4: Communication skills and ethics

Station 4


Communication skills and ethics



Contents



Introduction to communication skills and ethics



Cases



Discussing clinical management



Communication in special circumstances



Breaking bad news



Confidentiality, consent and capacity



End-of-life issues



Clinical governance



Other communication, ethical and legal scenarios




Introduction to communication skills and ethics




Communication skills



Effective communication

Effective communication in medicine means simply that doctor and patient (relative, colleague, etc.) understand each other. We could, broadly, consider two stages to an encounter with a patient. The first stage is concerned with information gathering. The aim is to answer the question: ‘What is the problem or what are the problems?’ The second stage is concerned with developing a management plan, aiming to answer the question: ‘How do I solve this problem or these problems?’ Management plans should be developed not just for patients, but also with patients. A plan is seldom a case of saying:



You have an overactive thyroid; you will need to take a tablet called carbimazole,


but more a case of:



Let’s look at how we could treat your overactive thyroid.


It is a two-way process of information sharing. The doctor does not so much know the solution to the problem (although may know what is clinically best), but reach a solution through communicating with the patient. This method of problem solving is more patient centred.



Doctor- and patient-centred communication

At first sight, allowing patients to be involved in management decisions might seem to be relinquishing medical expertise and merely facilitating what patients want. This would be unprofessional, and we could deservedly question how patients can know what they want without medical knowledge and training. Were you to say to the thyrotoxic patient:



We could treat your overactive thyroid with tablets called carbimazole or we could use radiotherapy or we could arrange for you to have an operation. Now which will it be?


she would probably respond:



Well, I don’t know what’s best. You’re the doctor.


Patient-centred communication does not mean abdicating decision making to patients. It is the process of providing patients with the appropriate knowledge and understanding to enable them to make informed decisions and take appropriate responsibility for their care. Such an approach combines the professional knowledge and opinions of the doctor with respect for the autonomy of the patient. A better way to approach the thyrotoxic patient would be:



There are a number of ways to treat an overactive thyroid. One would be to take tablets for a few months to see if they settle it down. They are often very effective, although some patients do eventually need to have an operation. Another choice would be to consider surgery at the outset, but in my experience most surgeons prefer to operate if tablets don’t work. A third option would be something called radiotherapy, but this may not be a good idea if you were planning to become pregnant in the near future. I usually prefer patients to take advice from a doctor who specialises in thyroid problems before deciding, but wonder if you have any immediate thoughts about these treatments.


The degree to which we engage in open discussion depends upon the patient. At one end of the spectrum are patients with seemingly very little interest in decision participation – I’ll go with whatever you think is best, doctor. At the other extreme are patients who ruminate over everything that happens to them, and want to know everything – How many stitches would the surgeon need to use, doctor?


Patients differ. Yet when we look for evidence-based management of disease, we find management plans that focus on disease and not the permutations of our patients. Traditionally, doctors have been disease centred, but diseases are wrapped in packages that are patients and a fundamental clinical skill is applying evidence-based medicine to the spectrum of different patients. Guidelines might advise against radioactive iodine in pregnancy and the patient might say:



I was thinking about having a family soon.


But she might also say:



My mother had a thyroidectomy 30 years ago and had terrible swallowing problems afterwards until the day she died.


Those swallowing problems may not have been associated with the thyroidectomy. One could also say that surgery has moved forward in 30 years. But the patient may nevertheless have decided she does not want to contemplate surgery. The point is that the optimal management of a disease is not automatically the optimal management for a patient with that disease.


Taking into account how a patient feels about their disease and its management is what is meant by patient centredness. Pure doctor centredness is doctor controlled and tends to be inflexible from patient to patient. Management decisions are made by the doctor and the patient is expected to comply. The key to patient centredness is not to abandon the strengths of disease and doctor-centred practice, but to share information so that decisions about management are shared with and acceptable to the patient. Patient centredness and doctor centredness should work together, the former relating to clinical knowledge of disease and how it should be managed, the latter a means of harnessing the patient’s perspective to convert that knowledge into an acceptable management plan. Because patients have a fundamental ethical right to be involved in decisions about managing their disease, doctors have a duty to be patient centred.


