Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5230_Библиотеки_им_академика_М_И_Перельмана.pdf
Patients’ relativesCommunication with relatives can be dicult if done
badly, or rewarding if done well. They may be scared, assuming the worst,
and be in the frustrating position of not knowing what is going on. They
could have a full- time job that prevents them coming in during theday:
• If you are on- call and do not know the patient well then be honest about
this, but attempt to answer simple questions as best possible using the
notes; explain what times the usual ward sta will be present
• Try to arrange a time when you can discuss the patient’s progress in a
quiet room (ask a colleague to hold yourbleep)
• To avoid repeating yourself, speak to the family collectively or ask them
to appoint a representative
• Check the patient is happy to have their condential medical details
discussed (E p. 29) and encourage them to be present if possible
• Address concerns and answer each question inturn
• Be honest about your limitations and involve seniors where necessary
• Document the date, time, what was discussed, and who was present.
Patient communication A patient’s perception of your abilities as
a doctor depends largely on your communication skills. Remember that
patients are in an alien environment, often feel powerless, and are worried
about their health.
IntroductionsAlways introduce yourself to patients and clearly state your
name and position. Ask your patient how they wish to be addressed
(eg Dennis or Mr Smith). Patients meet many sta members daily so
reintroduce yourself each time you see them (Box.0).
General adviceTry to avoid using medical jargon. Be honest with your re-
plies to them, and give direct answers when asked a direct question. You
will have to deliver bad news—do not shy away from this. If you do not
know the answer, be honest about thistoo.
ResultsExplain why a test was done, what it shows, and what itmeans.
DiagnosisTry to give the everyday name rather than a medical one (heart
attack instead of MI). Explain why this has happened. A patient who
understands their condition is more likely to comply with treatment.
Prognosis Along with the obvious questions about life expectancy
(E p. 24), patients are most interested in how their life will be affected. Pitch your explanation in terms of activities of daily living (ADLs),
walking, driving (E p. 633), and working. Bear in mind that patients may
want to know about having sex, but are often too embarrassed toask.
T Box .0 Hello my nameis...
Kate Granger was a geriatrician, patient, and campaigner for compassionate and personalized care who sadly died at the age of 34 in 206.
She was diagnosed with terminal cancer in 20 and spent her subsequent years campaigning for better communication between doctors
and patients. Frustrated at the lack of introductions from healthcare sta
caring for her in hospital, she started the #hellomynameis campaign in
203. Founded on the simple idea of reminding sta that a condent
introduction is often all that is needed to put patients at ease, the campaign raised £250,000 for cancer charities and has received widespread
public and professional support. It is a reminder to us all never to forget
something as simple as introducing ourselves properly.
23COMMUNICATION AND CONDUCT
24 CHAPTER Being adoctor
Breaking badnews
Ideally, breaking bad news should be done by a senior at a predetermined time when relatives and friends ± specialist nurses can be present.
In reality, you are likely to be involved in breaking bad news, often while
on- call. It can be a positive experience if donewell.
Preparation Read the patient’s notes carefully and ensure that all re-
sults are up to date and for the right patient. Be clear in your mind about
the sequence of events and meaning of the results. Consider the further
management and likely prognosis— discuss with a senior if unsure.
Consent and condentiality(E p. 3, p. 29.)Apatient has a right
to know what is going on, or to choose not to know. Ask before the investigations are done and document their response. If a patient does not
want their relatives to know about their diagnosis you must respect this.
Always ask, do not assume— many families have complex dynamics.
Warning shotGive a suggestion that bad news is imminent so it is not
completely out of the blue, eg ‘I have the results from. . .would you like
anyone else here when Itell you them/ shall we go to a quiet room?’
How todo itThe SPIKES model is oftenused:
SettingAsk a colleague to hold your bleep, set aside suitable time (at least
30min), silence your mobile phone, use a quiet room, and invite a nurse
who has been involved in the patient’s care. Arrange the seats so you
can make eye contact and remove distractions. Introduce yourself and
nd out who everyoneis.
