DIFFICULT CONVERSATIONS Flashcards
2WW
what structure would you use for explaining a 2WW?
BUCES
- background
- understanding
- concerns
- explanation
- summarise
2WW
what should you ask about background?
- clarify reason for consultation
- what is the background to their referral
- what are the symptoms
- have the symptoms changed
2WW
what should you ask to check understanding?
- what has been explained to you about your referral?
- what do you know about 2 week waits?
- could you briefly explain to me what we have discussed so far?
2WW
how would you explore ICE?
IDEAS
- what do you know about this referral?
- do you know why the referral was made?
CONCERNS
- what are you most concerned about at this point?
- is there anything in particular that worries you?
EXPECTATIONS
- is there anything you wanted to focus on today?
2WW
how would you explain what a 2WW referral is?
- referral was made to investigation something concerning
- will be offered an appointment at the hospital to see a specialist within 2 weeks
- this is to avoid delay so we can start tests and make a diagnosis
- symptoms suggest a serious underlying condition such as cancer
- normal to feel worried
- important to remember that most patients referred do not have cancer but may have another condition requiring treatment
2WW
why is it important to be seen quickly?
- rapid referral means we can rule out cancer or make a diagnosis + start treatment as soon as possible
- this significantly improves chances of successful treatment and recovery
2WW
how would you explain what to expect after the referral is made?
- will receive a letter or phone call informing you of your appointment within 2 weeks
- some departments ask patients to have tests done first to investigate symptoms first
- letter will tell you what to expect
- will meet with specialist who will go through symptoms, examination + discuss results of tests
- may need further investigations, be discussed in a team meeting or referred to a different specialist to get to the bottom of your symptoms
2WW
what safety netting advice should be given?
- if symptoms become worse or become unwell, seek medical attention urgently
- ensure contact information is up to date
- if you do not receive appointment details within 2 weeks, let us know so we can follow up
- important to attend appointment as early diagnosis + treatment can improve outcomes
- if you can’t attend, inform hospital so they can provide an alternative appointment
2WW
what support should be offered?
- any questions speak to GP or specialist
- organisations like macmillan can provide further information and support
- bring family member or close friend to appointments for support
EXPLAINING MEDICAL ERROR
what structure should be used?
SPIKES
- setting
- perception
- invitation
- knowledge
- emotions and empathy
- strategy and summary
EXPLAINING MEDICAL ERROR
what should you explore for perception?
- explore sequence of events leading up to this point + how patient is feeling
- explore patient’s ideas about the situation and what they already know
EXPLAINING MEDICAL ERROR
what should you explore for invitation?
- check patient wants to discuss the issue
- explore if they have any specific concerns
EXPLAINING MEDICAL ERROR
what should you explore for knowledge?
- explain error in simple language
- allow a large pause so the patient can digest what you have told them
- apologise ‘I’m really sorry that this happened’
- offer to provide more details
- explain circumstances of mistake
EXPLAINING MEDICAL ERROR
what should you explore for emotions and empathy?
- recognise + respond to emotions with acceptance, empathy and concern
EXPLAINING MEDICAL ERROR
what should you explore for strategy and summary?
- explain next steps
- reassure patient the situation will be reviewed and taken seriously (submitted formal incident report)
- provide patient with details of how to make a formal complaint (can get form so you can make a formal complaint)
- allow them to ask any questions
DNACPR
what are the steps for a DNACPR discussion?
- explore prior understanding
- explain cardiac arrests and resuscitation
- explain what DNACPR is and why it is appropriate
DNACPR
how would you explore prior understanding?
- explore current health state including sequence of events up to this point
- introduce concept of planning for future
- ask what they understand about DNACPR
DNACPR
how would you explain what a cardiac arrest is and what CPR is?
- heart may stop beating, called cardiac arrest
- CPR involves chest compressions, ventilation, defibrillation + IV drugs
- it is an invasive process
- it has a low success rate
DNACPR
how would you explain what DNACPR is?
- means that in a specific event of cardiac arrest, CPR would not be administered
- specific to only cardiac arrest
- does not apply to other interventions or treatments
- does not mean giving up on the patient
- it is a standard part of advance care planning
DNACPR
how would you explain why a DNACPR is appropriate for the patient?
- CPR is likely to be futile
- likely to lead to poor outcomes for the patient
DNACPR
what should you do if the next of kin do not agree with the decision?
- listen and address concerns
- escalate to a senior clinician for a second opinion
BREAKING BAD NEWS
what structure is used?
SPIKES
- setting
- perception
- invitation
- knowledge
- emotions and empathy
- strategy and summary
BREAKING BAD NEWS
how would you explore perception?
- discuss sequence of events leading up to this point + assess patients emotional state
- ask about symptoms
- establish what the patient already knows or is expecting e.g. “symptoms like the ones you described can be sometimes the result of an infection, but sometimes they can be as a result of something more serious”
BREAKING BAD NEWS
how would you explore invitation?
