Communication Flashcards
What are the basics of communication that are assessed?
- Uses a balance of open and closed questioning to obtain a concise history
- Uses language appropriate to the patient’s level of understanding i.e. avoids jargon
- Displays the use of active listening to explore a patient’s concerns and expectations.
- Allows the patient to react emotionally to the situation and responds appropriately to non-verbal cues
- Give clear discharge advice
- Displays genuine empathy and gives reassurance
What are some general tips for communication in all stations?
Introduce yourself
Establish rapport with patient (including good use of body language and eye contact)
Appropriate body language ie adequate distance from patient, sit down at patient level, good eye contact
Maintain confidentiality and assure patient/colleague of this
Start with open ended questions
Use appropriate language (e.g. not medical jargon)
Actively listen and resist interrupting early
Respond to prompts and non-verbal cues
Convey understanding and empathy
Logically use second order questioning to focus on and differentiate presenting problem/s or concerns
Avoid premature closure
Repeat back parts of what the role player has said to confirm listening and understanding and try to use shared decision making
Conclude by asking for any further information that the patient wishes to convey
What are the most important elements in an open disclosure?
- An apology or expression of regret (including the word SORRY)
- A factual explanation of what happened
- An opportunity for the patient/carer to talk and relate their experience
- An explanation of the steps being taken to both manage the event and prevent any recurrence
AKA the 5 A’s
- Ackknowledge
- Apologise
- Assure
- Assess (through formal channels ie root cause analysis)
- Action (to prevent recurrence etc)
Open disclosure may take place over several meetings, if asked if they will see you again then the answer is yes.
Consider organising a follow up meeting with the patient/carer at a later date
How should emergency contraception and sexual health screening be approached?
- Discuss MAP (1.5mg Levonorgestrel or 30mg Ulipristal), use and side effects
- Screen for risk factors for HIV, Hep B/C
- Testing vs empiric treatment for Chlamydia/Gono
- Ongoing contraception plan
- Serology testing and follow up
- Empathetic approach
- Counsel on safe sex practices
What is a quick and easy mnemonic for determining capacity? what are the 5 points in capacity assessment?
ID & CURE
I- Impairment/intoxication
D- Derangment
C- Communicate (a choice)
U- Understand (info, pros, cons and alternatives)
R- Retain (information)
E- Employ (the information given to them to make a decision)
5 points (MURAW mnemonic)
- Maintain and communicate choice
- Understand the relevant info
- Retain the information
- Appreciate situation/consequences
- Weigh info in rational fashion
When should mandatory reporting to AHPRA be done for a colleague?
- Impairment
- Intoxication
- Departure from standards
- Sexual misconduct
What is the standard approach for dealing with an impaired colleague or trainee? What are the 6 B’s of assessing well being in a colleague?
Bonkers- mental health concerns
Booze- drugs and alcohol
Boys(/girls)- Relationship issues
Bereavement- loss of loved ones
Blues- Depression etc
Bank- Financial difficulties
How should a patient leaving against medical advice be approached?
Attempt to convince to stay
- Social work, family members
- Inpatient specialist involvement (ie ICU, cardiology)
- Offer incentives (sandwich, valium etc)
Risk assess capacity
- MURAW or ID & CURE
- Respect patient autonomy if they have capacity
- Reassure them they are welcome back if they change their mind
Discharge safety netting
- Give helpful medications (ie aspirin, clopidogrel, B-block and GTN for a STEMI patient etc)
- Contact their LMO for early follow up
- Attempt to get them to return to ED for review (ie if leaving to perform a task can return after)
- Ideally have family/friends aware of critical diagnosis and to bring back if worsens
- Inpatient specialties aware and organise follow up (ie cardio)
- Give discharge summary clearly outlining risks, prevention strategies and when to return
- Alert them about issues with the law and insurance (ie shouldn’t drive etc)
Tips for difficult communication
Unexpected pregnancy in a minor approach?
Establish rapport + basic questions
- Spend time doing this
- Important with any adolescent
- Establish sexual history, risk factors for STI
- Establish if abuse or statutory rape
- Consider full HEADS screen
Establish competency
- Oriented, not intoxicated
- Maintains, understands, reasons
- Understands the implications, consequences and issues
- 16-18yo can consent but cannot deny lifesaving procedures
- 14-16yo is grey area, Gillick competence assessment (no proper assessment, do you think they can make decisions?)
