Module 3

Communication: Building Understanding with Patients

and Caregivers

Knowledge requirements

Know the relevance of good communication in the consent process

Know communication in depth Understand cultural awareness and respect Understand how to communicate risk to

patients

Performance requirements

Use a range of tools and techniques to improve communication

Be culturally respectful Use a range of ways to talk about risk to

patients

Trigger tape

Introduction

Why is communication so important in health care?

patients can only make decisions after giving and receiving all the relevant information

information is both verbal and non verbal

How professionals talk to patients is just as important as what they say

Consent

More than a signature on a form Law Facilitates communication Ethical

Schloendorff v. Society of New York Hospital (1914) “Every human being of adult years and sound

mind has the right to determine what shall be done with his or her own body; and a surgeon who performs an operation without his patient’s consent commits an assault”

Communication and consent

Diagnosis & any test results / procedures Degree of uncertainty in the diagnosis Risks involved in the treatment Treatment options including

information on recovery time name, position, qualifications and experience of

health workers availability and costs of any service required after

discharge from hospital

General to the particular

General-the type of procedure, Common risks of the procedure

Specific-the risks specific to this procedure

Particular-the individual circumstances of this patient, The material risks for this particular patient

to the

to the

Ethical basis for consent

The beneficence model provide medical benefit

The autonomy model the doctor’s obligation to disclose information and

get permission is established primarily by the principle of respect for autonomy

Consequences of many options

Exponential increase in interdependencies: 2 people : 1 relationship 10 people : 45 possible relations / interactions [x=n(n-1)/2]

increased risk of communications problems at interfaces

Cumulative error rates in a multi-stage process (assuming 95% error free):

1 stage - 5 % chance of error 10 stages - 40% chance of cumulative error

Good & bad communication

POSITIVE understanding mutual respect better outcomes enhanced safety

NEGATIVE misunderstanding hostility mistrust poorer outcomes anger failure harm error

What is culture?

Culture consists of a body of learned beliefs, traditions and guides for behaving and interpreting behaviour that are shared among members of a particular group

Disease and illness

Disease malfunctioning of the physiological and /or

psychological processes in an individual

Illness psychosocial experience and meaning of the perceived

disease for the individual

Communicating risk

Know how to communicate risk information to patients and caregivers in an appropriate way and assist them to make informed decisions

What is risk?

The probability that a hazard will give rise to a harm

The language describing it is influential Perceptions of risk varies from one individual

to another Wide variation in the interpretations of

numerical data among doctors described in the literature

Edwards A & Elwyn G Understanding risk and lessons from clinical risk communication about treatment preferences Quality in Health Care 2001;10(Suppl I):i9-i13

SEGUE framework

Set the stage Elicit information Give information Understand the patient’s perspective End the encounter

Communication barriers

Develop the role play Set the stage Assign the roles Prepare Conduct the role play Discuss Conclude

SPIKES

Sharpen your listening skills Pay attention to patient perceptions Invite the patient to discuss details Know the facts Explore emotions and deliver empathy Strategize next steps with patient or family

Be culturally respectful …

Do not stereotype people Ask the patient what they think caused their

illness Respect the patient’s beliefs When possible incorporate the patient’s beliefs

into the treatment plan

… Be culturally respectful

Do not neglect the patient’s family Respect a patient’s concern about supernatural

influences on their health and well being Learn about the beliefs and practices of the

patient population in your community

Culturally sensitive medical interviewing tools LEARN Model Eliciting and Explanation Model

LEARN Model

Listen with empathy and understanding of the patient's perception

Explain your perceptions Acknowledge and discuss the differences and

similarities Recommend treatment Negotiate agreement

Elois Ann Berlin and William C. Fawkes Jr., A Teaching Framework for Cross-cultural Health Care. The Western Journal of Medicine , 1983, 139(6), 934.

Explanatory model …

What do you think caused your problem? Why do you think it started when it did? What do you think your sickness does to you? How severe is your sickness? Do you think it

will last a long time, or will it be better soon I your opinion?

… Explanatory model

What are the chief problems your sickness had caused for you?

What do you fear most about your sickness? What kind of treatment do you think you

should receive? What are the most important results you hope

to get from your treatment?

Talking to patients …

A discussion of the harms and benefits of treatments by describing the advantages and disadvantages of different options

Use of specific numerical data about potential outcomes

… Talking to patients

People differ in: their interpretation of language of risk (one in

10,000) the meaning or significance they attach to different

outcomes

Factors influencing preferences

Severity of the illness Other outcome concern Characteristics such as age, gender,

educational level, health status, recent illness experience

Framing

Framing is the presentation of logically equivalent information in different ways.

The way information is presented can manipulate consumer decisions

Best practice

Facts and figures should vary descriptive terms using scenarios numerical data graphic formats

Use multiple complementary formats descriptive, absolute and relative risk, numbers

needed to treat, graphical presentations

Communicating risk …

Establish the patient’s preference for amount / format of information

Assess and respond to patient’s ideas, concerns, and expectations

Discuss the clinical issue and the nature of the decision to be made

Identify all treatment alternatives

… Communicating risk …

Evaluate the research evidence Present the evidence consistent with the

patient’s preferences Discuss the pros and cons and help the patient

assess impacts of alternatives Discuss uncertainties

… Communicating risk

Assess the patient’s understanding of the alternatives

Ask the patient to express a preference, resolve any conflicts, and make or negotiate a final decision

Agree on an action plan / follow up Document

Summary

Good communication facilitates informed decision making

Multiple tools and techniques to assist effective communication

Show cultural awareness and respect Communicating risks to patients requires a

deep understanding of informed choice

Potential pitfalls

Try not to rush information sharing sessions Avoid information overload Avoid using the same method for conveying

risk information to patients

Pearls

Effective communication leads to better outcomes for patients

Approach each partnership with a patient or caregiver as unique

The time it takes to communicate effectively is time saved

Communication is part of health care; it is not an additional option