Patient centredness is central to helping patients decide what is best for them. Consider that the surgeon of the thyrotoxic patient felt thyroidectomy to be the best course of action. It would certainly be right to explore her understandable concerns about the operation. Negotiating the best course of action for her should address these concerns. A balanced explanation by the surgeon may emphasise the low incidence of serious complications, despite her fears, and include an expectation of what may happen if she does not proceed to surgery now. Despite this process of shared understanding, if the patient, competent to decide and aware of the risks, declines surgery, she is exercising her autonomy. More likely, she will be reassured and begin to find surgery an acceptable option.


Patients have a right to be involved in decisions that affect them. Practising modern medicine is not just about knowledge, but also about the skills to share that knowledge in ways that encourage patients to make sound informed choices. Patients, in general, value our ability to guide. When they are guided, rather than pushed, they are far more likely to keep going along the treatment path we suggest.



Ethics




Ethical principles

Four broad ethical principles underlie ethical decision making (Box 4.1).



Box 4.1   Ethical principles







Applying ethical principles

Specific cases have a vital role in ethical argument. Ethics is not a science where we agree upon a set of principles and then deduce what is right or wrong from these. Rather, the implications of the principles in specific cases must be explored.


Ethical reasoning is an interactive process that involves consideration of individual situations and application of ethical principles. One logical requirement to this process is consistency. If what you believe to be right in one situation seems inconsistent with what you believe to be right in another, you must either identify a morally relevant difference between the two situations or change your view. When considering individual patients and applying ethical principles, foremost in our minds in decision making should be what is deemed in the patient’s best interests. It helps, when making a decision, to ask why you have made it and to be able to justify it.




Cases



Discussing clinical management



Case 4.1 Explaining a diagnosis



Candidate information



Scenario


Re: Mrs Elizabeth Wright, aged 45 years


Mrs Wright has systemic lupus erythematosus (SLE). She has had a malar rash and pain in her hands for 12 months. Her clinical presentation, together with results of extensive investigations including autoimmune serology and radiology, supports the diagnosis of SLE confined to skin and joints without other multi-systemic involvement. She is here today for results. She is a hospital secretary and very concerned she may need to stop working.


Your task is to explain the diagnosis, addressing her concerns.



Your examiners will warn you when 12 minutes have elapsed. You have 14 minutes to communicate with the patient / subject followed by 1 minute of reflection. There will then follow 5 minutes of discussion with the examiners. Do not take the history again except for details that will help in your discussion with the patient / subject. You are not required to examine the patient / subject.



Patient / subject information

Mrs Elizabeth Wright is a 45-year-old hospital secretary with two sons. For the last year she has had intermittent but slowly worsening pain in the joints of her hands and a facial rash that is sensitive to sunlight. She is previously very well, takes no medications and is a non-smoker. She has been investigated recently in the outpatient clinic and informed that systemic lupus erythematosus (SLE) is a possibility. She is here today for the results of tests. She is very concerned that she may need to stop working, which she can ill afford as a single mother. She is also concerned because she is aware of a patient in her workplace needing dialysis, and an internet search advised that SLE was not a curable disease and could cause kidney failure. Otherwise she knows very little about SLE.



How to approach the case


Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law




3 Establish previous experience


Stronger candidates are guided by patients when giving explanations. They operate within a patient-centred framework. Weaker candidates think ‘Oh no! What do I know about SLE?’ and proceed to tell their patients very little or far too much, often in a disorganised fashion. Try to establish what your patient knows about their diagnosis before launching into your explanation. Rather than saying:



SLE is a condition which …

a better approach would be one of:

Have you heard of this condition before?


I wonder if you know anything about this condition before we start?


Have you any ideas about this condition?


What have you been told so far about this condition?


