This document discusses communication skills and ethics in clinical practice, with a focus on end-of-life care. It outlines the need for effective communication skills when interacting with patients, families, and colleagues. Key principles of medical ethics around autonomy, informed consent, privacy, and justice are also covered. The document then examines approaches to communicating with patients and obtaining consent. It provides examples of communicating in difficult situations and applying ethical considerations. Finally, it discusses end-of-life care, including identifying patients nearing end of life, components of end-of-life care, common problems, and ensuring quality care through the dying process.
2. 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
3. Communication
• Develop listening,
questioning, explanatory,
teaching skills
• Employ expressed, non-
verbal and implicit
information
Combines
-Effective exchange of
information
-Teaming
With:
Patients, their relations,
professional and work
colleagues and
associates
4. Ethics
Anchored on:
Autonomy
Voluntary participation and withdrawal
Full understanding
Informed consent
Privacy & confidentiality
Respect for the community
Consent form
Beneficence
Benefit individual & society
Monitoring – good changes
Non-maleficence
No harm
Monitoring – bad changes
Justice
Equal burden & benefits
Protection of weak and vulnerable
Correct conduct
of and values of
relationships
Practitioner and
• Patient
• Patient’s relations
• Other members of health
team
• Authorities
• Public
• The Law
5. 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.
6. 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
7. 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
9. Explaining
• Explain 24 hr urine collection
• Teach instrument use e.g. glucometer, inhaler
• Explain lifestyle changes
• Explain the need for admission
10. 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.
11. Communication with third parties
• Explaining to a spouse/relation
• Report to senior colleague/higher authority
• Obtaining information from a witness
• Explaining through an interpreter
12. 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
13. 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
14. Attitude
• Often embedded in/combined with other matters
• Key issues to be observed
-Confidentiality
-Autonomy
-Legal obligation
-Respect for life
-Duty to society
15. 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
18. 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
22. Location
May sometimes be determined by patient
• In hospital
• At home
• In care homes
• In a hospice
-always palliative, life expectancy <6 months
23. 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
24. 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
25. 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
26. Common problems in end of life care
• Pain
• Cough
• Oro-pharyngeal secretions
• Dyspnoea
• Dry mouth
• Constipation
• Nausea and vomiting
28. 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
29. 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
30. 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
31. 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
32. Causes of Inadequate Care at End of
Life
• Mistrust of the healthcare system
• Pain is subjective and self-report is
considered accurate
33. 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
34. Death issues
• Signs of death
• Certification
• Breaking the (bad)news
• Autopsy?
• Death Certificate
35. 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
36. References
• Dornan T and O’Neill P. Core Clinical Skills for
OSCEs in Medicine. Edinburgh:Churchill
Livingstone. 2008
