Abstract

This is a short algorithm for professional communication in specific clinical situations. Recommendations are developed on the basis of the guidelines on objective structured clinical examination. It is an educational material, intended for medical students and physicians, who have just started a clinical practice.  

How to consult

  1. Beginning:

  2. Mid counseling:

  3. Completion.

How to structure the explanation

  1. Disease explanation (in simple terms).

  2. The explanation of the procedure.

  3. Treatment explanation.

Important tips

  1. Give the patient the opportunity to manage the process of consultations and decide what to talk about.

  2. Follow the conversation and ask what patient want to know about. Ask about their worries.

  3. Do not forget about patient’s thoughts and emotions and his/her expectations.

  4. Always remember that you can share bad news don’t even realizing it.

  5. Avoid all medical jargon.

  6. Empathize.

Explanation of the diagnosis

Explain the essence of the disease/disorder. Avoid medical jargon; explaining should be performed in a simple, understandable to the patient language. For example:

“Depression (Major Depressive Disorder) is a common mental health problem that occurs due to insufficient production of serotonin by the body. Serotonin is a substance (neurotransmitter) that provides transmission of signals between brain cells (neurons). When the body lacks serotonin, the function of brain cells begins to suffer. Consequently, it causes mood changes, sleep problems, provokes negative thoughts, etc.”.

Explanation of the treatment

The patient should be given the information on treatment, and the possible mechanism of action. For example:

“Possible option in the depression treatment could be cognitive-behavioral therapy (CBT) or antidepressants. Psychotherapy helps the brain cope with a lack of serotonin by including additional "reserves". CBT helps the cerebral cortex, which is responsible for reasoning, to regulate those parts that are responsible for emotions.”

“Another treatment option is taken a medication. Antidepressants (SSRIs) act directly on neurons that responsible for emotions and transmit signals using serotonin. SSRIs allow existing serotonin neurotransmitters and some others to act more efficiently when transmitting a signal between neurons.”

If there are several treatment options, according to clinical protocols, the doctor must discuss them with the patient, explain differences, as well as their risks and benefits and choose one in accordance with patient preferences.

Providing other relevant information

Patients should be informed the following relevant information about the prescribed treatment:

  • Treatment form, dosage regimen, and time when the medication should be taken. For example: "Tablets, 1 time a day, in the evening, at least 1 hour after a meal."

  • Frequent side effects. No need to enumerate all theoretically possible side effects! Specify the contraindications for administration.

  • The expected treatment duration and time to onset of effects. For example, "The first effects usually appear within 4 weeks after starting treatment, and treatment lasts 3-6 months after it became better."

  • Necessary tests. For example, “warfarin is a drug that thins the blood to prevent blood clots, because of this there is a need to perform blood tests to assess blood clotting. It is usually done on the 5th and 8th day and periodically throughout the treatment.

Guidelines

Bad news should be provided in accordance with SPIKES protocol (Setting, Perception, Invitation, Knowledge, Emotion, Strategy and Summary) 1 .

Setting appropriate conditions

Make sure you're with the patient in a comfortable room. Ideally, it should be a special private room. Alternatively, patient’s ward can be used, but be sure that you are alone and no nobody would interrupt the conversation. On patient’s request, one or two family members can be invited. Confidentiality must be assured!

Ask the patient whether he/she wants to sit down; it helps to relax and shows that you are not in a hurry. Maintain eye contact to establish rapport. If the patient is comfortable, you can touch him or take a hand. Ideally, you need to create the conditions in which you will not interrupt. But if such a situation is possible - inform the patient.

Patient's perception of the current situation

Before giving the patient any information, you should find out what the patient already knows. For example, "What do you already know about your current state of health, what can you tell about it?", "Do you understand why MRI/CT/biopsy was performed?".

If the patient has a misconception about his health, it should be described in more details. It is also essential to determine whether the patient has a form of disease’s denial:

  • Is he/she skipping important “bad” information about the condition?

  • Does he/she have unrealistic expectations about the treatment?

Invitation

Asking the patient which information should dwell more during conversation is a good practice. It can be the treatment, test results or anything else. Acknowledge a patient about the ability to ask questions in the future, if they appear. Ask whether the patient wants the presence of someone from the family if it was not done earlier:

"I have your test results; would you like me to explain them in more detail?"

“How would you like me to deliver information about the diagnosis and treatment?”

“Tell me please if you will want to receive additional information about anything that will be discussed.”

Knowledge. Delivering information

  • Warn the patient that there is bad news. There is a common idea that this can reduce the patient’s shock compared to reporting the diagnosis at once.

  • Explain diagnosis (step by step). The diagnosis should be reported with the short thesis.

  • Each phrase should be followed by a pause. Wait for the patient to ask questions (if he/she has one). Then move on to the next thesis. At this point, silence is one of the most appropriate strategies that physician can apply. Upon delivering bad news, the patient may fidget a million different thoughts. He needs time to comprehend.

  • If silence seems uncomfortable, the patient can be asked about what he/she feels.

