ORAL - COMMUNICATION / ETHICS Flashcards
How to break bad news
I will use the SPIKES mnemonic to attempt to break bad news
S - setting (appropriate setting)
P - perception (patient / family’s perception)
I - information (ask to share information)
K - knowledge (share knowledge + informatino)
E - emotions (talk about feelings + empathize)
S - strategy (plan going forward / social work / spiritual care)
How to de-escalate conflict
proactive - knowing own biases + triggers and prevent conflict
create a safe place to address conflict respectfully
avoid accusations or inflammatory language
clarify needs
active listening + communicate effectively
consider a neutral mediator
reflection
How to disclose an adverse event
address safety - ensure any urgent or emergent current clinical needs are addressed
prepare - who, where, when and learn the facts
disclosure - disclose event
- explain next steps in care going forward
- apologize
- assure steps are being made to ensure it doesn’t happen again
- avoid blame
- thorough documentation of disclosure
How to verbally descalate a patient
- SET UP
2 arms length away
1st person to contact should lead
non confrontational body posture - COMMUNICATE
Simple / concise language
identify feelings / desires
summarize what patient is saying - SET LIMITS
agree w points you agree w / agree to disagree
lay down law + set clear limits
offer choices / optimis - DEBRIEF - patient and staff
violent patient percautions
- assess with door left open
- escape plan
- security
- alarm systems / panic button
- no neck ties / stethoscopes
- remove all potentially weaponized objects
- verbal de-escalation techniques
- physical restraints
- environmental restraints
- chemical restrains
how to take down
- trial verbal de-escalation
- 5 person take down (w security) => 1 person per limb + leader on head
=> appropriate PPE
=> patient on stretcher supine in 5 point restraints
=> HOB30, 1 arm up, 1 down
=> frequent monitoring (VS / neurovitals)
- chemical restrains (ketamine 4-5mg/kg IM, midz 5mg, haldol 5mg IM)
ETHICS CASES (ALL)
ensure confidentiality
duty to report (label mandatory vs permissive)
Consult SW and ethics board if available
Call CMPA if unsure
Consider CFS if peds case
name ethical principles invovled
Principles of ethics
ethical dilemma between (usually 2)
1. autonomy (right to make personal decisions + self determination)
2. beneficence (duty of doing good)
3. non malificence (duty to prevent harm)
4. confidentiality (doctor will not reveal what patient has shared)
5. justice (fairness in resource allocation)
6. personal integrity (right to adhere to ones own reasoned + defensible set of values + moral standards)
Outline rapid approach to ethical problems in ED
If no ethical rule would apply the following tests:
1) impartiality test - would i accept the action as patient
2) universality test - would i be comfortable if a collegue made the same decision as me
3) interpersonal justifiability test - my reasoning would be accepted by my peers, public and superiors
List the elements of futility
physicians don’t have to provide tx that will not benefit a patient if it is:
1. not medically indicated
2. will not contribute to goals of care
3. unethical
three components of futility:
QUANTITATIVE – odds of success
PHYSIOLOGIC – intervention won’t fix it (anti viral for bacterial infection)
QUALITATIVE - if success, outcomes is bad
What are 3 exceptions to informed consent
Emergency consent - limb or life threatening
mental health
communicable disease
Components of capacity
KAC
Knowledge of the procedure, do they understands
Aware OF CONSEQUENCES + PERSONAL COST BENEFIT (weigh risks and benefits)
Consistent with previous medical choices / values
ensure decision is not affected by depression, delusions or psychosis
if unable to prove capacity will document that the patient does not have capacity and find a substitute decision maker
HAS CAPACITY + WANTS TO LEAVE
Assess capacity (KAC)
Document capacity in chart
ensure this is an informed decision (understands risks + benefits and alternate options)
involve others (family etc) if patient allows
provide harm reduction tx specific to case and
documentation of instructions and patient’s reasons for leaving
discharge instructions and patient to sign AMA
encourage RTED
JEHOVAHS WITNESS + REFUSING BLOOD / CARRYING CARD
(decr LOC + needs blood)
physician can’t do anything for patient / to a patient without valid consent
patient of sound mind has right to personal autonomy (refuse treatment even if leads to death)
if child of Jehovah’s witness
- if stable, allow patient to make decision, involve CFS (if decision is not inkeeping with child’s best interest)
- if unstable - parents can’t make decisions that would harm child
Order of priority of SDMs
legal guardian
appointed attorney
conset/capacity board
spouse/partner => child >16 => parent => siblings
other relative
trustee
When is it ok to breach confidentiality
mandatory reporting
permissive reporting [duty to warn] 1) physician incapacity 2) disclose to prevent harm (risk to person, group, risk of harm/death, imminent danger)
Mandatory reporting indications
Child abuse
can’t drive
Pilots / air traffic controller safety
sexual abuse of patient
Gun shot wounds
communicable / reportable disease*
long term care + retirement homes
births / still births / deaths
reportable diseases
MMR vaccine => measles, mumps, rubella, diphtheria, tetanus
polio, anthrax, TB, pertussis, botulism
sex: HIV, syphilis, gonorrhea, chlamydia
Difficult Learner
Outline approach to evaluating learner
assessment includes constructive neg feedback
outline concerns to PD
recognize resident is not training for emerg
