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AETCOM (Attitude, Ethics and Communication module)

  1. AETCOM (Attitude, Ethics and Communication module) Dr. Karun Kumar Assistant Professor Dept. of Pharmacology
  2. Principle • Changing a person's attitude can change his or her behaviour
  3. Foundations of communication • Communication is a fundamental prerequisite of the medical profession • Bedside skills is crucial in ensuring professional success for doctors • During professional year II, the emphasis is on 1. Active listening 2. Data gathering
  4. Foundations of bioethics • Cardinal pillars of ethics 1. Autonomy 2. Beneficence 3. Non-maleficence 4. Justice
  5. Autonomy 1. Respect the decisions of adults who have decision-making capacity 2. Always seek the consent or informed agreement of the patient before any investigation or treatment takes place 3. Respect the privacy of others 4. Protect confidential information
  6. Beneficence • To act for the benefit of others by providing benefits and balancing benefits and risks/harms 1. Protect and defend the rights of others 2. Prevent harm from occurring to others 3. Remove conditions that will cause harm 4. Help persons with disabilities 5. Rescue persons in danger
  7. Nonmaleficence • Not to inflict harm on others 1. Do not kill 2. Do not cause pain or suffering 3. Do not incapacitate 4. Do not cause offense
  8. Justice • Individuals should be treated the same 1. To each person an equal share 2. To each person according to need 3. To each person according to effort 4. To each person according to contribution 5. To each person according to merit
  9. Case introduction • Evaluate Mrs. Lakshmi Srinivasan who is a 48 year old woman presenting with lymphadenopathy • She had been complaining of mild fever and weight loss for the past 4 -5 months • Examination of the neck shows large rubbery lymph nodes that are present also in the axilla and the groin • There is a palpable spleen • She is accompanied by her caring husband
  10. • Lakshmi undergoes a lymph node biopsy and the pathologist calls you and tells you that she has a lymphoma • That evening Mr. Srinivasan comes in first into your office and leaves the report on your table • As you read the description you realise that the final diagnosis has been altered to Tuberculosis by whitening out the pathologist’s report
  11. • When you look up he tells you –“Sir, I googled lymphoma - it is almost like a cancer. My wife can’t handle that diagnosis. She has always been a worried frightened person. I want you to tell my wife that she had TB. She is waiting outside, doctor. I thought I will call her in after I had a chat about this with you”
  12. Points for discussion: 1. Does the patient have a right to know their diagnosis? 2. What should the patient be told about their diagnosis, therapy and prognosis? 3. How much should be told to a patient about their illness? 4. Are there exceptions to full disclosure? Can family members request withholding of information from patient?
  13. • In Western countries, the concept of patient autonomy dictates that a physician must offer every patient the information regarding their diagnosis and the treatment options available to them • This allows the patient to make informed treatment decisions • South and Southeast Asian countries, including China and India, practise collective autonomy: where the patient’s family plays a vital role in treatment decisions
  14. • The stage of the disease is also something that plays an important part in disclosing the cancer to the patient • If the cancer is in early stage and has a good chance of cure, the patient and family will take it better compared to an advanced stage cancer • In early stage, compliance to treatment is very important to have good results in cancer • An informed patient is more likely to be compliant
  15. • Education and a strong support system also have a greater impact in cancer management • An educated person is more likely to understand the diagnosis and outcomes • This is not because he is emotionally different than the one who is not educated but because he has the ability to acquire and understand information about his disease
  16. • To a certain extent, the family is right in requesting to hide the diagnosis from a family member with terminal cancer • But eventually all patients come to know what they are suffering from • Slowly but surely they are losing weight, losing energy, confined to bed, need more and more assistance, more and more medications to keep the pain away
  17. • All these are signs of an incurable disease • Frequent trips to chemotherapy centers, hush-hush discussion among family members repeatedly remind them of their disease • There was a time when the diagnosis of a cancer was almost like a death sentence • Nowadays cancer care has made tremendous progress and many cancers that were considered terminal a few decades ago, now have high cure rates with latest cancer treatments
  18. • The doctor has an obligation to disclose the diagnosis to the patient • He is bound by professional oath and he can’t withhold the truth if the patient asks him directly • Though the family has the best interest of the patient in mind, it is ultimately the patient who has to consent for the all the tests and treatment
  19. • Every major test and invasive procedure and treatment needs a written informed consent from the patient (guardian in case of minor) • It is practically impossible to proceed with the treatment without informing the patient what he is suffering from and taking a consent to proceed further
  20. • Regardless of the family’s wishes the patient may have a different opinion and view point about his disease • He/she may not wish to pursue treatment at all • Such views and decisions can be discussed only when all the information is shared with the patient • It is the patient’s right to “refuse or accept treatment” • The diagnosis of cancer is a deeply personal issue
