorten it a bit and explain the meaning a little more. And this is the hard part because context matters a lot when we're thinking about what a piece of information means to someone, so it can be heard in these first meetings.

Thanks. So I think it's okay in your meaning to acknowledge that right now we

don't know exactly what it's going to be, but best case scenario, what do you think his things will look like? So best case scenario, he's going to be quadriplegic and his brain function May or may not recover to where it was, but it'll take months to see that.

So, maybe putting those together more succinctly. I hope that the listeners can pick up that this is like, a really hard skill. To formulate a concise headline of What is the core information plus what does it mean and not fill it in with a bunch of their stuff to the point where I still will write down my headline statement on a piece of paper and take that into the meeting with me, because.

In the heat of the conversation, it's really challenging to not add all of the medical jargon and fillers in because that's sort of our comfort zone

of where we communicate with other people on a daily basis. So, what I would suggest is something like, he has severe injuries and hasn't woken up yet.

But it can take months before we know what his brain recovery will be. Or he has a serious brain injury and spine injuries, and it's too early to know what his brain recovery will be, but we think it's unlikely he'll be independent again. Grace, do you want to practice one of those choices? Okay, so, let's see.

As you've communicated to me, you know that he has a serious spine injury, which has left him quadriplegic, so unable to move his arms or legs or below the neck. And then he also has a serious brain injury. And at this point, being only five days out from his injury, it's hard to say what his recovery will look like.

That may take six months to a year to see where he set us up. Yeah, I think that that

sounds good. Yeah. And she may ask more questions, and you know that you're gonna have to give more information after the headline statement, so don't feel like you need to jam pack every single piece of this into the headline statement.

All right, let's time back in. Let's pick it up from, you've just asked Brenda, what have the other doctors been telling you about what's been going on, and she's been sharing with you. We'll start with Brenda saying, I know he hit his head. He, you know, he broke his spine. I just want to make a teaching point really quick about, because initially you said, tell me what your understanding is.

And to some people, when a doctor says, tell me your understanding, it can kind of create this hierarchy of like, they feel like we're testing them. And so that's why I offered, you know, tell me what other people have told you so far and I'll fill in any gaps. It's a little bit less Testing. Yeah. It's less

judgmental.

Less judgmental, It places less of the onus on the patient to kind of show up with all of the information on their own. Yeah. And it feels more kind of safe for them to volunteer information they have heard without feeling like they need to understand the entire extent of all the implications. Right.

Understand's a big word. Yeah. Okay. Take it away. Okay. So let's see. We I just want to kind of set up what we're going to talk about. So, Robert has had a big spine injury. So he's quadriplegic. He's also had a big brain injury. And it's unclear what level of recovery he'll have from that, it's only five days out.

It may be six months to a year before we know how much he recovers from his brain injury. Six months to a year? Before we know? But I mean, well, I thought like, once the swelling goes down, won't that make a big difference? It takes a long

time, yeah. And are you sure that, that his spine will never recover?

I mean, how can you know that? It's, it's so early. I'm sure, I'm, I'm sure other, I've heard and read about other people who've had like miraculous recoveries. And, you know, Robert's young and he's strong. And, I mean, I just don't see how you can know that right now. I'm going to time myself out. Good, good.

It'd be great if you could do that in real life. All right. So at this point, I'm trying to think about earlier about them. I, is she really asking for more information or asking me to kind of like, see what she's feeling? And I think it's more the latter. But yeah, get your thoughts on that. Great. So trying to differentiate, is she actually asking for more information or are these emotional cues?

Yeah. And I think you've identified in what you've just said and by timing yourself, out that Brenda is starting to escalate again after

reacting probably to the information that you've just given. And so she's talking about, she's asking a lot of questions. She's talking about miracles. I think there's a lot of different places that we can go from here, but that you've identified that this is probably her emotion again.

And so what are some skills you might use to respond to that? I'm kind of just naming the emotions that I'm seeing and recognizing them. I could also I guess, do respecting statements again. And then also maybe try to narrow it down onto one thing that we can talk about, because she's kind of going about multiple different topics.

Yeah, and I think what you're getting at, the different things you're saying are this seems like a time for an empathic response. So now we can go back to our arsenal of nurse statements and see if one of them feels right. And I think you've really wonderfully identified that this is a time for an empathic response rather than trying to give more information.

You answered her first question above, you know, six months to a year with more information. Do you remember how she responded to that? Yeah she didn't really hear me, just kind of kept going, I think. Yeah, she kept asking more questions and her emotion is really starting to escalate like we talked about, so I think identifying now as you, you want to find a way to Kind of slow things back down for her.

Lindsay, Virginia, do you guys want to help brainstorm some other nurse statements to respond to Brenda? Sure. I think one option could be, I can imagine how upsetting and scary this must be. I think another option could be, Robert's really lucky to have you by his side. You've been so dedicated to caring for him and being here for him on a day to day basis, and that's been amazing for him.

Yeah, so Lindsay, I'm kind of hearing an understand statement and Virginia, you were doing a respect statement. I think those are both really nice choices. So let's go back to where Brenda's saying, Well, but he's young. How do you know? Don't you have to

wait for the swelling to go down? All right, let's turn back in.

But he's so young and strong. And I mean, how can you possibly know that now? Yeah, this is a lot to take in and anybody would be frustrated and a lot of concern with this kind of news. This is such a nightmare. I can't believe this is happening. I'm so sorry this is happening.

