Respecting Patient Rights

Basic Bioethics For Residents, CCF Residency Programs, November 28, 2000

I. Communicating with Patients and Families

II. Informed Consent: Empowering Patient Participation in Decision Making

III. Assessing Patients' Decisional Capacity

IV. Maintaining Patient Confidentiality

V. Honoring Patients' Advance Directives

I. Communicating with Patients and Families

Good communication with patients and family members is a primary means of creating and sustaining a therapeutic relationship. Good communication can also provide the physician's with protection against lawsuits by patients and families. Basic techniques and skills are needed for routine communication of clinical findings and distressing information. These techniques and skills can be learned and practiced.

In any situation in which information will be disclosed, physicians should do so with attention to the setting. Sitting with the patient, or leaning against something if no chair is available, gives the impression that the physician is not hurried and is making time for the patient. Use of open-ended questions and frequent short summarizing statements of what the patient has said demonstrates that the physician is interested and listening to the patient. Listening to the patient's verbal cues and observing non-verbal ones will help to identify signs of emotional distress.

In situations in which distressing information must be disclosed to the patient, the conversation should be held in private and in person (rather than on the telephone or through e-mail). The presence of a support person for the patient or family member should be facilitated whenever possible. Attention should be paid to the non-verbal aspects of the interaction. Physicians should communicate gentleness, warmth and empathy. The physician should sit down near the patient and identify the patient by name. Touching the patient's hand or shoulder may be appropriate. Adequate time for discussion should be planned. A box of facial tissues should be available.

The following steps provide an outline of what should occur during most physician-patient encounters:

Find out what the patient knows ("What do you understand about your illness?" "How would you describe your medical condition?" "What did your other doctor tell you?").
Find out how much the patient wants to know ("If your condition turns out to be serious, do you want to know?" "Is there someone else you would like me to talk to?").
Be straightforward, but sensitive when disclosing information. Trying to spare the listener distress by minimizing the seriousness of the situation may lead to vagueness and confusion. Avoid medical jargon. Check to verify the patient's own understanding.
Respond to the patient's feelings. A verbal acknowledgement such as "I wish the news were different" may be helpful. Allow patients time to express their emotions.
Plan follow up for additional tests, more discussion, and establishing long-term goals. Assure patient and family that you will be available to answer follow up questions or to discuss their concerns.

Attention to language is especially important when talking to patients and families. Imagine, for example, that a physician wishes to discuss with a family the writing of a DNR order. If the physician begins by saying to the family, "Mrs. Jones, do you want us to do everything we can for your mother?" the expected response of any good son or daughter would be, "Yes, of course!" The physician might mistakenly hear the answer as "The family wants everything done." The physician should clarify vague terms (e.g., "What do you mean by 'everything done'"?). Another potential problem occurs with use of the term "withdrawal of care." It is ethical to withdraw or withhold treatment that will not benefit the patient, but withholding or withdrawing care and caring for the patient is never ethically acceptable. You know that, make certain that the patient and family are assured that comfort care will continue.

Some practical hints for learning and improving communication skills include:

Observe/critique the technique, both good and bad, of other physicians.
Practice or role-play with your colleagues before talking with a patient or family.
Recognize/tolerate the occurrence of medical failure, i.e., that disease cannot always be cured.
Realize that style and skill in communication comes with practice and experience.

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