Delivering Bad NewsDelivering Bad NewsMom never said that it would be Mom never said that it would be

like thislike this

A fantasyA fantasyOnce upon a time, there were two families who lived next door to Once upon a time, there were two families who lived next door to

each other. At 110 First Avenue, lived Bob and Barbara Bluster each other. At 110 First Avenue, lived Bob and Barbara Bluster and their two children, Morgan and Fran. At 112 First Avenue and their two children, Morgan and Fran. At 112 First Avenue lived Larry and Lori Luster, their son Henry, Larry’s mother, lived Larry and Lori Luster, their son Henry, Larry’s mother, Sadie and Sadie’s beloved cat Fabula. Bob and Larry had been Sadie and Sadie’s beloved cat Fabula. Bob and Larry had been friends since college. They married classmates. Each friends since college. They married classmates. Each frequently asked each other to take care of their homes while frequently asked each other to take care of their homes while they would go on vacations. they would go on vacations.

As happens with long-term friendships and families, over the As happens with long-term friendships and families, over the years they had grown to tolerate each other’s annoying habits. years they had grown to tolerate each other’s annoying habits. Bob had a very blunt and direct way of giving bad news. Larry, Bob had a very blunt and direct way of giving bad news. Larry, on the other hand, preferred, in his words, to “sugar” it up a bit. on the other hand, preferred, in his words, to “sugar” it up a bit. Fortunately, this difference had never been tested until this Fortunately, this difference had never been tested until this day.day.

A fantasy (continued)A fantasy (continued)Larry, Lori, Ruth and Henry were going on their annual vacation. Originally Larry, Lori, Ruth and Henry were going on their annual vacation. Originally

Sadie was going to go as well, but she developed a cold the night before Sadie was going to go as well, but she developed a cold the night before the family was to leave and was unable to go with them. So, Larry asked the family was to leave and was unable to go with them. So, Larry asked Bob to keep an eye on “my mom” and Fabula while they were gone. Bob to keep an eye on “my mom” and Fabula while they were gone. Bob said, “Sure thing.”Bob said, “Sure thing.”

Three days after Larry and his family arrived at their destination, Larry Three days after Larry and his family arrived at their destination, Larry called Bob to see how things were going. “How’s Fabula?” Larry called Bob to see how things were going. “How’s Fabula?” Larry asked. “She died.” “What! How can you say that. That’s terrible. What asked. “She died.” “What! How can you say that. That’s terrible. What happened?” Bob proceeded to explain that the cat had crawled out an happened?” Bob proceeded to explain that the cat had crawled out an open window in Sadie’s room, tried to jump to the tree next to the house, open window in Sadie’s room, tried to jump to the tree next to the house, couldn’t grab on to the tree because she had been declawed, and fell to couldn’t grab on to the tree because she had been declawed, and fell to her death. Larry was furious at Bob because he was so blunt. “Bob, her death. Larry was furious at Bob because he was so blunt. “Bob, why couldn’t you give it to me gently. You know, tell me about the tree why couldn’t you give it to me gently. You know, tell me about the tree next to the house, the window being open and the cat getting out and next to the house, the window being open and the cat getting out and my mom called the fire department and they came and they couldn’t my mom called the fire department and they came and they couldn’t save Fabula. Why must you always be so darn blunt!” Well, tell me how save Fabula. Why must you always be so darn blunt!” Well, tell me how did my mom take it?” After a long silence, Bob says, “Well Larry, you did my mom take it?” After a long silence, Bob says, “Well Larry, you know the tree next to the house, the window was open . . . .”know the tree next to the house, the window was open . . . .”

Bad newsBad news

Bad news: telling others you don’t want to tell them Bad news: telling others you don’t want to tell them about something they don’t want to hearabout something they don’t want to hear

• In the Bob and Larry story, there are two In the Bob and Larry story, there are two choices: both are not always appropriatechoices: both are not always appropriate

• Where to get guidance: from survey procedures; Where to get guidance: from survey procedures; and from psychologyand from psychology

• We’ll be spending time today on both, more on We’ll be spending time today on both, more on the psychology of giving bad news.the psychology of giving bad news.

What do S&C Procedures have What do S&C Procedures have to say?to say?

