When I was a new hospice nurse, I attended a care planning meeting at a Long Term Care Facility. The facility staff reported that they wanted to increase our patient’s anti-anxiety medication because she was being disruptive. She would flail her arms, hum and vocalize loudly, and was resistant to personal care. I felt myself getting a bit defensive, wanting to guard against overmedicating the patient.
I didn’t know quite what to say, so I asked the question: “Do we know what the patient did for a living, or what her hobbies and interests were?” Now, they looked at me like I had lost the thread of what was important here, but I noticed that the chaplain slipped out of the meeting. My question had made him curious, so he called the family. He shared that the patient had been a professional opera singer.
Takeaway: After a meeting about a troublesome patient, we discovered we didn’t have the whole story. Asking “What matters?” led us to find an unexpected solution.
We were all a bit dumbstruck. The chaplain suggested that we bring in a CD player and see if opera music would make a difference. We found a CD of arias by the great diva Maria Callas. When we hit play, the patient’s eyes lit up, and she began gesturing with her arms and humming along with the arias. She didn’t need more medication, she needed music. The patient continued to decline, but throughout the rest of her life, her beloved music was ever present, and her death was peaceful – what everyone had wanted for her.
I learned a lot from this experience. During the meeting I had felt judgmental of the facility staff, and I thought I knew my patient very well. Instead, we all had made assumptions based on our own points of view.
It as a beginning of my journey in developing the C.A.R.E. process. Creating reminders to keep me on track:
The “C” is for “Connect.” First, we can connect with ourselves. Taking a breath, brings us back to ourselves and centers us. We also want to connect with our co-workers and facility staff by making eye contact, and asking how they’re doing. Connecting with the patient helps us really see them; remembering that they have lived life. We’re only seeing a small slice of that life.
“A” for “Assess.” Taking a moment to notice our judgements is so important. Asking “Is that true?” helps us identify what might be our opinion or bias. We can realize that the patient is seeing things from their world view. We can take assessment to the next level with the patient by asking not only “what’s the matter?” but “what matters?” Being curious about the patient and really listening to the answer – listening with the goal of understanding. Even a nonresponsive patient has a history, and knowing something about that history can make a difference.
The “R” stands for “Respond instead of react.” In healthcare, we’ve trained and studied for years to know how to solve the problems our patients have. By having an open mind about their perspective, we can ask questions to find the best possible solution, and not jump to conclusions. Taking a pause before speaking, derails that first impulse to fix or launch into an explanation. What the patient often wants is validation that their needs will be accommodated.
And “E” for “Evaluation.” Taking a moment to evaluate the interaction is helpful. Did we connect with ourselves and others? Did we give ourselves a chance to assess what was really going on? Did we learn more about the people involved? And did we respond with respect in alignment with our values? Did we act with compassion? It’s not always comfortable to think we may have missed the mark, but by not beating ourselves up, and offering ourselves self-compassion, we can learn. We can celebrate when things went well, too!
Maybe the most poignant thing about working in hospice is realizing that when I visit a patient, it might be the last time I’ll see that person. Using the C.A.R.E. reminders helps me know that I’ve done my best, so I can move forward to the next patient peacefully.