Transcript Clinical Review

Clinical Review for the
Hospice and Palliative
Nursing Assistant
Communicating with
Veterans at the End of Life
1
Objectives
2
1. Define the concept of communication
2. Discuss the impact of cultural
differences military service, age, and
gender on communication
3. Identify methods of therapeutic
communication with Veterans and their
family
4. Discuss how to deal with conflict
successfully
Basic Concepts of
Communication



Sending and receiving
Verbal communication
Non-verbal communication





3
Physical appearance
Actions
Face person
Silence1
Presence
Setting the Environment




4
Make sure listener can see you
Be at their level
Quiet, private place
Vision or hearing problems
Listening2-4





5
Receiving, paying attention to, and
making meaning
Active process
Stop talking
Take time
Nonverbal communication
Speaking






6
Introduce yourself
Speak slowly, clearly, and unhurriedly
Use familiar words and simple
sentences
Avoid distracting behaviors
Repeat ideas if necessary
Your nonverbal communication
Written Materials



7
Information to refer to later
Talk directly to the reader
Be sensitive to the cultural
Cultural Differences




8
Communication rules
Communication style
Expressiveness of communication styles
Meaning of words
Cultural Differences




9
Expectations
How is death discussed
Avoiding stereotyping
Medical interpreters
Veteran Culture

Numbers of Veterans5



10
1 in 4 Americans who die each year are
Veterans
Common bond of military service to
their country
Warrior culture6
Veteran Culture



11
Stoicism6
Effects of combat6
Honor Veterans
WWII Veterans6





12
U.S. involvement – December 7, 1941
to December 31, 1945
Proud of their legacy at the end of life
Glamorized war
Segregation
Service related complications
Cold War Veterans6


End of WWII to mid 1990s
Exposed to radiation




Korean Conflict – June 27, 1950,
through January 31, 1955


13
Risk for leukemia and cancer
Mistrust of government
VAs Ionizing Radiation Program
The forgotten war
Cold sensitivity
Vietnam War Veterans6




February 28, 1961 through May 7, 1975
Mistrust and uncertainty
Better battlefield care
Hypervigilance




14
PTSD
Agent Orange exposure
Mistreated when returned
End-of-life
Gulf War Veterans6



August 2, 1990 through 1991
Exposure to environmental toxins
Gulf War Syndrome



15
Non-specific symptoms though disabling
Memory loss
Generally not feeling well
OEF/OIF Veterans6


Operation Enduring Freedom
(OEF)/Operation Iraqi Freedom (OIF)
Veterans – 2001Psychological and physical toll



16
Depression is on the rise
Traumatic brain injury (TBI)
Multiple disabilities
Veteran Differences in
Communication6





17
Strong survival response
See death as the enemy
Combat veterans
PTSD
Build trust
Gender Differences



18
Men and women have different styles
Older women may defer to a male to
make decisions or talking about
concerns
Older female Veterans
Influence Of Age




19
Children
Cultures
First address the older adult by formal
name
Hearing or eyesight loss
Identifying Communication
Styles





20
Identify your own communication style4
Differences in communication styles
If conflicts arise, seek assistance from
the team
Avoid labeling
We all have different ways of
expressing ourselves
Special Communication Issues
in Working with the Dying


Effective communication is key
Challenges





21
Cultural and societal issues
Experience with death
Fears, emotions, and knowledge
Concerns of the care provider
Difficulties with communicating
Common Patient and Family
Fears and Emotions



22
Fear
Anger
Guilt
Common Patient and Family
Fears and Emotions



23
Sadness
Confusion
Hopelessness/helplessness
Therapeutic Communication



24
Saying the “RIGHT” thing
Telling their story
It’s okay to say “I don’t know”
Important Messages to
Communicate





25
“I will listen to you.”
“I will be honest and truthful with you.”
“I will not abandon you.”
“I value you as a person.”
“I will respect your values and goals
and help you to achieve those goals as
much as I am able.”
Important Messages to
Communicate

