Please write a 300-word response to the below essay by my fellow peer.
Reflective Analysis of Clinical Experience: A Family Encounter
The day following an intense family meeting, the patient’s daughter requested a private conversation with me outside of the patient’s room. During this time, the daughter shared her frustration about topics discussed in front of the patient, including treatment options, prognosis, and end of life care. The daughter felt strongly that the family should have been more informed about what was going to be discussed during the meeting prior to the meeting occurring. She felt that the family should have had input in whether the patient had capacity to make medical decisions and if a capacity assessment was going to occur. In summary, the family was angered by the information presented and that it was presented to the patient without their input.
To further reflect on this experience, I will be utilizing the Gibb’s Cycle of Reflection (Monash University, 2017). This is a six-step process that allows one to briefly describe an experience, learn from the experience and prepare for a similar experience in the future. I chose to reflect on this experience for a few reasons. It is a good example of the types of stressful situations my patients and their families encounter daily. It also demonstrates how I handle situations and how I wish to handle situations in the future. Lastly, it is an example of emotional intelligence (Chism, 2021), which is an important of a doctor of nursing practice graduate.
Feelings
During this scenario, I experienced a range of feelings. Initially, I was nervous about the conversation, knowing that the patient and family were unhappy at the end of the encounter the day before. My nerves were further rattled when the daughter asked to speak to me outside of the room. When the daughter started sharing her anger and frustrations, I could feel my energy increasing and a sense of anger myself. I felt that the reason for her anger was the result of events I had no control over, and I felt that she had an inappropriate amount of anger towards me. Ultimately, I felt overwhelmed enough by the emotions I was feeling that I let the daughter know that I needed to walk away and post-pone the conversation for another time.
Evaluation
When reflecting on a situation like this, initially it is difficult to find the positives. In the weeks prior to this encounter, I attempted to build rapport with the family, advocating for their mother’s needs. On this day, I attempted to create space for the daughter to vent her frustrations. I entered the encounter with openness to listen and provide support. I attempted to let the daughter feel heard with her concerns. I also brought a chaplain on my team with me to provide myself with support but also because I anticipated the family’s needs.
There were a lot of negative aspects in this encounter as well. I felt anxious about it before it even started, so my emotions were heightened. I was likely the first provider the daughter had seen since the day before, which means the family had a lot of time to simmer before they were able to release their emotions. I allowed the daughter to isolate myself outside of the patient’s room instead of staying with the patient and allowing her and her husband to be a part of the conversation. Also, on this day the patient was more physically ill than the day prior, which probably led to even further intensified feelings.
Additionally, prior to the meeting I attempted to present to the multidisciplinary team (MDT) barriers I had already encountered in communicating concern with this family. I also shared with the MDT the family’s reluctance to share negative information with the patient. This meeting was arranged by a colleague when I was out of the office, therefore I did not have opportunity to coach the family about what might come up during the meeting. Lastly, during the family meeting, the patient and family were not asked permission to discuss difficult information.
Analysis
Emotional intelligence is necessary in the field of palliative care, where we are engaged with patients and their families who are faced with incredibly difficult information and decisions about their health. Characteristics of emotional intelligence include self-awareness, self-management, social awareness, and relationship management (Chism, 2021). In situations like these, I try to utilize empathy to understand the perspective of my patient and their family and to understand how difficult this information must be to hear and process. I believe the daughter felt a loss of control over the situation and an extreme sadness that her mother is dying. She felt very limited in what she could do except protect her mother from feelings of sadness. The daughter was also likely protecting herself from feelings of sadness and a need to explore end of life preferences with her mom. Ultimately, she was feeling a cascade of emotions that needed to be released. Our encounter was likely the result of her not utilizing other coping strategies for the stress, sadness, and the loss of control she was feeling.
Conclusion
I agree with the family they were not well prepared for the topics discussed in the meeting. In palliative care we do extensive training in communication surrounding transitions and goals of care. One strategy we utilize to break bad news is the GUIDE tool, which was created by VITALtalk (2019). GUIDE stands for Get Ready, Understand, Inform, Demonstrate Empathy, and Equip. Ideally prior to a family meeting, a provider makes sure all the necessary information and people are available. The next step is to understand what the patient and the family already know. In this scenario, both these components occurred. The next step is to provide the patient and family with a headline, summarizing the news, and stop. Before any more information is provided, the practitioner assesses the room. It is at this time empathy is employed and the patient or family are assessed for readiness to continue with the conversation (Vitaltalk, 2019).
In the case of the family meeting, these last two steps did not occur. If the patient was presented with the headline prior to the meeting, the family was not and were not prepared for the discussion. The family was also not asked at any point if they were ready to proceed with further discussion. At each step along the way of the initial conversation, the family could have been asked whether they were okay with going on to the next topic needing to be discussed. In other words, the information did not need to be presented in one setting.
Action Plan
In the future, I plan to be more prepared for a family meeting as well as prepare the patient and family for a family meeting. I believe some of what occurred in the second encounter was the result of how the prior encounter was perceived. In addition to utilizing the GUIDE tool during a family meeting, I hope to better prepare the patient and her family about the topics that might be discussed. This would occur in a separate visit by the practitioner offering a theoretical outline of what will be discussed in the meeting. This way the patient and family can decide what they need to prepare for the meeting in advance. Is it additional family members? A spiritual guide?
Additionally, the goal of these meetings is to share bad news, to obtain a better understanding of the patient’s goals and wishes relating to that information and develop a plan for next steps. However, it is not necessary that this all be accomplished in one sitting. In the future, I hope to better assess the needs of the patient and the family during these conversations and advocate for a pace that is more comfortable for them. In doing so, I believe that the outcome of the next encounter can be different because the patient and family were more prepared for the information and the information was delivered at a pace they could manage. Emotional intelligence plays a role in managing relationships with patients and their families as well as having self-awareness and social awareness (Chism, 2021). In the future, I hope this reflection allows me to learn from this experience and perform differently (Monash University, 2017) as it is likely to be a scenario encountered in the future.
References
Chism, L. A. (2021). The doctor of nursing practice: A guidebook for role development and professional issues. Jones & Bartlett Learning.
Monash University. (2017, June 18). Reflective writing [Video]. YouTube. https://www.youtube.com/watch?v=N2qZX3M_9MY
VitalTalk. (2019) Serious news: Breaking bad news using the GUIDE tool. https://www.vitaltalk.org/guides/serious-news/
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