LO QUE QUEDÓ DE LA UNIDAD DEL IMPERIO

León III: coronación imperial

LO QUE QUEDÓ DE LA UNIDAD DEL IMPERIO

8 2 Sexual History Taking Taking a Sexual History 1 x 2hr tutorial in groups of 24

INFORMATION SHEET 4b

COMMUNICATION WITH A PALLIATIVE CARE PATIENT

“Effective symptom control is impossible without effective communication.”

(A) SOURCES OF DIFFICULTY IN COMMUNICATING WITH DYING PATIENTS The social denial of death

Lack of experience of death in the family, high expectations of health and life, high value placed on material possessions and the changing role of religion all contribute to a process where dying is perceived as alien and fearsome.

Patient’s fears of dying

Every person dying has a unique combination of fears and concerns in facing the prospect of dying.

Some commonly expressed fears are about:

• Physical illness (e.g., symptoms, disability, disfigurement)

• Psychological effects (e.g., not coping, dementia)

• Dying (e.g., religious concerns, existential concerns)

• Treatment (e.g., side effects, mutilation/change in body image)

• Family and friends (e.g., being a burden, loss of family role)

• Finances, social status and job Factors originating in the health care professional

Results of a survey (Buckman, 1984) suggest a number of factors may be operating that contribute to the discomfort of talking with a dying person:

• Sympathetic pain (overwhelmed by the patient’s distress)

• Fear of being blamed (“blaming the messenger for the message”, a sense of therapeutic failure)

• Fear of the untaught. As professionals we like to follow guidelines to do things “properly”.

Often there are not rigid guidelines to follow in palliative care.

• Fear of eliciting a reaction.

• Fear of saying “I don’t know.”

• Fear of expressing emotions (while it is appropriate not to show panic or rage, a doctor who shows no emotions when the patient is facing death is likely to be perceived as cold or insensitive.)

• ambiguity of phrase “I’m sorry” (doctors may fear it sounds as though they are apologising b and taking blame)

• own fears of death and suffering

• fears of the medical hierarchy. (e.g., the young intern not wanting to upset the consultant by asking the patient the “wrong” thing)

(B) DEFINITIONS AND STANDARDS OF PALLIATIVE CARE

Palliative care has been defined by the World Health Organisation (WHO) as:

“…an approach that improves the quality of life of individuals and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”

The WHO further states that palliative care:

• provides relief from pain and other distressing symptoms

• affirms life and regards dying as a normal process

• intends neither to hasten nor postpone death

• integrates the psychological and spiritual aspects of care

• offers a support system to help patients live as actively as possible until death

• offers a support system to help the family cope during the patient’s illness and in their own bereavement

• uses a team approach to address the needs of patients and families, including bereavement counselling, if indicated

• will enhance quality of life, and may also positively influence the course of illness

• is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing complications Standards of palliative care

Palliative Care Australia has developed national palliative care standards based on the principals of

• Dignity of the patient, caregiver/s and family

• Empowerment of the patient, caregiver/s and family

• Compassion towards the patient, caregiver/s and family

• Respect for the patient, caregiver/s and family

• Equity in access to palliative care services and resources

• Advocacy on behalf of the expressed wishes of patients, families and communities

• Excellence in the provision of care and support

• Accountability to patients, caregivers, families and community Putting the standards into practice….

(C) BASIC COMMUNICATION SKILLS FOR PALLIATIVE CARE

• Physical context: ensure privacy wherever possible.

• Introductions: ensure the patient knows who you are and what you do. You may wish to shake hands. Offer handshake as well to spouse if present.

• Sit down: conveys a willingness to listen and conveys an attitude of unhurriedness that is helpful.

• Body language. Maintain a comfortable distance and lean forward slightly. Eye contact is important in conveying attention, understanding, and concern.

• Touch: may be very helpful, but need to be sensitive to reactions of patient.

• Facilitate the flow of the dialogue with general communication skills (e.g., ask open-ended questions, don’t speak on top of the patient, use minimal encouragers)

• Tolerate short silences. Silences don’t mean the patient has stopped thinking. S/he may be experiencing feelings that are too intense to easily express. If you have to break the silence, it may help to ask gently, “What were you thinking about just then?” or “What made you pause just then?” Silence may also indicate the patient is weary or breathless and needs to pause.

• Repetition and reiteration. Use patient’s key words to convey that you have been listening carefully.

• Identify the patient’s emotion and its origin, and respond in a way that tells the patient you have made the connection; e.g., It must be very distressing for you to know that all that chemotherapy didn’t give you a long (or any) remission.” Professionals don’t have to feel the same emotion as the patient (sympathy) but it is important they convey to the patient that they are making an effort to understand his/her experience (empathy).

• Dignity offers a useful overarching framework to guide palliative care staff, patients and significant others in defining goals and considerations at the end of life. Patients feel worthy and esteemed when they are treated with respect and their symptoms are well managed.