A specific, uncommon condition like SLE may mean very little to a patient. Other diagnoses such as multiple sclerosis, cancer and rheumatoid arthritis are well known but often poorly understood. Establishing prior knowledge or preconceptions helps determine at what level to start your explanation. She might not know that SLE can be a multisystem disease affecting more than skin and joints. Alternatively, she might say:



I was reading that it can affect the kidneys and that some patients end up on dialysis. Is that likely to happen to me?











Case 4.2 Explaining an investigation



Candidate information



Scenario


Re: Mr Roger Thornhill, aged 74 years


Mr Thornhill has been losing weight for 5 months, and feeling slightly breathless on exertion. He has hitherto been a well man, playing golf every day until admission to hospital last week with cough and possible pneumonia. He feels the antibiotics have helped. However, his chest X-ray showed mediastinal widening and a computed tomography (CT) scan confirmed a mass arising from the left hilum, which is likely to be primary lung cancer but possibly lymphoma. He was aware that the chest X-ray showed an abnormal shadow but does not know the results of his CT scan. He has not smoked for 20 years.


Your tasks are to explain the results of the CT scan and discuss bronchoscopy as the best next step.



Your examiners will warn you when 12 minutes have elapsed. You have 14 minutes to communicate with the patient / subject followed by 1 minute of reflection. There will then follow 5 minutes of discussion with the examiners. Do not take the history again except for details that will help in your discussion with the patient / subject. You are not required to examine the patient / subject.




How to approach the case


Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law












Discussion


An 86-year-old woman with moderately severe dementia has a suspicious lesion on chest X-ray. Would you recommend bronchoscopy?

Guidelines for investigating and treating suspected lung cancer suggest bronchoscopy or percutaneous biopsy to guide appropriate treatment – surgery, chemotherapy, radiotherapy or palliation. But guidelines often fail to address significant comorbidity. Here, assessment of cognition, functional and social support and symptom control are likely to supersede attempts to confirm a diagnosis, but investigation may be warranted if likely tumour-related symptoms develop to allow more secure planning of palliative measures. Her capacity to understand the issues should be explored, ideally in the presence of next of kin, and empirical treatment considered if she does not accept investigation. If she accepts investigation, the least likely to cause distress should be arranged, for example a computed tomography scan rather than bronchoscopy.



What do you understand by the terms sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV)?

Sensitivity and specificity are to do with finding or not finding disease. Sensitivity is concerned with finding disease, and specificity with not detecting disease in those without the disease. Disease positives and negatives are based on ‘gold standard tests’ (ultimate diagnostic tests as the profession sees them). Predictive values are to do with diagnostic / screening tests. If a test is positive, the question is whether or not it is good at detecting disease; if a test is negative, the question is whether or not it is good at not missing disease. Sensitivity and specificity are not affected by the prevalence of a disease; predictive values are (Table 4.1).











Which factors may influence a decision to investigate older people?

Guidelines for investigating conditions can fail to address individual factors that should be considered when assessing the potential benefits and risks of investigation; such factors become more common with advancing age. Comorbidity and multiple pathologies become more likely in older patients, with an increase in chronic diseases, and it can be more appropriate to identify problems and use problem solving than seek single unifying diagnoses, and more appropriate to make judgements as to which problems are most probably affecting quality of life. Cognitive impairment, either mild or dementia, may preclude informed consent for an investigation. Physical disability such as osteoarthritis can, for example, thwart exercise stress testing. Patients’ views and wishes are of course most valuable in deciding the best way forward. A common example is the extent to investigate anaemia in an older person once a basic ‘blood screen’ has been completed.


A pragmatic way of decision making for investigating older people is to select investigations most likely to change management or yield prognostic information. If a patient is competent to give informed consent to an investigation then it is possible to proceed; if not then it may be discussed with those close to the patient, and a decision made in the patient’s best interests as judged by the doctor. If either a competent patient or those close to a patient not competent refuse investigation then empirical treatment might be offered.


Automatic investigations that will not benefit patients are inappropriate but discrimination against older patients by restricting access to investigations is equally unacceptable. Decisions should be made by balancing potential benefits and risks, and not determined by age.



Case 4.3 Discussing treatment



Candidate information



Scenario


Re: Mr James Bonde, aged 80 years


Mr Bonde is recovering well from a non-ST elevation myocardial infarction. Although well before admission, coronary angiography is not being considered and he is keen to go home. He is currently taking aspirin. Beta blockade is deemed risky on account of sinus bradycardia. His blood pressure is 160 / 90. You think he might benefit from clopidogrel, a statin and an angiotensin-converting enzyme inhibitor to further modify risk.


Your task is to explain these treatments to him, and allow him to make an informed choice about whether or not to take them.



Your examiners will warn you when 12 minutes have elapsed. You have 14 minutes to communicate with the patient / subject followed by 1 minute of reflection. There will then follow 5 minutes of discussion with the examiners. Do not take the history again except for details that will help in your discussion with the patient / subject. You are not required to examine the patient / subject.




How to approach the case


Communication skills (conduct of interview, exploration and problem negotiation) and ethics and law




3 Give the patient a chance to react to the need for treatment


Remember that a lot has happened to him recently. His world has been changed by the heart attack. He probably had an enormous fright when admitted, and is still coming to terms with the repercussions of his diagnosis. He will have received a great deal of advice from doctors, nurses and members of the cardiac rehabilitation team. He will be on a range of tablets indefinitely. It is important to recognise that his hopes and yours may not immediately be the same. There may be a mismatch of agendas. You want him to start more tablets and then see your next patient but he desperately wants some good news. Yet more tablets may not be what he had in mind. Going home may be. Give him a chance to react to what you see as the most important next step, and appreciate his.










Discussion


Are you more reluctant to prescribe medications for older people?

Treating older people must aim for maximum benefit (it is older people who often derive most benefit from a particular drug) and minimal adverse effects by avoiding excessive or inappropriate medications. To achieve this balance, individualised prescribing that considers comorbidity, co-prescription and social aspects of care, and careful judgement of overall frailty and likelihood of benefit, are crucial. Older people are often inappropriately under-represented in therapeutic trials, and so the size of benefit might be underappreciated in an older person, but so might the absolute risk increase. Six rules in prescribing for older people are shown in Box 4.3.



Box 4.3   Prescribing for older people









Is drug treatment for coronary syndromes the same for older as younger patients?

Thrombolytic agents provide a greater absolute benefit in older people and should only be withheld if there are contraindications, although these are more likely in older people. Meta-analyses of aspirin trials show around 25% reduction over 2 years in secondary prevention of major vascular occlusive events, relative risk reduction being similar in younger and older people but absolute benefit greatest for high-risk patients over 65 years (but the risk–benefit ratio tips aspirin out of favour for low-risk older people in primary prevention). Beta blockers after myocardial infarction reduce mortality from ischaemia and arrhythmias with evidence up to 75 years, but beyond this age benefit can only be extrapolated and older people are more likely to have relative or absolute contraindications, such as sinus pauses or postural hypotension. Angiotensin-converting enzyme inhibitors reduce mortality and morbidity in cardiovascular disease but again older patients are more likely to have contraindications such as hypotension, moderate aortic stenosis or vulnerable renovascular disease.






What do you know about drug-induced disease?

Any drug may cause disease, and drugs should always be included in the differential diagnosis of symptoms. For example, a glance at the drug chart might reveal the concomitant use of a selective serotonin reuptake inhibitor (SSRI), a tricyclic antidepressant and tramadol; SSRIs are enzyme inhibitors that enhance the action of the other drugs and the combination of a SSRI and tramadol can produce a serotonergic syndrome. Common drugs causing disease include non-steroidal anti-inflammatory drugs (NSAIDs), aspirin, clopidogrel, warfarin, diuretics, angiotensin-modifying agents and corticosteroids, but these drugs are commonly prescribed. Over-the-counter drug use should also be explored, as around 25% of hospitalised patients may be taking these yet in only around 1% of patients do they appear in their case records.



What do you know about adverse drug reactions (ADRs)?

ADRs are a challenge for both primary and secondary care, and reflect the value of a strong pharmacist presence in the health-care team. Year on year drugs are withdrawn because of safety concerns, examples in recent years including cerivastatin, rofecoxib and co-proxamol; 6.5% of hospital admissions are due to ADRs, and 14.7% of patients experience an ADR in hospital, a major proportion of these thought to be potentially preventable. Drugs should thus always be considered in the differential diagnoses of presentations. To assess cause and effect may require any of a temporal relationship, re-challenge, exclusion of other causes, novelty or de-challenge (dose reduction or withdrawal). Errors in omission appear to be more common than commission. Alternative medicines are a large problem, and for example ginseng, feverfew and garlic reduce platelet function and St John’s wort induces drug metabolism of protein pump inhibitors and this combination may result in gastric bleeding. The Medical Research Council for Drug Safety Science Hospital Admission Study revealed the top 10 causative drugs for ADRs as NSAIDs, diuretics, warfarin, angiotensin-converting enzyme inhibitors, antidepressants, beta blockers, opiates, digoxin, prednisolone and clopidogrel. NSAID-induced peptic ulceration is the most frequent ADR cause of admission. Antiplatelet agents are a common example of the benefit–harm balance consideration, as they benefit vascular disease but may cause gastrointestinal bleeding, the latter risk increased with NSAIDs and former benefit reduced by some gastroprotective agents.




What do you know about drug licensing?

Drug licensing is not able to influence the vigilance all doctors must have to licensed drugs, but is a vital line of defence against drug-induced disease. The British Medical Journal in 1909 published a report on ‘Beechams Remedies’, a popular product at the time which falsely claimed a dazzling range of benefits, but which contained little else than soap and ginger. Licensing became formalised in 1958 in the thalidomide era, and now to gain a licence a drug must pass the hurdles of quality of manufacture, efficacy in the proposed indication and reasonable safety. The Medicines and Healthcare products Regulatory Agency (MHRA) in the UK, through its Commission on Human Medicines and Licensing Authority, has a pivotal role. On introduction, most drugs go through the phases of initial high expectation then subsequent disappointment before finding their balanced place. Drugs then generally have a period of patency protection before coming ‘off-patent’ and becoming generic, whereupon ‘me-too’ products at competitive rates may consume 90% of sales. Pharmaco-vigilance is vital, and MHRA pharmaco-vigilance groups receive yellow cards from reporting doctors, and these provide vital cumulative clues of danger; not enough doctors submit these.



Case 4.4 Discussing management, prognosis and possible complications in a patient with multiple problems



Candidate information



Scenario


Re: Mr John Rowe, aged 76 years


Mr Rowe had a partial gastrectomy for gastric cancer 2 years ago. It was diagnosed very early, by oesophagogastroduodenoscopy for dyspepsia. After surgery and a course of Helicobacter pylori eradication he had no further symptoms and his surgeon told him all appeared to be clear. He now has recurrence of dyspepsia and is seeing you urgently in clinic and wants to know if the cancer might have returned. He has recently seen the cardiologists because of suspected angina and awaits angiography. He has been started on aspirin, a statin and an angiotensin-converting enzyme inhibitor but not a beta blocker on account of mild chronic obstructive pulmonary disease for which he takes inhalers. He also wishes to talk to you about his angina and breathing because he feels the cardiologists did not tell him very much. And he has recently had two episodes of fresh rectal bleeding, but he is not too troubled by this. You may assume systematic enquiry otherwise unremarkable.


Your task is to address his concerns and discuss a way forward.



Your examiners will warn you when 12 minutes have elapsed. You have 14 minutes to communicate with the patient / subject followed by 1 minute of reflection. There will then follow 5 minutes of discussion with the examiners. Do not take the history again except for details that will help in your discussion with the patient / subject. You are not required to examine the patient / subject.

Related posts:

  1. 3: Cardiovascular and nervous system
  2. 2: History-taking skills
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  4. 5: Integrated clinical assessment

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Jun 3, 2017 | Posted by in GENERAL SURGERY | Comments Off on 4: Communication skills and ethics

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