Perception Find out what the patient already knows by asking them dir-
ectly. This will give you an idea of how much of a shock it will be, and
their level of understanding to help you give appropriate information.
Invitation Explain that you have results to give them and ask if they are
ready to hear them. It helps to give a very brief summary of events so
they understand what results you are talkingabout.
Knowledge Break the news, eg ‘A doctor has looked at the sample and
I’m sorry to say it shows a cancer’. Give the information time to sink
in and all present to react (eg shock, anger, tears, denial). Once the patient is ready, give further information about what this means, and the
expected management. Give the information in small chunks, and check
understanding repeatedly. Prognosis can be dicult; never give an exact
time (‘months’ rather than ‘4months’). Be honest and realistic. Try to
oer hope, even if it is just symptom improvement or leaving hospital.
EmpathyAcknowledge the feelings caused by the news; oer sympathy.
This will take place alongside the ‘Knowledge’ step. Listen to their concerns, fears, and worries. This will guide what further information you
give and help you to understand their reactions.
SummaryRepeat the main points of the discussion and arrange a time for
further questions, ideally with you and a senior present. Give a clear plan
of what will happen over the next 48h. Document the discussion in the
patient’s notes (diagnosis, prognosis, expectations) with your name and
contact details.
Cross- cultural communication
For patients who can’t understand or speak the same language as you,
the consultation can leave them feeling isolated, frustrated, and anxious.
You may have to rely on a third party to translate for you (Box.).
Professional interpretersProfessional interpreters can be arranged
before the appointment— ask ward sta or phone switchboard.
• Allow extra time for the consultation and check the interpreter is
acceptable to the patient
• Address both the patient and the interpreter and look at the patient’s
non- verbal response to gauge their level of understanding
• Ask simple, direct questions in short sentences to avoid overloading or
confusing the interpreter; avoidjargon
• Use pictures or diagrams to explain things wherever possible; provide
written/ audiovisual material in the patient’s own language to takeaway
• If you cannot organize an interpreter, you may be able to contact a
telephone interpreting service who can translate for you and the patient
directly over the phone (ask nurses or switchboard)
• Document that a trained interpreter has been used with their name
and contact details so that the same interpreter can accompany the
patient for future appointments.
Never assume you know what the patient wants without askingthem.
Family members as interpreters There are many reasons
why family members and friends should not be used as interpreters.
Nevertheless, in emergency situations, this may prove necessary. Address
the patient directly and look carefully at the patient’s response to gauge
their understanding. Record the fact that a family member was used for
interpretation in thenotes.
Friends and relatives They are commonly used as informal interpreters.
The main drawbacks are the lack of condentiality and the bias the
relative may have on the patient’s decision- making— particularly when
underlying family issues are present (you may be unaware of these).
ChildrenThey can interpret for their parents from an early age, but again their
views can bias the consultation and its outcome (eg sexual health and vulnerable adults) and even routine clinical questions can be very frightening or inappropriate for children. Use only as a point of last resort.
Conict ofinterestsIf you think the relative is biasing the conversation or it
is an important issue, then explain that you are professionally obliged to
request a trained interpreter.
ConsentRelatives cannot consent on behalf of adults (Ep. 3).
Box . Who can interpret?
• Hospital interpreters
• Local interpreting agencies
• Hospital sta (switchboard may have alist)
• Telephone service with which the hospital has a contract
• Family and friends— as a last resort.
25CROSS-CULTURAL COMMUNICATION
26 CHAPTER Being adoctor
Outside agencies
Outside agencies who could enquire about your patients include:police, media, solicitors, re brigade, paramedics, GP, researchers, and the
patient’s employer. Patient condentiality must be respected.
Therules
• Do you really know who you are talkingto?
• Check and arrange to call them back unless certain
• Do they have any right to the information they are seeking?
• GPs, healthcare professionals, and ambulance sta may well
do, police have limited rights (see later in this topic), many
othersdonot
• Should you be the one discussing this or should it be a more senior
member of theteam?
