session 6 egener compassionate refusal

NW Center -- Egener. Comp refNW Center -- Egener. Comp ref

The Compassionate The Compassionate Refusal of OpioidsRefusal of Opioids

A Negotiation StrategyA Negotiation Strategy


NEGOTIATING WITH DRUGNEGOTIATING WITH DRUGSEEKING PATIENTSSEEKING PATIENTS

NEGOTIATION STEPSNEGOTIATION STEPS1.1. Elicit The Patient’s PerspectiveElicit The Patient’s Perspective

2.2. Present Your PerspectivePresent Your Perspective

3.3. Arrive At Common GoalsArrive At Common Goals

4.4. Set LimitsSet Limits


NEGOTIATING WITH DRUGNEGOTIATING WITH DRUGSEEKING PATIENTSSEEKING PATIENTS

NEGOTIATION PROCESSNEGOTIATION PROCESS• Deal With EmotionsDeal With Emotions• Don’t Be DefensiveDon’t Be Defensive• Share ControlShare Control• Focus On Function, Not PainFocus On Function, Not Pain


Negotiation Step #1:Negotiation Step #1:Elicit the Patient’s PerspectiveElicit the Patient’s Perspective

Help the patient describe:Help the patient describe:• The nature of the problem and how the The nature of the problem and how the

problem has affected him/herproblem has affected him/her• Beliefs about causationBeliefs about causation• Concerns about consequences of pain/ the Concerns about consequences of pain/ the

futurefuture• Expectations: Expectations: ExactlyExactly what help the patient what help the patient

wantswants

DON’T ASSUME YOU KNOW!DON’T ASSUME YOU KNOW!


Negotiation Step #2:Negotiation Step #2:Present Your PerspectivePresent Your Perspective

Create an Empathic BridgeCreate an Empathic Bridge

Present Your PerspectivePresent Your Perspective

Patient EducationPatient Education


Negotiation Step #3:Negotiation Step #3:Agree on Common GoalsAgree on Common Goals

Concentrate on Areas of AgreementConcentrate on Areas of Agreement

Allows Collaboration Despite Allows Collaboration Despite DisagreementDisagreement

If unable to identify common goals, If unable to identify common goals, revisit patient perspective (step #1)revisit patient perspective (step #1)


Negotiation Step #4:Negotiation Step #4:Set LimitsSet Limits

Frame limits professionally, not Frame limits professionally, not personallypersonally

Concentrate on what you Concentrate on what you areare willing to willing to do, rather than on what you refuse to do do, rather than on what you refuse to do


DEALING WITH EMOTIONSDEALING WITH EMOTIONS

ReflectionReflection

ValidationValidation

SupportSupport


REFLECTIONREFLECTION

““You seem upset by what I’ve said.”You seem upset by what I’ve said.”

““You seem pretty angry.”You seem pretty angry.”


VALIDATIONVALIDATION

““Anyone would be upset if they had to Anyone would be upset if they had to deal with pain 24 hrs a day.”deal with pain 24 hrs a day.”

““I can understand that you might be angry I can understand that you might be angry with me for not prescribing narcotics with me for not prescribing narcotics when that’s the main reason you came when that’s the main reason you came in today.”in today.”

YOU DON’T HAVE TO AGREE TO YOU DON’T HAVE TO AGREE TO EXPRESS UNDERSTANDING!EXPRESS UNDERSTANDING!


SUPPORTSUPPORT

““I’m sure it’s been difficult to keep going to I’m sure it’s been difficult to keep going to the doctor and to repeatedly have these the doctor and to repeatedly have these tugs of war about a prescription.”tugs of war about a prescription.”

Or, for example, instead of speaking, Or, for example, instead of speaking,

Hand a crying patient a tissue.Hand a crying patient a tissue.


Don’t Be DefensiveDon’t Be Defensive

Defensiveness Escalates EmotionDefensiveness Escalates Emotion

Instead, make a statement about the Instead, make a statement about the patient’s experiencepatient’s experience


Share ControlShare Control

Models CollaborationModels Collaboration

Empowers the Patient to Make Empowers the Patient to Make Changes Changes


Focus on FunctionFocus on Function

Permits progress despite ongoing painPermits progress despite ongoing pain

What can the patient do?What can the patient do?

What do the symptoms prevent?What do the symptoms prevent?


When Doctor and Patient Can’t AgreeWhen Doctor and Patient Can’t Agree

Identify the impasseIdentify the impasse

Clarify boundariesClarify boundaries

Manage your reactionsManage your reactions


Identify the ImpasseIdentify the Impasse

““It seems like we have reached an It seems like we have reached an impasse.”impasse.”

““You and I have very different views on You and I have very different views on how best to manage your pain.”how best to manage your pain.”


Clarify BoundariesClarify Boundaries

What you What you willwill do: do:

““I’d like to be your doctor and continue to I’d like to be your doctor and continue to help you with your help, despite our help you with your help, despite our disagreement.”disagreement.”

What you What you will notwill not do: do:

““Prescribing more of this medicine is Prescribing more of this medicine is something that is not in your best long-something that is not in your best long-term interest. It is something that I feel term interest. It is something that I feel uncomfortable with and cannot do.”uncomfortable with and cannot do.”


Manage Your ReactionsManage Your Reactions

When you say “No”When you say “No”

• What do you feel?What do you feel?

• What thoughts do you have?What thoughts do you have?


Learn to Soothe YourselfLearn to Soothe Yourself

BreatheBreathe

Self-talk:Self-talk:““I’m being a helpful doctor.”I’m being a helpful doctor.”

““I can get through this.”I can get through this.”

session 6 egener compassionate refusal

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