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Goals of Care Conversations Training Reframing: Were in a Different Place

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ii Reframing: Were in a Different Place

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Goals of Care Conversations: A Five Part Series 1Delivering Serious News 2Reframing: Were in a Different Place 3Mapping the Future: Clarifying Priorities 4Aligning with Patient Values 5Conducting a Family Meeting

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Setting Perception Invitation Knowledge Empathize Name Acknowledge Summarize/Strategize Review: Delivering Serious News SPIKES

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Since Last Time, Have You Delivered Serious News? What went well? Any challenges?

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Goals of Care: What Makes these Conversations Tough? Expectations Uncertainty Emotions And the lack of a framework within which to enter the conversation

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What We Will Learn REMAP: A Talking Map for Goals of Care Conversations

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How We Will Learn Define skills (lecture) Observe skills in action (videos) Practice (drills)

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Reframe Expect emotion Map out whats important Align with patient values Plan treatment to match patient values REMAP: Discussing Goals of Care

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The message: you have an illness that could get worse in the coming days/weeks/months - we need to think about the future Bad news needs to be processed BEFORE moving on to decision-making Goals of care should not be discussed at the same time as really serious news REMAP: Reframe

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Given where you are in your illness, it seems like a good time to talk about where to go from here Were in a different place than we were [X] months ago worse REMAP: Reframe (examples)

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Most patients will have an emotional response to hearing the reframe. This is normal. The emotional response might sound like a factual question: Isnt there something else you can do? Are you sure weve looked into everything? REMAP: Expect Emotion

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Respond to emotion with empathic statements Even if the patient is asking a question Use Name and Acknowledge Ask permission before moving on REMAP: Expect Emotion (Responding)

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I can see that you are really concerned I get a sense that this is not what you were expecting to hear today Is it OK for us to talk about what this means? Ask permission before moving on REMAP: Expect Emotion (examples)

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REMAP: Reframe and Expect Emotion

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What did you see?

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Time to Practice!!

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Review drill as a group Divide into pairs to practice the drill Practice the drill script (person with bigger feet goes first) Switch roles Debrief with one another: How did it feel to speak the clinician role One thing clinician role noticed while doing this One thing patient role noticed about clinicians delivery Drill Instructions

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Drill: Reframe ClinicianPatient Im not getting better with this treatment, but theres got to be something else out there. (Improvise) Tell me what you understand about your illness I wish we had a more effective treatment

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Drill: Swap Roles PatientClinician

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How did it feel to say the words? One thing clinician noticed One thing patient noticed Drill: Debrief

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Drill: Reframe 2 ClinicianPatient I know Ive got COPD, and my breathing has gotten worse over the last several weeks. But Ive had this for quite a while, and it will probably get better (Improvise) What is your sense of where things are? You have been living with this disease a long time. And, I think were in a different place now.

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Drill: Expect Emotion PatientClinician I cant even imagine what its like for you to be hearing this. So, what are you saying that Im supposed to give up? (Improvise)

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Drill: Expect Emotion 2 ClinicianPatient Im a fighter. I know I can still beat this thing. (Improvise) Its probably a good time to step back and talk about where we go from here. I really admire your spirit and everything youve done to keep on living despite your illness

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Drill: Moving Forward ClinicianPatient Youre right. Ive just kept hoping that the treatments would work. (Improvise) 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?

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How did it feel to say the words? One thing clinician noticed One thing patient noticed Drill: Debrief 2

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Where do you think youll get stuck? What do you want to take forward?

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REMAP: A talking map for goals of care Reframe Expect Emotion Whats one thing youre going to try this week? Summary

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Goals of Care Conversations Goals of Care Conversations training materials were developed and made available for public use through a U. S. Department of Veterans Affairs contract with VitalTalk. [Order VA777-14-P-0400] Materials are available for download from VA National Center for Ethics in Health Care at vaww.ethics.va.gov/goalsofcaretraining.asp.