Communication Flashcards
Breaking Bad News
INTRODUCE
- I’m the senior doctor who who has been caring for X tonight…
? SUPPORT PERSONS
- Is there anyone else that you would like here with you before we speak?
CURRENT UNDERSTANDING
- What do you already understand about the situation?
WARNING SHOT
- Dead: the news I have for you is very bad
- Sick: I am very worried about X
DELIVER NEWS
- I’m really sorry to give you the news….
- X died shortly after arriving to hospital
- X is on life support, but isn’t going to survive this illness/ these injuries
SILENCE
- I have some more information to give you when you feel ready
BRIEF DESCRIPTION
OFFER TO SEE
- Would you like to see X?
- You will see……
CONSULTANTOID
- Coroner
- Organ donation
- Social work/ Religious support
Organ Donation
FAMILY UNDERSTANDING BRAIN/ INEVITABLE DEATH
RAISE TOPIC
- I would like to speak with you about something you may not necessarily be expecting, and that is organ donation
- There is the opportunity for X to help a lot of people
CURRENT UNDERSTANDING
? PRIOR WISHES
- Do you know if X had registered for organ donation?
–> Still need family consent.
- Do you have a sense for what they would have wanted?
REFERRAL
- We have a team who are experts in this field and can give you a lot more information about what is involved.
- Process: discuss with team, medical testing, harvest, return of body for funeral.
Open Disclosure
INTRODUCE AND REASSURE
- Do you know what has happened?
- X is stable and comfortable now, you will be able to see them soon
- If missed Dx, first ensure safety and comfort.
EXPRESS REGRET
- I’d like to offer an apology for what has happened
- Errors like this are not common, and its being taken seriously
FACTUAL ACCOUNT of events
THEIR PERSPECTIVE
- What has been the experience from your side of this?
CONSEQUENCES
- Actual and potential
- Pain, time off work, return appointment etc.
STEPS TO RESOLVE AND MITIGATE
- There will be a formal investigation process (describe)
- Find out what went wrong and how to prevent it happening again
FOLLOW UP
- I can give you a call in X time to keep you informed of progress?
…Would you now like to go and see X?
CONSULTANTOID
- Complaints avenues
- SLRS
- M&M, RCA
- Educations sessions
Complaint
LISTEN
- What is your perspective here?
VALIDATE
- I can see you’re upset
- I can understand why
HOW BEING ADDRESSED
- We are taking this seriously
- A full investigation will occur, which will involve A,B,C
- This info used to prevent similar happening again
FORMAL AVENUES
- There are avenues for making a formal complaint. I would suggest contacting the hospital Patient Liason Officer
FOLLOW UP
- I will call you in 48 hours to keep you informed of progress
CLOSURE
- Do you have any further concerns you feel we haven’t covered?
Angry Patient/ Family
EXPLORE AND LISTEN
- Can you tell me what’s concerning you?
THANK THEM for explaining
“SAVE”
Support: “I’d like to work with you to resolve this”
Acknowledge: “You appear to be quite upset”
Validate: “Given what you’ve described, I can understand you feeling this way”
ANYTHING ELSE GOING ON?
- Is there anything else contributing to your strong emotions today?
CLARIFY FACTS PRN
- The reason this has occurred is…
OFFER TO HELP
- What do you feel I could do to help you?
CONSULTANTOID
- Formal complaints avenue
- Reassure concerns noted +- escalated
- Offer to meet again (suggest write down further questions)
_______
If in danger: “you’re clearly quite upset and I don’t feel safe at the moment. I need to ask that we stop this meeting here. Lets arrange to meet at another time when we will be in a better position to engage”
Capacity Assessment
OPTIMISE SITUATION
- Ensure alert, feeling well
- Interpreter
- Hearing/ visual aids
CHECK UNDERSTANDING
- Can you tell me why you’re in hospital?
- What to do you understand about your options for X?
GIVE INFORMATION
ASK THEM TO SUMMARISE BACK (comprehension)
EXPLORE DECISION AND RATIONALE (manipulation, expression)
- What are you thinking you would like to do?
- May I ask you to explain why you’ve chosen this?
- Is there any more information you need from me for your final decision?
With consent, can confirm consistent with usual decisions (GP, records, family).
