Unit 3: Communication skills and discussing sensitive topics

REMAP framework

The REMAP framework was designed to help clinicians navigate difficult conversations in the context of palliative care. It is a useful tool to use if you encounter any difficulty in communicating with family carers during Family Care Conferences. It stands for:

• Reframe your question/your statement to the family carer
• Expect emotion from the family carer and respond with empathy
• Map out patient values and what’s important to the family carer
• Align your recommendations with the values required to deliver the best care
• Plan with the family carer and set out a way to match what is important to them with the values required to deliver the best care for the person with dementia

The REMAP framework and how to use it

In this video, Dr Karen Harrison Dening talks you through how to use the REMAP framework to aid you in any difficult conversations with family carers:

Key principles of good communication when discussing sensitive topics

As nurses, you will be aware of the principles of good communication that underpin your interactions with residents and their families. The key principles of communication we have listed below are especially important when discussing sensitive topics and you should focus on these during Family Care Conferences:

• Check the family carer’s understanding; for example: “what do you understand about why we are meeting today/your father’s condition?”
• Clarify anything they do not seem to understand, avoiding use of jargon. Use language that is appropriate to the family carer’s level of understanding (try to reflect the language they use)
• Give the family carer the time they need to absorb and process the information you are giving them and to ask questions
• Try not to assume their thoughts/feelings and encourage them to express any concerns they have
• Give them space to express any feelings they are experiencing and validate these if they share them with you; for example: “I can understand that it is painful for you to think about losing your mum”, “it sounds like you are feeling overwhelmed and scared of making the wrong decisions. Is this where you’re at right now?”
• Reassure them and remind them that you are there to support them. Signpost them to other sources of support if needed
• Make sure the family carer has understood what you have discussed by asking them to briefly summarise the key parts of your meeting; for example: “before we finish our meeting, I want to check in with you to find out what you feel are the key points we have discussed today. What are our next steps?”

Best interests’ decision-making

The person responsible for making end-of-life decisions for a person with advanced dementia should ideally be the person with dementia themselves; so, if they have an advance care directive or advance care plan in place, this should be consulted.

However, people with dementia often have not made advance care plans and may not have capacity to decide things such as their preferred place of care and medical treatments they would or would not wish to receive as their dementia progresses to an advanced stage. In these situations, the person responsible for making end-of-life decisions will usually be a power of attorney (if a person has appointed one to advocate for their health and welfare), a social worker, doctor, or a consultant – depending on the kind of decision it is. For instance, decisions about medical treatment would be the responsibility of a doctor. The Alzheimer’s Society provide more information on this here.

It is important that family members are encouraged to participate and share their insight into the person’s wishes and preferences, and independent mental capacity advocates can be appointed where necessary.

In this video, Dr Karen Harrison Dening and Rita Brady describe the process of decision-making and explain best interests’ decisions:

This video shows you an example of how to approach a disagreement between two siblings at a Family Care Conference. It includes elements of the REMAP framework outlined in Unit 3:

Here is an example of a rushed Family Care Conference. You can see this does not go well and that many of the resources from Units 2 and 3 have not been used to guide this conversation. It is important to implement the learning in this resource to achieve a positive outcome from these meetings:

This is an example of how interruptions and being underprepared could impact on your meetings with family carers. Make sure you refer to the guidance in Unit 2 on planning and preparing for a Family Care Conference; simple practices such as preparing the room, using signage to indicate a meeting is in progress, and putting your phone on silent can set the meeting up for success:

Unit 3 Quiz

Please answer the following questions to show how much you have learned from Unit 3: