Explanation and planning

What are the objectives of explanation and planning?

Provide the correct amount and type of information Provide the correct amount and type of information Deliver information in a form that aids accurate recall and understanding Deliver information in a form that aids accurate recall and understanding Reach a shared understanding about what is discussed Reach a shared understanding about what is discussed Encourage the patient to become involved collaboratively in making decisions about their care Encourage the patient to become involved collaboratively in making decisions about their care

Providing the correct amount and type of information Give comprehensive and appropriate information Assess the individual patient’s information needs Neither restrict nor overload

Skills to use Chunking and checking Chunking and checking Use the patient’s response as a guide for how to proceed Use the patient’s response as a guide for how to proceed Assessing their starting point Assessing their starting point Ask for their prior knowledge early Ask for their prior knowledge early Ask what other information would be helpful Ask what other information would be helpful Eg aetiology, prognosis Eg aetiology, prognosis Give explanations at appropriate times Give explanations at appropriate times Avoid giving advice, information or reassurance prematurely Avoid giving advice, information or reassurance prematurely

Chunking and checking Doctor gives information in small pieces, pause and check for understanding before proceeding Doctor gives information in small pieces, pause and check for understanding before proceeding Be guided by the patient’s reaction to see what information is required next Be guided by the patient’s reaction to see what information is required next Acts as an aid for accurate recall and to achieve a shared understanding Acts as an aid for accurate recall and to achieve a shared understanding

Assessing their starting point University lecturer vs. Manual labourer University lecturer vs. Manual labourer Beware the unexpected. The manual labourer’s parents may have both had diabetes so explaining his new diagnosis may be made a lot easier! Beware the unexpected. The manual labourer’s parents may have both had diabetes so explaining his new diagnosis may be made a lot easier! Some patients are more receptive for information than others, so ask them what they would like Some patients are more receptive for information than others, so ask them what they would like

Ask what other information would be helpful (Helman’s folk model 1981) Common patient responses: Common patient responses: “What has happened?” “What has happened?” “Why has it happened?” “Why has it happened?” “Why to me?” “Why to me?” “Why now?” “Why now?” “What would happen if nothing were done?” “What would happen if nothing were done?” “What if I do something about it?” “What if I do something about it?”

Give explanations at appropriate times Avoid being drawn into explanations when data gathering Avoid being drawn into explanations when data gathering

Deliver information in a form that aids accurate recall and understanding Make information easier for the patient to remember and understand

Skills to use Organise explanation Organise explanation Divide into discrete sections Divide into discrete sections Use explicit categorisation or signposting Use explicit categorisation or signposting “There are 3 things I’d like to discuss.....” “There are 3 things I’d like to discuss.....” Use repetition and summarising Use repetition and summarising Reinforces information Reinforces information Language Language Concise, easily understood statements, avoiding jargon Concise, easily understood statements, avoiding jargon Use visual methods to convey information Use visual methods to convey information Diagrams, models, written information and instructions Diagrams, models, written information and instructions Check understanding of the information given Check understanding of the information given Ask patient to restate in their own words Ask patient to restate in their own words

Reach a shared understanding about what is discussed Provide explanations that relate to the patient’s perspective Discover the patient’s thoughts and feelings about information given Encourage interaction

Skills to use Relate explanations to the patient’s illness frameworks Relate explanations to the patient’s illness frameworks Previously elicited ideas, concerns and explanations Previously elicited ideas, concerns and explanations Provide opportunities for the patient to contribute Provide opportunities for the patient to contribute To ask questions or seek clarification To ask questions or seek clarification Pick up and respond to verbal and non-verbal cues Pick up and respond to verbal and non-verbal cues Need to ask you questions Need to ask you questions Information overload or distress Information overload or distress

Encourage the patient to become involved collaboratively in making decisions about their care Enhance patient’s understanding of the decision making process Involve the patient in decision making at the level they wish Increase patient commitment to plans made

Options for explanation and planning If offering an opinion and discussing significance of problems If negotiating a mutual plan of action If discussing investigations and procedures

If offering an opinion and discussing significance of problems Offer opinion of what is going on and name if possible Offer opinion of what is going on and name if possible Reveal rationale for opinion Reveal rationale for opinion Explain Explain Causation, seriousness, expected outcome, short and long term consequences Causation, seriousness, expected outcome, short and long term consequences Elicit patient’s beliefs, reactions, concerns Elicit patient’s beliefs, reactions, concerns

If negotiating a mutual plan of action Discuss options Discuss options No action, investigation, medication, surgery, non-drug treatments, preventative measures No action, investigation, medication, surgery, non-drug treatments, preventative measures Provide information on action or treatment offered Provide information on action or treatment offered Name, how it works, benefits, possible side effects Name, how it works, benefits, possible side effects Obtain patient’s view of: Obtain patient’s view of: Need for action, perceived benefits, barriers, motivation Need for action, perceived benefits, barriers, motivation Accept patient’s views; advocate an alternative viewpoint if needed Accept patient’s views; advocate an alternative viewpoint if needed Elicit patient’s reactions and concerns about plans and treatments including acceptability Elicit patient’s reactions and concerns about plans and treatments including acceptability Take patients lifestyle, beliefs, cultural background and abilities into consideration Take patients lifestyle, beliefs, cultural background and abilities into consideration Encourage patient involvement in plans Encourage patient involvement in plans Ask about patient support systems Ask about patient support systems

If discussing investigations and procedures Provide clear information on procedures Provide clear information on procedures Relate procedure to treatments plan Relate procedure to treatments plan Value Value Purpose Purpose Encourage questions about and discussion of potential anxieties or negative outcomes Encourage questions about and discussion of potential anxieties or negative outcomes

Tasks for the registrar

List the essential information you consider as a doctor you should attempt to get across to the patient.....

.....who presents with a new diagnosis of: Hypertension Hypertension Diabetes Diabetes Epilepsy Epilepsy Osteoarthritis Osteoarthritis

.....or requests a prescription for: HRT HRT The oral contraceptive pill The oral contraceptive pill Temazepam Temazepam

.....or requesting a: PSA test PSA test Cholesterol level Cholesterol level Back X-ray Back X-ray

Looking at DVDs

Was an attempt made to discover the patient’s need for information as well as their prior knowledge and understanding? Was an attempt made to discover the patient’s need for information as well as their prior knowledge and understanding? Was the information given in chunks that were clear and manageable? Was the information given in chunks that were clear and manageable? Was there an attempt to check their understanding? Was there an attempt to check their understanding? Was there any evidence of uncertainty of doubt in the patient? Was there any evidence of uncertainty of doubt in the patient? Was there negotiation of differences when they occurred? Was there negotiation of differences when they occurred? Was the patient involved in planning final management? Was the patient involved in planning final management? Was safety netting and contracting used at the end? Was safety netting and contracting used at the end?

Role plays

Give a diagnosis of childhood asthma with a parent and starting them on a steroid inhaler Give a diagnosis of childhood asthma with a parent and starting them on a steroid inhaler Give the news that there is an abnormality on their CXR that needs referral to a specialist Give the news that there is an abnormality on their CXR that needs referral to a specialist Visit a febrile child with anxious parents. Explain it is a viral illness which involves discussing potential diagnostic uncertainty as well as you using strategies to minimise risk Visit a febrile child with anxious parents. Explain it is a viral illness which involves discussing potential diagnostic uncertainty as well as you using strategies to minimise risk A patient has failed to take treatment or adhere to an expected plan of action. See if you can identify and explain the origins of failure A patient has failed to take treatment or adhere to an expected plan of action. See if you can identify and explain the origins of failure