2. COMFORT* Communication (narrative) Orientation and opportunity Mindful presence Family Openings Relating Team * Wittenberg-Lyles, E., Goldsmith, J., Ferrell, B., & Ragan, S. (2012). Communication and palliative nursing. New York: Oxford.

3. Objectives Understand the duality of task and relational communication Discover foundations of narrative clinical practice Learn to practice person-centered messages

4. Task Communication The content of the message Teaching - confirm and explain bad news Advocating - share information with healthcare team (Price, et al., 2006; Radziewicz & Baile, 2001) Coordinating - mobilize needed resources (Pavlish & Ceronsky, 2009)

5. Relational Communication The relationship between the people as conveyed by the message Caring - provide patient/family support Sharing - emotional reactions and providing opportunities to process the bad news (Warnock, et al., 2010)

6. Narrative Nursing Being with and relating to others while honoring their voice & lived experience Bearing Witness: 1.Recognize individuality 2.Understand life prior to illness 3.Refocus beyond medical information Kendall, 2007; Hess, 2003

7. Recognize Individuality Deconstruction Active listening Use adjectives to describe patient uniqueness to others Your Role: Listen for vulnerabilities/uniqueness Identify story structure – Who are the main people involved?

8. Recognizing Individuality Tell me about times when you arent thinking about illness/your loved ones disease. How would you describe this illness/the shared experience of illness? Is there anything else that could explain your/his/her illness? Im wondering if there is more to this than meets the eye. Who else is involved in your/his/her illness?

9. Understand Life Prior to Illness Externalization Solicit/employ information – Encourage reflection – Incorporate psychosocial history in diagnostic assessment Your Role: Encourage sharing to identify and address feelings Adopt multiple perspectives – What are the relationships between the people involved?

10. Understanding life prior to illness How has your illness (or his/her illness) affected your life and your relationships? How do you think ignoring this will affect your life? How does your illness (or his/her illness) reflect on you as a person? How do you see the future? How are you affected by others opinions? What do you think influences this experience?

11. Go Beyond Medical Facts Re-authoring Help revise and widen narrative lens beyond illness Solicit history to understand illness Help patient/family understand and accept current circumstances Your Role: Consider the mental health of patient/family member Creative skills (What solutions can be drawn?) Tolerate uncertainty as you listen to the story

12. Going beyond medical facts What people in your life are supporting you? What do you think needs to happen in order for you to be able to care for your loved one/yourself? What needs to change? What does your success in solving problems related to care say about your abilities? How is this experience affecting your life?

13. Person-Centered Messages (PCM)* Speaking in a supportive way to validate and affirm patient/family Support is conveyed with clear language – Be realistic, yet supportive – Focus on the patients feelings *Burleson, 1994

14. Practicing Person-Centered Messages Explicitly recognize and acknowledge the patient/familys feelings but does not elaborate on those feelings. Provide an elaborated acknowledgement and explanation of the patient/familys feelings Help the patient/family to gain a perspective on his or her feelings

15. Person-centered messages From the following, choose the most person- centered message: (a) I can see why you are upset. Thats a normal reaction. (b) Im so sorry this has happened. Did you think this was coming? (c) Lets talk about your treatment from this point forward. Can I see you tomorrow?

16. Examining person-centered messages (a) I can see why you are upset. Thats a normal reaction. (b) Im so sorry this has happened. Did you think this was coming? (c) Lets talk about your treatment from this point forward. Can I see you tomorrow?

17. When discussing bad news… Clearly explain prognosis, elaborate Respond to impact on life Show clear respect for feelings Integrate life/work into decision-making Address pain, family role in care Plan, present team structure, hospice/Advance directives (if appropriate)

18. The unique role of the nurse Presence before, during, and after bad news Vulnerable to questions from patient/family – provide supplemental information – assess information needs – clarify misunderstanding – educate Your role is to validate bad news to aid in patient/family acceptance.

19. Challenges for the nurse Physician assumptions about your role, knowledge Not being present for bad news delivery Not knowing all of the patient/family information when confronted Ambiguity about your role on the team and appropriate communication topics to discuss

20. Breaking Bad News Scenarios for the Nurse Over the phone I know this is not ideal, but I can talk to you now over the phone about your health and we can meet together tomorrow to talk more. Nurse not present during bad news disclosure Since I was not here for the news, can you tell me how the conversation with the team went? [response]. Now, as I listened to you these are the questions I think you still have [relay concerns], is that right?