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Communication Skills and Ethics-1.pdf
- 1. Communication Skills andEthics S. Kadiri
- 2. Outline • The needfor the skills • What to look for or do • Clinical scenarios/application • End of life care - aging population - growing role of geriatric medicine
- 3. Communication • Develop listening, questioning,explanatory, teaching skills • Employ expressed, non- verbal and implicit information Combines -Effective exchange of information -Teaming With: Patients, their relations, professional and work colleagues and associates
- 4. Ethics Anchored on: Autonomy Voluntary participationand withdrawal Full understanding Informed consent Privacy & confidentiality Respect for the community Consent form Beneficence Benefit individual & society Monitoring – good changes Non-maleficence No harm Monitoring – bad changes Justice Equal burden & benefits Protection of weak and vulnerable Correct conduct of and values of relationships Practitioner and • Patient • Patient’s relations • Other members of health team • Authorities • Public • The Law
- 5. Curriculum requirements • Beable to demonstrate punctuality, responsiveness, maintenance of good relations and establishment of efficient communication with other members of the health team; be able to maintain good relations and communicate effectively with patients, patients’ relations and the community; demonstrate professionalism, observance of medical ethics and confidentiality; be able to determine the need for coroner’s attention; be able to recognise limitations and the need for appropriate referral.
- 6. Approach • Introduce selfadequately • Establish the purpose of the meeting • Obtain agreement to continue • Reassure patient/subject • Explore patient’s/subject’s concerns, fears and expectations • Show understanding and empathy • Use verbal and non-verbal skills
- 7. Approach (cont) • Appropriatequestioning; probe and take leads and hints • Use clear language and provide clear expectations • Confirm patient’s/subject’s understanding • Agree a course of action • End the meeting appropriately • Show knowledge of the use of ethics and the law • Show overall common sense
- 8. Situations/scenarios • Explaining • Obtainingconsent • Communication with third parties • Difficult/sensitive situations • Ethics • Attitude • Combinations
- 9. Explaining • Explain 24hr urine collection • Teach instrument use e.g. glucometer, inhaler • Explain lifestyle changes • Explain the need for admission
- 10. Obtaining consent • Forprocedure e.g liver biopsy, LP • HIV testing • Therapeutic procedure e.g HD cannulation, CV line insertion • Cancer chemotherapy, radiotherapy • Indeed for virtually any procedure.
- 11. Communication with thirdparties • Explaining to a spouse/relation • Report to senior colleague/higher authority • Obtaining information from a witness • Explaining through an interpreter
- 12. Difficult/Sensitive situations • Attendingto a complaining patient • Break bad news • Broaching a sensitive topic e.g ED, STD • Dealing with a talkative patient • Dealing with a difficult (e.g rude) patient • Do not resuscitate order
- 13. Ethics and legality •Often embedded in/combined with other matters • Respect for patient/person – autonomy • Maintain confidentiality • Provide information fully • No coercion/force • Show beneficence • Show non-maleficence conduct • Safety of health personnel & the public • Recognise institutional responsibility • Show justice • Relevant knowledge of the law • Requirements of the medical council
- 14. Attitude • Often embeddedin/combined with other matters • Key issues to be observed -Confidentiality -Autonomy -Legal obligation -Respect for life -Duty to society
- 15. Examples of attitudetesting • Hepatitis-B/HIV/Ebola virus infection and procedures • Potentially criminal behaviour • Return to work after seizures • Refusing admission/treatment • Terminal care
- 16. End of LifeCare
- 17. End of lifeCare - Definition
- 18. Identification of endof life Recognised in the following settings • Patient likely to die in next 12 months • Presence of advanced incurable disease • Presence of life threatening acute condition • Sudden deterioration in existing condition
- 19. Trajectories for themajor groups of terminal illnesses
- 20. Key elements andsteps in care
- 21. Components • Palliative care •Spiritual care • Social care • Physiotherapy • Occupational therapy • Psychotherapy
- 22. Location May sometimes bedetermined by patient • In hospital • At home • In care homes • In a hospice -always palliative, life expectancy <6 months
- 23. Initial discussions • Beginearly • Assess patient’s understanding of illness • Discuss patient’s expectations • Future investigations and treatment • Assess patient’s relationship with family members – identify who should participate in decision making • Assess patient’s limits of acceptance
- 24. Initial discussions (cont) •Respect dignity, encourage settling of issues, wills • Inquire about patient’s concerns • Clarify all again and agree on important steps • May need to give more time and revisit • Use clear language, avoid jargon
- 25. Physician’s actions • Discussand explain • Obtain the services of interdisciplinary team • Nursing interventions • Satisfy spiritual/religious needs • Use prophylactic analgesia • Discontinue procedures/treatment producing negligible effects • Avoid heroic measures • Referral to palliative care physician
- 26. Common problems inend of life care • Pain • Cough • Oro-pharyngeal secretions • Dyspnoea • Dry mouth • Constipation • Nausea and vomiting
- 27. Common problems (cont) •Anorexia, cachexia • Fever • Delirium • Anxiety, insomnia • Depression
- 28. Signs of impendingdeath • Mottling of skin • Clammy skin • Deep set eyes • Accumulating secretions in throat - Death rattle • Persistently low BP • Cheyne-Stokes breathing • Prolonged coma
- 29. Barriers to QualityEnd-of-Life Care • Failure of healthcare providers to acknowledge the limits of medical technology • Lack of communication among decision makers • Disagreement regarding the goals of care • Failure to implement a timely advance care plan
- 30. Barriers to QualityEnd-of-Life Care (cont) • Lack of training about effective means of controlling pain and symptoms • Unwillingness to be honest about a poor prognosis • Discomfort telling bad news • Lack of understanding about the valuable contributions to be made by referral and collaboration with comprehensive hospice or palliative care services
- 31. Causes of InadequateCare at End of Life • Disparity in access to treatment • Insensitivity to cultural differences – Attitudes about death – Attitudes about end-of-life care – African-Americans prefer aggressive life- sustaining treatments – Mexican-Americans, Korean-Americans, and Euro-Americans prefer less aggressive treatment – Nigerians generally would want to prolong life
- 32. Causes of InadequateCare at End of Life • Mistrust of the healthcare system • Pain is subjective and self-report is considered accurate
- 33. Do-not-resuscitate order In consultationwith patient, relations, other personnel. Indications • No likelihood of successful resuscitation • Extremely poor quality of life Expectations/results • Saving resources • Relief of tension on patients relations and staff • Opening of discussions on end of life
- 34. Death issues • Signsof death • Certification • Breaking the (bad)news • Autopsy? • Death Certificate
- 35. Death certificate • Name •Age at death • Date, time of death • Place of death • Cause of death -immediate disease (not mode) leading to death -disease leading to immediate disease… -disease leading to disease leading to… -comorbities contributing to death • Whether seen/not seen after death • Coroner not needed
- 36. References • Dornan Tand O’Neill P. Core Clinical Skills for OSCEs in Medicine. Edinburgh:Churchill Livingstone. 2008
- 37.