Use Difficult Conversations to Provide Better Healthcare

Justin Porter, RN/EMT-P
Justin Porter, RN, EMT-P

Pretend you are a dust bunny behind the couch. Your life has meaning there, and you find happiness even though this is not what you expected. Times have been better, but things could be worse after all. The default in this world though is to be the fur on the back of a cat, not just some collection of fur, dust and house plant debris.

Today, you have a problem and you need help. You aren’t exactly clear on what you want to happen, you just know that you need help. What arrives to your plea is a broom and a dustpan. The broom does not ask many questions – it just sees you as a dust bunny. 

Unfortunately, EMS agencies are like a broom that sweeps people toward the dustpan of interventions and life-prolonging treatment. Like a dustpan and broom, we are called to do a job: we sweep, scoop, toss and get ready for the next mess. EMS providers seldom take the time to ask that dust bunny with COPD what he or she truly wants, based on the facts.

Why is this so? The most obvious reason is due to the way most EMS agencies can bill for service. We must take the patient somewhere (hospital, rehab center, helipad) in order to be reimbursed, so it makes sense that emphasis is placed on getting going. Also, there are times, of course, when speed is needed due to truly life-threatening emergencies, but these occur for the minority of EMS calls.

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Another reason that EMS systems act like a broom sweeping toward the emergency department (ED) is that it protects EMS providers from having tough, emotionally significant conversations that they may not be trained for. To ask a patient about allergies and medications is critical prehospital work, yet it is surface level. To ask a patient what he worried about most before calling 911 gets to some deeper meaning and root causes.

When asking a question like this, you often hear stories of trauma, sadness and loss. When asking questions like this you must respond with empathy, which sometimes can feel like a liability. Recently I had a 911 call for an elderly woman with a nosebleed. She was shaking and worried — far more worried than she needed to be for a nosebleed. About ten minutes into pinching her nose, I asked her what she feared most. Her answer was that she was scared that her son would have to watch her die just like he watched his dad die. 

For a moment, let’s set aside discussions of billing and scenarios that involve life-threatening emergencies. Let’s talk about tough conversations, which is what so many of our patients need. When we engage in tough conversations, something profound can occur. We can start to hear the patient’s story and how he or she views the current situation. 

I have found that three things happen when tough conversations and questions happen during 911 calls. The first is that the patient is the boss, they decide exactly what they want based on the facts and the risks. Believe it or not, there are times when dying isn’t the worst option. Emergencies, by definition, are non-specific. What I mean by this is that everyone gets to decide what constitutes an emergency based on the risks and the outcomes that they desire.

Dying on hospice of congestive heart failure might be a meaningful and calm experience for one person while the exact same symptoms might be an emergency for another person. When patients are the boss of their care, they have higher rates of satisfaction with the care that they receive. Studies have shown evidence of a positive association between ED provider self-reported empathy and after-care instant patient satisfaction. The more we can connect with our patients in caring ways, the higher satisfaction they feel with their care.  

Calling 911 delivers a blunt instrument akin to a broom. The second thing that happens when we engage in tough conversations is that we deliver a more precise care that is based on the patient’s wishes. Like Goldilocks looking for the soup at just the right temperature, we need to find the care that fits the patient. When we don’t do this, we waste healthcare dollars and more importantly, we miss an opportunity to provide better patient results. We take patients to expensive care without exploring the best options based on their wishes.

Thirdly, if the first two things are true (that patients have higher rates of satisfaction and we reduce healthcare costs) then I believe we have better outcomes and healthier communities. Resources are utilized more appropriately, and people get the care that they need and want.  

When we were students or new hires, we learned how to talk to patients by watching more senior professionals and modeled their actions for our own practice. This is how we became brooms. We watched that 30-year vet grunt and never engage with the human being they were caring for. We watched that burned out nurse or paramedic scream at a patient for calling again. We need to learn a better way to dialog with our patients. This doesn’t take talent. Being good at difficult questions and conversations is a behavior that can be taught and learned. So how do you do it?

Our rural EMS agency is, at best, an hour from the closest ED. We often must go over mountain passes to reach the patient or the ED. Our rural, mountain living patients are fiercely independent. Because of these logistics, we cannot act like a broom. In fact, 50% of our 911 calls end up being non-transports. We have had to learn how to come to the right decision for the patient based on their wishes and risk tolerance. We cannot just scoop and run for many of our calls. We have started to train the behaviors that lead to difficult conversations. Many of these behaviors were learned through VitalTalk, which is a 501c3 nonprofit that aims to disseminate healthcare communication research into the real world.

So how do you “do” difficult conversations? It is quite simple once you get going, but I would say that there are three basic behaviors that we use.

1) We ask reflective questions. For example, “do you want to go to the hospital” is not a reflective question. Instead you might learn more from your patient by asking: “Based on what we have found in our assessment, how best can we help you,” “how do you see this situation,” or “what do you want to know?” The list of reflective questions that can be used in healthcare settings is endless, but I have found you only need a couple at the ready. Another thing that reflective questions can do is they can provide a window into the patient’s perception. It allows the provider to assess what the patient knows.

2) We acknowledge emotion. For example, “the tears in your eyes tell me that you are sad,” “it sounds like you are frustrated,” or “I sense how upset you are.” Often what results after acknowledging emotion is that the patient says something like, “well, yeah I am very sad and scared because….” When we name the emotion, we support them in exploring this emotion instead of blowing past it with reassurance or avoidance. Things generally don’t get better by avoiding them, they tend to build. By acknowledging the emotion, you allow them to answer to the worry, fear, concern, and turn down the intensity a notch. 

3) We offer silence. This is by far the hardest behavior to do. Silence can be uncomfortable. We often want to fill it with hope and comfort. By doing this we take the power from the patient to be the boss by labeling how and what they should feel. “This isn’t so bad, don’t cry.” Instead try being quiet, it offers the patient space to think and explore their situation. One thing that I have found is that silence is mostly uncomfortable to the person offering it. People in crisis and deeply emotional circumstances don’t feel uncomfortable with silence, they feel supported by the presence of the person offering silence. It can take minutes before someone is ready to talk, but what ensues will help the patient process the circumstances far better than encouragements.

When you start to use these behaviors, something transformative can happen. The weight and stress of these moments is lessened for you as the provider. You enter emergencies with a plan and learned skills. As an EMS provider you no longer need to make as many decisions, you can allow the patient to make the decisions based on the facts. You no longer need to have answers, because often the patient has all the answers based on the history, assessment and his or her wishes.

Of course, these conversations will take more of your time when compared to a broom and dustpan model. But you will deliver the most appropriate care to the patient and save time for the healthcare system by not sweeping patients toward care that they may not desire. 

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