Life Review As a Clinical Tool

Life Review

M-III / M-IV

SENIOR MENTOR SESSION

LIFE REVIEW AS A CLINICAL TOOL

Goal:To understand in older adults the benefits of:

1. patient-centered interviewing
2. assessing psychosocial issues, values, beliefs, and the meaning of an illness

Session Objectives:

The student will:

1. Utilize patient-centered interviewing by using the “L-I-S-T-E-N” method to conduct a brief clinical life review.
2. Demonstrate integrative reasoning skills after conducting a brief clinical life review by depicting main events, stresses, successes, values, and meaning on a time line and/or with a pictorial representation.
3. Analyze and write the brief clinical life review interview identifying dominant themes and aspects of meaning as they relate to the senior’s health and well-being.

Didactic Session: The instructional session will be held in the M-III year during your Psychiatry Clerkship for the Columbia students and at M-III orientation on July 6, 2004 for the Greenville students. Dr. J.T. Thornhill will be the instructor for this one-hour session which will use a lecture format combined with role play and group discussion.

Instructions to Students:

Introduction:

In order to develop satisfying patient/physician relationships, physicians need to understand patients’ perceptions of their illness and how their values and beliefs affect behavior and health outcomes. Patient-centered encounters result in improved patient and physician satisfaction, fewer diagnostic tests and referrals, and do not extend the time of office visits. At the same time they provide a way to learn about the meaning the patient attributes to an illness. Brief clinical life review provides one way to get to know a patient, and through this knowledge understand his/her life perspective.

This assignment will help you cultivate your listening skills, and thereby learn the meaning attributed to an illness. The key is to listen carefully to learn what is important to the patient. For example, as a physician you may be most concerned about your patient’s diabetes, while she is most concerned about her backache and how it is affecting her ability to travel. Learning her perspective may then reveal why she focuses more on pain medications than on behaviors to manage glucose levels.

Paradoxically, the present medical system rewards physicians for getting facts, on which to diagnose and treat disease. It does not emphasize listening and considering the patient as a person. (Cluff, 2001; Spiro, 1993). However, this exercise is not about gathering information, it is about getting to know your mentor as a person, and how this knowledge may help you understand behaviors which affect his/her health and well being. It is a way for you to understand your mentor as a person not just as an old person with an illness.

We will not quiz you on this exercise, yet we hope you learn how life review and reminiscing may be of value in medicine, and how values, beliefs, and circumstances influence health and health behaviors.

Steps to Follow

Step One:Participate in the interactive seminar “Life Review as a Clinical Tool.” See Appendix A: Life Review as a Clinical Tool: Power Point Presentation (page 6).

Step Two:Study skill review handouts. See Appendix B (page 14):

1) Branching question

2) Open-ended questions

3) Summarizing

4) L-I-S-T-E-N format

Optional: (1) Watch film entitled A Trip to Bountiful or Strangers in Good Company; (2) read an article from the life review bibliography (Appendix C, page 16). These are available in the Office of Curricular Affairs, Room 310 Medical Library Building, Columbia.

Step Three:Visit your senior mentor. Begin the session by taking your mentor’s blood pressure. Don’t forget to record it on the blood pressure card and in your paper.

Step Four:Conduct a brief clinical life review interview (1/2 -1 hour) with your mentor using the branching question and L-I-S-T-E-N interview format. See Appendix B (page 14). If your mentor is willing to be audio taped, take a tape recorder so you can leave the audiotape with your mentor. Many of the mentors have expressed the value of having a copy as a documentary/keepsake of their life for their family members.

Step Five:After the interview, diagram with your mentor's input what you have learned from the interview. Use a pictorial representation. Be sure to note branching points. Give particular attention to health-related events, stresses, and successes.

Diagramming Life Review

Many methods can be used to visually depict a person’s life. For this exercise do not use a timeline. Although a timeline can be an effective way to represent chronological life events, it utilizes a different format. This exercise should be based on a mentor-centered interview in which the mentor decides how to tell about his/her life without interruption. This exercise utilizes four open ended questions and a tree analogy rather than the time line.

Using a tree analogy will illustrate the branching metaphor and will be helpful in presenting what you have learned from your mentor in an integrated fashion. First, think of how you might characterize the tree based on what you learned in the life review interview. Next, draw the tree with its distinguishing branches and characteristics. Once this is complete, insert representations for important events. You may use words or symbols to depict important events and values. Color coding may help to distinguish various types of events: for example, red to signify health events, green to represent growth events, gold for successes, and blue for stresses, pain, or suffering.

Step Six:Finally, an important step in completing the life review interview is to check for understanding. You can do this by summarizing the branching points and/or by discussing the diagram of the mentor’s life with him/her.

Check with the individual to determine whether the assessment is accurate and complete. Make modifications according to what your mentor reflects back the feedback you receive. This dialog fosters understanding. Remember this is the mentor’s story and your mission is to understand what they understand about their life and health.