  • Do not start a full explanation. Just answer the patient’s questions. Because of the influx of emotions usually patient doesn’t remember what happened at this stage.

  • The question should be answered in a way that patient could understand.

  • Avoid excessive directness. The phrase, "You have a very aggressive malignant tumor, and you're going to die" - is an unacceptable way for reporting a diagnosis.

"As you know, we took a biopsy (tissue sample for examination). Unfortunately the results were not as we had hoped," pause and wait.

"I am sorry to inform you, but we have found a tumor."

Emotions and empathy

  • Understand and reflect patient’s emotions of the patient (including body language).

  • Do not try to solve patient’s problems or reassure him/her, just listen and summarize patient’s worries and concerns (it shows that you are listening and empathies).

  • If silence is long, you can ask about patient’s emotions.

"I see that news is a huge shock," pause and wait.

"You look extremely concerned," pause and wait.

"So you told me your biggest concern is how you announce this to children/are the consequences of chemotherapy?"

"How do you feel now, after receiving this news?"

“You are very silent; can I ask about your thoughts?”

“What worries you the most?”

Strategy (plan) and summary

  • Agree with the patient on how to proceed. Ask the patient if he/she is ready, before proceeding with a discussion of the treatment plan.

  • Summarize the patient’s concerns.

  • Evaluate the emotions with which patient is taking a leave.

Introduction

  • Wash hands, introduce yourself, ask the name of the patient and how he/she wants to be called. Explain the purpose of the consultation.

  • Check prior knowledge of the patient, what he/she knows about asthma/chronic obstructive pulmonary disease (COPD) and their treatment.

Initial explanation

  • Explain the types of inhalers, their purpose, and the application. Salbutamol inhaler is used for relieving symptoms during the asthma attacks and steroid inhaler - for attack prevention.

  • The inhaler contains a fixed dose of medication.

  • The primary task is to deliver a medication into the lungs.

  • The drug is released by pressing on the device (demonstrate).

Steps

  1. Check the expiration date of the drug.

  2. Intensively shake the container.

  3. Remove the cover and check the purity of inhaler cap.

  4. Take straight standing or sitting position.

  5. Hold the inhaler upright with the help of the index finger on the upper side and thumb on the lower side. Make the deepest breath.

  6. Enfold mouthpiece with lips tight. At the same time, click on the canister and make a slow deep breath (focus on the back of the throat, not to interfere with the tongue).

  7. Hold your breath for as far you can, preferably at least 10 seconds. Then exhale normally.

  8. Replace the inhaler cap.

  9. Repeat after 1 minute if required.

Demonstration

  • Demonstrate by yourself.

  • Ask the patient to independently demonstrate how they will use it (with a placebo inhaler).

  • Monitor the patient and correct errors.

  • Ask the patient to repeat the procedure until it does not make it right.

  • Ask the patient if he/she has got any questions.

Special cases

  • Call an ambulance in case of an increase of symptoms or if the attack is not withdrawn by an inhaler.

  • Visit a therapist if there are side effects or using reliever inhaler too often.

Possible questions

  • Parents want to know more about the children’s vaccination. Provide the necessary information regarding the vaccine and the disease, from which vaccination could protect.

  • Parents do not agree with the vaccination of children. Share the benefits of vaccination.

  • Parents have heard some information in the news, e.g., cases of autism associated with vaccination (there are none!).

Important goal

  • Empathize.

  • Do not make value judgments.

  • Identify patients’/parents’ concerns bother and beliefs associated with vaccination.

  • Explain the benefits of vaccination (they far exceed possible risks).

Immunization schedule

USA; according to Center for Disease Control and Prevention 2 .

  • At birth - Hepatitis B.

  • 1 month - Hepatitis B.

  • 2 months - Rotavirus, DTP (diphtheria, tetanus, pertussis), Hib (Haemophilus influenzae), PCV (Pneumococcal conjugate)

  • 4 months - DTP, Polio, Hib, rotavirus, PCV.

  • 6 months -Hepatitis B, DTP, PCV, Polio.

  • 12 months - Hib, PCV, MMR (measles, mumps, rubella), Varicella, Hepatitis A.

  • 15 months - DTP.

  • 18 months - Hepatitis B, DTP, Polio.

  • Preschool (4-6 years) - DTP, Polio, MMR, Varicella

  • 11-12 years - Meningococcal, DTP, HPV (human papillomavirus, for girls).

  • 16 years - Meningococcal.

  • Influenza - annual vaccinations.

Ukraine; according to Ukrainian Ministry of Health [ 3 ].

  • At birth - Hepatitis B

  • 3-5 days- Tuberculosis.

  • 1 month - Hepatitis B.

  • 2 months - DTP, Polio, Hib.

  • 4 months - DTP, Polio, Hib.

  • 6 months - DTP, Polio, Hepatitis B.

  • 12 months - MMR, Hib.

  • 18 months - DTP.

  • 6 years - Diphtheria, Tetanus, Polio.

