Advanced Directives

It’s not what you say, but It’s not what you say, but how and when you say ithow and when you say it

End-of-life CareEnd-of-life CareRaymond Zakhari, NPRaymond Zakhari, NP

MetroMedicalDirect.comMetroMedicalDirect.comRaymond Zakhari The Adult HealthRaymond Zakhari The Adult Health Nurse Practitioner of New York, LLCNurse Practitioner of New York, LLC

New York Presbyterian- New York Presbyterian- Weill Cornell Medical CenterWeill Cornell Medical Center

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Sigy getting ready for Sigy getting ready for Bourbon St.Bourbon St.

Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Medical Direct Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Medical Direct

Sigy after Bourbon St.Sigy after Bourbon St.

Raymond Zakhari The Adult Health Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Nurse Practitioner of New York, LLC Metro

Medical Direct Medical Direct

Sigy sleeps it offSigy sleeps it off

Raymond Zakhari The Adult Health Nurse Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Practitioner of New York, LLC Metro


ObjectivesObjectives

The Transtheoretical ModelThe Transtheoretical Model Relapse Prevention ModelRelapse Prevention Model Motivational InterviewingMotivational Interviewing Group PracticeGroup Practice Summary/ QuestionsSummary/ Questions


In the 21In the 21stst century, health is century, health is increasingly about long-term increasingly about long-term condition/ chronic symptom condition/ chronic symptom management—management—

First, do no harm, and then do good, First, do no harm, and then do good, but if you can’t do good, at least do but if you can’t do good, at least do no further harmno further harm..


Transtheoretical ModelTranstheoretical Model

““That which I want to do, That which I want to do, I do not do, I do not do,

and that which I do not want to do, and that which I do not want to do, I do.”I do.”

Intention to changeIntention to change Willingness to changeWillingness to change Barriers to changeBarriers to change Process of changeProcess of change


TTM: Core ConstructsTTM: Core Constructs

• • Stages of ChangeStages of Change

• • Process of ChangeProcess of Change

• • Decisional BalanceDecisional Balance

• • Self-EfficacySelf-Efficacy

Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLCRaymond Zakhari The Adult Health Nurse Practitioner of New York, LLC

TTM: Process of Change,TTM: Process of Change, Consciousness Raising [increasing Consciousness Raising [increasing

awareness]awareness] Dramatic Relief [emotional arousal]Dramatic Relief [emotional arousal] Environmental Reevaluation [socialEnvironmental Reevaluation [social

reappraisal] reappraisal]

Social Liberation [environmental Social Liberation [environmental opportunities]opportunities]

Self Reevaluation [self reappraisal]Self Reevaluation [self reappraisal]


TTM: Process of Change,TTM: Process of Change,BehavioralBehavioral

• • Stimulus control [re-engineering]Stimulus control [re-engineering] • • Helping Relationships [supporting]Helping Relationships [supporting] • • Counter conditioning [substituting]Counter conditioning [substituting] • • Reinforcement management Reinforcement management

[rewarding][rewarding] • • Self Liberation [committingSelf Liberation [committing


Decisional Balance– Decisional Balance– Pro’s & Con’sPro’s & Con’s

• • Ambivalence is normalAmbivalence is normal • • Listening is crucialListening is crucial • • Tipping the decisional balanceTipping the decisional balance

Self-Efficacy: Self-Efficacy: the belief that thethe belief that the individual has in one self that theyindividual has in one self that they can do a particular behavior.can do a particular behavior.


