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31/10/24 Difficult Communication Zona IsmailUse code CBOSCECREW24 at checkout on geekyquiz.com for 10% off OSCE flashcards, OSCE stations and knowledge bundles. Session Structure Teaching session CCA practice 45 minutes 1 hourQuiz! Which of the following documents is legally binding? A) Advanced statement B) Advanced decision C) DNACPR form In which of the following situations can you break confidentiality? A) A patient has been diagnosed with HPV following a routine cervical smear. They intercourse.to tell their partner, with whom they have unprotected sexual B) A patient thinks their partner (another one of your patients) has an STI, and wants to know if they came to see you. You are aware that the partner recently tested negative in an STI screen. C) An inpatient has become unconscious and unresponsive. Their relatives, who were not aware that the patient was admitted, have arrived and want to know what has happened. Learning Objectives ● Dealing with strong emotions ○ How to approach the station ○ Ensuring your language and tone is patient-centred ○ Use of ICE ● Raising concerns about care ○ Patient complaints ○ Duty of candour ● Consent, capacity, confidentiality and safeguarding ○ Definitions and legalities ○ Screening for safeguarding issues e.g. HARK questionnaire if concerned about domestic violenceDealing with strong emotions How to approach the station ● Provide structure to the conversation ○ “Golden minute” – make sure you and the patient are on the same page ○ Brief background ○ ALWAYS ICE! Ideas Concerns Expectations ○ Summarise (sensitively) and confirm Action Plan ● Acknowledge patient’s emotions throughoutWhat are some signs that a patient is angry/frustrated? • Loud speech or shouting Swearing/verbal abuse • Oversensitivity to what is being said • Aggressive posturing/not wanting to sit down • Walking/threatening to walk away • Shaking/fist-clenching • Change in eye contact • Frowning Beginning the consultation ● After introducing yourself, and getting their name and DOB, ask what they would like to be called – don’t assume first name! ● Check why they have come to see you: o “It’s my understanding that ….. is that right?” o Important to be on the same page! ● Thank the patient for speaking with you/reassure that you’re happy to discuss their concerns with them ● Open questions – gather background sensitively, don’t interrupt! Ideas and understanding ● Responding to cues/emotions when gathering information ○ Reflecting emotions – “That must have been quite upsetting”, “I can see that this has been upsetting/frustrating” MATCH PATIENT TERMS/TONE ○ Remain calm but compassionate ○ Non-verbal communication – pauses, nodding ○ Sensitive wording of questions – e.g. “Can/May I ask why…/what…” ○ Provide structure whilst letting the patient lead the conversation - balance ● What does the patient know – any misinformation/misunderstanding ○ E.g. If there’s a long wait, they may not know that emergencies must be prioritised/ if they want to go home with an untreated MI, they may not know that it could be fatal Concerns ● Summarise regularly, show that you are listening and care ● Acknowledge the clear concern, and ask if there’s anything else: ○ Other than the long wait in A&E, which has been quite frustrating, is there anything else that you’re concerned about/worried about/you’d like to discuss Expectations ● Good time to summarise ● Similarly to concerns, give suggestion of their expectations and ask if there’s anything else ○ E.g. You’ve mentioned that you’d like to be seen as soon as possible/Other than being seen quickly, is there anything else you’d like me/the medical team to do for you? Apologise or not? ● Saying the word “sorry” is not a bad thing! ○ Can help the patient feel heard/ help you connect with the patient ○ Clear demonstrator of empathy However, avoid false reassurance: ● Avoid assigning blame to certain members of the medical team, but DO acknowledge that certain things should not happen e.g. incorrect medication given ● General apologies are often effective ○ ”I’m sorry that you have been put in this position” ○ “I’m sorry that this has happened” ○ “I’m sorry that you’ve been made to feel this way” Summarise and Action Plan ● Another summary! ● Check the patient is satisfied with the plan: ○ “Does that sound alright?” ○ “Is there anything else you’d like me to do” ● Ensuring the patient is aware of an action plan is key! ○ Pulls everything together ○ “What I will do next”, “What we can do is..” ● Thank the patient for their time/ for speaking with you Top Tips! ● Always ICE – do this early in the station ● Don’t be afraid of strong emotions ● Pauses are perfectly fine, and can be effective – if you get stuck, summarise! ● Allow the patient to talk freely without interruptions ● In CCAs, if you say the right thing/acknowledge the patient’s emotion and situation, they will be open to discussing further, and creating a planRaising Concerns about Care Station Brief Mr Smith has been diagnosed with Community-Acquired Pneumonia, and was admitted for treatment with IV antibiotics. He was prescribed co-amoxiclav, despite a known penicillin allergy. The medical team recognised this error, and Mr Smith did not come to harm. His daughter is frustrated that this has happened, and would like to speak to you about their options. Mr Smith has given his consent for you to share details of his condition and care. Beginning the station ● Stick to a structured approach! ○ Introduce yourself ○ Gather information, ensuring you and the patient/relative are on the same page ○ ICE Sequence of raising concerns/ Advice to give ● Ensure that they are aware of their options ● Encourage them to speak with those directly involved in the patient’s care ● When appropriate, signpost to: ○ Practice manager in GP setting ○ PALS (Patient Advice and Liaison Service) in Hospital setting ● Be aware of the process of