Transcript Decision Assessment and Counseling in Abortion Care: Skills for

SKILLS FOR WORKING WITH
CHALLENGING PATIENT
SCENARIOS
Alissa Perrucci, PhD,
MPH
Wo m e n ’ s O p t i o n s
Center/6G
B i a n n u a l N P / PA / C N M
Professional Practice
Group Conference
October 1 8, 201 2
LEARNING OBJECTIVES
 Describe a new technique for better “listening”
 Articulate a new open-ended question that you can apply in
your conversations with patients
 List one way to “validate” and one way to “normalize” in
conversations with patients
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AT THE WOMEN’S OPTIONS CENTER
 Decision assessment and counseling
 Philosophy of the decision assessment
 Decision conflict
 Decision ambivalence
 The approach and framework is applied across all pregnancy
decision-making issues
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APPROACH
 Listen.
 Do not assume!
 Self-reflect.
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FUNDAMENTAL PRINCIPLE
The patient has the answer
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LISTEN
 Listening means shutting up!
 How do we open conversations with our patients?
 We announce the result, give a medical explanation of the facts,
provide a list of options, and then ask a closed -ended question:
“Would you like to proceed with X or with Y?”
 What if we…
 Announced the result and defined medical terminology
 Gave a brief explanation
 Checked in with the patient
 How are you doing with this information?
 What feelings are coming up for you?
 Validate the feelings that you see and hear
 Let the patient lead
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LISTEN
 Being open to, curious about, fascinated with, and interested
in the patient’s process – but not personally invested in the
outcome (the decision)
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LISTEN
 Asking open-ended questions instead of closed -ended
questions
 When you get the “wrong” answer to a closed -ended question you find
yourself behind the eight ball
 Why not start with an open-ended question?
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OPEN-ENDED QUESTIONS
 What thoughts do you have about what you might do?
 What was it like for you to make the decision to do X?
 What would be good about [choosing option A]? What would
not be good?
 Let’s go back to the moment when [you first got your
diagnosis]. What did you think [feel]?
 Revisiting a past decision without appearing judgmental
 “How’s it been for you since deciding X?”
 “How have you been feeling about proceeding with Y?”
 “What was it like for you at that moment when you chose Z?”
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DO NOT ASSUME
 That you and the patient share the same understanding of
medical terminology, feelings or beliefs
 Remember to define test results – a “positive” result for some
conditions is good and for others is bad
 Your pregnancy test result came back positive – that means you are
pregnant.
 Seek understanding of feelings and beliefs:
 I’d feel guilty if I didn’t choose to have the surgery
 I’ve always been against abortion
 I don’t believe in taking medications
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DO NOT ASSUME
 That you “know best”
 Not assuming means taking a step back from “professional mode.”
You do not have The Answer, nor are you obligated to find it for the
patient.
 “Nurse, what would you do if you were me?”
 Normalize the desire to know
 Validate the desire for an end to the uncertainty
 “You know, a lot of patients have asked me that. It’s okay to wonder what
I would do. Probably right now it seems like it would be helpful to know
what I would do but it would be momentary relief. You have the answer to
what is the best way for you to go. I will be here as your guide.”
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DO NOT ASSUME
 Not assuming means you are free to inquire, investigate, and
learn from the patient
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SELF REFLECT
 What scenarios are hard for me?
 What particular decisions do I want patients to make?
 What decisions do I think are foolish?
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FRAMEWORK
 Level 1: Validate and normalize.
 Level 2: Seek understanding.
 Level 3: Reframe.
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VALIDATE AND NORMALIZE
 Removing shame, stigma, and judgment
 Listening, hearing, and acknowledging
 “The patient is unique, but not alone”
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VALIDATE AND NORMALIZE
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It’s okay to cry here
I can tell that you’re angry
That’s okay; everyone is scared
You know, lots of people have asked me that question
That’s not a strange question at all; I’m so glad you’ve asked
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SEEK UNDERSTANDING
 Witness, hold and survive
 There is no solving here
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SEEK UNDERSTANDING
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Can you say more about that?
What is that like for you?
How do you feel about that?
How’s that been for you?
What’s been going on for you?
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SEEK UNDERSTANDING
 Attend to the exceptional statement
 It may be buried within a litany of congruous statements
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REFRAME
 She is a good person making a moral decision
 As you learn from the patient, you and he discover strengths,
resources and wisdom
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REFRAME
 Reassure the patient that he is a good person no matter what
decision he makes
 Let her know that she is not “wrong” or “bad” if she chooses
one alternative over the other
 Remind the patient that he can change his mind later and
that is okay
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WAYS TO REFRAME
 You are really brave; I’m proud of you
 What you are sharing with me is very intense, and I am
honored to be present with you during this experience
 I see someone who is trying to take care of his family
 What I hear is that you are making this decision because you
care about your child’s well -being
 You are making changes in your life; it’s hard and there have
been set backs, but you are continuing to move forward
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THANK YOU
Alissa Perrucci
Women’s Options Center/Ward 6G
[email protected]
415-206-4027
Decision Assessment and Counseling in Abor tion Care:
Philosophy and Practice ( Rowman & Littlefield, 2012)
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