1 Goals of Care Conversations – Part 1 Reframing: We’re in a Different Place FACILITATOR NOTES: Before the Training •Familiarize yourself with the content and flow of your session / run through your complete slide deck •Practice for timing and transitions •Have hand-outs ready for distribution •Have white board (or flip chart) and markers available •Test your access to the slides and video functionality in advance •Arrive at the room early When You Arrive •Watch the time: Make sure you have a clock in your line of vision that displays time visibly •Arrange the room: If you have a large room and few attendees, ask people to move to the front •Keep in mind: •Speak up - make sure the whole room can hear •Look up - keep focus on the audience; not your notes Get Started •Introduce yourself •Base your introduction on the one you created and refined in the VA Facilitator preparation training •State the vision and purpose of this training initiative, and how this training relates •Tell a short (3-4 sentence) personal story about the challenges of discussing goals of care, what you’ve learned, and why this motivates you to train others Reframing Module • Reframing: We’re in a Different Place Serious Illness Communication Skills Training •Delivering Serious News • •Conducting Goals of Care Conversations •Part 1 - Reframing: We’re in a Different Place •Part 2 - Mapping the Future: Clarifying Priorities •Part 3 - Aligning with Patient Values •Part 4 - Discussing Life-Sustaining Treatments FACILITATOR NOTES: “Today’s session is the first in a series designed to teach the skills required to conduct a goals of care conversation with high-risk patients and their families.” •Setting •Perception •Invitation •Knowledge •Empathize §Name §Acknowledge •Summarize/Strategize • Review: Delivering Serious News * SPIKES FACILITATOR NOTES: “Now we’re going to review what we discussed at the last session.” Ask the group to walk through the acronym, call out each step before putting it on the screen, and ask for examples of how this skill is done. This is an opportunity to use “call and response.” For example, after going through the E – Empathize, you could make an emotional statement that a patient might say (e.g., “You’re telling me I have cancer?!!”) while looking at someone in the group and encourage them to give an appropriate naming or acknowledging response. Since Last Time, Have You Delivered Serious News? üWhat went well? üAny challenges? FACILITATOR NOTES: •Lead a discussion about what the participants have put into practice since the last session. •“Thinking back over your clinical experiences since the last Module, have you had a chance to try these skills?” Ask: 1.What went well? (Explore this with participants – encourage them to tell the stories of how any of these tools have made conversations easier.) 2.Where did they got stuck? (Explore the stuck places participants have encountered and help them deconstruct where the challenges lie. It will usually be about addressing the emotion, instead of the facts.) 3.What was most surprising? Stay positive! Goals of Care: What Makes these Conversations Tough? üUncertainty üEmotions üAnd … the lack of a framework within which to enter the conversation FACILITATOR NOTES: Start the discussion by asking the group the question “What makes Goals of Care conversations hard?” Elicit stories from the group. Then, click through to the bullets and describe these issues: •Expectations of patients, families and clinicians – these may be very different and are often not explicitly discussed •Care has been focused on extending lifespan •Change in goals may seem like a failure •Uncertainty is difficult – we often don’t know what to expect and we have to make decisions in the face of uncertainty. All people manage uncertainty differently, and many people don’t do well with it. •Emotion – every discussion about goals of care is laden with emotion. Clinicians need to recognize and respond to it. •Most clinicians do not enter goals of care discussions with a clear idea of how to get from “here to there,” or a “start-middle-end.” What We Will Learn REMAP: A Talking Map for Goals of Care Conversations What We Will Learn FACILITATOR NOTES: One of the hard parts about any difficult conversation is not knowing how to get from “here” to “there.” We will provide you with a step-by-step “Talking Map” that provides you a guide to discuss goals of care. REMAP is a step-by-step approach to discussing goals of care How We Will Learn üDefine skills (lecture) üObserve skills in action (videos) üPractice (drills) FACILITATOR NOTES: This session will take less than an hour (MAKE SURE TO FINISH ON TIME!) We will start with brief “mini-lecture” in which I define and outline the skills that we’ll learn. I’ll then show you some videos that give you examples of what these look like in action. However, learning communication is like learning to improve at a sport, or a musical instrument. You only get better with practice and we’ll have a chance to do that, in a very easy and not-scary way. * Reframe * Expect emotion * Map out what’s important * Align with patient values * Plan treatment to match patient values • REMAP: Discussing Goals of Care box around R and E FACILITATOR NOTES: REMAP is a 5 step talking map for goals of care conversations. (Click for rectangle) Today, we will only work on the first two steps — Reframe and Expect emotion • * “Would it be ok if I talk to you about