1. + Faculty prep session October 20, 2009 Beyond the Health Care Proxy: Advance Care Planning for Patients with Serious Illness

2. + Review in this Session Objectives for small group sessions 1 and 2 Behavior Change Model as it applies to physicians and patients approaching advance care planning Principles of reflective listening Use of nominal process

3. + Objectives: Small group 1 This is session is devoted to developing personal awareness around the issue of ACP and by its conclusion, participants: will be able to describe circumstances under which they have personally found ACP discussions challenging, and will, with the help of colleagues, revisit and reframe these challenges

4. + Objectives Small Group 2 This small group session is devoted to skills practice, and by its conclusion, participants: will be able to describe an 8 step protocol * useful in guiding advance care directive conversations will know, and be more comfortable using, phrases that can operationalize those steps in guiding the patient and/or family through this decision making process will be able to identify prognostic clues in a patient’s clinical presentation

5. + Behavior Change Behavior change is the foundational principle underlying both small group sessions, and it applies equally to: what motivates physicians to change their behavior relative to ACP what motivates patients to engage in ACP

6. + Our tasks As clinicians identify our patient’s readiness to change (in this case, to engage in ACP) use what tools and interventions are stage appropriate to help them to move forward As educators help our learners’ to identify their impediments to moving forward with ACP help them develop the personal awareness and skills that will enable them to move forward

7. + Stages of change Precontemplation Not yet acknowledging that there is a need for ACP or that they are seriously ill; not interested in discussing, see no need, are in “denial” Contemplation Acknowledging that they may indeed by seriously ill, but ambivalent, on a teeter-totter, but not yet ready or sure of what might be the right choices to make; may be more receptive to discussion Preparation/Determination Getting ready to change; active gathering of information, trying to decide what is best Action Actively making decisions; open to support, help, guidance from others Maintenance, Relapse,Transcendence

8. + Listening and Thinking Reflectively Thinking reflectively is inherently part of good reflective listening and includes  interest in what the person has to say respect for the person's inner wisdom key element is a hypothesis testing, using phrases like “So you feel...” “It sounds like you...” “You're wondering if...”

9. + Levels of Reflective Listening and Responding Repeating or rephrasing – listener repeats or substitutes synonyms or phrases; stays close to what the speaker has said Paraphrasing – listener makes a major restatement in which the speaker’s meaning is inferred Reflection of feeling – listener emphasizes emotional aspects of communication through feeling statements – deepest form of listening

10. + Nominal Process Allows everyone present to contribute to discussion Levels the playing field Enables those who are quiet and have difficulty “getting in” or “finding a place at the table” to have space and time automatically allotted to them Facilitator starts discussion by inviting the most junior, youngest, or newest person to speak first, moving through the group by age/experience etc, to the last person

11. + Nominal Process In nominal process, there is no discussion of ideas to begin with. Participants are asked to contribute a single idea or thought as concisely as possible. The facilitator turns to each participant and continues to do that until all ideas have been solicited. Only then does discussion begin. This is useful in groups of 6 or more, or even in a smaller group if you know, or discover, there is someone who does all the work for the entire group, of if you have one person who dominates discussion. You may, or may not, choose to use this technique

12. + In your small groups, please do  Help participants to identify key phrases in patient discussion that represent  Clues to assessing readiness stage  Opportunities to move readiness to another level