  • 7 - Tuberculosis.

  • 14 - Polio.

  • 16 - Diphtheria, Tetanus; and every 10 years.

Review of diseases covered by a vaccination

Diphtheria

  • Symptoms: weakness, fever, sore throat, gray and membranous protrusions on the tonsils, throat narrowing.

  • Complications (disease): cardiomyopathy, renal failure.

Tetanus

  • Symptoms: weakness, muscle spasm in the area of the jaw and other muscles (including respiratory muscles).

  • Complications: impairment of respiratory muscles.

Poliomyelitis

  • Symptoms: weakness, central nervous system damage.

  • Complications: paralysis.

Haemophilus influenzae

  • Symptoms: epiglottitis, meningitis, pneumonia.

  • Complications: brain impairment.

Rotavirus

  • Symptoms: diarrhea, nausea, and vomiting.

  • Complications: severe dehydration.

Pneumococcal infection

  • Symptoms: pneumonia, otitis media, sinusitis.

  • Complications: meningitis, osteomyelitis.

Measles

  • Symptoms: high body temperature, cough, conjunctivitis, rash, rhinitis.

  • Complications: encephalitis, corneal ulcer.

Mumps

  • Disease: low temperature with swelling in the neck (inflammation of the lymph nodes) and headache.

  • Complications: orchitis and infertility, bilateral deafness.

Rubella

  • Symptoms: flu-like symptoms with a rash.

  • Complications: brain inflammation, pneumonia.

Human papillomavirus infections

  • Symptoms: warts.

  • Complications: cervical cancer, oropharyngeal cancer, rectal cancer.

Tuberculosis

  • Symptoms: a cough, fever, night sweats, weight reduction.

  • Complications: dissemination of the pathogen to the bone tissue, central nervous system (meningitis), lymphatic system; emphysema, pulmonary heart disease.

Advantages and disadvantages of vaccination

Advantages

  • Prevention of severe diseases with serious consequences and highly contagious diseases.

  • Support the eradication of dangerous diseases at the population level that keeps millions of children's lives around the world.

  • It is much safer to use the vaccine than not use.

Safety

  • Vaccines are highly safe.

  • Vaccines are constantly under control. Vaccinated patients are routinely monitored.

Risks

  • Like any other medication, vaccines have side effects.

  • They are very rarely serious and usually held for a few days.

Contraindications

  • If a child feels sick and has a fever, vaccination should be delayed.

  • Avoid live vaccines for patients with immunosuppression (BCG live vaccine against rubella, polio, measles, and mumps).

  • Avoid vaccination if there ever been anaphylactic reactions to a vaccine component.

Possible side effects of vaccination

  • Local effects: swelling, redness.

  • Fever.

  • Allergic reactions and anaphylactic shock (can be managed!).

  • MMR - fever, lymph nodes swelling, and rash.

What to do?

  1. Acknowledge to the patient - "You look worried/aggressive."

  2. Voice the reason - "It is clear in your situation. You have gone through a lot. You are worrying about your relative, but you were told to wait another 2 hours before you can see him."

  3. If the cause is not obvious, try to find it, "Is there something else what makes you angry?". Do not interrupt the patient when he/she is talking to you.

Important tips

  • Never say "I understand" to an angry patient/relative.

  • Speak to him/her softly, quietly, and slowly.

  • Encourage the patient to tell the story. Ask questions and show verbal and nonverbal cues that you are listening.

  • Do not take it personally. In many cases, aggression is just one of the ways of coping with stress/negative experience.

  • Do not confront with aggressive patient/relative. Do not block his path to the exit. Do not transfer the blame to others to avoid accusations from patient’s/relative’s side.

Answers to the questions and remarks

  1. The patient may present verbal and nonverbal cues which show the need of an answer from a physician.

  2. Show that you are listening.

  3. Empathize.

  4. Explore the meaning of the remarks and questions: "Will it be normal if I ask about it in more detail?".

  5. Answer/help in solving problems only if necessary (a direct question, nonverbal cues) - in most cases it is not necessary!

What to do?

  1. Provide comfort and privacy.

  2. Acknowledge to the patient: "You look upset/disturbed."

  3. Explore the thoughts that underlie sadness/anxiety: "Are you willing to share what are you thinking at this moment."

  4. Normalize patient's emotions: "I think that most people would feel the same in this situation."

  5. Provide information about the situation which triggers these emotions, if it refers to yours competence.

Important tips

  1. Empathize.

  2. Show that you are listening. Verbally ("Do I understand you correctly that ...") and non-verbally (open posture, eye contact, etc.).

  3. If the patient is crying, you should give him/her the time and space. Often, silence is the best strategy.

  4. Don’t depreciate patient’s emotions.

  5. You can use physical contact if you and the patient are comfortable with it.

  6. Repeat health information/treatment when a patient’s emotions decrease. Check if he/she understands it.

  7. Don’t provide the reassurance that everything will be fine if it is not true.

Competing interests

The authors declare that no competing interests exist.

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