• Do not talk to the media about a patient/ your hospital unless:
• you have the patient’s permission,and
• you have permission from your consultant/ management (for trust
issues),and
• you are accompanied by the trust public relations ocer
• Do not ‘chat’ to a police/ prison ocer about a patient, no matter what
the alleged circumstances; all patients have an equal right to privacy
• Breaching a patient’s condentiality without good cause is treated as
misconduct by theGMC.
Condentiality and thepolice
Immediate investigation ofassaultsThe police may well ask about the clin-
ical condition of an assault victim. ‘Is it life- threatening, doctor?’ The purpose of this question is to know how thoroughly to investigate the crime
scene. It is reasonable to give them an assessment of severity.
In thepublic interestIn situations where someone may be at risk of serious
injury, disclosure is permitted by the GMC. This should be a consultantlevel decision.
The Road Trac ActEveryone has a duty to provide the police with infor-
mation which may lead to the identication of a driver who is alleged to
have committed a driving oence. You are obliged to supply the name
and address, not clinical details. Discuss with your seniorsrst.
Being a witness incourtInform your clinical supervisor; they should
accompany you to court. Remember you are a professional witness to the
court so your evidence should be an impartial statement of the facts. Do
not get rattled by the barristers— stick to the facts, do not give opinions,
explain the limits of your knowledge/ experience. Address your remarks
to the judge. Dress smartly. Get an expenses form from the witness unit
to claim your costsback.
Medical researchYou may be asked to provide patient details for re-
search. Ask the researcher to provide you with ID and if they have consent
from the patient. Unless the researcher has specic permission to screen
medical notes, they may ask you to seek initial permission from any potential participant before passing on the patient’s details to the researcher.
Clinical governance/ quality
DH denition: ‘Clinical governance is the system through which NHS
organisations are accountable for continuously improving the quality of
their services and safeguarding high standards of care by creating an environment in which clinical excellence will ourish.’
What this means foryou asan individual
• You are responsible for your clinical practice which you should be
aiming to continuously improve
• You need a mechanism for assessing the standard of your practice
• While in training, this is done for you by your consultant/ trainer as part
of your regular appraisal process. Additionally, you may have audits and
regular departmental meetings
• You should be aiming to continuously learn and improve your care for
patients. Again, while still in training, this almost goes without saying;
revising for endless examinations and diplomas helpstoo.
What this means foryou aspart ofateam
• You should ensure you stick to departmental or hospital protocols
and don’t undertake procedures for which you have not been trained
• You will be asked to participate in regular departmental audits, usually
of morbidity and mortality. These are used to ensure consistency of
practice and to pick up problemsearly
• You should attend departmental and hospital- wide audit meetings and
grand rounds to keep up to date with changes
• You should answer any responses to complaints promptly.
Clinical governance/ quality mechanisms The clinical govern-
ance structure in every hospital includes:
• Audit of practice (eg reattendances within wk or wound infections)
• Appraisal and revalidation structures
• Regular departmental meetings (eg morbidity and mortality) to allow
clinicians to compare their care and highlight common concerns
• Clear routes of accountability for all sta. It can be obvious when these
have broken down, leading to problems which everyone can identify
but seemingly no one is responsible forxing
• A risk management structure to identify practices which jeopardize
high- quality patient care (critical incident reporting,Ep. 34)
• A complaints department to respond to complaints and ensure
lessons are learned from them; may be part of the risk management
department
• A clinical governance/ quality committee structure which oversees
and ensures compliance with all of theabove.
Compliance with clinical governance/ quality mechanisms are measured
both regionally and nationally through quality boards.
27CLINICAL GOVERNANCE/QUALITY
28 CHAPTER Being adoctor
Medicalethics
What is medical ethics?Ethics are moral values, and in the context
of medicine are supported by four main underlying principles:
AutonomyThis is the right for the individual to make decisions for them-
selves, and not be overtly pressurized or swayed by others (namely
doctors, nurses, relatives, etc). Patients should be allowed to contribute
when decisions are made about their care. If an individual lacks capacity
(E p. 30) then it might not be appropriate to let them make important
autonomous decisions.
