Challenging Medical Communications. Dr Thiru Thirukkumaran Palliative Care Services Northwest Tasmania
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1 Challenging Medical Communications Dr Thiru Thirukkumaran Palliative Care Services Northwest Tasmania
2 What are the common Challenging situations?
3 Common Challenging situations Handling difficult questions Engaging with emotional stress Dealing with angry patients Collusion Denial Patients refuse to talk
4 Handling difficult questions A terminally ill cancer patient asking you the following questions: Am I dying doctor? How long do I have? Am I getting better with treatment? How do we approach these questions?
5 Handling difficult questions Assess patient s perceptions (1) What makes them ask the question? (2) What do they think themselves? (3) Explore all the reasons (4) Allow time for their own contemplation If appropriate Continue further (1) Warning shot or Forecasting if appropriate (2) Confirm their perceptions if possible (3) Pause to assess response (4) Address concerns raised in a realistic manner that maintains appropriate hope (5) Assess patient s feelings and on-going concerns (6) Assure Continuing care and support
6 Handling difficult questions If patient changes subject, decides against taking their questions further or indicates they are not ready for the answers Leave it there for the time being They will be ready after some time Remember patients have insight Their functional status or their progressive symptoms made them thinking about the worse case scenario The success depending on the professional s thought provoking questions at the encounter
7 Engaging with emotional stress Identify the feelings that provoke the patient Silence Affirmative acknowledgement Tissues Go with pain (resist temptation to try to take emotion away)
8 Dealing with angry patients-1 Allow ventilation & Recognition Pause The patient experiences being understood, is therapeutic Stepping back rather than defending our side initially (Lets patient diffuse the emotion) Active listening and feedback to story Position, Posture, eye contact, facilitative responses & appropriate silence Permission to talk, Requesting & Accepting the Correction... Did I get it right? It will make them feel better that they are controlling the situation, not us Explore reasons for situation (Consider motivation -? Secondary gain,? Hidden agenda) Framing - sounds like what you are telling me.. - Let s see if I have this right. Reflecting Content Factual as well as nature and intensity
9 Dealing with angry patients-2 Focus on individuals stress / feelings Identifying & Calibrating the anger I can imagine how angry I d feel if that happen to me.. That situation really got you, didn t it? By acknowledging their feelings, you are no more in their opposite site, but patient & the professional are on the same side Empathy to diffuse anger 3 implications Cognitive : Enter patient s perceptive, but don t lose your own Affective : Put yourself in patient s place Action Component: Verify emotion so patient can correct and/or feel listen to Professionals honest attempt to understand should facilitate trust Apologise if appropriate Negotiate a solution
10 Collusion Example: Collusion on some information given by the doctor Acknowledgement & Exploration Feelings Their own perception Reasons for not being truthful Strain on the relationship What will happen as condition deteriorates Assess the patient s questions to relative Look for window of Knowledge Agreement to assess patient Reassure not giving the info.. if information not wanted
11 Denial The function of denial is to protect the patient against distress could be intolerable, and lead to psychological disorganisation or suicide.
12 Checking the strength of denial Challenging any inconsistencies in the story You say it couldn t have been serious, yet you tell me you had an intensive course of chemotherapy?... Look for a window on denial Is there ever a movement when you don t think things are going to workout?... Do you ever worry you won t get better?...
13 Patients refuse to talk-1 Reasons: 1. Denial 2. Incorrect information 3. Depression 4. Difficulty adjusting to the situation 5. Talking to someone else 6. Already dealt with so don t want to cover again 7. Dementia & learning difficulties 8. Cultural & spiritual issues
14 Patients refuse to talk-2 Decide how urgent it is that the patient needs to talk Build relationship & look for a window of opportunity Explore sensitivity Liaise with others involved in care Consider being frank if necessary Consider involving relatives
15 Movie Clips
16 Bad Consultation
17 Cancer patient Am I going to get better doctor?
18 Any thoughts?
19 Thank You
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