  21. • Beyond the diagnosis, one must understand that the patient also has to undergo physically challenging treatments, bear health impairment and disability, pain and loss of income • There may be varying degree of permanent change in his health and body
  22. • Family members often feel that it is their duty to protect the patient from a sense of hopelessness • However, withholding the truth may have opposite effects • Lack of information can give rise to more anxiety and distress
  23. • To keep the severity of the diagnosis hidden there is a risk of opting for less intensive treatment regimens than more effective ones • The patient may come to know about the diagnosis from a third party or an unreliable source which can cause total loss of trust between patient and the family
  24. Advantages of disclosing the diagnosis 1. After disclosure most of the decisions regarding treatment become transparent 2. There is no fear among the family and caregivers that some third party will spill the beans 3. Though the diagnosis has a profound psychological effect on the patient, it gives them a chance to make important decisions of their life- like one may want to make formal will, one may want to complete a bucket list, one may want to meet close friends etc.
  25. 4. Preserves the dignity of the patient by taking their opinions on the matter 5. Cancer treatments are long. The patient and family have to have a trusted relationship with the doctor. And trust can only be built by truthfulness and honesty.
  26. • Hiding the diagnosis alienates the patient • Someone with cancer experiences immense amount of psychological stress • If there was no open discussion about the disease, the patient will never be in a position to discuss the problems he is facing openly • He may even think that his family and friends are more distressed than him
  27. • Many who were kept in the dark were also able to guess on their own – in a process that they have described as painful and demoralising • Patients who don’t know their diagnoses have a tougher time • They expect to feel better with treatment and become disappointed when they don’t • Then they slowly lose trust in the treatment team and the process
  28. • If indeed they have a poor life expectancy, they spend the last few days of their lives trying to figure out what is happening rather than seeking the sort of care and support that could help them • Knowing the diagnosis and the disease outcome also gives patients an opportunity to plan what they will do with their days: meet people, tie up loose ends, ask for (or give) forgiveness – all leading to a peaceful and dignified death
  29. • Each patient is different and has different response to such sad news • There is no clear path that can be taken every time • A skillful doctor will understand every situation and adjust his responses accordingly • The treating doctor can consider discussing the diagnosis and treatment in a graded manner • He can talk to the relatives and patient, first to gauge their understanding and wishes • Based on this understanding he can decide how to break the news
  30. • Even if the family has expressed its wish to keep the diagnosis from the patient, as long as the patient is present in the consulting room the doctor must address the patient directly and at least reassure that all the possible steps are being taken to help him/her regain his health • While discussing the diagnosis and treatment in such scenario it is better to avoid words like cancer, stage 4, chemotherapy, etc.
  31. • If the patient expresses desire to understand the diagnosis (mostly a head of the family or a sole breadwinner of the family in Indian context etc. ) the doctor can start by Asking how much the patient wants to know • It is surprising how different each patient is • While some want to know every detail of the treatment, some wish to know only the broader aspects
  32. • If the family and the patient are not really sure how to go about it then the doctor must decide the steps of action • To build trust with the patient and family :- 1. Give information in small chunks 2. Avoid medical terms 3. Start at patient’s vocabulary and comprehension 4. Summarizing in the end
  33. Take home message 1. Revealing the diagnosis to patients doesn’t negatively impact patient’s quality of life, and may even be associated with better disease outcomes 2. Breaking bad news is not easy. Physicians use techniques such as SPIKES (short for ‘Setting, Perception, Invitation, Knowledge, Empathy, and Summary’) to share bad news with their patients.
  34. 3. Patients often prefer knowing the diagnosis along with their family members, not after the family has already been told 4. They also expect to be offered some form of hope and to have all the treatment options explained to them 5. Doctors (based on their assessment of the patient) should reveal the diagnosis in an empathetic manner and involve patients in decision-making to the maximum possible extent

Editor's Notes

  1. Active listening is to make a conscious effort to understand the speaker's intent. You do that by asking questions, reading their body language and making observations. Some examples of passive listening are listening to presentations, the radio and even watching movies. Communicate to patients in a patient, respectful, non-threatening, non- judgmental and empathetic manner. Sympathy is more of a feeling of pity for another. Empathy is our ability to understand how someone feels while sympathy is our relief in not having the same problems.
  2. prevent from functioning in a normal way
  3. A biopsy is a procedure to remove a piece of tissue or a sample of cells from your body so that it can be tested in a laboratory