- check if the patient wants to receive their results today
“I have the result here today, would you like we to explain it to you now?”
BREAKING BAD NEWS
how would you explore knowledge?
- use warning shot “as you know we did a scan and unfortunately the results were not as we hoped”
- allow a large pause
- use simple language “I’m sorry to tell you this but the results of the investigations show you have cancer
- respond to patients emotion “I’m so sorry I had to break this news to you today”
BREAKING BAD NEWS
how would you explore emotions and empathy?
- recognise + respond to emotions with acceptance, empathy and concern
- do not lie about prognosis
- if don’t know prognosis = “I’m so sorry but at this stage I do not have enough information to answer that. Hopefully in the next few weeks once we have completed other tests I can be clearer. Sorry I can appreciate that it’s frustrating to be left with unanswered questions.”
- “I can see this is a huge shock for you”
- “I can see this is not the news that you expected. I’m so sorry.”
BREAKING BAD NEWS
how would you explore strategy and summary?
- plan to meet patient again
- inform them of the next steps
- reassure patient that they are being referred to specialists for follow up
- answer any questions
- offer assistance to tell others
- highlight where the patient can go for advice or support
- offer leaflets
- consider asking religious preference and whether the patient would like to see the chaplain
DEALING WITH ANGRY PATIENTS
what are the steps?
- recognise the patient is angry
- adjust style of communication
- try to understand why they are angry
- respond to anger
- apologise if error has occurred
- thank the patient
- encourage questions/solutions
DEALING WITH ANGRY PATIENTS
what should you avoid doing?
- suggesting a quick fix
- getting angry yourself
- being defensive
DEALING WITH ANGRY PATIENTS
how can you explore why the patient is angry?
ask open questions
- can you tell me more?
- why are you feeling this way?
- is there anything else that happened that is making you angry?
DEALING WITH ANGRY PATIENTS
how can you respond to the patient’s anger?
EMPATHY
- “given everything you have told me it’s understandable you feel that way”
- “it sounds like you have a lot going on at the moment, and it’s natural to feel angry”
DEALING WITH ANGRY PATIENTS
how would you apologise if an error has occurred?
APOLOGISE IF AN ERROR HAS OCCURRED
- I’m so sorry that this mistake has occurred and caused you harm”
- acknowledge the seriousness of the mistake and legitimize anger
- explain when medical errors do happen they are taken very seriously and reports are filed to ensure things do not happen again
DEALING WITH ANGRY PATIENTS
how would you apologise if you/the medical team is not at fault?
be careful about how you apologise
I’m sorry that you are feeling so angry about what has happened
DEALING WITH ANGRY PATIENTS
how would you thank the patient?
thank you for sharing how you feel with me, it’s important i understand how you feel so we can work together to help you
DEALING WITH ANGRY PATIENTS
what should you do if the patient is angry and does not want to sit down
if they do not seem to sit down any time soon, sometimes remaining standing + talking to the patient at the same level is helpful
do not be aggressive in posture
if you are both seated and the patient stands up, try to remain seated to not appear confrontational
DEALING WITH ANGRY PATIENTS
what should you do if you feel threatened?
remove yourself from the situation
prioritise your own safety by positioning yourself between the patient and the door without blocking it
DEALING WITH ANGRY PATIENTS
what should you do if your colleague is to blame?
- try not to get too defensive
- use neutral phrases such as “i’m so sorry this happened”
SUICIDE RISK ASSESSMENT
what is the structure?
- introduction
- explore current episode
- ask specific questions about method of SH
- screen for other MH disorders
- previous episodes of SH
- past psych history
- past medical history
- drug history
- family history
- social history
- agree management plan
SUICIDE RISK ASSESSMENT
what would you say during introduction?
- introduce self
- anything said is confidential unless I feel another person is potentially at risk
- I would then need to share some information
- understand some questions may be difficult to answer
- if there is anything you do not want to answer, we can come back to it another time
SUICIDE RISK ASSESSMENT
how would you explore the current episode of self harm?
BEFORE
- was there a precipitant (argument, recent bereavement)
- was it planned or impulsive?
- did they carry out any final acts e.g. suicide note, will, terminating contracts
- were there any precautions against discovery e.g. closing curtains, locking doors, waiting until everyone was out, going somewhere remote
- was alcohol used (amount, previous use)
DURING
- method of self harm
- whether they were alone
- what was going through their mind
- did they think the self harm would end their life
- what did they do immediately after
AFTER
- did they call anyone? who were they found by?
- how did they feel when help arrived
- how do they feel about their attempt now
- do they regret it
- current mood
- still feeling suicidal?
- if they were to go home, what would they do?
- if they feel like this again, what might they do differently
- what do they think may prevent them from doing this again
- will they accept treatment
SUICIDE RISK ASSESSMENT
what should you ask specifically about overdose?