TTM: Process of Change, TTM: Process of Change, ExperientialExperiential

• Consciousness Raising Consciousness Raising [increasing [increasing awareness]awareness]

• Dramatic Relief Dramatic Relief [emotional arousal][emotional arousal]• Environmental Reevaluation Environmental Reevaluation [social [social

reappraisal]reappraisal]• Social Liberation Social Liberation [environmental [environmental

opportunities]opportunities]• Self Reevaluation Self Reevaluation [self reappraisal][self reappraisal]

TTM: Stages of ChangeTTM: Stages of ChangePrecontemplatio

n

No intentionNo problem

Contemplation

ProblemPro’s & Con’s

Preparation to take Action

I need to do something

Action

Doing somethingabout problem

Maintenance

Trying to keep the action going

PrecontemplationPrecontemplation(no problem identified)(no problem identified)

• “• “The doctor’s will do what they The doctor’s will do what they think isthink is

best”best” • • When it’s there time it’s there time.When it’s there time it’s there time. • • II just want to be aroundII just want to be around • “• “She’s looking around more”She’s looking around more” • “• “They seem more responsive”They seem more responsive” • “• “Is she going to get better?”Is she going to get better?”


Contemplator—Contemplator—acknowledges problemacknowledges problem

• “• “They can’t go on like this forever” They can’t go on like this forever” “S/he doesn’t look comfortable”“S/he doesn’t look comfortable”

“ “They didn’t want live with assist They didn’t want live with assist devices”devices”

“ “This was supposed to be a short This was supposed to be a short termterm

bridge to recovery”bridge to recovery”Listen for cues that identify theListen for cues that identify the

individual is not happy with the status quoindividual is not happy with the status quo..

Preparing to take ActionPreparing to take Action(wanting to fix problem)(wanting to fix problem)• “ “ I want them to be comfortable”I want them to be comfortable”• ““I want to do what they would I want to do what they would

have wanted, or what we have wanted, or what we discussed”discussed”

• ““How can I promote quality of How can I promote quality of life?”life?”

• ““I want to know that the right I want to know that the right thing was done”thing was done”

Listen for cue that convey a Listen for cue that convey a desire to take action.desire to take action.

Action StageAction Stagedoing the intended behaviordoing the intended behavior

• ““I would like to speak to you about I would like to speak to you about my mothers care”my mothers care”

• ““If my family member winds up If my family member winds up taking a turn for the worse I don’t taking a turn for the worse I don’t want to use heroic measures”want to use heroic measures”

• ““I just want you to promote the I just want you to promote the quality of there last days on earth”quality of there last days on earth”

• ““I don’t want them on a respirator I don’t want them on a respirator or feeding tube.”or feeding tube.”

Doing the value the aspired to.Doing the value the aspired to.

Maintenance Stage Maintenance Stage (> 6 months of Action)(> 6 months of Action)

• ““Mom seems very peaceful”Mom seems very peaceful”• ““She’s involved in many She’s involved in many

activities”activities”• ““She looks comfortable”She looks comfortable”• ““I’m glad we addressed those I’m glad we addressed those

issues before we got to this issues before we got to this point”point”

Listen for cues that the person is Listen for cues that the person is satisfied with their decision and satisfied with their decision and would do it again if confronted with would do it again if confronted with the same thing.the same thing.

SOC in which the Change SOC in which the Change Processes are most emphasizedProcesses are most emphasized

Stages of ChangeStages of ChangePrecontemplation Contemplation Preparation Action Maintenance

Consciousness Raising

Dramatic Relief

Environmental Reevaluation

Self-reevaluation

Self-liberation

Reinforcement Management

Helping Relationships

Counter conditioning

Stimulus Control


Relapse Prevention ModelRelapse Prevention Model


Relapse PreventionRelapse Prevention

High Risk SituationsHigh Risk Situations Self-EfficacySelf-Efficacy Abstinence Violation Effect (AVE)Abstinence Violation Effect (AVE)


Craving mediated by Expectancies For immediate effect

Rationalization,

Denial, and apparently irrelevantdecisions

Lifestyle imbalance(Shoulds> wants)

Desire for indulgence or immediate gratification (I owe myself)

Precursors to High Risk Situations

High Risk Situation

Coping Response

No Coping Response

Increased Self-Efficacy

Decreased Self-Efficacy

Decreased probability of relapse

Lapse

Abstinence Violation Effect

Relapse

Cognitive Behavior Model of the relapse process

High Rates of Relapse:High Rates of Relapse:

• Negative Emotional State (35%)Negative Emotional State (35%)

• Interpersonal Conflict (16%)Interpersonal Conflict (16%)

• Social Pressure (20%)Social Pressure (20%)

Cummings, Gordon, & Marlatt 1980; Marlatt & Gordon 1980

What might this sound What might this sound like like

in terms of end-of-life in terms of end-of-life care?care?