DAMA
EXPLORE WHY
OFFERS OF COMFORT
- Tea, blankets…
- Is there anything else I can offer you that would make you feel more comfortable staying?
RE-EXPLAIN
- Illness, proposed Mx
- Consequences of DAMA
ASSESS CAPACITY- by asking them to summarise back the above and explain their choice.
–> If no: DOC or MHA.
RISK MITIGATE
- Home with someone else
- Oral meds
- Written advice
- Invitation to return/ alternative care options
WELCOME BACK
End-Of-Life/ Goals of Care Discussion
CLARIFY UNDERSTANDING
WARNING SHOT
- You are very seriously unwell. We need to discuss what we would do if you were to get worse despite treatment
- We have tried A, B, C and have not seen any improvement. I’m afraid X is not going to recover, and is reaching the end of their life
EXPLAIN MEDICAL LIMITS
- If X were to get worse, I think it would be appropriate to focus on keeping X as comfortable as possible. If things led to their heart stopping, we would not try to restart it
- You may be aware of other treatment that exist: for example CPR, life support with mechanical breathing. We offer these where we think they are likely to benefit somebody.
- In X case, I am certain it will not benefit them, and instead would contribute to pain, distress.
EXPLAIN WHAT WILL BE OFFERED
- X will still receive care in the form of A, B, C.
- If X condition deteriorated, we would switch the focus to comfort in the form of D, E and F
_____
Patients can decide what they don’t want.
What they can have, is a medical decision.
Suspected NAI
ADDRESS MEDICAL
- X is okay. She’s received…. and is getting….
- You will be able to see her shortly
SIGNPOST
- I’m here to ask a little more about her injury, to try and get a sense for how it happened and how to prevent anything similar
HISTORY
EVENT
- Mechanism
- People present
- First aid
- Delay to presentation
GENERAL
- Who in house eg. new partners
–> and how does Y get along with the children?
- Child care
- Parenting stress/ other
- Supports
- Other children? Where are they now?
FLAG CONCERNS
- The injuries X has are not consistent with a childhood accident/ the way the accident has been described… OR In situations like this where it’s not entirely clear what has happened..
- ….I am obligated by law to flag these findings to CPS
- I am not making accusations.
- CPS have lots of experience and can look into this further
- They
1- try to find out what has happened
2- support you and your family
3- do NOT want to remove children
- Our priority- like yours- is Xs safety, and this is the right thing to do by her.
EXPLAIN PROCESS
- Further Ex/ Ix
- CPS will come and speak to you, and give recommendations on what may need to occur
- This may include X being admitted to the hospital while CPS are doing their investigation
- NOT about taking child away- only when absolutely necessary.
REEITERATE
- Legal obligation
- Not accusing
- Normal process
- NOT looking to split up family
- In interests of child
Informed Consent
VALIDITY
- Are you feeling well and clear to discuss this now?
- Is there anyone else you would like here?
PROPOSED TREATMENT/ TREATMENT OPTIONS
–> INDICATIONS
–> RISKS (material)
–. EXPECTED OUTCOMES
ALTERNATIVES
CHECK UNDERSTANDING
- Can I check that you’ve so far understood those options?
QUESTIONS?
- Are there any specific concerns or questions you have, regarding this treatment for YOU?
WRITTEN INFORMATION
ALLOW TIME
- Would you like some more time to consider things?
…..It is okay to change your mind at any time
Special Consent Circumstances
MINOR
- 16 and over can consent TO treatment. Cannot refuse.
- <16 can consent TO treatment, if:
–> Gillick competent
–> Emancipated
- For major/ life-altering decisions, NO MINOR has capacity.
Make all attempts possible to obtain parental consent.
If not:
-Duty of Care (no consent)
-Other parent
-Medical superintendent
-Child Protection –> Emerg. G’ship
________
ADULT WITHOUT CAPACITY
- Duty of Care
- Advanced Care Directive
- Alternate Decision Maker *(guardian, Health POA)
- Gauge likely wishes with collateral Hx
- Independent Advocate
__________
REFUSAL
- Ensure not because of lack of capacity, coersion or misunderstanding.
–> Ie. INFORMED and VALID.
Graded Assertiveness
CUSS
I’m concerned about using X…
I’m uncomfortable with this plan..
This is not a safe thing to be doing..
STOP.