Some examples of dignity-promoting questions are:

- “Is there anything we can do to make you more comfortable?”

- “Is there anything further about your illness that you would like to know?”

- “Is there anything in the way you are treated that is undermining your sense of dignity?”

- “What about yourself or your life are you most proud of?”

- “What are your biggest concerns for the people you will leave behind?”

• As death approaches, patients will communicate increasingly nonverbally. This should not stop professionals talking to them, describing what they are doing, and treating them as people with feelings. Patients may still hear though be unable to speak (be careful of what is discussed around the bed). Relatives may feel tense and distressed and need to be supported sensitively. Needs and wishes need to be regularly reviewed.

• Cultural/religious practices are to be respected and should be discussed when the patient is admitted to the palliative care unit/home visiting service.

(D) OTHER CONSIDERATIONS

As well as fear, dying patients may experience a range of other distressing emotions.

Anger: at the rest of the world; who will survive after s/he has gone; anger at God/fate; anger at any one who is trying to help. Behind anger are often feelings of powerlessness and a desperate search to regain some sense of control and meaning. It is often helpful for the patient/family’s anger to be acknowledged and respectfully explored. (“I can understand that you feel very angry that…… . Would you like to tell me more about …”). Remaining calm and non defensive are key tasks for professionals in these situations.

Denial: Denial is a useful protective mechanism in a dangerous situation. Professionals need to understand the individual’s need to protect themselves, without colluding with the denial by pretending to share it. A supportive comment such as, “When things are difficult, it helps to think about something pleasant.” recognizes the pain of the situation, but also notes the patient’s avoidance. Professionals should not collude with patients’ denial such that key information is withheld; for example, regarding diagnosis (ie, disseminated cancer) and prognosis (eg, not more than a few months). However, this does not mean that every conversation between the patient and doctor needs to involve confrontation or argument about the “facts”. (Over time, the inevitable deterioration in a patient’s condition usually breaks down his/her initial use of denial as a coping strategy.) Denial may need to be confronted openly (but still sensitively) in some circumstances, e.g., when a single parent is dying and plans are not in place for the care of young children.

Depression, sadness and despair: Sadness at the ending of one’s life is a normal reaction and patients should not be “jollied out” of their legitimate feelings. However, clinical depression needs to be treated and not ignored just because the patient is terminally ill. Patients often feel lonely as they progress toward death. Supportive communication (between patient and significant others, including palliative care staff) will help to reduce these painful feelings of isolation.

Asking for euthanasia: From time to time, patients ask to have their death actively hastened. (“You wouldn’t let a dog live like this”.) It is helpful to explore with the patient/carer what aspects of the

will not be unnecessarily prolonged (e.g., through heroic, medical gestures). Furthermore, the patient and their family need to understand that symptomatic treatment will be administered even to the extent that the nature and dose of medication may contribute to significant side effects.

CONCLUSION

Sheldon (1993) has observed, “It is not possible to be perfectly prepared for whatever comes. So courage is needed along with a solid value base and some understanding of basic skills. Most important though is a faith in the potential of the partner in the dialogue, whether that person is dying or bereaved, to change and grow in response to the crisis of loss and death.”

(Professionals can grow and change too!) References

Buckman, R., (1993). “Communication in palliative care: a practical guide.” In D.Doyle, G.Hanks and N.MacDonald (Eds), Oxford textbook of Palliative Medicine. (pp.47-61). Oxford University Press.

Chochinov, H.M. (2002). Dignity-conserving care: a new model for palliative care. JAMA, 287, (17) 2253-2260.

Mitchell, G. (2010). Communicating with dying patients and their families. In M.Groves and J Fitzgerald (Eds.), Communication skills in Medicine: promoting patient-centred care (p.159- 170). Melbourne .IP Communications

Palliative Care Australia (2005). Standards for providing quality palliative care to all Australians, Canberra.

Sheldon, F. (1993). “Communication”. In C Saunders and N.Sykes (Eds.), The management of terminal malignant disease. (pp.15-32). London: Edward Arnold.

World Health Organisation (2002). National Cancer Control Programmes: Policy and Managerial Guidelines (2nd Edition). Geneva: World Health Organisation.