- what medication was used
- where did they get the medication from
- how much medication did they take
- what did they take the medication with
- what did they think that amount of medication would do
- what made them decide to take medication
- how long had they been thinking about taking an overdose for
- what did the patient do after taking the medication
- how did the patient get to hospital
SUICIDE RISK ASSESSMENT
what specific questions should be asked for self harm from cutting?
- where are the cuts
- how many cuts are there
- how deep are the cuts
- how did the patient feel whilst they were cutting
- how did the patient feel when they saw the blood
- what were they hoping the cutting would do?
SUICIDE RISK ASSESSMENT
how would you screen for other mental health conditions?
DEPRESSION
- anhedonia “do you feel you no longer enjoy activities you previously used to?”
- low mood “how has your mood been recently?”
- fatigue “what have your energy levels been like recently?”
PSYCHOSIS
- thought insertion “are the thoughts to harm ever not your own?”
- auditory hallucinations “do you ever feel like there are voices telling you to harm yourself?”
ANOREXIA
- how would you describe your eating habits
- do you feel you are eating enough
- what is your appetite like
- have you lost weight recently
- are you satisfied with your weight
SUICIDE RISK ASSESSMENT
how would you explore previous episodes of self harm?
- ever carried out self harm in the past
- what methods
- did they get any help from support network or other agencies
SUICIDE RISK ASSESSMENT
what should you explore in social history?
- living situation
- support network
- occupation
- alcohol
- recreational drug use
SUICIDE RISK ASSESSMENT
what should you include in a management plan?
- seek support from family + friends
- recognise stressor + address them
- avoid harmful alcohol use when stressed
- ask who they could tell if they felt this way again
- advise they can seek help from GP, samaritans, A&E and local MH support services
- signpost to relevant agencies to help address stressors/risk factors
ADVANCE CARE PLAN + RESPECT FORMS
what are the discussion points?
- advanced decision to refuse treatment
- DNACPR
- treatment escalation plans
- emergency care and treatment plans
- lasting power of attorney
ADVANCE CARE PLAN + RESPECT FORMS
what is an advance decision to refuse treatment?
- may express wishes to not undergo specific treatments
- needs to be documented and name every treatment that is not wanted
- must be written and signed by patient
ADVANCE CARE PLAN + RESPECT FORMS
what is a treatment escalation plan?
- details which investigations and treatment would or would not be appropriate
- aim is to reduce distress for patient and family
- can help decide how far treatment would be escalated
- whether feeding via NG tube or admission for IV antibiotics
ADVANCE CARE PLAN + RESPECT FORMS
what are emergency care and treatment plans?
- for patients with complex morbidity and longstanding illness
- document what should happen if person suddenly becomes unwell
- alleviates additional stress
ADVANCE CARE PLAN + RESPECT FORMS
what is lasting power of attorney?
- allows someone to appoint a person to speak for them in the event that they become unable to do so for themselves
ADVANCE CARE PLAN + RESPECT FORMS
how can you initiate a conversation about advance care planning?
“What is most important to you about your care?”
“Is there anything you do not want to happen in your care?”
“Is there anyone you want to help deciding your care, should you be unable to answer?”
ADVANCE CARE PLAN + RESPECT FORMS
what are the benefits of advance care plans?
- supports ability to make decisions + feel control over future
- minimise suffering
- enables more quality time to be shared without worrying
- clear instructions for healthcare team so they know they are following patient’s wishes
PSYCHIATRIC RISK ASSESSMENT
what are the main areas to consider?
- risk to self
- risk from others
- risk to others
PSYCHIATRIC RISK ASSESSMENT
how would you assess risk to self?
- any thoughts of harming themselves
- whether they plan to act on thoughts
- any self-harm
- how do they cope with thoughts of self harm
“Sometimes, when people are going through difficult things, they might have thoughts of wanting to harm themselves – is this something you’ve experienced?”
if the patient has self-harmed:
- find out events before, during and after episode
- what was going through their mind
- what was the method
- was it planned or impulsive
- were there attempts to not be found
- what did they think would happen/what was the outcome?
- how do they feel now
- do they have any further plans
- any protective factors
PSYCHIATRIC RISK ASSESSMENT
what would you want to explore for physical health?
- substance abuse
- personal hygiene
- nutrition (when did you last eat?)
- taking more risks than usual
- taking medication as prescribed
PSYCHIATRIC RISK ASSESSMENT
how would you assess the risk from others?
ensure patient is alone
- do you feel safe at home
- anyone making you feel scared
- anyone controlling you
- has anyone threatened you
- any problems with partner
PSYCHIATRIC RISK ASSESSMENT
how would you assess risk to others?
- any thoughts to harm others
- any plans to harm others
- any hallucinations (anyone telling you to harm others)
- do you feel in control of your thoughts and actions?
MENTAL CAPACITY ASSESSMENT
what are the components of capacity?
- understand information
- retain information
- use information to make decision
- communicate decision
MENTAL CAPACITY ASSESSMENT
how do you assess understanding?
- could you tell me why you are in hospital?
- what do you understand about the options for your treatment?