Significant Event Analysis (SEA) Significant Event Analysis ● Reflection on why an event occurred ● Completion of an incident report form ● Formal investigation to prevent it happening againConsent, Capacity, Confidentiality and Safeguarding (The Law) Legalities and responsibilities Key legislation to be aware of for your CCAs: ● Mental Capacity Act ● DNACPR ● Advanced decisions ● Advanced statements ● Lasting power of attorney (LPOA) Helpful resources: ● GMC guidance ● OSCEstop Legalities and responsibilities Key legislation to be aware of for your CCAs: ● Mental Capacity Act ● DNACPR ● Advanced decisions ● Advanced statements ● Lasting power of attorney (LPOA) Helpful resources: ● GMC guidance ● OSCEstopMr Jones is an 87-year-old man, who has been diagnosed with late-stage dementia. His daughter, Sally, is his carer and would like to speak with you about how his care and how decisions are made given his fluctuating confusion The Mental Capacity Act ● Patients are assumed to have capacity until proven otherwise ● Capacity is time and decision specific ● If a patient lacks capacity, you must act in their best interests ● Just because you believe a decision is unwise, it doesn’t mean the patient lacks capacity - their autonomy must be respected Two-Stage Test to Assess Capacity The patient only lacks capacity if the answer to both questions is YES: 1. Does the patient have an impairment/disturbance of brain function? 2. If YES, does this mean that they are unable to make this decision at this time? o To be able to make a decision, a patient must be able to : Understand information Retain information Weigh up/ use the information to make an informed choice Communicate their decision back to youExample station This is June, a 72-year-old lady who has been diagnosed with Stage 4 pancreatic cancer. She would like to know more about how she can plan her future treatments and decision-making. DNACPR Do Not Attempt Cardio-Pulmonary Resuscitation ● A decision made to not start cardiopulmonary resuscitation in the event of cardiac arrest ● Does NOT mean that other treatment or care will be compromised ● Medical decision, not patient’s, but should be discussed with them and patient MUST be aware. ● NOT legally binding, decision can be changed by medical team, particularly for reversible causes. Advance Decision to Refuse Treatment ● Legally binding document, signed by patient and a witness ● Enables someone 18+ with capacity to make a decision to refuse a specific treatment in the future ● Allows medical team, relatives, and carers to be aware of patient’s their wishes if they become unable to make or communicate those wishes themselves ● Patient can change their mind at any time Advanced Statement ● NOT Legally binding! ● General statement of patient wishes. ● Can include any aspect of care that is important to them https://www.ageuk.org.uk/globalassets/age-uk/documents/factsheets/fs72_advance_decisions_advance_s tatements_and_living_wills_fcs.pdf Lasting Power of Attorney ● Legally binding ● Can appoint someone to make decisions on your behalf, in the event that you lack capacity to do so yourself. ● Two types! Important to clarify ○ Health and welfare ○ Property and financial affairs Confidentiality Patient confidentiality is a key responsibility of the whole medical team. ○ Maintains the public’s trust in profession GMC : You must respect the wishes of any patient who objects or any information being shared with others providing care, except where they would put others at risk of death or significant harm” When can confidentiality be broken? When there is significant risk of harm to the patient, or another person ● Children ● Vulnerable adults ● Blood borne diseases e.g. HIV, syphilis but NOT other STIs like chlamydia ● Notifiable diseases ● DVLA and drivers Domestic Violence ● Approach sensitively, with open, gentle questioning e.g. “Could you tell me how things are at home?” “I’m worried that you might not be safe at home.” ● HARK questionnaire – Humiliate, Afraid, Rape, Kick ● ALWAYS RISK ASSESS! ● Signpost to resources ○ Women’s Aid ○ Helplines https://oscestop.education/communication/domestic-violence/ Helpful Links/Resources https://oscestop.education/osce-learning/ (ethics and law in “communication” section) https://www.gmc-uk.org/education/standards-guidance-and-curri cula/guidance/student-professionalism-and-ftp/achieving-good-m edical-practice/domain-3-communication-partnership-and-teamw ork#maintaining-patient-confidentiality https://www.nhs.uk/live-well/getting-help-for-domestic-violence/ Which of the following documents is legally binding? A) Advanced statement B) Advanced decision C) DNACPR form Which of the following documents is legally binding? A) Advanced statement B) Advanced decision C) DNACPR form In which of the following situations can you break confidentiality? A) A patient has been diagnosed with HPV following a routine cervical smear. They intercourse.to tell their partner, with whom they have unprotected sexual B) A patient thinks their partner (another one of your patients) has an STI, and wants to know if they came to see you. You are aware that the partner recently tested negative in an STI screen. C) An inpatient has become unconscious and unresponsive. Their relatives, who were not aware that the patient was admitted, have arrived and want to know what has happened. In which of the following situations can you break confidentiality? A) A patient has been diagnosed with HPV following a routine cervical smear. They intercourse.to tell their partner, with whom they have unprotected sexual B) A patient thinks their partner (another one of your patients) has an STI, and wants to know if they came to see you. You are aware that the partner recently tested negative in an STI screen. C) An inpatient has become unconscious and unresponsive. Their relatives, who were not aware that the patient was admitted, have arrived and want to know what has happened.