Explanation and planningExplanation and planning

What are the objectives of explanation and What are the objectives of explanation and planning?planning?

Provide the correct amount and type of informationProvide the correct amount and type of information

Deliver information in a form that aids accurate recall and Deliver information in a form that aids accurate recall and understandingunderstanding

Reach a shared understanding about what is discussedReach a shared understanding about what is discussed

Encourage the patient to become involved collaboratively in Encourage the patient to become involved collaboratively in making decisions about their caremaking decisions about their care

Providing the correct amount and type of Providing the correct amount and type of informationinformation

Give comprehensive and appropriate informationGive comprehensive and appropriate informationAssess the individual patient’s information needsAssess the individual patient’s information needs

Neither restrict nor overloadNeither restrict nor overload

Skills to useSkills to use

Chunking and checkingChunking and checking Use the patient’s response as a guide for how to proceedUse the patient’s response as a guide for how to proceed

Assessing their starting pointAssessing their starting point Ask for their prior knowledge earlyAsk for their prior knowledge early

Ask what other information would be helpfulAsk what other information would be helpful Eg aetiology, prognosisEg aetiology, prognosis

Give explanations at appropriate timesGive explanations at appropriate times Avoid giving advice, information or reassurance prematurelyAvoid giving advice, information or reassurance prematurely

Chunking and checkingChunking and checking

Doctor gives information in small pieces, pause and check for Doctor gives information in small pieces, pause and check for understanding before proceedingunderstanding before proceeding

Be guided by the patient’s reaction to see what information is Be guided by the patient’s reaction to see what information is required nextrequired next

Acts as an aid for accurate recall and to achieve a shared Acts as an aid for accurate recall and to achieve a shared understandingunderstanding

Assessing their starting pointAssessing their starting point

University lecturer vs. Manual labourerUniversity lecturer vs. Manual labourer

Beware the unexpected. The manual labourer’s parents may Beware the unexpected. The manual labourer’s parents may have both had diabetes so explaining his new diagnosis may have both had diabetes so explaining his new diagnosis may be made a lot easier!be made a lot easier!

Some patients are more receptive for information than Some patients are more receptive for information than others, so ask them what they would likeothers, so ask them what they would like

Ask what other information would be helpfulAsk what other information would be helpful(Helman’s folk model 1981)(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 timesGive explanations at appropriate times

Avoid being drawn into explanations when data gatheringAvoid being drawn into explanations when data gathering

Deliver information in a form that aids Deliver information in a form that aids accurate recall and understandingaccurate recall and understanding

Make information easier for the patient to Make information easier for the patient to remember and understandremember and understand

Skills to useSkills to use

Organise explanationOrganise explanation Divide into discrete sectionsDivide into discrete sections

Use explicit Use explicit categorisation or signpostingcategorisation or signposting ““There are 3 things I’d like to discuss....There are 3 things I’d like to discuss.....”.”

Use Use repetition and summarisingrepetition and summarising Reinforces informationReinforces information

LanguageLanguage Concise, easily understood statements, avoiding jargonConcise, easily understood statements, avoiding jargon

Use Use visual methodsvisual methods to convey information to convey information Diagrams, models, written information and instructionsDiagrams, models, written information and instructions

Check understandingCheck understanding of the information given of the information given Ask patient to restate in their own wordsAsk patient to restate in their own words

Reach a shared understanding about what is Reach a shared understanding about what is discusseddiscussed

Provide explanations that relate to the patient’s Provide explanations that relate to the patient’s perspectiveperspective

Discover the patient’s thoughts and feelings Discover the patient’s thoughts and feelings about information givenabout information givenEncourage interactionEncourage interaction

Skills to useSkills to use

Relate explanations to the patient’s illness frameworksRelate explanations to the patient’s illness frameworks Previously elicited ideas, concerns and explanationsPreviously elicited ideas, concerns and explanations

Provide opportunities for the patient to contributeProvide opportunities for the patient to contribute To ask questions or seek clarificationTo ask questions or seek clarification