Ira Byock7






26
I love you
Thank you
I forgive you
Please forgive me
Goodbye
Maintain a good match between verbal
and nonverbal messages
Timing for end-of-life
Communication





27
Physical
When does the person want to talk?
Pain-free opportunities to talk
Teachable moments
Do not rush conversations
Asking Questions






28
Nursing assistant’s scope of practice
Limited energy
Focus questions
Show interest
Respect privacy
Sensitive questions
Providing Hope Without False
Assurances8



29
Maintaining hope
Seek direction from team
Hope is many things
Ways to Support Patients’ and
Families’ Hope




30
Ask about goals
Help to meet their goals
Be present
Show respect
Patients’ Communication
Needs at End of Life9




31
Reminiscing
Use of symbols
Near death awareness
Settling relationships and apologizing
for past actions
Supporting Patients & Families
in Terminal Illness




32
Importance of open communication at
end of life
Formal and informal education
Role modeling
Written materials
Dealing With Conflict4



33
Family conflicts
There are many sides to every situation
Conflict directed at other family
members
Dealing With Anger
Directed At You





34
Tips for managing responses2
Emotional step back
Think about your emotions
Talk with other team members about
how you are feeling
Use “I” statements
Communicating with Angry
or Distressed People3





35
Respect
Answer questions clearly
Stay calm
Recognize emotions
Tips for communicating with someone
who is angry or distressed
Working and Communicating
with the Healthcare Team3





36
Everyone has something to offer
Each team member’s skills
Identify ways to show respect
Respect differences
Entire team is there to help people
Working in a Team

Role definition





37
What does each person on the team do?
How can we best work together?
Role expectations
Appropriate boundaries
Maintain flexibility
Working in a Team

Collaboration






38
Encourage sharing
Patient and family are a part of the team
Valued all roles
All team members contribute
Assigned tasks
Goals of care
End-of-life Staff Stresses8

Sources of stress






39
Your own grief
Personal comfort level with dying
Feelings of helplessness
Sense that others do not care as you do
Lack of time
Accept that stress exists
Manifestations of Stress





40
Physical distress and fatigue
Feeling irritable
Emotional withdrawal
Trouble with personal relationships
Starting to feel like you are the only one
who can give good care
Job Related Stress







41
Everyone on the team needs each other
Balance in personal life
Take care of personal relationships
Rest, nutritious meals, physical exercise
Emotional and spiritual needs
Strong support system
“Even Superman is Clark Kent most of
the time!”
References
1.
2.
3.
4.
5.
42
Bednash G, Ferrell BR. End-of-Life Nursing Education Consortium
(ELNEC - Geriatric). Washington, DC: Association of Colleges of
Nursing; 2007.
Fallowfield L. Communication in palliative care: A practical guide. In:
Doyle D HG, MacDonald N, eds. Oxford Textbook of Palliative
Medicine. 2nd ed. Oxford: Oxford University Press; 2005: 101-112.
Sorrentino S, Gorek B. Communicating with the resident. Mosby's
Textbook for Long-Term Care Assistants. St. Louis: Mosby; 1999: 7892
Richards M. Communication at the end-of-life. Palliative Care
Resource Education Team (PERT) curriculum. Seattle (WA): Swedish
Medical Center; 2002.
National Center for Veteran Analysis and Statistics. Washington, DC:
U.S. Department of Veteran Affairs; 2010. Available at
http://www1.va.gov/vetdata/. Accessed March 11, 2010.
References
6.
7.
8.
9.
43
Grassman DL. Peace at Last: Stories of Hope and Healing for
Veterans and their Families. St. Petersburg, FL: Vanamere
Press; 2009.
Byock I. Dying well: The prospects for growth at the end of
life. New York: Riverhead Books; 1997.
Ersek M. The meaning of hope in the dying. In: Ferrell BR,
Coyle N, eds. Textbook of Palliative Nursing. 2nd ed. New
York, NY: Oxford University Press; 2006: 513-529.
Callanan M, Kelley P. Final gifts: Understanding the special
awareness, needs, & communications of the dying. New York,
NY: Bantam Books; 1992.