Communication Skills and Ethics

S. Kadiri
 Outline
• The need for the skills
• What to look for or do
• Clinical scenarios/application
• End of life care
- aging population
- growing role of geriatric medicine
Communication
• Develop listening,
Combines questioning, explanatory,
-Effective exchange of
information
teaching skills
-Teaming

• Employ expressed, non-

With:
Patients, their relations,
verbal and implicit
professional and work information
colleagues and
associates
 Anchored on:
Autonomy
Ethics Voluntary participation and withdrawal
Full understanding
Informed consent
Correct conduct Privacy & confidentiality
Respect for the community
of and values of Consent form

relationships
Beneficence
Practitioner and Benefit individual & society
Monitoring – good changes
• Patient
• Patient’s relations
• Other members of health Non-maleficence
No harm
team
Monitoring – bad changes
• Authorities
• Public
• The Law Justice
Equal burden & benefits
Protection of weak and vulnerable
 Curriculum requirements
• Be able to demonstrate punctuality,
responsiveness, maintenance of good relations
and establishment of efficient communication
with other members of the health team; be able
to maintain good relations and communicate
effectively with patients, patients’ relations and
the community; demonstrate professionalism,
observance of medical ethics and confidentiality;
be able to determine the need for coroner’s
attention; be able to recognise limitations and
the need for appropriate referral.
 Approach
• Introduce self adequately
• Establish the purpose of the meeting
• Obtain agreement to continue
• Reassure patient/subject
• Explore patient’s/subject’s concerns, fears and
expectations
• Show understanding and empathy
• Use verbal and non-verbal skills
 Approach (cont)
• Appropriate questioning; probe and take leads
and hints
• Use clear language and provide clear
expectations
• Confirm patient’s/subject’s understanding
• Agree a course of action
• End the meeting appropriately

• Show knowledge of the use of ethics and the

law
• Show overall common sense
 Situations/scenarios
• Explaining
• Obtaining consent
• Communication with third parties
• Difficult/sensitive situations
• Ethics
• Attitude
• Combinations
 Explaining
• Explain 24 hr urine collection

• Teach instrument use e.g. glucometer, inhaler

• Explain lifestyle changes

• Explain the need for admission

 Obtaining consent
• For procedure e.g liver biopsy, LP

• HIV testing

• Therapeutic procedure e.g HD cannulation, CV

line insertion

• Cancer chemotherapy, radiotherapy

• Indeed for virtually any procedure.

 Communication with third parties
• Explaining to a spouse/relation

• Report to senior colleague/higher authority

• Obtaining information from a witness

• Explaining through an interpreter

 Difficult/Sensitive situations
• Attending to a complaining patient
• Break bad news
• Broaching a sensitive topic e.g ED, STD
• Dealing with a talkative patient
• Dealing with a difficult (e.g rude) patient
• Do not resuscitate order
 Ethics and legality
• Often embedded in/combined with other matters

• Respect for patient/person – autonomy

• Maintain confidentiality
• Provide information fully
• No coercion/force
• Show beneficence
• Show non-maleficence conduct
• Safety of health personnel & the public
• Recognise institutional responsibility
• Show justice
• Relevant knowledge of the law
• Requirements of the medical council
 Attitude
• Often embedded in/combined with other matters

• Key issues to be observed

-Confidentiality
-Autonomy
-Legal obligation
-Respect for life
-Duty to society
 Examples of attitude testing
• Hepatitis-B/HIV/Ebola virus infection and
procedures

• Potentially criminal behaviour

• Return to work after seizures

• Refusing admission/treatment

• Terminal care
End of Life Care
End of life Care - Definition
 Identification of end of life
Recognised in the following settings

• Patient likely to die in next 12 months

• Presence of advanced incurable disease
• Presence of life threatening acute condition
• Sudden deterioration in existing condition
Trajectories for the major groups of terminal illnesses
Key elements and steps in care
 Components
• Palliative care
• Spiritual care
• Social care
• Physiotherapy
• Occupational therapy
• Psychotherapy
 Location
May sometimes be determined by patient

• In hospital
• At home
• In care homes
• In a hospice
-always palliative, life expectancy <6 months
 Initial discussions
• Begin early
• Assess patient’s understanding of illness
• Discuss patient’s expectations
• Future investigations and treatment
• Assess patient’s relationship with family
members – identify who should participate in
decision making
• Assess patient’s limits of acceptance
 Initial discussions (cont)
• Respect dignity, encourage settling of issues,
wills
• Inquire about patient’s concerns
• Clarify all again and agree on important steps
• May need to give more time and revisit
• Use clear language, avoid jargon
 Physician’s actions
• Discuss and explain
• Obtain the services of interdisciplinary team
• Nursing interventions
• Satisfy spiritual/religious needs
• Use prophylactic analgesia
• Discontinue procedures/treatment producing
negligible effects
• Avoid heroic measures
• Referral to palliative care physician
 Common problems in end of life care
• Pain
• Cough
• Oro-pharyngeal secretions
• Dyspnoea
• Dry mouth
• Constipation
• Nausea and vomiting
 Common problems (cont)
• Anorexia, cachexia
• Fever
• Delirium
• Anxiety, insomnia
• Depression
 Signs of impending death

• Mottling of skin
• Clammy skin
• Deep set eyes
• Accumulating secretions in throat - Death rattle
• Persistently low BP
• Cheyne-Stokes breathing
• Prolonged coma
Barriers to Quality End-of-Life Care
• Failure of healthcare providers to
acknowledge the limits of medical
technology
• Lack of communication among decision
makers
• Disagreement regarding the goals of care
• Failure to implement a timely advance
care plan
 Barriers to Quality End-of-Life Care (cont)

• Lack of training about effective means of

controlling pain and symptoms
• Unwillingness to be honest about a poor
prognosis
• Discomfort telling bad news
• Lack of understanding about the valuable
contributions to be made by referral and
collaboration with comprehensive
hospice or palliative care services
 Causes of Inadequate Care at End of
Life
• Disparity in access to treatment
• Insensitivity to cultural differences
– Attitudes about death
– Attitudes about end-of-life care
– African-Americans prefer aggressive life-
sustaining treatments
– Mexican-Americans, Korean-Americans, and
Euro-Americans prefer less aggressive
treatment
– Nigerians generally would want to prolong
life
 Causes of Inadequate Care at End of
Life
• Mistrust of the healthcare system
• Pain is subjective and self-report is
considered accurate
 Do-not-resuscitate order
In consultation with patient, relations, other
personnel.

Indications
• No likelihood of successful resuscitation
• Extremely poor quality of life

Expectations/results
• Saving resources
• Relief of tension on patients relations and staff
• Opening of discussions on end of life
 Death issues

• Signs of death
• Certification
• Breaking the (bad)news
• Autopsy?
• Death Certificate
 Death certificate
• Name
• Age at death
• Date, time of death
• Place of death
• Cause of death
-immediate disease (not mode) leading to death
-disease leading to immediate disease…
-disease leading to disease leading to…
-comorbities contributing to death

• Whether seen/not seen after death

• Coroner not needed
 References
• Dornan T and O’Neill P. Core Clinical Skills for
OSCEs in Medicine. Edinburgh:Churchill
Livingstone. 2008
Thank you