This is the most useful piece I have read on this topic in my 40+ years of working in palliative care. Congratulations and thank you to the authors of the original paper and this superb commentary. Susan Block, MD
This is a keeper! As someone who is asked to participate in ordinary bedside ethics, that are never really ordinary, I will refer to this essay agin and again. Thank you for sharing.
What do you think of the role of Motivational Interviewing in palliative care for exploring ambivalence with patients? This article summarizes how Motivational Interviewing techniques can be applied in palliative care settings: "Applying Motivational Interviewing Techniques to Palliative Care Communication" (https://doi.org/10.1089/jpm.2010.049). The examples used are a bit clunky, but they point to how the basic techniques might be helpful. I'd be interested in hearing your thoughts.
I think there's definitely a place for MI in serious illness conversations. Like other communication skills, it involves respecting where people are and honoring the pace at which they can move. However, it can also come off feeling clunky, as you observe; their examples might be lifted straight into someone's clinical encounter. It feels clunky either because the clinician isn't used to doing this, or they don't really care about the process. They're using it with the hope that it's a secret password to get this person to do what they think is the right thing.
I am in the process of learning MI, and I now see that it’s more of an art form that requires practice and refinement rather than just a technique to add to the toolkit. And, like any art form, it can be beautiful when skillfully done.
The developers of MI recognize the importance of ethical sensitivity when applying MI, as it could be used as a technique for persuasion or, worse, manipulation, as you alluded to. A core part of the method is “focusing,” where the patient and clinician agree on the desired direction before exploring motivational factors. The authors advocate for counseling with neutrality and using decisional balance (giving equal emphasis to both sides of ambivalence) when a clear direction for the patient hasn’t been established yet. Evidence shows that decisional balance might reinforce rather than resolve ambivalence. However, it could also help the clinician and patient identify which of the nine types of ambivalence-related mental states are involved and offer a framework for addressing some of the relevant strategies. Additionally, it may increase the likelihood of peace of mind for the patient, family, and staff if all sides of ambivalence are voiced and explored before making a decision.
One thing I love about MI is its integrity, which draws on the humanistic leanings of the model's developers. The 4th edition manual begins by describing the "Spirit of MI":
• Partnership (combining the expertise of the helper and the ambivalent person to ‘dance’ together, neither simply leading nor following)
• Acceptance (in the manual, the authors paraphrase Rogers, “When people feel accepted as they are, they can change”)
• Compassion (the intention to alleviate suffering and support growth according to the needs and values of the ambivalent person)
• Empowerment (a strengths-based perspective rather than a deficit view, recognizing that people already have much of what is needed within them, and a helper's job is to evoke or bring it forth)
This underlying spirit, to me, harmonizes with the philosophy of palliative care. I, for one, would love to see more research conducted on the use of MI in palliative and critical care.
This is the most useful piece I have read on this topic in my 40+ years of working in palliative care. Congratulations and thank you to the authors of the original paper and this superb commentary. Susan Block, MD
Thank you for your kind words. This is a bedeviling topic and I’m glad these authors wrote so helpfully about it.
This is a keeper! As someone who is asked to participate in ordinary bedside ethics, that are never really ordinary, I will refer to this essay agin and again. Thank you for sharing.
Thank you for your kind words! I agree - these papers are frequently in my mind and I reference them often.
What do you think of the role of Motivational Interviewing in palliative care for exploring ambivalence with patients? This article summarizes how Motivational Interviewing techniques can be applied in palliative care settings: "Applying Motivational Interviewing Techniques to Palliative Care Communication" (https://doi.org/10.1089/jpm.2010.049). The examples used are a bit clunky, but they point to how the basic techniques might be helpful. I'd be interested in hearing your thoughts.
I think there's definitely a place for MI in serious illness conversations. Like other communication skills, it involves respecting where people are and honoring the pace at which they can move. However, it can also come off feeling clunky, as you observe; their examples might be lifted straight into someone's clinical encounter. It feels clunky either because the clinician isn't used to doing this, or they don't really care about the process. They're using it with the hope that it's a secret password to get this person to do what they think is the right thing.
I am in the process of learning MI, and I now see that it’s more of an art form that requires practice and refinement rather than just a technique to add to the toolkit. And, like any art form, it can be beautiful when skillfully done.
The developers of MI recognize the importance of ethical sensitivity when applying MI, as it could be used as a technique for persuasion or, worse, manipulation, as you alluded to. A core part of the method is “focusing,” where the patient and clinician agree on the desired direction before exploring motivational factors. The authors advocate for counseling with neutrality and using decisional balance (giving equal emphasis to both sides of ambivalence) when a clear direction for the patient hasn’t been established yet. Evidence shows that decisional balance might reinforce rather than resolve ambivalence. However, it could also help the clinician and patient identify which of the nine types of ambivalence-related mental states are involved and offer a framework for addressing some of the relevant strategies. Additionally, it may increase the likelihood of peace of mind for the patient, family, and staff if all sides of ambivalence are voiced and explored before making a decision.
One thing I love about MI is its integrity, which draws on the humanistic leanings of the model's developers. The 4th edition manual begins by describing the "Spirit of MI":
• Partnership (combining the expertise of the helper and the ambivalent person to ‘dance’ together, neither simply leading nor following)
• Acceptance (in the manual, the authors paraphrase Rogers, “When people feel accepted as they are, they can change”)
• Compassion (the intention to alleviate suffering and support growth according to the needs and values of the ambivalent person)
• Empowerment (a strengths-based perspective rather than a deficit view, recognizing that people already have much of what is needed within them, and a helper's job is to evoke or bring it forth)
This underlying spirit, to me, harmonizes with the philosophy of palliative care. I, for one, would love to see more research conducted on the use of MI in palliative and critical care.
SORRY, Joshua!
Jonathan, I echo Dr. Block. This is excellent.