1. Working With The Challenging Family Patrick J. Dawson, MD ‘Facing Tomorrow’s Challenges Today’ Wroten & Associates Long Term Healthcare Conference May 13, 2010

2. Even when life seems easy – it just keeps on getting harder. Deets in “Lonesome Dove” The Red Queen shook her head. “You may call that nonsense if you like,” she said “but I’ve heard nonsense, compared with which that would be as sensible as a dictionary!” “Through the Looking Glass” Lewis Carroll Hell is other people. Sarte

3. Changing the Prevailing View of Long Term Care Public policy Public expectations and perceptions Professionalism Personal standards Passion Cheryl Phillips, CALTCM, 2004

4. Yet Another Task – Involving the Physician Areas of Physician Service at End-of-Life provide excellent communication advance care planning with clear decision-making support discharge and home care planning empathy for family emotions attention to grief and bereavement Michael Rabow, MD

5. Communication Is Fundamental “We stand here confronted by insurmountable opportunities.” Pogo Trust Is Inextricably Entwined With Communication

6. Poor Communication And Plaintiff Dissatisfaction Physician deserted the patient Physician devalued the patient/family views Physician delivered information poorly Physician failed to understand patient/family perspective Norcal Mutual Ins, Co. Claims Rx Jan. 2005

7. Patients Who Sued Physicians Identified Why Communication Failed Physician did not return phone call promptly Physician did not answer questions or listen Physician was too busy to talk or explain Staff members were not attentive listeners Staff members did not explain what they were going to do

8. Communication Components We Own Medical information Explaining the nursing home environment Detection of resident/family concerns Understanding resident/family NH experiences Learning prior caregiver roles

9. Advance Care Planning Not just “Code Status” Resident values, beliefs, preferences Resident – and family – expectations and goals Resident instructions and NH realities

10. Advance Care Planning Can Be… How power is to be shared in the resident-family-physician-facility relationship and How we focus on the resident while facilitating the Family’s adaption.

11. Family Systems Theory Maladaptive family structure in LTC – enmeshment disengagement hierarchies triangulations coalition

12. The Conflicted Surrogate Syndrome Complaints made in other than good faith. Complaints made as a result of psychological problems or mental illness. Complaints made due to pathological family dysfunction.

13. Very Few Related Studies With Limited Explanations Families react more intensely Families have different expectations Families felt like outsiders Families did not feel trusted

14. The Meeting Be prepared – who will attend? do they know? where? when? length? who is chair? who is note taker? what is on the agenda? Pay attention to time Introduce and sign-in State the purpose of the meeting

15. The Meeting Remember techniques to facilitate communication: allow one person to speak at a time allow everyone to have the chance to speak avoid interruptions do not bring other work to the meeting avoid side conversations with tangents make it safe to disagree listen

16. The Meeting Prime and direct the conversation: “Tell me what you understand about your dad’s condition.” “Tell me what you think about NH compared to a hospital.” “How has your family been handling the physical and emotional demands of caregiving?” “When families place a loved one in a NH, it isn’t unusual to feel guilty. Have you?” “What are your expectations for your husband’s stay here?”

17. The Meeting If there is an agenda, try to cover it. Ask if there are any questions. Summarize issues, promises, questions. It should be clear who is doing what by when. How will we communicate? Who is the contact person? When is the next meeting?

18. Risk Management Avoid defensiveness, anger and confrontation, but do not try to avoid the family. Be honest and realistic, but do not make excuses or give false hope. Document and do not alter the record. Organize and nurture a team approach. Try to objectively understand the family complaints. Who can you call? When should you call? What can you do?

19. Every morning in Africa a gazelle wakes up. It knows it must run faster than the fastest lion or it will be killed and eaten. Every morning in Africa a lion wakes up. It knows it must run faster than the slowest gazelle or it will starve to the death. It doesn’t matter whether you are gazelle or a lion, when the sun comes up you better start running.