Time out. How is that different? Better. And, it was more just, I think, being pleasant with her instead of trying to figure out the next thing to say. Yeah. Yeah, you're, you're sitting in that emotional discomfort, right? And just being there with her, and sometimes we don't know the right thing to say, and it's okay to say anything

sometimes.

One thing I noticed is that you were like, I'm sorry. This is happening. You could have tacked on and made this like a complex empathic response by saying, I'm sorry, this is happening. And we're going to be there every step of the way. Like that supporting statement to again, just really align with her.

And I think for those of you who aren't in the room, what I noticed is that Brenda, her body language changed after you gave that empathic response. Before she was ramped up, she was almost standing up in her chair. Her fists were clenched. After that, she sat back. She sighed. She relaxed her arms. And you get some verbal cues from patients, too, about how they're feeling and when they're ready to start hearing more information.

So, let's move on in the case. You use nurse statements to respond to Brenda's emotion. You're able to share more details about his injuries

and make a plan to check in in a couple days. Now, let's say it's two days later when Robert remains unresponsive off sedation. You're meeting with Brenda again to check in and you start by assessing her understanding again.

She catches you up and we'll jump back into the scenario here as you're ready to give another headline. So Brenda, what has changed over the past couple days is that we stopped sedation a couple days ago now, and he still hasn't responded in terms of waking up more or interacting with us more. This makes us concerned about his long term recovery.

Okay, two days ago, you told me that this would be six to 12 months before we knew anything. And now two days later, you're telling me that you're concerned about his recovery? I mean, I get it. He's been off sedation. He hasn't woken up. But you said six to 12 months, and now you're saying, Now it sounds like you're saying something completely different.

And, You know,

maybe I just need, maybe we need to get a second opinion or a third opinion, or maybe I just need to have him transported somewhere else where he'll, he'll, where people will actually give him the time he needs to recover. It's a lot of anger. Okay. Yeah, no, it's hard to shift with new information.

And, well, it seems to me like you don't know what you're doing. I mean, you said six months minimum, and now two days later, you're shifting with new information. I mean, which is it? So I think now we're trying to respond to what we've seen. And I can tell that you've been I'm struggling. Time out.

Yeah. Okay. So. You said it, you're getting a lot of anger, right? So your brain is saying, okay, here's, this is data. This is emotional data coming to you. And I think when you can look at it that way, it becomes a little bit more objective. So she's

giving you anger, and in your brain, you're saying, how am I going to respond with an empathic statement that's going to make her feel heard?

So this, this is not the news she was hoping to hear today, right? Yeah. Yeah. So something maybe like an understanding statement. I understand this is hard to hear. Not the direction you hoped for. Yeah, or the direction that we were all hoping for, you know, we're, we're all on the same team here. Any other thoughts team?

One small thing is that, I heard you say, I understand and I would just be careful with that wording. I think the meaning behind what you're trying to say is spot on. I just caution you when you say, I understand,

because we're not in the situation that sometimes is all patients here and can escalate.

So I think if you drop that and use the rest of your statement, it will land. So let's time back into when Brenda is saying it seems like you don't know what you're doing. Maybe we need another opinion or I'll transfer him somewhere else. Well, it seems to me like you don't, you don't know what you're doing.

I mean, you said 6 months now, you're saying 2 days later that it's too late. Maybe maybe we need to get. Another opinion, like, or I should transfer him to another hospital where they, where they'll give him the time that he needs to recover that you said he had. I, I hear you that this is not the news that any of us wanted to, to give or hear.

And I know this is, this is very hard to hear. Well, I just don't understand how, I mean, do we, we still get our six months, right? It's not like we have to, It's not like it's over. I mean, the

swelling hasn't even gone down. I mean, are they going to do more scans or like they have to do something? No, one's giving up.

We're all still, you know, on your side. We're all doing our best. We just wanted to give you the update and make sure that we're on the same page. Okay. As long as no one's giving up. Time out. How is that different? Okay. Better, I, I think I said, I know something, something that approaches of that, but other than that, I think she was able to, to hear me better and I was able to hear her.

Yeah, I think you really tuned into that, that fear of the medical team giving up and that's something that we. We see a lot and we deal with a lot. And so you were able to give a really good support statement. And, and then she didn't feel so alone anymore. I agree. You de escalated. the situation again and you

avoided the trap of answering all of her questions about, well, why don't we transfer?

Who else can we call? What about the swelling? You didn't go down those rabbit holes and you, I think, accomplished more by addressing this emotional response and, and being able to get her back to this place where now you can move forward in the conversation. It's very tempting to answer all those questions.

I feel like that's how I can be helpful As my usual mode is providing information and support that way. So it's hard to walk back from that. And also in my brain to deescalate my own emotion of having anger directed towards me. What do I do? Yeah, I think you really hit the nail on the head there, that we do feel more comfortable in this space of telling the data that we're comfortable with, that we're confident in.

And being in this space with patients is a lot harder because we don't get trained how to do it and we don't have to do it as often.

Great. Now that we're done with the role play, would you guys mind introducing yourselves? Hi, I'm Grace Pak. I'm a general surgery resident at Madigan Army Medical Center.

And I'm Diana Trotter. I'm a Seattle actor and acting coach. Well, thank you both again for helping us illustrate these skills. To recap, start by assessing, then use a headline statement to give a medical update and what that information means. Throughout the conversation, be ready for a range of emotional responses and use empathic statements to give their brain a chance to process before moving on to more information.

And remember, just like with other technical skills, practice makes perfect when it comes to applying these communication skills. You can go to vitaltalk. org for more information about crafting a headline statement and using nurse statements to respond to emotion. And until next time, dominate the day.