We are extremely fortunate to have the wisdom of a friend and colleague of mine for this blog; her name is Carla Arkless and I can say that I am proud to include her thoughts on compassionate conversations. Carla is a Nurse Practitioner, she works as part of the ambulatory care team for Nelson Marlborough District Health Board (NMDHB) in New Zealand. If you have any questions about Carla’s work then please drop me an email and I will refer your comments on.
Compassionate conversations that ease fear and suffering by Carla Arkless
I live in a semi-rural district at the top of the South Island of New Zealand, with a population of 150,000 across 227,000 square kilometres; we have two public hospitals.
I work in a recently formed community rapid response team made up of nurses, doctors, and allied health staff. The team was set up to respond to high numbers of seriously ill people in the community, in the context of a health system overwhelmed by the COVID-19 pandemic. We are very fortunate in New Zealand to have avoided this scenario; however the team continues to respond to people in the community and in Aged Residential Care facilities who do not need or want to go to hospital, but who need assessment, support or intervention. The team has responded to a wide range of needs, including doing swabs for housebound people who meet the criteria for COVID-19 testing, medical assessment and treatment at home which would ordinarily have required a trip to hospital, and welfare and coping checks for frail older people following discharge from the Emergency Department who might otherwise have been admitted.
One of the things the team has been doing is having a conversation with these people and their families about what matters most to them, and about their values, goals, and care preferences. These conversations are not always easy, especially if we need to talk about serious illness, or the possibility of not recovering; however, they are so very important and really change outcomes and experiences for patients and their families. On the whole, people want to have these conversations, they are just waiting for us to initiate them. People want to be heard; they want us to know what matters to them as a human being, not just whether they are able to shower themselves, or what medication they are taking. They want to be treated in a way that values their choices, their own goals, their beliefs. They want to trust that they will be cared for in line with their values and goals when they cannot care for themselves.
We use a framework to have conversations, to elicit this important information. Firstly, we need to be on the same page about what is happening with their health – the patient tells us their understanding and we fill in any gaps if needed. Then we ask permission to tell them what we believe might be ahead for them, and if this is difficult for them to hear, we pause and respond to the emotion. We then ask a few questions to explore their priorities and worries if their health declines, what capabilities are most important to them, what treatments and other interventions they would be willing to go through for more time, and how much they have shared with their family about what’s important to them. We then come up with a shared plan going forward, which honours these things. Of course, all the way through the conversation we are acknowledging what they are saying, and we are demonstrating empathy. By finding out this information, we can ensure that any interventions we offer are in line with their values and preferences, and we appropriately direct their care. In addition, they feel heard, they build trust in us that decisions made will be in their best interests, and anxiety is reduced.
This is truly person-centred care. Our team operates 7 days a week, recognising that people’s health and illness is not dictated by office hours, and that by responding in a timely way, anxiety and distress is reduced, thus improving overall outcomes. We do not aim to replicate existing services – we are here to fill gaps. We respond to situations identified to us, we make sure the patient and their family have the care they need at the time, and if an existing service should or could have managed this person’s needs, then we address that with relevant services afterwards. Our primary goal is to ensure the patient and family have their needs taken care of in a timely way, and then address systems issues separately. So, our decisions are more driven by the needs and preferences of the patient, rather than by the needs and preferences of the organisation / system.
This is a very satisfying way to work and I look forward to a day when this approach is central to all healthcare systems. It is energising to connect with patients as fellow human beings, as well as professionally, and I am convinced that even one conversation that is focussed on what matters most to a person, has the ability to significantly change their healthcare experience and outcomes.