Students are also encouraged to consult Clinical practice guidelines for the psychosocial care of adults with cancer (2003). (Prepared by the National Breast Cancer Centre and National Cancer Control Initiative)

CCS#Module#6#“Communicating#in#Mental#Health”#

Semester#1,#2013#

•# Tolerate#short#silences.##Silences#don’t#mean#the#person#has#stopped#thinking.##

S/he#may#be#experiencing#feelings#that#are#too#intense#to#easily#express,#or#their#

thinking#may#be#slowed.##Look#for#signs#that#they#may#be#responding#to#

hallucinations#and#it#may#be#prudent#to#ask#if#something#is#distracting#them,#if#

they#appear#to#have#“tuned#out”.#

•# Repetition#and#reiteration.##Use#the#person’s#own#words#when#summarising#to#

convey#that#you#have#been#listening#carefully.##

•# Identify#the#person’s#emotions#and#respond#in#a#way#that#tells#them#that#you#have#

made#the#connectionP#e.g.,#“It#must#be#very#distressing#for#you.”##Professionals#

don’t#have#to#feel#the#same#emotion#as#the#patient#(sympathy)#but#it#is#important#

they#convey#to#the#patient#that#they#are#making#an#effort#to#understand#his/her#

experience#(empathy).#Often#this#is#where#Doctor#and#Patient#can#agree#common#

goals,#as#neither#wants#the#patient#to#feel#distressed.#

•# Dignity#People#are#often#resentful#at#being#detained#and#treated#against#their#will.##

Engaging#them#in#their#recovery#and#agreeing#on#common#goals#is#important#in#

building#the#therapeutic#alliance.#Simple#questions#can#help,#e.g.#

,# “Is#there#anything#further#about#your#illness#that#you#would#like#to#know?”#

•# Cultural/religious#practices#are#to#be#respected#and#it#is#important#to#check#their#

possible#impact#on#beliefs#about#the#illness,#its#cause#and#treatment.#

Further(reading(

Othmer,#E.#and#Othmer,#S.#(1994).##The#clinical#interview#using#DSMZIV.##Volume#1:#

Fundamentals.##Washington:#American#Psychiatric#Association#

# #

CCS#Module#6#“Communicating#in#Mental#Health”#

Semester#1,#2013#

# INFORMATION(SHEET(6.2(((

OUTLINE(OF(AN(INTERVIEW(WITH(A(PATIENT(IN(A(MENTAL(HEALTH(SETTING(

Presenting#complaint#and#history#of#presenting#complaint##

Past#psychiatric#history#

Past#medical#history/Medications/Allergies#

Family#historyP#family#psychiatric#history#

Personal#history#

Birth#and#early#life#

Schooling#

Higher#education/training#

Employment#history#

Psychosexual#history#(relationships)#

Forensic#history#

Use#of#alcohol#and#other#drugs#

Premorbid#personality#

Suicide#risk#assessment##

History#of#previous#selfZharm#

Presence#of#depression#

Suicidal#ideation#

Plans#

Means#to#carry#out#plans#

How#close#to#attempting#to#carry#out#plans#

CCS#Module#6#“Communicating#in#Mental#Health”#

Semester#1,#2013#

Information#Sheets#6.3#and#6.4#(Students(to(Bring(to(lecture# 5#

INFORMATION(SHEET(6.4(

OUTLINE(OF(MENTAL(STATUS(EXAMINATION((

Appearance#and#Behaviour#

# Eye#contact#and#Rapport#

# Personal#Hygiene#

# Facial#Expressions#

# Motor#behaviour#

# Autonomic#arousal/Level#of#consciousness##

Speech#

# Form#

# Volume#

# Content##

Mood#

Affective#expression#

Appropriateness#

Presence#of#suicidal#ideation#

Thoughts#

# Stream#of#thought# # Form##

# Thought#content#

Perceptions##

Delusions#

Presence#of#hallucinations#

Cognition#

# Orientation#

# Concentration#and#attention#

Registration#

# Memory#Recall#

# General#knowledge# # Insight#

INFORMATION SHEET 8.1

COMMUNICATING ABOUT SEXUAL HEALTH AND FUNCTIONING

Communicating with patients about their sexual health and functioning requires skill and sensitivity. Such a conversation will be required in a range of different situations; for example, when the patient presents with explicit problems with sexual health or functioning (such as abnormal vaginal or urethral discharge, loss of libido, erectile dysfunction, pain associated with intercourse; concerns about sexual orientation); or when discussing relationship distress; when providing contraceptive advice; when discussing side effects of medications/surgery.

PROFESSIONAL DISCOMFORT

There are a number of reasons why medical students and doctors experience difficulty talking to patients about sex. For example:

There may be embarrassment and personal unease with the subject

Students and junior doctors may feel they are too young to ask older patients about the details of their sexual relationships

There may be concern that the patient will be offended by questions There could be a belief that a sexual history is not relevant to the complaint It may be assumed it is someone else’s task (eg., a clinical psychologist or

genitourinary specialist)

There may be lack of skills in dealing with the complexity of patients’ personal relationship problems

The medical student may feel inadequately trained for the task STEREOTYPES

Further, stereotypes and assumptions about behaviour and lifestyle may be a barrier to open communication. Some common assumptions and misconceptions about sexuality:

Older adults don’t have sex Gay men only have sex with men

A married person couldn’t possibly have a sexually transmitted disease Everyone understands the basics of reproduction

You can tell a person’s sexual orientation by their appearance SKILLS

Clinicians need to be sensitive to the patient’s embarrassment. Some suggestions for dealing sensitively with a patient’s embarrassment include:

Acknowledge your own anxiety/discomfort (don’t pretend it is not there) Practise (alone or with peers) the use of questions that are comfortable for you

Aim to use the same tone of voice and manner as you would when enquiring about other parts or functions of the body

Where possible, it may be more comfortable to start with more general questions first (eg, general health, general relationship functioning) before moving to more sensitive topics.

