Communication Framework Flashcards
Communication framework
(M: IT ID CE FB AE C)
A. Introduction
- Introduce yourself: Good morning, my name is Dr __
- Confirm identity: Am I speaking to ___
B. Task
- The reason we are here today is to __
Hold off saying sensitive information at this stage (SPIKES)
C. Ideas (choose 1 opening)
- What have you been told so far about your condition
- Have you been informed anything about this condition before we start?
- Have you any ideas about this condition
D. Diagnosis and Explanation +/- warning shots
- Provide warning shots
- Explain in details about the condition and etc in Layman terms
E. Concerns
- What are your concerns? What are you worried of in particular?
F. Expectations and reactions
G. Feelings
- I understand this news must be quite traumatising, how do you feel?
- Acknowledge feelings and provide empathy
H. Background
- Explore background and personal history
- Explore previous encounters or stories
I. Agenda
- Explore on hidden agendas
J. Ethics conflict
K. Conclusion and way forward
Ethical principles in communications
A. Beneficience
- Duty to do good and of patient’s best interest
B. Non-maleficence
- Avoid doing harm
- Weighing risks and benefits
C. Justice
- Universal fairness and equity
- Avoid discrimination, abuse or exploitation
D. Autonomy and dignity
- Respects patients capacity to think and decide, and act on basis of such thought and decision freely and independently
- Even if their decisions are not the best course of action
E. Confidentiality
- Upholding patient’s rights for confidentiality
Discussing “incurable” but treatable conditions
- The condition can be potentially serious but treatable and controlled with medications
- It may return without treatment
- Nevertheless it is likely to be fully controllable
- May still lead a normal and healthy life with good control, on top of leading a healthy lifestyle
Avoid using the term “incurable” even if it is so
Explaining an investigation or procedure
- Description of the investigation
- Purpose/indication
- Diagnostic
- Therapeutic
- Monitor response to treatment - Risks involved
- Alternatives and their downsides
Explaining benefits and risks of treatment
- Explain as accurately as possible
- Explore any prior experience/stories
- Reassure patient that many others are taking the same treatment, and approved by larger body of current medical opinion
- Balancing side effects with benefits. Reassure monitoring for side effects
- Advise to stop if symptoms occur
Avoid overwhelming patients with studies outcomes
Balancing prescribing for older people
- Review indications
- Review side effects and limit prescribing
- Do not withhold treatment that works
- Stop inappropriate medications
- Be imaginative with routes of administration
- Consider concordance - medication list with reasons for each
Issues to be aware of in managing older people
- Reduced body reserve
- Atypical presentation
- Multiple problems
- Polypharmacy
- Social adversities
Risk perception, response efficacy and self efficacy
Risk perception can determine risk reducing behaviour
- People who are able to perceive increased risk will adopt risk reducing behaviour
- However it may be difficult to motivate, or downplayed by people, thus failure to adopt it
Risk perception:
- Likelihood: probability of event occuring
- Severity: how severe when it occurs
Risk communication - shares information about risk, how to reduce it and ensure patients have confidence to change their behaviour
Response efficacy
1. Outline benefits to current disease
2. Widespread benefits of preventing other diseases
Self efficacy
1. Explore on expected outcomes
- Desire to return/maintain normal life
- What do you think may impact family life if you are ill again?
- What are the chances of the disease happening again?
2. Consequences in future of failing to modify behaviour
3. Baby steps if modification is too hard
- Slow reduction in smoking with eventual aim to stop completely
- Incremental exercise regime
- Healthy diet with cheat days to maintain quality of life
4. Support networks and assistance
Emotion control after issue adequately addressed
(Use this after emotional issue adequately addressed to take back control)
I understand that you are upset with (issue). I will get the (relevant department) to speak to you about it to further address it.
My concern and role here is to address and treat your medical problem. Let’s get back to ____
Broaching on partial code and comfort care in a critically ill patient
Opening sentence
It is important for you to know that not everyone with (disease) survives. And those who survive don’t usually live very long afterwards due to recurrence and complications.
There may not be an easy way out of this.. or worse there may not be a way out of this
This would be the time to reflect on patient’s wishes about the type of medical care he would or would not want if things get worse ahead.
