2. COMFORT* • Communication (narrative) • Orientation and opportunity • Mindful presence • Family • Openings • Relating • Team * Wittenberg-Lyles, E., Goldsmith, J., Ferrell, B., & Ragan, S. (2012). Communication and palliative nursing. New York: Oxford.

3. Objectives • Describe a typology of family caregivers from a communication perspective • Identify two communication skills that could be used with family caregivers

4. Foundations: Family as System • Family system • Bounded, interrelated, identifiable communication • Interdependent • Influence one another • Environment • Interaction, adaption/resistance • Boundaries • Define system, communication between/with other systems

5. Family Communication Climates • Over time, families establish a communication climate (McLeod and Chaffee, 1972) • Two fundamental communication orientations contribute to this environment • Conformity • Conversation (Ritchie and Fitzpatrick, 1990; 1991; 1994)

6. Conversation Orientation • Degree to which all family: • Are encouraged to participate freely • Are encouraged to participate frequently • Are encouraged to participate without time limits • Are encouraged to participate without topic limits

7. Conformity Orientation • Degree to which all family • Stresses homogeneity of attitudes • Stresses homogeneity of beliefs • Stresses homogeneity of values • Stresses fixed family roles

8. Caregiver Type: Manager High family conformity/High family conversation • Caregiver dominates care planning • Caregiver as self-appointed Family Spokesperson • Caregiver controls decision-making • Context of illness exaggerates: • Limited communication within/by family • Lack of diversity in perspectives about illness • Obligation to conform in family

9. Things to look for* • Direct blocked communication • Hang up phone • Refuse to answer • Agree not to talk about illness • Indirect blocked communication • Not responsive • Appear uncomfortable • Self-censored speech *Kenen, R., Ardern-Jones, A., & Eeles, 2004

10. Caregiver Type: Carrier Low family conversation/High family conformity • Limited patient-caregiver discussions • Caregiver coping takes place outside of family • Illness perceived as private • Context of illness creates: • Dynamic of caregiver as a proxy for patient authority • Family conflict due to low conversation • Self imposed pressure to over-perform caregiving

11. Understand family coping style • Could you give an example of a difficulty your family has faced when you were growing up? • What helped your family get through this? • What was tried that did not help?

12. Caregiver Type: Partner High family conversation/Low family conformity • This caregiver partners with family and healthcare team • Ability to engage all quality of life dimensions • Family-prompted internal family meetings • Context of illness creates: • Open discussions about solutions and increased quality of life • An opportunity for this caregiver to be part of the care process • A place for family members to realize their caregiving strength

13. Assess family stressors • What else is going on in your family’s life? • What has helped you in dealing with these stressors? • What has not been helpful?

14. Caregiver Type: Loner Low family conversation/Low family conformity • A focus on one dimension of quality of life • Experiences caregiving as one acute crisis after the next • Can feel like a constant outsider to team and family • Context of illness creates: • Further isolation for patient, caregiver, and family • Unrelenting caregiver burden • Conflicts for healthcare team and system

15. Assessing family relationships • Tell me about your family. • Who is close to whom?

16. Team-based Family Care • Managers • Moderate family communication • Carriers • Encourage self-care • Mediate patient-caregiver communication • Partners • Establish clear routine • Educate about home care/pain meds • Loners • Provide assistance in information seeking • Spiritual care/counseling