Listen Between the Lines

The Hospitalist. 2006 June;2006(06):

June 1, 2006 | The Hospitalist

Fighting—with denial or ignorance—the resistance that patients might put up will more than likely provoke them. A fight for control can undermine and sabotage the best intentions of the provider and the greatest wishes for the patient to experience comfort or regain health and well-being. Rather than justifying wresting control from elderly patients because it’s for their own good, advises Solie, what we must do instead is to “step back, hand them the control baton, and allow them to run with it.”1

A person’s admission to the hospital “might be such a huge crisis for them, whereas for us it’s our routine work,” says Dr. Chittenden, who practices as a hospitalist and also works on her institution’s inpatient palliative care service. “And many people who are hospitalists—who are even in their late 20s, 30s, 40s—have been totally healthy their whole life, so it is hard to relate to what it’s like to be older and to be losing function, losing friends who are also dying, losing their house … . I think that it can be very helpful for the hospitalist to take a little more time and explore some of those issues [of loss and legacy]. I try to meet the person where they’re at and try to understand what their goals, needs, ... and fears are [as well as] their functional status.”

Allowing older patients to engage with you about their lives and their pasts is a privilege for any healthcare provider. Engaging with them in a way that will help facilitate their loosening the reins on control may expedite and allow greater quality into their healthcare. It may provide an opening whereby you can order that home-health visit with less struggle.

How to Address Patients’ Perceptions of Loss of Control

Watch your tone.
Listen (and wait) for the real message, the values.
Acknowledge where they are before encouraging them to move somewhere else in a decision. Use sentences such as “I know it is hard to keep going in the face of all these setbacks.” Or “I know you’re dealing with a lot of loss with this new set of news and what’s been going on with you over the past year. How can I help you regain a sense of balance?”
Remember that the first “no” may be a warm-up answer.
Keep in mind that a change in direction may reveal something else of significance.
Consider that explosive responses signal unresolved control issues.
Remain patient while listening to the details.
Keep your perspective.

It is no wonder that older adults exhibit what we consider to be resistance to their changing lives. In terms of a hospitalization, this may mean saying “no” to medications, individual providers, tests, surgery, home-health visits, or something as small as being talked to or touched in what they perceive as a disturbing or mechanized manner.

Create Openings

“There are a lot of different ‘on-ramps’ to asking the life-review questions, which are extremely comforting,” says Solie. “For example, you might say, ‘Mary, I notice that you were born in Iowa. You know, my family on my father’s side came from Iowa. Where were you raised?’ And ‘Do you have a big family on your farm, because my aunt had cows.’”

Once you get a response that engages the patient, then you “are in the slipstream. Physicians have such a high experience curve, they see so many patients,” he says. “They don’t have to go very far into their inventory of experiences [to find one] that essentially matches up with that patient.”