BenecenceThis is concerned with doing what is right for the patient and
what is in their best interests. This does not necessarily mean we should
do everything to keep a 90- year- old patient alive who has widespread
metastatic disease. There will be times when it is benecent to keep a
patient comfortable, and allow them to die naturally.
Non- malecence This ensures caregivers refrain from doing harm to the
patient, whether physical or psychological. An example of a breach in
non-malecence would be if a patient came to harm as a result of a
doctor performing a procedure in which they had inadequate training
or supervision.
JusticeThis requires that all individuals are treated equally and that both
the benets and burdens of care are distributed without bias. Justice also
covers openness within medical practice and the acknowledgment that
some activities may have certain consequences— specically legal action.
Two further principles are important to consider:
Dignity This should be retained for both the patient and the people
delivering their healthcare.
Honesty This is a fundamental quality which doctors (as well as other
caregivers) and patients should be expected to exhibit in order to
strengthen the doctor– patient relationship.
Ethical conict Ethical dilemmas frequently arise in clinical practice
and are probably not discussed enough. While the principles listed do not
necessarily provide an immediate answer, they do create a framework in
which the various components of the conict can be teased out and addressed individually. All doctors should be able to discuss common ethical
dilemmas by analysing how each principle is relevant and weighing them
up against one another. In ethics there are no right answers, but careful
thought and discussion of situations can allow a harmonious solution to
befound.
Ethics and communication It is quite common that apparently
complex ethical issues arise because of a failure in communication between the patient or their loved ones and healthcare professionals. The
solution to most of these conicts is the establishment of eective and
transparent lines of communication.
Patient confidentiality
To breach patient condentiality is unlawful and unprofessional; several
doctors are disciplined and even struck o the medical register each year
for this. You should be careful when talking about patients in public places,
including within the hospital environment, and only disclose patient information to recognized healthcare sta as appropriate. Pieces of paper
with patient information on must never leave the hospital and should be
shredded if they are no longer required. Do not leave patient lists lying
around. Personal electronic databases of patients should be disguised so
individual patients cannot be identied. Electronic devices on which patient information is stored outside of the hospital should be encrypted
and registered under the Data Protection Act. You avoid giving any information (names or nature of injuries) to the police, press, or other enquirers; ask your seniors for advice when dealing with these (Ep. 26).
Publications Medical journals will often insist that any article which
involves a patient must be accompanied by written consent from the patient for the publication of the material, irrespective of how dicult it
would be to track down and identify that patient.
Presentations and imagesIf you are talking about a patient to a group
of healthcare workers in your own hospital you do not need to obtain consent, but doing so is courteous. If you are talking to an audience from outside
your hospital it is advisable you seek the patient’s consent unless the patient is
fully anonymized. Equally, if you want to keep copies of radiographs or digital
images, ensure these are made anonymous and if this isn’t possible obtain the
patient’s written consent. Bear in mind that presentations can easily end up
online and be accessed by those other than your original audience.
Relatives Your duty lies with your patient and if a relative asks you a
question about the patient, it is essential you obtain verbal consent from
the patient to talk to the relative; alternatively, oer to talk to the relative
in the presence of the patient. Relatives do not have any rights to know
medical information. If the patient lacks capacity then seek senior advice
before talking to the relatives. Document all conversations in thenotes.
ChildrenAs described for adults, if the child has capacity to give con-
sent (see Gillick competence/ Fraser guidelines E Box .2), you must
seek verbal consent from the patient to tell the relatives (parents) about
their health. If the patient refuses, then oer to talk to the patient about
their condition in the presence of their relatives. If you sense the situation will be dicult, seek senior advice/ support.
