W11 Counselling and Palliative Care

how is counselling defined in speech pathology

• a helping relationship in which the clinician’s intentions are to assist a person or family member to understand a communication or swallowing disorder, its impacts on their lives and ways of preventing, managing, adjusting to or coping with these disorders

why do speech pathologists provide counselling

• communication and swallowing disorders can cause people to develop strong reactive emotions

• shape an integral part of our lives

• emotions can adversely impact the client’s motivational states and engagement in treatment

• need to understand how individuals may experience grief and loss as it may impact the way in which we work with clients, families and communities

why might someone encounter grief and loss

• the onset of the disorder or diagnosis, the progression of a disorder/diagnosis and plateau of recovery

• family members may also encounter grief and loss

what is loss and different types

• when something that is valued that once was present is now changed or gone

• non-finite loss: remains present and may become more prominent over time e.g. progressive condition

• finite loss: e.g. death, the loss will not be repeated continually

• physical loss: loss of significant person (death/separation), loss of skill, loss of bodily function

• symbolic loss: loss of something that is important to the individual’s identity

grief

• natural and predictable reaction to that loss (psychological and physiological reactions)

• can be short or longer term

what might clients experience loss of

• ability to communicate/swallow

• person - death/separation

• self esteem

• identity “former self”

• future, dreams

• job, licence, possessions

• relationships

• independence, freedom, control

• innocence

Is grief in stages

• Stage Theory - 5 Stages of Grief: no scientific foundation, people do not grieve in stages

what is integrated grief

• when grief is acute - intense emotions and preoccupation with thoughts and memories of deceased

• often feel a sense of disconnection from themselves

• fear they will never again be able to feel happy or fulfilled

• adapt to loss by accepting its finality and consequences

• re-envisioning a future with possibilities for happiness, joy, connection and meaning

• those who adapt is called integrated grief

complicated grief

• roadblocks to adaptation

• severe, prolonged and disabling grief symptoms

• symptoms are similar to those of acute grief but does not decrease over time

• risk of complicated grief is higher following traumatic events

• impairment in functioning

acute grief

• common and expected response to loss

• disbelief

• yearning and sorrow

• insecurity, emptiness, loss

• other intense feelings

• insistent thoughts

• withdrawal

strategies which can help people work through the pathway into integrated grief

• understanding and accepting grief

• recognising painful emotions

• planning for a meaningful future

• strengthening ongoing relationships

• telling the story of the death/loss

• learning to live with reminders: facing the anxiety, revisiting the activities which have been avoided

• establishing an enduring connection with memories of the person who died

Different theories of Counselling

1. Ways of being: how the counsellor should be with a client

2. Way of understanding: to describe and explain the client’s experience, issues and strengths

3. Way of intervening: explanation of how change occurs and what techniques or processes stimulate that change

basic counselling skills in speech pathology

• self-awareness

• attend - active listening

• gather information

• provide information

• promote change

Counselling skills Step 1: Self-Awareness

• need to be internally prepared to engage with client/family

• acknowledge our own strengths, challenges, internal reactions and own influence on communicative behaviour

• respect differences

• cultural responsiveness

• knowing how you are impacted to grief reactions

what are some things that might make attending and listening difficult

• own stress and anxiety

• judgements about the client - conscious/unconscious bias

• being eager to respond so only listening partially

• rehearsals of what the clinician is planning to say

• similarities between clinician and client’s problems and therefore splitting attention between those

• difficulty relating to the client not feeling well or being preoccupied by own physiological needs, such as hunger, fatigue, needing to go to toilet

Counselling skill - Step 2: Attending

• alert, focused, show interest/value in what the client/family has to say

• non-verbal behaviour

• experience and communication of empathy

non verbal behaviour

• body posture and appropriate body motion

• eye contact

• non distracting environment

what do you do if someone is crying

• let them

• stay with them, provide a tissue/drink

• syaing “it’s okay to cry”

counselling skill: Skill 2: Attending - Experience and communication of empathy

• empathy: careful listening, understanding and communicating that understanding tot eh client

• “I can see why you’re so upset” rather than “I know how you feel”.

• show that you have listened and accept the situation

2 fundamental skills for skill 2: active listening

1. reflection: acknowledge the elements of the heard message with a word

2. Summarisation: pulls reflective information together

Counselling skill: Skill3 - Gathering Information

• to understand the person

• using active listening to ask strategic questions to identify what’s important

• open ended and functional questions

counselling skills: Skill 4: Providing information

• information sandwich

• Begin with observations of a strength, process of optimistic view

• share the difficult news, barrier or change in a straightforward way

• conclude by pulling together the strength or optimistic view with a plan or opportunity related to the difficulty

• two-way conversation

Counselling Skill 5: Promoting Change

• starts with a trusting and supportive partnership with a personally salient treatment plan

• building on strengths

• reframing challenges

• understand that when a client is distressed, your reframe won’t fix everything

• provide an environment of unconditional positive regard, genuine acceptance, integration of client’s goals and perspectives, and belief in client’s potential for improvement

