Topic 2- Communication

Situation: 63yo male brought in by ambulance to Royal Perth Hospital with acute onset of shortness of breath (SOB). He appeared cyanotic, anxious, had an increased work of breathing, and was pale/clammy. He was only able to speak in words, not sentences. He had his last dialysis 2 days earlier (unsure if he is fluid restriction compliant), and he makes minimum urine.

His past medical history includes: Renal Failure (dialysed 3x/week via a Hickman Line), Uraemia, Non insulin dependent diabetes Mellitus, Cardiovascular accident, Schizophrenia, Hypertension, Splenectomy. Chest xray showed an increased opacity L lower lobe and R costophrenic angle. Bloods showed an increase in potassium, urea, creatinine, white cell count, platelets and troponin, and a decrease in bicarbonate, haemoglobin and red cell count. Arterial blood gases showed a uncompensated metabolic acidosis. The social history for this pt is as follows: he lives alone, no help at home, no stairs or rails at home, he normally walked independently with no aid for about 5-10mins before needing a rest. He is retired and a non-smoker. Upon return to the ward, the patient was confused and convinced that the doctors were trying to kill him.



Task: To conduct an initial assessment and treatment session for this patient.



Action: I was able to conduct and assessment on this patient, where he gave me a idea of his social history, and he was able to report to me that he was SOB all the time ("it is hard to breathe"). He had no chest pain today and had an unproductive cough. He reported that he has been walking independent to the toilet today. His Obs today were as follows: temp: 36.1, BP: 160/95, PR 95, RR 22 and SpO2 95% on Room air. The previous day the patient had been very confused and believed that the doctors were out to kill him. Today the patient refused further assessment or treatment as he believed that he did not require it, and that he was much better. I used my communication skills to explain to the patient about the role of physiotherapy and its importance, as well as how the doctors wanted to know how far he could walk before they send him home.

Results: I tried for about 15mins to convince him that physio would be beneficial through the means of education and by trying to convince him that the doctor needed him to do it. I tried to vary my approaches and my tutor even tried to reiterate the points I had made but the patient still refused further assessment and treatment, just as he has refused some necessary medical interventions as well.

Evaluation: I think I did well trying to convince this difficult patient. I was an effective communicator and educator to this patient. I had good body language and was also an effective listener. The only criticism that I have is that I was slightly too polite. I gave the patient too much opportunity to refuse treatment by asking him "if that is ok?" and "would you like to".

Strategies: The strategy that I feel would help my communication skills would be to become more assertive. I need to find the balance between being polite and not giving the patient too much opportunity to turn down therapy. I think further practice of my subjective and interview questioning would greatly improve my skills. Constructive feedback from my supervisor or tudor (like I am currently getting) will help to consolidate my questioning.