what lies ahead with your illness?” * “Today, I wonder if we can talk about how things are going with your medical problems?” • REMAP: Introducing the conversation FACILITATOR NOTES: It can be hard to know how to start a goals of care conversation. •Keep it brief •Use simple, jargon free language to introduce the conversation •Asking permission to talk about what lies ahead can make the patient feel prepared for the discussion • * “What is your understanding of your illness?” * If pt doesn’t have a clear understanding: “We’re in a different place than we were [X] months ago” * If pt has a clear understanding: “Given where you are in your illness, it seems like a good time to talk about where to go from here” REMAP: Reframe FACILITATOR NOTES: A key learning point for this module is that: •One cannot discuss goals of care with a patient without first being sure they understand their medical situation, and have processed the emotional reaction to that. •Here are a couple of statements that can be used to transition the patient from their understanding of the news, to a discussion about goals. •Some patients will have a clear understanding of where they are in their illness, others may not and will need a serious news discussion before moving on to talking about goals of care. * Most patients will have an emotional response to hearing the reframe. This is normal. * The emotional response may sound like a factual question: •“Isn’t there something else you can do?” •“Are you sure we’ve looked into everything?” • REMAP: Expect Emotion FACILITATOR NOTES: A key learning point here is that many emotional reactions are delivered as statements or questions. The clinician must read the language and the affect carefully and err on the side of giving an empathic response. Even if a patient has a clear perception of their illness – many patients often display emotion when discussing how serious their illness is. This still needs to be attended to before moving the conversation forward. * Respond to emotion with empathic statements * Even if the patient is asking a question * Use “Name” and “Acknowledge” * • REMAP: Expect Emotion (Responding) FACILITATOR NOTES: This slide is a reminder of responding to emotion which was covered in the Delivering Serious News module. * * “I can see that you are really concerned” * * * “I get a sense that this is not what you were expecting to hear today” * * * Ask permission before moving on –“Is it OK for us to talk about what this means?” REMAP: Expect Emotion (examples) FACILITATOR NOTES: The first two bullets are reminder examples of words you can use when naming and acknowledging emotion. The last bullet point is an example of asking permission as a transition for moving the conversation forward. It is important to note that this step should only be used AFTER the emotion has been attended to. REMAP: Reframe and Expect Emotion Video explaining expecting emotion FACILITATOR NOTES: Set up the video carefully: •“Here is an example of a doctor responding to a patient’s question of ‘Is there anything more?’ using reframing.” After the video, move to the next slide. What specifically did the doctor do that you liked? FACILITATOR NOTES: After the video, turn to the audience and ask: •What specifically did the doctor do that you liked? Or… •What did the doctor say? Make sure that they catch all the things that happen here: •Rather than responding immediately to the question, the doctor probes for more about the emotions that are driving the question: “Can you tell me more about what you’re thinking?” •Doctor uses an, “I wish” statement to align with the patient when she expresses the desire to pursue more treatments that wouldn’t be helpful. You may also want to ask: What was the effect of what the doctor said on the patient? Time to Practice!! FACILITATOR NOTES: Tell the group: “Now that you’ve heard and seen what these skills look like, let’s practice them.” Ask the group, “How do athletes or musicians practice?” Facilitate the responses, and then (if they haven’t gotten there on their own), talk about drills. Something like, “Even the world’s best athletes or musicians do drills every day. Basketball players practice shot after shot and pass after pass. Professional musicians play 30-60 minutes of scales every day – even though they know them by heart. Drills build and retain muscle memory, and also allow us to learn new things.” We’re going to practice using the words we’ve been talking about, and we’re going to make it really easy for you by giving you exact words to say. It may seem easy, or even silly, but it’s just like a great basketball player practicing layups” (or choose another similar analogy that you’re comfortable with). Drill Instructions * Review drill as a group * Divide into pairs to practice the drill * Practice the drill script (person with bigger feet is the clinician first) * Switch roles * Debrief with one another: –How did it feel to say the words? –One thing clinician noticed –One thing patient noticed • – – – * Drill Instructions FACILITATOR NOTES: Walk the group through the drill instructions. At the end, ask if there are any questions and make sure there is complete clarity in the room about how to do this. Ask the group to divide into pairs. Read the first two drills out loud – or, better yet – have two learners in the audience read them out loud for you using the slides. Then, have the people that just demonstrated, switch roles