Follow up sentence
Right now we are doing everything medically reasonable to treat him, may I also make a recommendation of how we would best honour his wishes in case the treatment does not work?
Maintaining confidentiality and privacy from families and surrogates
- Establish doctor-patient relationship
- We have been seeing this patient for many years and he has expressed his desire for confidentiality and privacy when he was well. - Harmless reasoning/white lie
- Patient has expressed confidentiality. It is hard to answer why he doesn’t want to share the information. But it could be that he does not wish to burden you with his condition
- He may have some medical condition that may explain his current illness, but he has expressed his wish that his underlying condition need not be shared - Deflect with questions, reduce providing answers
- DO NOT EVER say diagnosis - Explore family members feelings
- What is going through your mind now?
- I can hear from you that you wish you had spent more time with him when hr was well - If asked whether it is xxx condition
- I am sorry but I am unable to tell you.
- If you are concerned, you should advocate/take care of your own health and go get tested - Firm stance when family insists
- For as long as he remains alive, there is a chance he may get well.
- It is our duty to uphold his rights and respect his wish to keep things private. - Provide confidence in patient care
- Even though we are not allowed to disclose his underlying condition to you, this does not stop the medical profession from providing the correct care
- Multidisciplinary teams are on his case to provide input and recommendations of treatment and he is receiving the best care from the team. - Does confidentiality end after death?
- No? - NEVER bring up the law unless asked by family “is there such law/is this legal?”
Poor Compliance in Treatment
- Explore reason for poor compliance
- Financial
- Side effects of medication
- Poor understanding of disease
- Discrepancy between what patient sees as important vs doctor - Repeat important information and confirm understanding
- Encourage feedback and invite questions
- Summarise and way forward
Discussing smoking cessation
- Current smoking status and influence from family members or friends
- Explore and explain benefits of smoking cessation
- What do you understand of the positive outcomes of smoking cessation? - Explore previous attempts to stop, motivations and hindrance
- Discuss ways of assisting
- Setting a date to stop completely
- Small steps progressive reduction
- Smoking cessation programme
- Nicotine replacement therapy - Think of themselves as “non-smoker” instead of “ex-smoker”
Communicating with angry patients/relatives
- Make it clear that you want to help
- We are here to try to help
- Don’t take criticisms personally - Deal with emotions before facts
- Anger is not usually anger
- Explore on fear, guilt, uncertainty; or financial issue
- “What is going through your mind now?” - Acknowledge and respond to concerns
- Obviously you are very upset by this. I understand. I too am very concerned about ___
- I agree we must sort this out quickly. I will do everything I can to help. It will help me if I understand what you fear most about ___ - Deflect from conflicts, steer to questioning rather than answering
- Give clear advice and honest professional opinions on matters that can be ameliorated
- DO NOT criticise colleagues
- Encourage feedback and giving conclusion
I would like to make a formal complaint
It is within your rights as a patient to lodge a complaint to the public relations department, but what is more important is we are here to find a mutual way forward / solution to your medical problem
Handling threatening, abusive and violent behaviour
- Maintain distance from patient care if threatened
- De-escalation
- Restraining often worsens situation
- Call security if physically violent
- Avoid temptation to take the law to own hands
- Seek advice from psychiatry if needed
- Empathy and support to affected staff
Discharge against medical advice
- Make it clear intention to help
- Explore reasons for wanting to self-discharge
- Inform medical reasons for continued stay
- Address patient’s concerns
- Explore understanding and mental capacity
- Accept patient may still self discharge
Medial overstayer
- Listen and agreeing to reason for continued stay
- Find the middle ground where both sides can agree - Explore ideas, concerns, expectations
- Inform of subadequacy of continued hospital stay for medically fit patient
- Acute hospital not the best place at this stage
- Nursing staff and therapists are so necessarily occupied with acutely unwell patients and priority
- Risks of prolonged hospital stay such as hospital acquired infection should not be taken for granted or ignored - Catch agendas and cues
- DO NOT criticise hospital managers
- Inform outcomes of resistance, and also positive assurance
- Hospital acquired infections
- Subadequate care
- We will not put patient forecefully put into an ambulance or evict
- HOLD OFF mentioning financial repercussions (social overstay charges) - Offer alternatives and assurance of these services
- Community hospital, home based services, nursing homes
- Early supported discharge
Breaking bad news - SPIKES protocol
SPIKES protocol
- Setting
- Perception
- Invitation
- Knowledge
- Empathy
- Strategy
Breaking bad news on cancer
- Establish ideas
- Can you tell me what you understand about your illness?
