Whole Person Narrative Patient-Centered Care

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Welcome

    Welcome to the Introduction to Narrative Patient-Centered Care. This Module is presented in three online units:
  1. Introducing Narrative Patient-Centered Care
  2. Communication Skills for Narrative Patient-Centered Care
  3. Whole Person Narrative Patient-Centered Care

In the third unit, Whole Person Narrative Patient-Centered Care, you will observe Wendy’s follow-up visit with her physician and her partner, Oscar, and explore the dimensions of whole person care, including spirituality.

Learning Objectives:

    After completing the third unit, you will be able to:
  • Explain the concept of Whole Person Care.
  • Reflect on your own comfort with discussing religion and spirituality with patients and family.
  • Apply communication skills for Narrative Patient-Centered Care to address whole person needs – physical, emotional, social, and spiritual – of patients and families.


". . . That business of the spirit, of the non-material self, of sympathy for and knowledge of others is the most important thing: in how we love, in how we live, and in what matters."

Colm Tóibín, writer and novelist


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Treating the whole person

Each time chronically ill patients experience a serious medical incident they are confronted with their mortality and the associated issues of meaning and grief that are critical dimensions of the whole person experience.

Whole person care seeks to comprehend and address the physical, emotional, social, and spiritual dimensions of the person to relieve suffering and promote healing in acute and chronic illness.

Whole person care is focused on accepting a changed life and draws on the inner resources of the patient and family with the patient in control. Whole person care complements biomedicine which is controlled by the physician and focused on preserving life.

Hutchinson T 2011


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Excerpts from Intoxicated by Illness, Anatoly Broyard

... it sounds trite, yet I can only say that I realized for the first time that I don't have forever....

In the first stages of my illness, I couldn't sleep, urinate or defecate - the word ordeal comes to mind. Then when my doctor changed all this and everything worked again, what a voluptuous pleasure it was. With a cry of joy I realized how marvelous it is simply to function. My body, which in the last decade or two had become a familiar, no longer thrilling old flame, was reborn as a brand-new infatuation.

I realize of course that this elation I feel is just a phase, just a rush of consciousness, a splash of perspective, a hot flash of ontological alertness. But I'll take it, I'll use it. I'll use everything I can while I wait for the next phase. Illness is primarily a drama and it should be possible to enjoy it as well as to suffer it. I see now why the romantics were so fond of illness - the sick man sees everything as metaphor. In this phase I'm infatuated with my cancer. It stinks of revelation.

As I look ahead, I feel like a man who has awakened from a long afternoon nap to find the evening stretched out before me. I'm reminded of D'Annunzio, the Italian poet, who said to a duchess he had just met at a party in Paris, ''Come, we will have a profound evening.'' Why not? I see the balance of my life - everything comes in images now - as a beautiful paisley shawl thrown over a grand piano....

Read the full essay in the New York Times


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What is good Patient-Care when there is no cure?


Think of a loved one or patient with serious illness who you believe received good medical care even when medicine did not have a cure for their disease. What made their care “good”?

Type your thoughts in the text box below:




Click on the button up to see what most patients and families say.




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Skills for Whole Person care

The Seven Questions presented in unit two will help you gain a deeper understanding of the whole patient and her family and ensures that the treatment you provide supports a meaningful life for everyone involved.


Bhang & Iregui 2013. Adapted with permission.

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The transcendent or spiritual dimension

Reflect a moment and rate yourself.


    I feel uncomfortable discussing patient’s spiritual and religious concerns and avoid such conversations.
  • Never
  • Rarely
  • Sometimes
  • Almost always
  • Always








    Skills for discussing spiritual and religious issues with patients and families:
  • Ask for clarification about their concerns, beliefs and needs
    • Make a connection by:
    • listening carefully
    • acknowledging concerns
    • exploring emotions
    • offering empathy
  • Identify common goals for care
  • Mobilize sources of support for them.

Lo, Ruston, Kates, et al. 2002


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Whole person care for Wendy

    Following Wendy’s initial visit, her primary care physician began an aggressive pain management regimen. By the third day:
  • Wendy’s pain is averaging 3/10.
  • She is using her breakthrough morphine IR less than once a day and never at night.
  • Her sleepiness is improving and her bowels are soft and regular.
  • After all these weeks equating pain with her cancer, she can’t believe she still has cancer.