• State Operations Manual State Operations Manual

• Exit ConferenceExit Conference

Hospital, Appendix A Hospital, Appendix A Exit ConferenceExit Conference

• Purpose: “preliminary findings”Purpose: “preliminary findings”

• Team consistency and organization Team consistency and organization

• BoundariesBoundaries– If provider is represented by counsel, may If provider is represented by counsel, may

refuse to conduct the conference if counsel refuse to conduct the conference if counsel tries to turn exit into evidentiary hearingtries to turn exit into evidentiary hearing

– If provider creates an environment that is If provider creates an environment that is hostile, intimidating, or inconsistent with exit hostile, intimidating, or inconsistent with exit as informal and preliminaryas informal and preliminary

Appendix P: Nursing HomesAppendix P: Nursing Homes

Team communication throughout surveyTeam communication throughout survey

Task 7 - Exit ConferenceTask 7 - Exit Conference

Purpose:Purpose: “ “preliminary findings”preliminary findings”

Who: personnel; ombudsman and officer of Who: personnel; ombudsman and officer of resident’s group, if one resident’s group, if one

• Provide opportunity for Provide opportunity for discussion/additional information discussion/additional information

• ““Ongoing dialogue” Ongoing dialogue” rare surprises rare surprises

Appendix M: HospiceAppendix M: Hospice

• Exit conference: to inform the hospice of Exit conference: to inform the hospice of observations and preliminary findings of observations and preliminary findings of the survey. the survey.

• ““ongoing dialogue” ongoing dialogue” rarely surprises rarely surprises Implement the following guidelines during Implement the following guidelines during the conferencethe conference::

Appendix J: Appendix J: ICFs/MRICFs/MR

• Pre-exit: Team discusses findings/make Pre-exit: Team discusses findings/make conclusions, subject to additional conclusions, subject to additional information provided by facility officials information provided by facility officials

• Determine need for more information Determine need for more information

• Ask for and consider additional information Ask for and consider additional information or clarification if necessaryor clarification if necessary

• If, per facility, “acceptable practice,” If, per facility, “acceptable practice,” request supporting referencesrequest supporting references

Summary: survey proceduresSummary: survey procedures

• PreliminaryPreliminary

• Respectful, open to change and to listen Respectful, open to change and to listen for more informationfor more information

• Factual Factual

• Context is informational exchangeContext is informational exchange

• Boundaries are Boundaries are

HHow Can Psychology Help?ow Can Psychology Help?

Cognitive TherapyCognitive Therapy

• What is it?What is it?

• Where did it come from?Where did it come from?

• How does it apply to this task?How does it apply to this task?

BeliefsBeliefsIrrational v RationalIrrational v Rational

What is Cognitive Therapy? What is Cognitive Therapy?

• Thinking Thinking Feeling Feeling Behaving Behaving

Where it came from:Where it came from:

• Research based: Most research based of Research based: Most research based of any therapy any therapy

• Viktor Frankl Viktor Frankl Man’s Search for MeaningMan’s Search for Meaning

• The young girl dying of Typhoid and The young girl dying of Typhoid and CHEERFULCHEERFUL

How Does Cognitive Therapy How Does Cognitive Therapy Apply to giving “Bad News”?Apply to giving “Bad News”?

• Thinking makes it so: Irrational v RationalThinking makes it so: Irrational v Rational

• Irrational thoughts – makes bad news Irrational thoughts – makes bad news worseworse

Distorted BeliefsDistorted Beliefs

• PersonalizationPersonalization (no connection to requirements) (no connection to requirements)• DefensivenessDefensiveness• Entitlement Seeking -- Entitlement Seeking -- “I deserve it”“I deserve it”• PerfectionismPerfectionism – No mistakes – No mistakes• Approval SeekingApproval Seeking• Over-responsibilityOver-responsibility

D. Burns (2000). Feeling Good. NY: D. Burns (2000). Feeling Good. NY: HarperCollins Publishers.HarperCollins Publishers.

Beliefs Beliefs Thoughts Thoughts

Thoughts that get you into troubleThoughts that get you into trouble1.1. All-or-Nothing Thinking. Black and white. All-or-Nothing Thinking. Black and white.

2.2. Overgeneralization. “Always” and “Never” fallacyOvergeneralization. “Always” and “Never” fallacy

3.3. Mental Filter. Facility’s history: in and out of compliance. New Mental Filter. Facility’s history: in and out of compliance. New ownership. Doesn’t matterownership. Doesn’t matter

4.4. Disqualifying the Positive. “My positives don’t count” Disqualifying the Positive. “My positives don’t count”

5.5. Jumping to Conclusions. Jumping to Conclusions.

a.a. Mind reading. You conclude that someone is reacting Mind reading. You conclude that someone is reacting to to you in a negative way, but you don't check it out to see you in a negative way, but you don't check it out to see if if it's true. it's true.

b.b. Fortune Teller Error. Based on observations you Fortune Teller Error. Based on observations you “know” “know” facility is out of compliancefacility is out of compliance

D. BurnsD. Burns

Thoughts that get you into troubleThoughts that get you into trouble6.6. Magnification or Minimization. Either make things way out of Magnification or Minimization. Either make things way out of

proportion or you shrink their importance. Binocular effect. proportion or you shrink their importance. Binocular effect. “Facility isn’t so bad. These are poor people anyway so it’s “Facility isn’t so bad. These are poor people anyway so it’s better than what they have at home.”better than what they have at home.”