- What have you been told about things so far?
- Did any possibilities cross your mind?
Q: “I’m worried it might be cancer”
A: So had you been worried about something like that?
- Establish what patient wants to know
- You said you wanted me to be honest and open with you. Would you like me to explain the problem as we understand it so far?
- How much information would you like me to give you about your diagnosis and treatment?
- Would you like to explore this together with a friend or relative? - Warning shot
- I’m afraid things look a little more complicated that we had thought/hoped
-I’m afraid it does not look like a straightforward infection - Breaking bad news gently
Q: “Just tell me what we have to do next, what do you mean not straightforward?”
A: When the pathologist/ radiologist looked at the test results, we found some abnormal ___ (then pause)
Q: “Enough, what do you need to do next?” or
Q: “Go on. What do you mean by abnormal?”
A: There is a possibility that they might be cancerous
- Acknowledge distress and feelings ventilation
- It is normal to be upset. This is very hard for you.
- DO NOT rush in with immediate optimism or reassurance (patient are too preoccupied with bad news) - Identify concerns
- What are particular things you are thinking about?
- How does this news make you feel? - Check background and any further information
- Is there anything else you want to ask me about?
- Do you want to tell me anything more?
- Have you encountered similar situation with friends or family? - Identify support systems
- Who is at home with you?
- What about family / friends / others? - Make clear support and treatment available
- Further investigations, treatments
- Support from hospital staffs and support groups
- Family support
Discussing advanced incurable disease
Q: Will I die without treatment?
A: I can answer that. But could I first ask you why you ask me this question?
(Deflect with questions which explores her background, avoid answering on the get-go)
Q: I have fears for chemotherapy due to husband’s previous bad encounter. Could we do anything else doctor?
A: Would you like further tests or treatment?
(Deflect again)
Q: No I do not wish anymore tests or treatment. When my time has come, my time has come.
A: We could make sure you are as comfortable as possible and try to let you spend as much time as possible at home
Confidentiality and disclosure
Duty of confidentiality continues even when patient has died, except in extreme circumstances
When can confidentiality be disclosed?
1. Legal court order
2. Statutory board duty (communicable disease notification), reporting of births, deaths, abortions and work-related accidents
3. National security - terrorism, major crime
4. Sharing information with healthcare team
5. Third party at risk of harm (contracting a serious infectious disease)
- DO NOT disclose if third party is AT NO RISK
6. Public interest - seizure patient driving illegally
- Last resort option - saying this usually nets unfavourable score/outcome but gets the job done
What are the driving advice in medical conditions?
(Answers based on DVLA UK)
- Seizure
- Seizure free for 12 months on or off medication
- Alcohol withdrawal does not qualify as provoked
- 3 years restriction if seizure continues but purely nocturnal
- No driving for 6 months following AED reduction (40% recurrence during reduction period)
(Only for non-heavy goods, non-public transport; if heavy goods/public transport - seizure free 10 years) - Cardiac
- ACS 4-8 weeks restriction (reduced to 1 week with PCI) - Stroke
- 4-week restriction if no weakness/vision/cognition impairment
- Visual field 120 degree horizontal, no loss of > 20 degree up or downgaze - Dementia
- As advised by doctor
- In Singapore, 65 years old and above require re-assessment
Disclosure of medical confidentiality to DVLA (LTA in Singapore)
- Patient should clearly understand that their condition affect safety of themselves and others
- Patient has an honest and legal duty to inform DVLA about condition
- If patient refuses to accept, suggest second opinion and assist in obtaining it while refrain from driving until it has been sought
- Encourage discussion with next of kin if patient still insists
- If all fails, last resort to inform DVLA medicolegally while informing patient intention to do so
(unfavourable score/outcome but getting job done)
Family requests not to tell patient about his condition
(stop at page 660)
I share your concerns / I appreciate how concerned you must be
I am unable to withhold information from him solely based on your wishes
Patient has the autonomy to know what has happened
We assure you that we would not force information on him, and to only explain as much as he appeared to want to know
AVOID stating legal rights