Telephone calls Wards receive many telephone calls asking how pa-
tients are and if they have had tests or operations yet. The potential to
break patient condentiality here is great. Often there is a telephone by
each bed, so encourage callers to speak to the patient directly. Otherwise,
inform the patient who the caller is and relay a message from the patient
to the caller. Apologize to the caller for not being able to oer any further
information and suggest that you could talk things over with both themselves and the patient when they visit. See ‘Outside agencies’Ep. 26.
0
For a good discussion of the ethical issues, see Draper H, Rogers W. Re- evaluating condenti-
ality:using patient information in teaching and publications. APT 2005;:5.
0
29PATIENT CONFIDENTIALITY
30 CHAPTER Being adoctor
Capacity
Someone who has capacity can comprehend and retain information
relevant to the decision, especially as to the consequences of not having
the intervention in question, and must be able to use and weigh this information in the decision- making process.
For a patient to have capacity theymust:
• Be able to understand the information relevant to making the decision
and consequences of refusal
• Retain the information long enough to allow for decision- making
• Weigh up the information to arrive at a decision
• Be able to communicate the decision they havemade.
Rememberthat:
• Patients may have the capacity to make certain decisions and notothers
• Capacity in the same patient may uctuate overtime.
Capacity is most often impaired by chronic neurological pathology such
as dementia, learning diculties, and psychiatric illness, but is also impaired by acute states such as delirium, acute severe pain, alcohol and
drug intoxication (both recreational and iatrogenic— eg morphine).
Children and capacityChildren under 6yr of age were once regarded
as lacking capacity to give consent, but now if the child meets the criteria then
they are regarded as having ‘Gillick’ competence (Fraser guidelines
give consent (Box .2). It is always advisable, however, to involve the parent or
guardian in discussions about the patient’s care if the patient allows.
No capacity The BMA provides guidance surrounding making decisions
for patients without capacity.
2
Broad principles should be followed, including
considering whether the patient is likely to regain capacity— can this decision
wait? Patients’ current and past views should still be considered (they may
even have created explicit advance decisions to refuse treatments). They
may have named a lasting power of attorney concerning health and welfare
who will become the lawful decision-maker. Even in lieu of legal powers,
family, friends, and carers should be involved in decisions. Where the patient
lacks capacity and there is no next of kin to consult, an Independent Mental
Capacity Advocate (IMCA)
3
may need to be appointed who advises clin-
icians in making decisions on behalf of the patient in their best interests.
K Box .2 Gillick competence/ Fraser guidelines
Although 6yr is the usual age at which people are automatically allowed
to give their own consent, younger people can consent to most treatments or operations if they are capable. This follows a famous case in
986 when Victoria Gillick went to the courts to get authority to be
informed if her daughters sought contraceptive treatments. The law disagreed and decided that if a child was competent, he/ she could consent
to treatment without parental knowledge— this is often referred to as
being ‘Gillick’ competent when a child meets the criteria in thatcase.
Wheeler R. Gillick or Fraser? Aplea for consistency over competence in children. BMJ
2006;332:807.
2
Mhttps://www.bma.org.uk/media/850/bma-best-interests-toolkit-209.pdf
3
Mhttps://www.legislation.gov.uk/ukpga/2005/9/pdfs/ukpga_20050009_en.pdf
), and may
Consent
Understanding consent and obtaining it satisfactorily can be dicult. If
you are ever unsure, seek seniorhelp.
Obtaining consentThe individual who obtains consent from the pa-
tient should be aware of the risks and benets and be able to communicate the procedure in a language that the patient will understand. If you do
not regularly perform the procedure yourself or are not trained to take consent
for the procedure then you must not obtain consent for it. Obtaining consent
satisfactorily is a skill that can be learned from senior colleagues, so initially
shadow your seniors when they are taking consent from a patient to learn
how to do it properly, then have a senior colleague supervise you the rst
few times to ensure you include all the relevant information.