Palliative Care

• an approach that improves the quality of life of patients and their families who are facing problems associated with life-threatening illness

characteristics of palliative care

• life affirming: supporting people to live as comfortably as possible

• quality of life

• holistic care: physical care, social care, emotional care, spiritual care, cultural care

difference between palliative and end of life care

• end of life care is part of palliative care: last few days of life

• however palliative care can be longer-term: months-years

family-centred care in palliative care

• family members are often the role as principle carer

• ensure to keep them informed

• explain what they can expect

• ongoing education about care and management

• support during decision making and end of life issues

• provision of emotional and spiritual support

• preparation for when death is imminent

• support after death

importance of early identification and assessment

• palliative care comes early in the course of illness

• emphasises active, comfort-focused care and a positive approach to reduce suffering

• improves QOL

• helps avoid burdensome interventions of low benefit

• reduced hospital admissions

aims of palliative care

• retain dignity of patients, caregiver/s and family

• empower the patient, caregivers and family

• show compassion

• provide equity in access to services and resource allocation

• respect the patient, caregivers, family

• provide advocacy on behalf of the expressed wishes

• provide excellence in provision of care and support

• be accountable

who needs palliative care

• regardless of age, have a life-limiting illness

• e.g. cystic fibrosis, HIV/AIDS, End-stage dementia

types of illness trajectories

• Trajectory 1: short, period of evident decline - mostly cancer

• Trajectory 2: long term limitations with intermittent serious episodes accompanied with hospital admissions - mostly heart and lung failure

• Trajectory 3: prolonged dwindling - mostly frailty and dementia, function is consistently low

types of palliative care

• Group A: Primary Care - access to specialist care is not required

• Group B: Intermediate needs - experience sporadic exacerbations of symptoms, temporary increase in level of need, specialist palliative care required

• Group C: Complex Needs - complex physical, social, spiritual, psychological needs

community-based palliative care

• homes

• residential aged-care

• supported accommodation

• correctional facilities

• general practices

• community palliative care clinics and day centres

hospital-based settings for providing palliative care

• inpatient palliative care beds

• other inpatient e.g. acute, subacute, etc.

• outpatient services, specialist rooms and other ambulatory clinics

• ICU

• ED

advanced care planning

• process which is constantly reviewed

• where a person thinks about and plans for their future should they become unable to communicate

• promotes open and ongoing communication between patients, their families and health professionals about end-of-life decisions

advance health directive

• legal document that allows you to give directions about your future health care and special health care

• must be completed by a legally competent patient or by a legally appointed proxy

• may be completed as part of the Advance Care Planning Process

• varies according to the state/territory

Volunteer Assisted Dying legislation and role of SLP

• explicitly names speech pathologists

• SLPs have the right to participate in the request and assessment process, administration decisions, be present for the volunteer assisted dying substances

• provide information

what must the speech pathologist do if they consciously refuse to provide speech pathology services

• inform their employer or the other person that they consciously object

• inform the employer of other position of another provider requiest access to voluntary assistnat

• be present at the time of the administration of a voluntary assisted

• provide informatin to another person about voluntar noise

voluntary assisted dyig

• if a speech pathologsit refuses to provide speech pathology services for any nof the step due to consciousness object

  • they must conscientiously object

  • not intentionally impede the person’s access to voluntary assisted dying

importance of SLP guidelines at EOL care

• SPA currently do not have any clinical guidelines in palliative care

• guidelines about EDAR

• guidelines about ageing population

roles and responsibilities for speech pathology

• 1. consultation to patient, families and members of the MDT

• develop strategies in the area of communication skills in order to support themr in decision-making, maintaining social closes and to assist the patient in fulfillment of EOL goals

• assist in optimizing function related to dysphagia symptoms

• communciate with members of the MDT

communication interventions in palliative and EOL care

• communicate abilities can be underpredictable

Universal goals when developing communication strategies

• social and emotional closeness between the person in palliative care and their family

• optimisation of expression of needs, concerns, and preferences related to daily care and EOL decisions

• ability to express emotional state or any concerns about death and dying including, achieving a sense of spiritual and emotional closure prior to death

problems in oral feeding and EOL Care

• being unable to swallow is a common symptoms in the 25 hours before death

• malnutrition and dehydration an can contribute to additional medical problems

goals of dysphagia management

1. aggressive, life prolonging care

2. time-limiting trials to allow the person time for potential recovery

considerations for implementation of SLP

• person/family-centred approach

• bioethical principles such as patient autonomy not aligned with therapist’s goal of beneficence

• education and supervision

practical considerations for palliative care

• ensure facts about the clinical circumstance

• find out what other professionals have told them

• mentally prepare yourself

• show empathy, care and compassion during the entire consultation

• engage in active listening

• before giving new information, use open and direct questions to clarify their understanding

• clarify patient concerns

• expect sudden mood shifts

• don’t change the subject if the patient starts talking about dying

• patient-led: use the language they use if they use “death” and “dying”

• consider greetings: “how have you been this week?”

• express your appreciation for the visit

• realistic hope

• prepare

• relate to the person

• patient and caregiver preferences

• provide info tailored to the individual needs

• acknowledge emotions and concerns

• encourage questions and discussion

• document

preventing burnout as a clinician

• know your strengths and weakness

• find other interests other than work

• monitor physical health