Life style imbalance Life style imbalance (Should > Wants)(Should > Wants)

• I ought to visit moreI ought to visit more• I need to take care of my family I need to take care of my family

herehere• I have a big project at workI have a big project at work• I have to make funeral I have to make funeral

arrangementsarrangements• I’ll have to sell the estateI’ll have to sell the estate

Desire for indulgence, I Desire for indulgence, I owe myselfowe myself

• I’m not going to answer the phone I’m not going to answer the phone when the hospital calls, I need when the hospital calls, I need some alone timesome alone time

• I have taken care of her, so she I have taken care of her, so she needs to be around for my kidsneeds to be around for my kids

• I deserve to live in this apartment, I deserve to live in this apartment, if she dies I’ll have to moveif she dies I’ll have to move

• People really seem to talk to me People really seem to talk to me more now that she’s on the more now that she’s on the ventilatorventilator

Craving Mediated by Craving Mediated by expected effectexpected effect

• We can finally feel like a family We can finally feel like a family againagain

• If she just gets through this ____ all If she just gets through this ____ all will be betterwill be better

• If he would just give me a sign, If he would just give me a sign, squeeze my hand etc.squeeze my hand etc.

Rationalization & Denial,Rationalization & Denial,

• She has to eat and then she’ll get She has to eat and then she’ll get strong enough to pull throughstrong enough to pull through

• Everyone keeps telling me how bad Everyone keeps telling me how bad the situation is, they don’t know her the situation is, they don’t know her like I do.like I do.

• Lots of people are on dialysis, this Lots of people are on dialysis, this will help her dementia if we clean will help her dementia if we clean her bloodher blood

It’s not what you say but how you say It’s not what you say but how you say it:it:

Motivational Interviewing as your Motivational Interviewing as your counseling stylecounseling style

The Spirit of MI vs. Treatment The Spirit of MI vs. Treatment As Usual (TAU)As Usual (TAU)

• CollaborationCollaboration

• EvocationEvocation

• AutonomyAutonomy

• Confrontation

• Education

• Authority

Motivational Interviewing (MI)Motivational Interviewing (MI)

• A client’s discomfort with cognitive A client’s discomfort with cognitive dissonance can be a spring board dissonance can be a spring board for change.for change.

• MI works by activating patients’ MI works by activating patients’ own motivation for changeown motivation for change

Develop DiscrepancyDevelop Discrepancy The client/ family should present the The client/ family should present the

arguments for change arguments for change (rather than (rather than the providerthe provider))

Change is motivated by a perceived Change is motivated by a perceived discrepancy between present discrepancy between present behavior and important personal behavior and important personal goals and values.goals and values.



ExpressExpress EmpathyEmpathy

Acceptance facilitates changeAcceptance facilitates change Skillful reflective listening is Skillful reflective listening is

fundamentalfundamental• DDesireesire• AAbilitybility• RReasonseasons• NNeedseeds

Ambivalence is normalAmbivalence is normal


Values vs. RealityValues vs. Reality

Advantages/disadvantages of status Advantages/disadvantages of status quoquo

Advantages/ Disadvantages of Advantages/ Disadvantages of changechange

Optimism for changeOptimism for change Intention to changeIntention to changeListen for change talk in the Listen for change talk in the

individual, Where are they are individual, Where are they are along the SOC?along the SOC?

Raymond Zakhari The Adult HealthRaymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Nurse Practitioner of New York, LLC

Metro Medical Direct Metro Medical Direct

Roll With ResistanceRoll With Resistance

Avoid arguing for changeAvoid arguing for change Resistance is not Resistance is not directlydirectly opposed opposed New perspectives are invited but not New perspectives are invited but not

imposedimposed The client is the primary resource for The client is the primary resource for

finding answers and solutionsfinding answers and solutions Resistance is a signal to respond Resistance is a signal to respond

differentlydifferently


R.U.L.E.R.U.L.E. Resist the righting reflexResist the righting reflex

• Psychological reactivity & Therapeutic Psychological reactivity & Therapeutic ParadoxParadox

Understand your patient’s motivationUnderstand your patient’s motivation• Why would they want to?Why would they want to?

