How do you engage people to talk about advance care planning? At Vital Decisions we spend a lot of our time thinking about this issue and how to help patients get the care they want. One of the key elements of this thinking is Motivational Interviewing and how it applies to advance care planning. This effort is led by our Chief Clinical Officer Colleen Marshall. Colleen has designed a program that regularly achieves a 40% engagement rate and she has trained hundreds of people on the process.
I sat down with Colleen recently to gain some insight on why Motivational Interviewing is working for Vital Decisions and how she overcomes some barriers with advance care planning conversations.
Motivational Interviewing is best known for its effectiveness for conditions like addiction or weight loss. How have you adapted those principals to Advance Care Planning conversations?
Colleen: At its core motivational interviewing is about helping people make a change with a clear target behavior. The principals, style of being with someone, skills and strategies can apply to a wide range of behaviors. In the case of advance care planning the target behavior is to help people think and make a decision now about their future healthcare choices and communicate those choices to others. In that case we want to be clear about what advance care planning is and listen for language that tells us someone is interested in taking steps now or they are thinking about changing their behavior of planning for care in the future and then helping them work through the process to make that real.
The four processes are:
Engaging – express and show empathy to truly understand what someone wants, what they are struggling with now and what they believe is important and feel is possible for them.
Focusing - collaboratively setting a focus for our work together to help the person work through a specific target they are thinking about making a change in.
Evoking - Evoke from the person their own ideas of what is important to them, what they want, why they want it, what they believe is possible and what they feel ready to do or what might help them feel ready to take the next step.
Planning – Once the person is clear on what they want, why they want that, and what they think is possible, planning helps think through all the things that will help them be successful to carry out that vision, that hope.
Our relationship to the patient needs to be empathetic and one where we care about their goals not ours, this sounds simple but can take years of practice and constant coaching. It is really hard to trust that all you can do is your best in offering a conversation about change and then let go of the outcome and support the other person’s autonomy in making their own choice. It really comes down to trusting in the individual and trusting that your goal is simply to guide but not control or influence
Engaging patients who have not or maybe do not want to talk about advance care planning is difficult yet you have achieved engagement rates of over 40% with your program. What is the key to your success?
Colleen: One of the core principals in motivational interviewing is to create a space where we don’t have an agenda about what we want someone to do or what decision we want them to make. We have a HOPE, but we don’t have an agenda. That might seem like a small difference but it takes a lot of practice to internalize and it makes all the difference in the world when you do.
When people feel pushed to do something rather than supported to make their own choice, they push back. That is why typically programs where engagement is about getting someone to agree to what you want them to do, rather than focused on understanding what they want to do have lower engagement rates. Our goal is to help people find what they want and help them do that. I believe that is at the core of our 40% engagement.
Engagement happens best when we recognize that each person's story is unique, we listen to their holistic story and don’t pressure them to do what we think is best but rather help them match their unique goals and their ideas on how to make that happen, to their future care goals.
That process always starts with letting people tell their story and understanding why they want what they want. If you don’t understand a patients WHY it is almost impossible to help them reach and sustain their goals.
Continue reading the second half of the interview here where Colleen explains how to have meaningful ACP conversations and how to overcome some common barriers that arise.
Thank you to Colleen for sharing her thoughts. If you would like to talk to her more about this you can contact her at CMarshall@vitaldecisions.net