Pick up and respond to verbal and non-verbal cuesPick up and respond to verbal and non-verbal cues Need to ask you questionsNeed to ask you questions Information overload or distressInformation overload or distress

Encourage the patient to become involved Encourage the patient to become involved collaboratively in making decisions about collaboratively in making decisions about

their caretheir care

Enhance patient’s understanding of the Enhance patient’s understanding of the decision making processdecision making process

Involve the patient in decision making at Involve the patient in decision making at the level they wishthe level they wish

Increase patient commitment to plans Increase patient commitment to plans mademade

Options for explanation and planningOptions for explanation and planning

If offering an opinion and discussing significance If offering an opinion and discussing significance of problemsof problems

If negotiating a mutual plan of actionIf negotiating a mutual plan of actionIf discussing investigations and proceduresIf discussing investigations and procedures

If offering an opinion and discussing significance If offering an opinion and discussing significance of problemsof problems

Offer opinion of what is going on and name if possibleOffer opinion of what is going on and name if possible

Reveal rationale for opinionReveal rationale for opinion

ExplainExplain Causation, seriousness, expected outcome, short and long Causation, seriousness, expected outcome, short and long

term consequencesterm consequences

Elicit patient’s beliefs, reactions, concernsElicit patient’s beliefs, reactions, concerns

If negotiating a mutual plan of actionIf negotiating a mutual plan of action

Discuss optionsDiscuss options No action, investigation, medication, surgery, non-drug treatments, No action, investigation, medication, surgery, non-drug treatments,

preventative measurespreventative measures Provide information on action or treatment offeredProvide information on action or treatment offered

Name, how it works, benefits, possible side effectsName, how it works, benefits, possible side effects Obtain patient’s view of:Obtain patient’s view of:

Need for action, perceived benefits, barriers, motivationNeed for action, perceived benefits, barriers, motivation Accept patient’s views; advocate an alternative viewpoint if neededAccept patient’s views; advocate an alternative viewpoint if needed Elicit patient’s reactions and concerns about plans and treatments including Elicit patient’s reactions and concerns about plans and treatments including

acceptabilityacceptability Take patients lifestyle, beliefs, cultural background and abilities into considerationTake patients lifestyle, beliefs, cultural background and abilities into consideration Encourage patient involvement in plansEncourage patient involvement in plans Ask about patient support systemsAsk about patient support systems

If discussing investigations and proceduresIf discussing investigations and procedures

Provide clear information on proceduresProvide clear information on procedures

Relate procedure to treatments planRelate procedure to treatments plan ValueValue PurposePurpose

Encourage questions about and discussion of potential Encourage questions about and discussion of potential anxieties or negative outcomesanxieties or negative outcomes

Tasks for the registrarTasks for the registrar

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

the patient.....the patient.....

.....who presents with a new diagnosis of:.....who presents with a new diagnosis of:

HypertensionHypertension

DiabetesDiabetes

EpilepsyEpilepsy

OsteoarthritisOsteoarthritis

.....or requests a prescription for:.....or requests a prescription for:

HRTHRT

The oral contraceptive pillThe oral contraceptive pill

TemazepamTemazepam

.....or requesting a:.....or requesting a:

PSA testPSA test

Cholesterol levelCholesterol level

Back X-rayBack X-ray

Looking at DVDsLooking at DVDs

Was an attempt made to discover the patient’s need for information as Was an attempt made to discover the patient’s need for information as well as their prior knowledge and understanding?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 playsRole plays

Give a diagnosis of childhood asthma with a parent and starting Give a diagnosis of childhood asthma with a parent and starting them on a steroid inhalerthem on a steroid inhaler

Give the news that there is an abnormality on their CXR that Give the news that there is an abnormality on their CXR that needs referral to a specialistneeds referral to a specialist

Visit a febrile child with anxious parents. Explain it is a viral Visit a febrile child with anxious parents. Explain it is a viral illness which involves discussing potential diagnostic illness which involves discussing potential diagnostic uncertainty as well as you using strategies to minimise riskuncertainty as well as you using strategies to minimise risk

A patient has failed to take treatment or adhere to an expected 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 plan of action. See if you can identify and explain the origins of failure failure