1. Alissa Perrucci, PhD, MPH Women’s Options Center/6G Biannual NP/PA/CNM Professional Practice Group Conference October 18, 2012 SKILLS FOR WORKING WITH CHALLENGING PATIENT SCENARIOS

2.  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 10/17/2012Alissa Perrucci, PhD, MPH 2 LEARNING OBJECTIVES

3.  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 10/18/2012Alissa Perrucci, PhD, MPH 3 AT THE WOMEN’S OPTIONS CENTER

4.  Listen.  Do not assume!  Self-reflect. 10/17/2012Alissa Perrucci, PhD, MPH 4 APPROACH

5. The patient has the answer 10/17/2012Alissa Perrucci, PhD, MPH 5 FUNDAMENTAL PRINCIPLE

6.  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 10/17/2012Alissa Perrucci, PhD, MPH 6 LISTEN

7.  Being open to, curious about, fascinated with, and interested in the patient’s process – but not personally invested in the outcome (the decision) 10/17/2012Alissa Perrucci, PhD, MPH 7 LISTEN

8.  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? 10/17/2012Alissa Perrucci, PhD, MPH 8 LISTEN

9.  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?” 10/17/2012Alissa Perrucci, PhD, MPH 9 OPEN-ENDED QUESTIONS

10.  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 10/17/2012Alissa Perrucci, PhD, MPH 10 DO NOT ASSUME

11.  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.” 10/17/2012Alissa Perrucci, PhD, MPH 11 DO NOT ASSUME

12.  Not assuming means you are free to inquire, investigate, and learn from the patient 10/17/2012Alissa Perrucci, PhD, MPH 12 DO NOT ASSUME

13.  What scenarios are hard for me?  What particular decisions do I want patients to make?  What decisions do I think are foolish? 10/17/2012Alissa Perrucci, PhD, MPH 13 SELF REFLECT

14.  Level 1: Validate and normalize.  Level 2: Seek understanding.  Level 3: Reframe. 10/17/2012Alissa Perrucci, PhD, MPH 14 FRAMEWORK

15.  Removing shame, stigma, and judgment  Listening, hearing, and acknowledging  “The patient is unique, but not alone” 10/17/2012Alissa Perrucci, PhD, MPH 15 VALIDATE AND NORMALIZE

16.  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 10/17/2012Alissa Perrucci, PhD, MPH 16 VALIDATE AND NORMALIZE

17.  Witness, hold and survive  There is no solving here 10/17/2012Alissa Perrucci, PhD, MPH 17 SEEK UNDERSTANDING

18.  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? 10/17/2012Alissa Perrucci, PhD, MPH 18 SEEK UNDERSTANDING

19.  Attend to the exceptional statement  It may be buried within a litany of congruous statements 10/17/2012Alissa Perrucci, PhD, MPH 19 SEEK UNDERSTANDING

20.  She is a good person making a moral decision  As you learn from the patient, you and he discover strengths, resources and wisdom 10/17/2012Alissa Perrucci, PhD, MPH 20 REFRAME

21.  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 10/17/2012Alissa Perrucci, PhD, MPH 21 REFRAME

22.  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 10/17/2012Alissa Perrucci, PhD, MPH 22 WAYS TO REFRAME

23. Alissa Perrucci Women’s Options Center/Ward 6G perruccia@obgyn.ucsf.edu 415-206-4027 Decision Assessment and Counseling in Abortion Care: Philosophy and Practice (Rowman & Littlefield, 2012) 10/17/2012Alissa Perrucci, PhD, MPH 23 THANK YOU