Check for understanding. You may need to schedule another visit with your mentor, or begin your next visit to your mentor with a review of the diagram. Ask your senior mentor about the accuracy and completeness of your diagram. Ask integrative questions such as those suggested below. Modify your diagram if indicated. Encourage your mentor to give suggestions, additions, and insights.

Remember to use integrative questions such as:

Where does your strength come from? (i.e. tree trunk)

What do you think are the roots of your life? (i.e.tree roots)

What gives your life meaning? (extrapolated from strength and roots)

Step Seven:Copy your diagram. Give the original to your mentor and submit a copy (preferably on 8 ½ x 11 paper) to Dr. Nancy Richeson in the Office of Curricular Affairs, Room 310 Medical Library Building.

Paper Due Date/Directions:One of your four Senior Mentor assignments is due by December 17, 2004. You may choose whichever one you would like to submit to meet this first deadline, keeping in mind that this particular assignment should not be completed until after your didactic session during the M-III Psychiatry rotation (or during the M-III orientation for the Greenville students). See the timeline in the overview for other due dates.

Write a reflection paper (11/2 - 2 double-spaced pages) incorporating the Student Questions listed below. Submit the reflection paper to Dr. Nancy Richeson as hard copy (Room 310, Medical Library Building) or electronically to . Please make sure that you also turn in your diagram as indicated in Step Seven above.

Student Questions:

1. What were the dominant early, mid-life, and late life themes in your mentor’s life? Summarize these in a few sentences.
2. Were there themes that seemed emotional? If so, what were they and how were they significant?
3. Were there themes that seemed to elicit expressions of meaning and /or value? If so, what were they and how have they been significant throughout your mentor’s life?
4. Which of your mentor’s values/beliefs may have significantly affected his/her health behaviors or outcomes? How?
5. How did any significant stresses/successes/health related events affect your mentor’s life or cause your mentor’s life to alter its course?
6. Describe how your mentor currently feels about his/her health.
7. What information surfaced in the interview that you think could influence future medical recommendations?
8. What was your mentor’s blood pressure? Please record it in your paper.

Skills:

1.Active, reflective listening

2.Patient-centered interviewing including: (1) using open-ended questions, (2) checking for listener understanding, and (3) mentor providing feedback to the interviewer

3.Conducting a brief clinical life review interview

4.Critical reasoning

5.Blood pressure determination and recording

Equipment / Materials to Take to the Life Review Interview:

1)Tape recording equipment and tape (if applicable). These can be checked out from Shelley Coburn at (733-1570) or from Shaun Riffle at (733-1583) at the SOM Office of Curricular Affairs and Faculty Support

2)Life Review Note Form (Appendix D -- page 17 of this packet)

3)Materials to make a diagram - paper, pencil (colored pencils, optional)

4)Blood Pressure Equipment:Blood Pressure Cuff, Stethoscope

5)Blood Pressure Card

6)White Medical Coat

7)TSAD Card

***DON’T FORGET TO HAVE YOUR TSAD CARD SIGNED BY YOUR MENTOR FOR BOTH THE VISITS AND THE ASSIGNMENTS. THE SENIOR MENTOR ASSIGNMENTS, HOWEVER, WILL REQUIRE A C0-SIGNATURE BY DR. RICHESON AFTER YOU HAVE SUBMITTED THE APPROPRIATE WRITTEN MATERIAL FOR THESE ASSIGNMENTS***

Appendix B – Skills Review

SKILL 1

BRANCHING QUESTION

MAIN QUESTION:

Use this question exactly as it is written. It will help focus and limit the interview while allowing the interviewee to interpret the events of his/her life. Practice using this question until you can use it naturally.

Your life, like a tree or river, has had branching points. Tell me about your life. What events, experiences, or circumstances have most affected your life -- have been the branching points that shaped your life?

FOCUSED FOLLOW-UP QUESTIONS

Follow-up 1: What health related events caused your life to branch or take another course?

Follow-up 2: What stresses caused branching points or life altering courses for you?

Follow-up 3: What successes or happy times caused branching points?

INTERPRETIVE FOLLOW-UP QUESTIONS

Follow-up 4: Where does your strength come from? (i.e. tree trunk)

Follow-up 5: What do you think are the roots of your life? (i.e,.tree roots)

Follow-up 6:What gives or has given your life meaning?

SKILL 2

OPEN-ENDED QUESTIONS

Open-ended questions are tools that promote creative thought, problem-solving skills, and integrative reasoning. Use open-ended questions, such as those below. You will be surprised at what you learn from your patients.

• How do/did you understand that event?
• What did that event mean to you?
• How did you …?
• What feelings did you have?
• In what ways were these events similar? Different?
• Why do you think this happened?
• How could things have been different/better/improved?
• Just suppose that…then what?
• What was this like for you?

SKILL 3

SUMMARIZING

Reflective listening requires that one paraphrase what has been heard and attempt to reflect the meaning of what was said. Reflective listening requires empathy. The listener reflects both the speaker’s feelings and the content. Content is important, but the intent behind the message is more important.