Speak clearly and purposefully, without being apologetic.

- Example: “I would like to find out something about your relationships to

doctors add, “It might be helpful for you to know that I sometimes find it a bit difficult to ask some of these questions!”

Use concrete and specific terms.

- Example 1: “For how long have you had this dull pain in your scrotum?”

(NOT: “For how long have you had the trouble ‘down below’?”) - Example 2: “Do you ever engage in sexual activities with partners other than your wife?”

(NOT: “Do you, you know, go elsewhere for it?”)

Remain non-judgemental about lifestyle. Avoid stereotyping. It may be better to ask, “Was that relationship/contact with a man or a woman?” rather than,

“Are you gay?”

Normalise as much as possible (eg, “Many men when they get older experience difficulties with erections. Can you tell me some more about the problem that you and your partner are experiencing?”)

ASSESSMENT OF SEXUAL DYSFUNCTION

For details of the categories of sexual dysfunction, see DSM IV-TR

Some patients will present with sexual difficulties and describe their symptoms quite matter-of-factly. Others will need to be prompted, for example, “Has your illness affected your sexual functioning?” Even when asked about any sexual concerns or problems, some patients may answer “no” but appear hesitant in their denial. It can be helpful to observe, “You seem a little doubtful. I’m wondering if everything is not that great?” Key areas of assessment typically include:

The nature of the problem needs to be examined frequency (“How often does this problem occur?”) intensity (“How would you rate the intensity of this pain?”) duration (“When did you first become aware of this problem?”

Is the problem primary versus secondary?

e.g., “Have you experienced this problem all your life, or just recently?”

Is the problem generalised or situational, that is, is the problem present in all relationships or only a specific one?

e.g., “Do you have any partners other than your wife? Does this difficulty occur in all/both those relation ships?”

Is the sexual difficulty reported a single problem or are there multiple problems?

(Premature Ejaculation and Erectile Dysfunction; Anorgasmia and Hypo Active Desire Disorder).

Enquire about partner’s perspective: “How is your partner responding to this problem?”

COMMUNICATING ABOUT SEX AFTER SURGERY OR CHRONIC ILLNESS Patients may experience a range of problems following illness/ surgery that impact on sexual functioning. For example,

Mechanical (eg., arthritis, surgical wounds) Physiological (eg., fatigue, shortness of breath) Neurovascular (eg., damage to nerves to bladder, pelvis)

Psychological (eg., change to body image owing to colostomy, mastectomy,

INFORMATION SHEET 7.1

STAGES OF CHANGE

The capacity to act on advice varies widely across patients. The patients’ willingness to accept the need for change or responsibility for change can inform the type of approach taken. The patient engaging in the harmful behaviour will be somewhere along the continuum of the Stages of Change (Prochaska & DiClemente 1982). Note that a patient might fluctuate between stages.

1. Pre-contemplation

• No interest in changing their behaviour.

• Unaware of or minimise health risks or harms.

• Benefits of unhealthy behaviour outweigh possible concerns.

Doctor’s task is primarily to give information and feedback, raise awareness and develop rapport.

2. Contemplation

• Ambivalent and undecided, considering costs and benefits of unhealthy behaviours.

• Do not necessarily perceive risks and harms of unhealthy behaviour outweighing benefits

• Might accept information about change.

• Not currently planning to change, but considering it in the next six months.

• Might stay in contemplation for two or more years before moving to next stage.

Doctor’s task is primarily to examine the pros and cons of behaviour and to help them tip scales in favour of change.

3. Preparation

• Concerns (perceived risks and harms) far outweigh the benefits of unhealthy behaviour.

• Making specific plans to undertake change within next 30 days.

• Setting a date to commence change.

• Doctor’s task is not so much motivating as matching change strategies that are acceptable, accessible and appropriate and effective.

Doctor’s task is not so much motivating as matching change strategies that are acceptable, accessible, appropriate and effective.

4. Action

• Implementing new behaviour/skills.

Doctor’s task is to assist patient in operationalising change and to assist in removing road blocks.

5. Maintenance

• Maintaining new behaviour, including coping with temptation or minor slips.

• Development of relapse prevention strategies.

In document MANUEL ESPINAR MORENO (página 153-184)