- Emancipated minor only if financially independent and living away from carers
Break the news
- Give time to process
- Allow to ask questions
- Establish baseline knowledge
Health Advocacy
- Contraception counselling
- Early pregnancy counselling
- Get patient to agree to letting you contact parents (must be done unless emancipated minor)
Conflict resolution approach?
Allow the person to vent
- Identifies the issues they have
- Helps with rapport
- Person can burn themeselves out
Use the ICENURS approach
- Explore Ideas, Concerns and Expectations
- Acknowledge their emotions by Naming them, show Understanding of them, Respect why they are feeling that way and show them Support
Explore the Presentation
- Patient may need reassessment
- Take ownership of the situation as the consultant (re-explore Hx, Ex and DDx)
- Offer analgesia, food, bed etc
Compromise with patient
- Basic investigations (as long as not harmful)
- Brief admission or SSU stay
- Consider SW/EDMH involvement
Explore other issues
- Screen for social or mental health issues
- Explore origin of concerns (ie previous child died and this is bringing up trauma) etc
If a patient/family member accuses your colleague of incompetence?
- State something along the lines of “I don’t know exactly what went into that decision making, but I will discuss with them how they approached this (your) problem. But I am the senior most decision maker and I can see that these are the things we need to do”
General breaking bad news approach
Initial rapport building
- Introduce self
- Establish identity and relation to patient (if not talking to patient)
- Ask if they want/need anyone else present (if not then confirm if nurse available to support them)
- Clarify what they know so far
- Give a “warning shot” ie “im really sorry, but I have some bad news to tell you”
Breaking the news
- Be straightforward, dont use jargon or colloquialisms, just say cancer, death etc
- Allow time to take in news and grieve, allow time for silence
- Offer sympathy and support
- Answer any questions
- Explain where to from here
- Ask again if they want anyone else here or anyone else telephoned, offer to do so to talk to them
- If not already done so, assure them you are a specialist but that you will get “additional” specialist expertise (ie NSx for a large brain bleed)
Post breaking the news
- Off social work, chaplaincy, elder support as appropriate
- If appropriate talk about coroner, police and/or organ donation
- If appropriate let them know that specialists will be involved, will talk to them and roughly what they might do
- Ask if they would like to see the patient (if appropriate)
Approach to Aboriginal patients in the ED?
When to cease CPR
Maintain CPR and resuscitation until adequate information is available
Ceasing resus is determined by the team leader, but in discussion with the team members
General considerations
- Pre-morbid medical state
- Known wishes, GOC form/legal ACD
- Cause of arrest if known
- Witnessed vs unwitnessed
- Time from arrest to (effective) BLS
- Time from arrest to ALS (ie ambulance arrival or code blue team)
- length of arrest or time to ROSC
- Time to first shock
- First rhythm
RF’s for poor outcome
- Prolonged time to defibrillation
- Prolonged time to CPR
- Asystole on arrival in ED
- Unwitnessed arrest
Indications to cease
- Asystole for >20mins
- Newborn with no detectable heart rate initially and none detectable after 10mins of effective NeoResus
- Legal ACD stating not for resus
- Persistent etCO2 <10 for >20mins
- If >20mins of CPR with no ROSC or shockable rhythm and no further or obvious reversible causes
- ROSC (obviously)
- Non-survivable pathology (non-survivable injuries, catastrophic TBI, 100% burns, no brainstem reflexes, decapitation, rigor mortis etc)
- Pre-existing issues preventing meaningful recovery (disseminated cancer, advanced dementia etc)
When to go longer
- young people with electrical storm
- Hypothermia
- Asthma with hyperinflation
- Toxicological arrest
- Thrombolytics given during arrest (at least for an hour, if not 2hrs)
- Advanced pregnancy (should at least perform resuscitative hysterotomy)
End of life care discussions
Helpful phrases
- I have only just met your father/mother, can you help me get to know them better so I can ensure get the most appropriate treatment
- In some cases we consider doing very invasive treatments to prolong life (CPR, intubation, ICU, pressors, dialysis etc) however in your fathers case I believe these interventions are unlikely to help and are actually likely to cause him harm
- My concern is that doing these invasive treatments will only prolong his suffering
- I think we should shift our focus to providing comfort and symptom relief