While Wendy’s nociceptive pain is controlled, she continues to describe a different kind of “pain” that doesn’t respond to her pain medications. It is a deep ache in her chest made worse when she thinks about what will happen to her grandchildren and her relationship with Oscar.

Treatment of nociceptive pain in cancer patients is a critical first step in addressing whole person pain. Continued support in dealing with the emotional, psychological and spiritual concerns of patients with advanced illness is also critical for treating the whole person’s pain.


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Setting a safe context: compare two approaches

At the end of the initial visit, the physician stated that he would like Oscar to participate in their next meeting to share his understanding of the situation so the three of them can work together.

Observe the differences in the attempts to set the context for the follow-up visit with Oscar and Wendy in the videos below. After watching each video you will be asked to identify the communication skills you observed.

Standard Practice

Check all that apply and then click to see what we observed.

The primary care physician effectively:

  • Invited Oscar to share his story
  • Encouraged Oscar to do most of the talking.
  • Explained the importance of knowing his story
  • Explained how knowing his story will allow the healthcare team to provide better care.




Narrative Approach

Check all that apply and then click to see what we observed.

The primary care physician effectively:

  • Invited Oscar to share his story
  • Encouraged Oscar to do most of the talking.
  • Explained the importance of knowing his story
  • Explained how knowing his story will allow the healthcare team to provide better care.





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Obtaining Oscar’s story

Quite a lot happens during the three-way discussion with Wendy, Oscar and the primary care physician. Use the check list below to identify the communication skills that that were most effective in this interaction.

Check all that apply and then click to see what we observed.

Wendy’s primary care physician uses the Seven Questions to ask Oscar about:

  • his understanding of the situation
  • his source of strength
  • his past experiences in caring for others who are seriously ill?
  • his hopes
  • his concerns, worries, fears
  • his family or others who will support him and Wendy
  • anything else the doctor should know about who he is or what he believes.

    • When Oscar mentions his belief in miracles, Wendy’s primary care physician:

  • asks for clarification
  • listens carefully
  • acknowledges concerns
  • explors emotions
  • offers empathy
  • identifies common goals for care
  • mobilizes sources of support for them.




There is no hard and fast script.

With experience, you will adapt the skills for Narrative Patient-Centered Care to your own personality and modify them as the situation requires.

As you will see, Wendy’s physician uses some, but not all, of the Seven Questions.

You will also notice that Oscar raises several important concerns before the physician asks about them. Some things he say surprise even Wendy.

Wendy’s physician does not shy away from discussing Oscar’s spiritual beliefs. He acknowledges Oscar’s beliefs without subscribing to them himself.

How do you feel about the physician’s approach?


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Summarizing and confirming: compare two approaches

Observe the differences in the attempts to summarize and confirm Oscar’s story in the videos below. After watching each video, you will be asked to rate the physician’s use of Narrative Patient-Centered communication skills.

Standard Practice


Rate the approach used by the primary care physician in summarizing and what he has learned about Wendy. Then click to see what we observed.


1 = Highly biomedical and 5 = highly narrative.


    1. Identified and confirmed Oscar’s values and goals for care.
    Biomedical Practice -----------------------------------Narrative Approach
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    2. Identified and confirmed Oscar’s personal values and goals.
    Biomedical Practice -----------------------------------Narrative Approach
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    3. Summarized Oscar’s story and confirmed the accuracy of his understanding.
    Biomedical Practice -----------------------------------Narrative Approach
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    4. Checked that his understanding is accurate
    Biomedical Practice -----------------------------------Narrative Approach
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    5. Allowed Oscar to correct any misunderstandings and fine tune what he had said.
    Biomedical Practice -----------------------------------Narrative Approach
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    6. Let Oscar know he had been heard
    Biomedical Practice -----------------------------------Narrative Approach
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    7. Created a path to common understanding.
    Biomedical Practice -----------------------------------Narrative Approach
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Narrative Approach


Rate the approach used by the primary care physician in summarizing and what he has learned about Wendy. Then click to see what we observed.


1 = Highly biomedical and 5 = highly narrative.