and do the two drills again. Then, explain that after these two drills, you’ll debrief. Hand out the drill sheets and have the pairs practice together using their drill sheets, reminding them to switch roles after they complete one round. Drill A: Reframe Patient Clinician Drill A: Reframe clinician icon Icon Patient I’m not getting better with this treatment , but there’s got to be something else out there. Tell me what you understand about your illness. I wish we had a more effective treatment. Clinician icon patient icon FACILITATOR NOTES: These first two drills are for the Reframe piece of REMAP. Read the drill out loud. Or, better yet, ask two people in the group to read it out loud for the group. I know I’ve got COPD, and my breathing has gotten worse over the last several weeks. But I’ve had this for quite a while, and it will probably get better…” What is your sense of where things are? You have been living with this disease a long time. And, I think we’re in a different place now. Patient Clinician Clinician icon patient icon Drill A: Reframe Drill A: Reframe • • FACILITATOR NOTES: Either read or have the two learners read out loud this drill as well. What is your sense of where things are? This must be hard. I hear that. Is it ok if we talk about where we can go from here? Patient Clinician Clinician icon patient icon Drill A: Expect Emotion I know I’m getting worse. I’m afraid I’m just a burden on my kids. It is. There is a lot happening. Drill A: Expect Emotion • • FACILITATOR NOTES: Either read or have the two learners read out loud this drill as well. Drill: Swap Roles Patient Clinician Clinician icon patient icon FACILITATOR NOTES: Ask them to switch roles and show again. Then hand out the drill sheets. When done demonstrating the drill…..go back to slide 18 (drill instructions) and ask everyone to do the two drills in their groups of two. Walk around the room and observe how they are doing, and when it looks like everyone has completed both drills, call for the switch. Drill: Debrief – * How did it feel to say the words? * One thing clinician noticed * One thing patient noticed * Drill: Debrief FACILITATOR NOTES: Ask each of the dyads to answer these questions just to each other. Give them 2-3 minutes to run through this exercise. Drill B: Expect Emotion So, what are you saying – that I’m supposed to give up? You have been living with this disease a long time. And, I think we’re in a different place now. I can’t even imagine what it’s like for you to live with an illness that keeps getting worse. Patient Clinician Clinician icon patient icon FACILITATOR NOTES: Now demonstrate the next three drills by reading them out loud, or having two learners read them out loud. The drills are for responding to emotion, the E of REMAP. I’m a fighter. I know I can still beat this thing. It’s probably a good time to step back and talk about where we go from here. I really admire your spirit and everything you’ve done to fight this illness. Patient Clinician Clinician icon patient icon Drill B: Expect Emotion FACILITATOR NOTES: Either read or have the two learners read out loud this drill as well. I’ve just kept hoping that the treatments would work. I can see how disappointing this is for you. I was hopeful too… Would it be all right if we talked about where we go from here? Patient Clinician Clinician icon patient icon Drill B: Moving Forward Drill B: Moving Forward • • • FACILITATOR NOTES: Either read or have the two learners read out loud this drill as well. Patient Clinician Clinician icon patient icon Drill: Swap Roles Drill: Swap Roles • • • FACILITATOR NOTES: Ask them to switch roles and show again. Then hand out the drill sheets. When done demonstrating the drill…..go back to slide 18 (drill instructions) and ask everyone to do the two drills in their groups of two. Walk around the room and observe how they are doing, and when it looks like everyone has completed both drills, call for the switch. Drill: Debrief – * How did it feel to say the words? * One thing clinician noticed * One thing patient noticed * Drill: Debrief Drill: Debrief FACILITATOR NOTES: Ask them to talk with their partners and answer the three questions: 1.How did it feel to say the words? 2.One thing the clinician noticed 3.One thing the patient noticed Then lead a group discussion about their reactions to practicing these words. What surprised you? What do you want to take forward? Anywhere you might get stuck? FACILITATOR NOTES: This is the debrief where deeper learning takes place. Ask everyone to write about each of these questions for 1-2 minutes. Then, lead a group discussion asking people to volunteer something they wrote in response to one of these questions. * REMAP: a talking map for goals of care conversations –Reframe –Expect Emotion * * What’s one thing you’re going to try this week? Summary FACILITATOR NOTES: Summarize very quickly and then ask everyone to write down on a piece of paper the one thing they’re going to try out this week, and keep that paper in their wallet/purse/pocket. Then thank the group, express appreciation for their willingness to practice and engage, and close the session. Goals of Care Conversations • •Goals of Care Conversations training materials were developed and made available for public use through U.S. Department of Veterans Affairs contracts with VitalTalk •[Orders VA777-14-P-0400 and VA777-16-C-0015]. • • National Center for Ethics in Health Care logo