Speak clearly and audibly, providing cues to the patient about the significance of the illness through the tone of voice. Go at a slow but steady pace which should be flexible in response to the patient.
Avoid jargon. Use words appropriate for the patient's educational background and intelligence.
Avoid emotive words. Phrases like 'cancer', 'failure' or "multiple sclerosis' may so distress patients that they stop paying attention. Such words may have to be used, bul it may be advisable to discuss ihe management and prognosis in genera] terms first.
GiVe the most important information first. This is usually an explanation for the presenting symptoms it may be a diagnosis, or if there is doubt, what the main possibilities are. Patients are more prepared lo relate to doctors who are uncertain and open about their doubts, than doctors who appear overconfident.
Packet the information. Categorise the information. In general, move through diagnosis, to investigations or referrals, then to immediate treatment and possible treatments. and end with prognosis. Identify areas of doubt, arid qualify what is or is not likely, bearing in mind widely held myths such as cancer invariably kills.
Monitor the patient's reactions and encourage dialogue.
Observe the patient's reactions and respond to facial cues such as puzzlement or distress. Check that patients understand what is being conveyed by asking them to summarise. Then tactfully correct any misunderstandings. Try to ensure that the patient is neither unduly positive or negative. Answer any immediate questions as truthfully and completely as possible. Break off if the patient is plainly too anxious or distressed to continue.
Provide the patient with as much choice as possible. Patients have differing views on what is appropriate for them, and it is important to take this into account when determining the management plan. For example, women who have breast cancer are more satisfied with their treatment and less likely to suffer from mood illness if their wishes are taken into account about the type of surgical operation when choice is feasible. Choice is not always possible, but issues where choice is available should be highlighted.
Repeat and reinforce the key points. Repetition should he used selectively to be effective. The same points can be repeated using other techniques, for example a surgeon may usefully explain an operation using a diagram or model - if the patient shows an interest in this (for some patients this might prove upsetting). Other ways of providing information which have been shown to be effective include audiolaping the interview, providing written information immediately or even a version of the medical assessment letter (which has the advantage of permitting errors of fact to be corrected). Such elaborate reinforcement is unnecessary in most clinical interviews: these techniques are adjuncts to be used selectively, usually when serious disease is established or likely and compliance with sometimes arduous investigations and dista-ssing treatment is vital.
Encourage questions at the end of the main information-giving. Patients vary in their concerns, and it is important lo allow airing of such worries - even if they are inappropriate. Patients may hold elaborate ;ind sophisticated theories about their illness sometimes commonly understanding it in lerms of some event in their life, either recent or remote, which may be relevant or not. Patients also vary in what and how much they want to know. Many want to know the answers to three basic questions - Why me? Why now? Why this particular illness?
Prognosis. 'How long have I got doctor?' This is a common question. Sometimes the best initial response is to ask why the patient wishes to know. This may then provide the opportunity to discuss particular fears and anxieties before dealing with the prognosis. It may also alert (he patient to the nature of the problem. It is important to emphasise that nobody can predict life-expectancy accurately. Il is best not to mention any specific time or range, and to maintain and share the uncertainty with the patient - 'neither of us knows". The focus can then be switched to something practical and relevant, such as whether the patient would want to know the signs or symptoms that might herald deterioration or what steps the patient ought to consider taking now, given the current status of the disease.
However, giving patients an approximate life-expectancy enables them to make important decisions about how they intend to use their remaining life and to prepare for death. The advice given to each patient should be influenced by the disease process, the patient's personality and circumstances and especially by Iheir wishes.
Follow-up appointments/arrangements. One session may not suffice. If further information needs to be conveyed or it is essential thai the pattern's understanding is adequate or the patient needs time to come to terms with the news, then follow -up will be required. 1 his is often best undertaken by the same clinician, but sometimes it may be more appropriate for (he general practitioner or a trained counsellor to take over. In such circumstances the person who is to (akc over should be personally briefed by the clinician about the onginal session but i( is far better if this can be anticipated: for instance, the attendance of the breast nurse counsellor at the first consultation of a woman w ith breast cancer with the surgeon is crucial in facilitating effective communication as much of the dialogue and information-giving will be taken over by the counsellor, who is usually better trained in this aspect and more approachable from the patient's perspective.
TAB LE 1.16 The health gains of effective communication
Better understanding of the disease
Reduced immediate psychological distress
Reduced long-term mood disorder
Fewer stress-induced physical symptoms
Better compliance with treatment
Greater likelihood of favourable behavioural change
Reassurance. Reassurance is a potent therapeutic tool which, like all treatments, has to be used appropriately and carries potential risks. Inappropriate reassurance is counterproductive. Reassurance given in response to specific anxieties is both necessary and usually beneficial. I( is of special value in helping to allay specific fears such as the control of pain and the lear of dying alone.
Table I. If» summarises the main health gain*, lhai arise from effective communication with patients. Bénéficiai clinical communication does noi unduly prolong an interview, provided the clinician has acquired the relevant skills.
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