Reflective listening allows individuals to solve their own problems. A skilled listener will help others see themselves in a mirror so they can make the necessary changes. Mastering this skill requires compassion and empathy. Intonation, emotions, and body language in addition to the words help clarify the meaning of the words. Listen to understand, not necessarily to agree. Summarize content and feeling.

When events that are emotional are revealed such as a death, loss, failure, or success – reflect back to the speaker the emotion that you detect rather than asking for facts or changing the subject. For example, say “That was a big loss for you.” When a stress is revealed, the listener can empathize by saying, “That was a difficult time.” Likewise, when your mentor discusses a particularly happy event you might respond, “What a joyous occasion!”. Do not redirect the conversation by your interjections. Just verify the emotion or in a half dozen words or less summarize the meaning of the event to underscore that you heard the importance of the revelation.

SKILL 4

L-I-S-T-E-N FORMAT

Using the LISTEN format will insure that the interview is patient-centered and provides a foundation for conducting a brief clinical life review.

6 Steps for Patient-Centered Interviewing

L earn from open-ended questions

I ntegrate facts with emotional content

S ummarize for accuracy and completeness

T alk about omissions and meaning

E mpathize by validating

N egotiate recommendations

Appendix C

Life Review as a Clinical Tool: Bibliography

Beck, R. S., Daughtridge, R., & Sloane, P. (2002). Physician-patient communication in the primary care office: A systematic review. Journal of the American Board of Family Practice, 15(1), 25-38.

Beechem, M. H., Anthony, C., & Kurtz, J. (1998). A life review interview guide: A structured systems approach to information gathering. International Journal of Aging and Human Development, 46(1), 25-44.

Bellet, P. S., & Maloney, M. J. (1991). The importance of empathy as an interviewing skill in medicine. Journal of the American Medical Association, 266, 1831-1832.

Birren, J. (1991). Guiding autobiography groups for older adults: Exploring the fabric of life. Baltimore: Johns Hopkins University Press.

Butler, R. N. (1980-81). The life review: An unrecognized bonanza. International Journal of Aging and Human Development, 12(1), 35-38.

Charon, R. (2001). Narrative medicine: A model for empathy, reflection, profession, and trust. Journal of the American Medical Association, 286(15), 1897-1902.

Cleaveland, C. (1998). Sacred space: Stories from a life in medicine. Philadelphia: American College of Physicians.

Cluff, L., E., & Binstock, R. H. (Eds.). (2001). The lost art of caring: A challenge to health professionals, families, communities, and society. Baltimore: The Johns Hopkins University Press.

Haight, B., Webster, J. D. (Eds.) (1995). The art and science of reminiscing: Theory, research, methods and applications. Washington, DC: Taylor & Francis.

Kaplan, S. H., Greenfield, S., & Ware, J. E. (1989). Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Medical Care, 17, S110-127.

McFarland, K. F., Rhoades, D. R., Campbell, J., & Finch, W. H. (2001). Meaning of illness and health outcomes in type I diabetes. Endocrine Practice, 7(4), 250-255.

Molinari, V. (1999). Using reminiscence and life review as natural therapeutic strategies in group therapy. In M. Duffy (Ed.), Handbook of Counseling and Psychotherapy with Older Adults (pp. 154-165). New York: John Wiley & Sons Inc.

Novack, D. H., Suchman, A. L., Clark, W., Epstein, R. M., Najberg, E., & Kaplan, C. (1997). Calibrating the physician: Personal awareness and effective patient care. Journal of the American Medical Association, 278(6), 502-509.

Remen, R. N. (1996). Kitchen Table Wisdom. New York: Riverhead Books.

Spiro, H., Curnen, M. G. M., Peschel, E., & St.James, D. (Eds.). (1993). Empathy and the Practice of Medicine. New Haven: Yale University.

Stewart, M., Brown, J. B., Donner, A., McWhinney, I. R., Oates, J., Weston, W. W., & Jordan, J. (2000). The impact of patient-centered care on outcomes. Journal of Family Practice, 49(9), 796-804.

Suchman, A. L., Markakis, K., Beckman, H. B., & Frankel, R. (1997). A model of empathic communication in the medical interview. Journal of the American Medical Association, 277(8), 678-682.

Suchman, A. L., & Matthews, D. A. (1988). What makes the patient-doctor relationship therapeutic? Exploring the connexional dimension of medical care. Annals of Internal Medicine, 108, 125-130.

Appendix D -- Life Review Notes Form

Name ______Date ______

1. Your life, like a tree or river, has had branching points. Would you tell me about your life? What events, experiences or circumstances have most affected your life—have been branching points that shaped your life?
2. What health related events caused your life to branch or to take another course?

1. What stresses caused branching points or life altering courses for you?
2. What successes or happy times caused branching points?

1. Tell me more.
2. Where did that lead?
3. How did that affect or influence you?
4. What meaning does that have for you?

Sample integrative questions:

What do you think are the roots of your life? (i.e. tree roots)

Where does your strength come from? (i.e. tree trunk)

What gives your life meaning? (use your own creativity)

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