Listen to your patientListen to your patient• Equal parts of listening & informingEqual parts of listening & informing

Empower your patientEmpower your patient• Help in contemplating the how and whyHelp in contemplating the how and why



Four Guiding PrinciplesFour Guiding Principles

1.1. RResist the righting reflexesist the righting reflex

2.2. UUnderstand the patients motivesnderstand the patients motives

3.3. LListen with empathyisten with empathy

4.4. EEmpower the patientmpower the patient


Three Communication Styles—Three Communication Styles—Three Core Communication SkillsThree Core Communication Skills

Guide-- AskingGuide-- Asking

Direct-- InformingDirect-- Informing

Follow-- ListeningFollow-- Listening

Open Ended Open Ended QuestionsQuestions

Affirm the PersonAffirm the Person

Reflect back Reflect back

Summarize Summarize perspective on perspective on changechange

Elicit --- Provide --- Elicit Raymond Zakhari The Adult Health Raymond Zakhari The Adult Health

Nurse Practitioner of New York, LLC Metro Nurse Practitioner of New York, LLC Metro Medical Direct Medical Direct

Reflective Listening

Validate & Affirm

Explore a Menu of Options

Explore the Pro’s and Con’s

Where are they on the SOC Where are they on the SOC continuum?continuum?

Ask permission

Set an Agenda

Ambivalence is Normal

Resist the Righting Reflex

Consider life balanceHigh Risk Situations

Explore Coping

Create Discrepancy

Readiness to Change?

What is the motivation

AbstinencAbstinence e Violation Violation EffectEffect

EmpathEmpathyy

Promote Self-Efficacy

Use Rulers

What’s Next?

Listen for and try to do these Listen for and try to do these thingsthings::

Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Medical Direct Metro Medical Direct

References References Curry, S. J., & Kim, E.L., (1999). Public health perspective on addictive behavior change Curry, S. J., & Kim, E.L., (1999). Public health perspective on addictive behavior change

interventions: Conceptual frameworks and guiding principles. In Tucker, J.A., Donavan, interventions: Conceptual frameworks and guiding principles. In Tucker, J.A., Donavan, D.M., & Marlatt, G.A. (1st ed.), Changing addictive behavior: Bridging clinical and public D.M., & Marlatt, G.A. (1st ed.), Changing addictive behavior: Bridging clinical and public health strategies (pp. 221-246). NY: The Guilford press.health strategies (pp. 221-246). NY: The Guilford press.

Larimer, M., Palmer, R., & Marlatt, A. (1999). Relapse prevention: An overview of Marlatt’s cognitive-behavioral model. Alcohol, Research & Health 23(2), 151-160.

Marlatt, G.A. (1985). Situational Determinants of Relapse and Skill-Training Interventions. In Marlatt, G. A. & Gordon, J. R. (1st ed.), Relapse prevention (pp. 77-81). NY: The Guilford press.

Marlatt, G.A., & Witkiewitz, K., (2005). Relapse prevention for alcohol and drug problems. In Marlatt, G.A., & Donovan, D.M. (2nd ed.), Relapse prevention: Maintenance strategies in the treatment of addictive behaviors (pp. 1-24). NY: The Guilford press.

Miller, W., and Mount, K. (2001). A small study of training in motivational interviewing: Does one workshop change clinician and client behavior? Behavioral and Cognitive Psychotherapy 29, 457-471.

Miller, W., Yahne, C., Moyers, T., Martinez, J., & Pirritano, M. (2004). A randomized trial of methods to help clinicians learn motivational interviewing. Journal of Consulting and Clinical Psychology 72(6), 1050-1062.

Miller, W.R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change: The Guilford press..



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Advanced Directives

Health & Medicine

Transcript of Advanced Directives