    1. Identified and confirmed Oscar’s values and goals for care.
    Biomedical Practice -----------------------------------Narrative Approach
  • 1
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  • 5


    2. Identified and confirmed Oscar’s personal values and goals.
    Biomedical Practice -----------------------------------Narrative Approach
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  • 5


    3. Summarized Oscar’s story and confirmed the accuracy of his understanding.
    Biomedical Practice -----------------------------------Narrative Approach
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    4. Checked that his understanding is accurate
    Biomedical Practice -----------------------------------Narrative Approach
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    5. Allowed Oscar to correct any misunderstandings and fine tune what he had said.
    Biomedical Practice -----------------------------------Narrative Approach
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  • 5


    6. Let Oscar know he had been heard
    Biomedical Practice -----------------------------------Narrative Approach
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  • 5


    7. Created a path to common understanding.
    Biomedical Practice -----------------------------------Narrative Approach
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Creating a shared narrative and a plan of care: compare two approaches

Observe the differences in the attempts to create a shared narrative and a plan of care in the videos below. After watching each video, you will be asked to rate the physician’s use of Narrative Patient Centered communication skills.

Standard Practice


Rate the approach used by the primary care physician in creating a shared narrative and plan of care with Wendy. Then click to see what we observed.


1 = Highly biomedical and 5 = highly narrative.


    1. Uses Oscar’s narrative to translate the medical narrative.
    Biomedical Practice -----------------------------------Narrative Approach
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    2. Identifies the values and goals that are shared by everyone.
    Biomedical Practice -----------------------------------Narrative Approach
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    3. Identifies the medical treatments that are consistent with supporting these shared goals and any treatments that are inconsistent with these shared goals.
    Biomedical Practice -----------------------------------Narrative Approach
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    4. Creates a common shared narrative.
    Biomedical Practice -----------------------------------Narrative Approach
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    5. Uses the common shared narrative to develop a care plan.
    Biomedical Practice -----------------------------------Narrative Approach
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    6. Offers a shared care plan that will support Wendy in living the best life possible within the context of available medical and social resources.
    Biomedical Practice -----------------------------------Narrative Approach
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Narrative Approach


Rate the approach used by the primary care physician in creating a shared narrative and plan of care with Wendy. Then click to see what we observed.


1 = Highly biomedical and 5 = highly narrative.


    1. Uses Oscar’s narrative to translate the medical narrative.
    Biomedical Practice -----------------------------------Narrative Approach
  • 1
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  • 5


    2. Identifies the values and goals that are shared by everyone.
    Biomedical Practice -----------------------------------Narrative Approach
  • 1
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    3. Identifies the medical treatments that are consistent with supporting these shared goals and any treatments that are inconsistent with these shared goals.
    Biomedical Practice -----------------------------------Narrative Approach
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    4. Creates a common shared narrative.
    Biomedical Practice -----------------------------------Narrative Approach
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    5. Uses the common shared narrative to develop a care plan.
    Biomedical Practice -----------------------------------Narrative Approach
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    6. Offers a shared care plan that will support Wendy in living the best life possible within the context of available medical and social resources.
    Biomedical Practice -----------------------------------Narrative Approach
  • 1
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  • 5






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Summary

In the third unit, Whole Person Narrative Patient-Centered Care, you observed Wendy’s follow-up visit with Oscar and her primary care physician. You saw that managing Wendy’s whole person care included both nociceptive pain control and attention to the other important issues that were causing her distress.

The communication skills learned in the third unit were used to deepen and extend the narrative approach during the follow-up visit, including spiritual issues.

  • Setting a Safe Context
  • Obtaining the patient’s and family’s stories using:
    • Ask tell ask
    • 7 important questions
    • Silence
    • Using continuers
    • NURSE
  • Summarizing and confirming the narrative
  • Integrating the patient’s and family’s stories with the medical narrative
  • Developing a plan of care based on this shared narrative.

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Further Reading

Hutchinson T. “Whole person care. In: Whole Person Care: A New Paradigm for the 21st Century. Hutchinson T, Ed. New York: Springer 2011.

Lo, Ruston, Kates, et al. Discussing Religious and Spiritual Issues at the End of life: A Practical Guide for Physicians. JAMA Feb 13, 2002-Vol 287, No. 6: 749754.

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