1. TNEEL-NE Mrs. Gregory Case Study Stuart J. Farber, MD

2. Slide 2 Connections: Communication Case Studies: Mrs. Gregory TNEEL-NE Case Study: Mrs. Gregory Mrs. Gregory is a 62-year-old woman who has been complaining of increasingly severe upper abdominal pain and weight loss. An ultrasound by Dr. Minor revealed a mass highly suspicious for primary liver cancer. Mrs. Gregory and the youngest of her three daughters, Gloria, have come to your office to discuss the test results. Click image to play video clip. Mrs. Gregory Age 62

3. Slide 3 Connections: Communication Case Studies: Mrs. Gregory TNEEL-NE Case Study: Mrs. Gregory Effective Responses (Click the response text to play an audio clip) Empathic: I can appreciate that this has been a difficult discussion. Reflective: I'm confused because I just heard you say two different things; That you don't want to hear any more bad news and also that you don't think anything is wrong. Open-ended: Could you share with me more about what you are thinking so we can work together? I can appreciate that this has been a difficult discussion. I'm confused because I just heard you say two different things; That you don't want to hear any more bad news and also that you don't think anything is wrong. Could you share with me more about what you are thinking so we can work together?

4. Slide 4 Connections: Communication Case Studies: Mrs. Gregory TNEEL-NE Case Study: Mrs. Gregory Less Effective Responses (Click the response text to play an audio clip) Empathic: I understand how you're feeling. Reflective: You don't seem to have heard what Dr. Minor has just told you. Open-ended: What is it that you don't understand? I understand how you're feeling. You don't seem to have heard what Dr. Minor has just told you. What is it that you don't understand?

5. Slide 5 Connections: Communication Case Studies: Mrs. Gregory TNEEL-NE Case Study: Mrs. Gregory Nonexamples (Click the response text to play an audio clip) Directive: The doctor says that you need to take these pills. Reflective: They are for your pain. Close-ended: You should take these pills every four hours. The doctor says that you need to take these pills. They are for your pain. You should take these pills every four hours.

6. Slide 6 Connections: Communication Case Studies: Mrs. Gregory TNEEL-NE Case Study: Mrs. Gregory Family-Oriented Responses (Click the response text to play an audio clip) Effective: You look really concerned. How are you doing? I can tell this has been really hard for both of you. What can we do now that would be of help to you? Less Effective: Your family may have a different idea about this. Nonexample: This is your choice to make. We'll do whatever you say. You look really concerned. How are you doing? I can tell this has been really hard for both of you. What can we do now that would be of help to you? Your family may have a different idea about this. This is your choice to make. We'll do whatever you say.

7. Slide 7 Connections: Communication Case Studies: Mrs. Gregory TNEEL-NE Case Study: Mrs. Gregory Click image to play video clip. Mrs. Gregory continues to deny that anything is wrong with her. Her daughter, Gloria, wants to help her come face-to-face with her liver cancer as well as the issues surrounding her illness. Gloria

8. Slide 8 Connections: Communication Case Studies: Mrs. Gregory TNEEL-NE Case Study: Mrs. Gregory Effective Responses (Click the response text to play an audio clip) Empathic: This must be really hard for you. Reflective: It sounds like you feel caught in the middle. Open-ended: If your mother agrees, what do you think about the possibility of you and your sisters coming in together for a family conference? This must be really hard for you. It sounds like you feel caught in the middle. If your mother agrees, what do you think about the possibility of you and your sisters coming in together for a family conference?

9. Slide 9 Connections: Communication Case Studies: Mrs. Gregory TNEEL-NE Case Study: Mrs. Gregory Less Effective Responses (Click the response text to play an audio clip) Empathic: I know just how you feel, my mother died five years ago. Reflective: This is hard for everyone. Open-ended: What do you want us to do? I know just how you feel, my mother died five years ago. This is hard for everyone. What do you want us to do?

10. Slide 10 Connections: Communication Case Studies: Mrs. Gregory TNEEL-NE Case Study: Mrs. Gregory Nonexamples (Click the response text to play an audio clip) Empathic: You'll get over it. Reflective: I talked to the doctor and I know he told her about how seriously ill she is and he wants to refer her to hospice. Close-ended: You and your sisters need to sit down and talk. You'll get over it. I talked to the doctor and I know he told her about how seriously ill she is and he wants to refer her to hospice. You and your sisters need to sit down and talk.

11. Slide 11 Connections: Communication Case Studies: Mrs. Gregory TNEEL-NE Case Study: Mrs. Gregory Family-Oriented Responses (Click the response text to play an audio clip) Effective: A lot of families find it helpful to come in together and discuss these issues. Less Effective: These things will all work out in the end. Maybe your sisters just need more time. Nonexample: If this is a problem, your mother will need to call us to discuss it. A lot of families find it helpful to come in together and discuss these issues. These things will all work out in the end. Maybe your sisters just need more time. If this is a problem, your mother will need to call us to discuss it.

12. Slide 12 Connections: Communication Case Studies: Mrs. Gregory TNEEL-NE Case Study: Mrs. Gregory Click image to play video clip. Family conference with Mrs. Gregory’s daughters discussing father’s death

13. Slide 13 Connections: Communication Case Studies: Mrs. Gregory TNEEL-NE Case Study: Mrs. Gregory Click image to play video clip. Mrs. Gregory’s Pain Goals

14. Slide 14 Connections: Communication Case Studies: Mrs. Gregory TNEEL-NE Case Study: Mrs. Gregory Click image to play video clip. Daughters debate Mrs. Gregory care – coma