Informed consentIn order to give informed consent, patients must rst
be deemed to have capacity to consent under the specic circumstances (E
p. 30). Consent should reect the fact that the patient is aware of what is
going to happen and why. They should be aware of the consequences of not
undergoing the procedure, the potential benets, and any alternatives, and
be free from any coercion. The common risks and side eects should be discussed, as should the potentially rare but serious consequences of the procedure. As a rule, any risks which might aect the decision of a normal person
should be discussed— plus any risks that might be of specic importance for
the individual patient, such as where the profession of the patient makes a
normal trivial risk of special importance (eg a tiny risk of postoperative vertigo might be of particular importance for a window cleaner). The patient
should be provided with information well in advance of the procedure to
allow them to think it over and prepare any questions they may wish toask.
Types ofconsentThere are three main types of consent:
Implied The patient oers you their arm as you approach them with a
needle and syringe to takeblood.
Expressed— verbalYou explain that you are going to insert a catheter, by
describing the procedure and potential complications, and the patient
agrees to have itdone.
Expressed— written The patient is given an extensive explanation of the
procedure and complications and informed of the alternatives. Arecord
of the consultation is made which both patient and doctor sign. This
document should be completed prior to the planned treatment or procedure, and consent veried at the time of the procedure.
Dicult situations There are many situations where problems arise
with consent issues. If in doubt, seek senior advice or consult one of the
medical defence unions (E p. 12) which have 24h telephone support.
If a patient has capacity to give or withhold consent, and chooses not to
receive treatment even in the face of death, then treating that patient
against their will is potentially a criminal oence. This includes patients
with psychiatric illness. Note that this situation is distinct from that of a
patient with a psychiatric illness who may lack capacity to make decisions
regarding psychiatric treatment, and may be detained and given psychiatric
(but not medical treatment) under the Mental Health Act (Ep. 395).
31CONSENT
32 CHAPTER Being adoctor
Medicalerrors
Every doctor makes mistakes, from the trivial and correctable to the severe and avoidable.
What todo atonce/ within anhour
• Stabilize the patient, call for senior helpearly
• Do not compound the error by trying to cover it up or ignoringit
• Correct where possible, apologizing to the patient as appropriate
• Don’t underestimate the seriousness of the situation
• If serious and you have time, start documenting events, includingtimes
• If after the error you wish to add more details, then do so but make it
clear when they were added. This is perfectly acceptable
• Amending notes, without making it clear that your entry was made
retrospectively and with a clear date and time, is serious misconduct.
Serious untoward incidents— rare
• An apology is not an admission of guilt, so apologize and explain to
the patient early. Apologize that the event has taken place (Box .3),
it is not necessary to ‘give confession’ at thisstage
• Inform your senior/ consultant immediately. If you believe your error
has caused the patient signicant harm then you should speak to your
defence organization (E p. 628) as soon as practical.
Disciplinary proceduresIf you have made a serious error the hospital
may exclude you from working temporarily pending preliminary enquiries.
This is not a judgemental act but allows a quick and calm investigation, but
you must be informed why you have been excluded. You may be asked not
to talk to others involved. If this happens, speak with your defence organization at once. You should be given a named person to contact within the
hospital and cannot be excluded for more than 2wk without review. Let the
hospital and others know how to get hold of you. Less serious errors should
be treated as training issues and dealt with by your consultant or tutor.
Aperiod of close supervision or retraining may be appropriate.
Sources ofhelp
Clinical eventsConsultant, supervisors, and defence organizations.
Non- clinical eventsYour consultant, the postgraduate dean, theBMA.
Don’t forget friends and family, and remember these events resolve very
slowly, sometimes years in big cases, so don’t expect answers quickly.
K Box .3 Duty ofcandour
Candour is being open and honest. While our ethical and professional duties of candour are well established, since 205 trusts and
their employees have a legal duty of candour towards their patients.
If an unexpected/ unintended incident occurs that could/ did result in
death, psychological harm for >28d, permanent reduction in function,
or non- permanent but signicant physical harm needing an increase in
treatment (eg longer admission, another procedure, treatment cancellation, transfer to higher- level care), then trusts are legally obliged to
apologize and explain to the patient, and notify them as investigations
evolve. Failure to do so may result in prosecution by theCQC.