7.7. Emotional reasoning. If I feel it, it must be true. “I feel Emotional reasoning. If I feel it, it must be true. “I feel inadequate to the rest of the team, so I must be.” inadequate to the rest of the team, so I must be.”

8.8. Should Statements. You motivate yourself or others with Should Statements. You motivate yourself or others with shoulds and shouldn'ts, or musts and oughts, or wills and shoulds and shouldn'ts, or musts and oughts, or wills and won'ts, that have no basis in law. won'ts, that have no basis in law.

9.9. Labeling. Extreme overgeneralization. “This team member Labeling. Extreme overgeneralization. “This team member is “a loser" is “a loser"

10.10. Personalization. You see yourself as causing some negative Personalization. You see yourself as causing some negative external event, which you have no control over.external event, which you have no control over.

D. BurnsD. Burns

The 3 R’s of Negative LivingThe 3 R’s of Negative Living

The Negative TriadsThe Negative Triads

Resentment Revenge

Resistance

Negative Triads (continued)Negative Triads (continued)

Victim Persecutor

Rescuer

SolutionSolution

• Speak from within your framework – Speak from within your framework – the requirementsthe requirements

• Attack the distorted thoughts with Attack the distorted thoughts with “EVIDENCE” -- Sunshine“EVIDENCE” -- Sunshine

• Examples: Examples: – Personalization: LD: No trace leftPersonalization: LD: No trace left– ““Shoulds”: My should or the Law?Shoulds”: My should or the Law?– Perfectionism: Impossibility Perfectionism: Impossibility

Change Thinking Practice SheetChange Thinking Practice SheetAntecedents or Triggers. Next to the words that come closest to capturing what Antecedents or Triggers. Next to the words that come closest to capturing what

you experienced, put a number from 1 to 10.you experienced, put a number from 1 to 10.• Angry Angry • Anxious Anxious • DepressedDepressed• GuiltyGuilty• Other. Specify __________ Other. Specify __________ • Other. Specify __________ Other. Specify __________ • Other. Specify __________ Other. Specify __________

What were your automatic thoughts? (Thoughts you have without thinking, which What were your automatic thoughts? (Thoughts you have without thinking, which just come into your head)just come into your head)

What distorted thinking was behind each automatic thought? [See previous slide]What distorted thinking was behind each automatic thought? [See previous slide]

What’s the evidence that disclaims your automatic thought? What words do you What’s the evidence that disclaims your automatic thought? What words do you use to talk back to your automatic thought? After talking back, what changes, if use to talk back to your automatic thought? After talking back, what changes, if any, do you see in the feelings you identified above?any, do you see in the feelings you identified above?

Look back at the feelings you rated at the top of this page and rate how you feel Look back at the feelings you rated at the top of this page and rate how you feel now. You should feel at least somewhat better. If you don’t, then repeat the now. You should feel at least somewhat better. If you don’t, then repeat the exercise.exercise.

Change Outwardly: Accurate Change Outwardly: Accurate EmpathyEmpathy

• A skill. You know and express the A skill. You know and express the other person’s thoughts and other person’s thoughts and motivations in such a way that the motivations in such a way that the response is, “Yes, that’s exactly what I response is, “Yes, that’s exactly what I mean.”mean.”

Build Team Build Team

• ConsistencyConsistency

• Practice – who will say whatPractice – who will say what

• CohesivenessCohesiveness

• Comfortable enough to disagreeComfortable enough to disagree

• Recognize the psychological strengths / Recognize the psychological strengths / challenges of each team member and challenges of each team member and emphasize the strengthsemphasize the strengths

Overall SuggestionsOverall Suggestions

• Know the Requirements/ProceduresKnow the Requirements/Procedures• If you survey facilities whose procedures omit If you survey facilities whose procedures omit

exit conference, ask supervisor if your group exit conference, ask supervisor if your group may adapt current procedures: preliminary, may adapt current procedures: preliminary, mutual, respectful, rare surprisesmutual, respectful, rare surprises

• Practice Self-awareness – Know and minimize Practice Self-awareness – Know and minimize distortionsdistortions

• Focus on “fact gathering and presenting” not Focus on “fact gathering and presenting” not friendship formingfriendship forming

• Reinforce your strengths and positives Reinforce your strengths and positives individually and as a teamindividually and as a team