Approach to difficult clinical communications in acute and critical care settings

Opening Vignette Mdm Tan, a 75-year-old Chinese woman, was transferred from the general ward—where she had been admitted for urosepsis and treated with antibiotics—to the intensive care unit (ICU). Her medical history included hypertension, diabetes mellitus and moderate Alzheimer’s disease. Premorbidly, she was independent and ambulant with a walking stick. At the ward, Mdm Tan was found unresponsive, with bradycardia, hypertension and irregular breathing. In a peri-arrest state, the ICU team was activated, and she was emergently intubated. An electrocardiogram revealed new-onset atrial fibrillation, and computed tomography of the brain showed a massive acute infarct with haemorrhagic conversion and cerebral oedema causing a midline shift. After consulting neurosurgery and with the next of kin’s consent, the patient underwent urgent decompressive craniectomy. Following surgery, she was transferred back to the ICU. As the medical officer on duty, you were asked to speak to the patient’s visibly distressed family at the bedside, as they had many questions for the medical team.DEFINITION AND CLINICAL RELEVANCE Difficult clinical communications are defined as challenging interactions between physicians and patients and/or their families or surrogates that stem from discrepancies in expectations, perceptions and/or conversations.[1] Fifteen percent of all primary care clinical encounters were described as difficult by the attending physicians,[2] and nearly 30% of physician-familial conversations in intensive care units (ICU) involved conflicts.[3] A local study reported a complaint case rate of 1.17 per 1000 visits in an emergency department (ED), with one in four complaints related to perceived communication deficits (mostly found to be valid).[4] Although trends in the prevalence of difficult clinical conversations are not well known, we surmise that the shift from a traditionally paternalistic model of healthcare delivery to a patient- and family-centred model[5] may potentially increase the complexity of clinical communications due to the active involvement of patients and their families in medical decision-making. While difficult communications are common in outpatient primary and tertiary care settings, often attributable to busy practices with high patient loads and long waiting times, there is also a proclivity for difficult patient–physician interactions in acute and critical care settings. This is due to high patient turnover rates with lack of care continuity, multiple care transitions leading to information discrepancies,[6] and the nature of clinical cases, which frequently involve serious, life-threatening illnesses that warrant emotionally charged discussions and decision-making.[3] Challenging communications, if poorly handled, can spiral into formal complaints[4] and lead to patient dissatisfaction, with poor outcomes such as non-adherence to medical recommendations and increased ED visits.[7] In turn, physicians involved may also become emotionally exhausted, demoralised and burnt out.[7] Moreover, physicians may form implicit biases against ‘difficult’ patients, leading to impaired clinical judgement and suboptimal management.[8] Therefore, it is important for frontline clinicians to understand the root causes of difficult clinical encounters and be attuned to practical communication interventions that can help them circumvent these challenging situations. FACTORS CONTRIBUTING TO DIFFICULT CLINICAL COMMUNICATIONS In general, factors that contribute to difficult clinical encounters can be classified as patient- or family-related, clinical or situational, physician-related, or systemic factors.[1,9,10,11] [Box 1]. Firstly, patient or family-related factors refer to inherent attributes such as personal beliefs and expectations,[1] challenging (e.g. highly anxious) or manipulative personality traits[1] and other unique psychosocial circumstances.[11] Naturally, when physician and patient personality traits clash, there may be a higher propensity for conflict to occur. However, for some patients with inherent distrust of the medical system or pre-existing beliefs (especially those who subscribe to medical disinformation), it may be very challenging to build rapport or trust to secure their acceptance of medical recommendations. In Asian and more collectivistic cultures, families are often more heavily involved in clinical communications and decision-making.[12] In such situations, clinical communications can become very challenging when there are disagreements or complex, difficult familial dynamics, especially pertaining to matters such as treatment decision-making, goals of care, disclosure of terminal diagnoses (i.e. collusion) and/or caregiving responsibilities.[12]Box 1: Factors contributing to difficult clinical encounters.Secondly, clinical or situational factors relate to the challenging nature of certain discussions such as breaking bad news,[1] goals-of-care discussions,[13] disclosure of medical errors[14] or conveying clinical uncertainty.[15] Generally, discussions that revolve around serious or debilitating conditions, poor prognosis, or death and end-of-life issues often evoke negative emotions such as fear, anxiety and grief, making such conversations particularly challenging. Thirdly, physician-related factors are often due to poor communication skills, such as giving unclear explanations, providing inconsistent or discrepant information, failing to listen to patients, lack of empathy, using insensitive language, excessive medical jargon, and failing to elicit concerns,[1,10,16] or a poor physical or mental state that affects their behaviour.[7] Lastly, systemic factors may involve environmental circumstances or constraints that predispose to conflictual patient–physician interactions such as long waiting times, inadvertent delays or cancellations, resource constraints, an unconducive consultation environment and inadequate communication adjuncts or aids.[1] PRACTICAL APPROACH TO DIFFICULT CLINICAL COMMUNICATIONS Based on the identified causes of challenging clinical encounters in acute and critical care settings, we propose a practical ‘PATCH’ (predict and prepare for difficult communications, acknowledge difficulty of the situation, targeted and empathic communication strategies, conflict resolution strategies and ask for help) model, which summarises the key strategies and communication interventions that can be adopted to manage difficult clinical communications [Figure 1].Figure 1: The ‘PATCH’ model for navigating difficult clinical communications.Predict and prepare for difficult communications Difficult clinical encounters can often be predicted, based on the clinical topic that will be discussed (e.g. breaking bad news of clinical deterioration, discussing extent of care, disclosing errors or conveying uncertainty) or from reviewing past clinical records, which may contain documentations of communication challenges that were previously encountered. Before speaking to patients or families, it is important to make some crucial preparations beforehand. Firstly, consider who will be involved in the encounter from both the healthcare team and the patient’s side.[12] From the healthcare team, it is prudent to consider who might be most suitable to participate in the discussion, taking into account seniority, knowledge and experience.[12] If there are multiple family members or spokesperson(s) involved in the discussion, it is useful to understand their relationship with the patient, extent of involvement in patient care, and their knowledge of the situation and expectations,[12] through reviewing clinical records of previous conversations and gathering feedback from other members of the healthcare team who have interacted with them. Secondly, consider what needs to be discussed so that there is an outlined discussion agenda or set of objectives that can be agreed upon at the start of the meeting.[12] Thirdly, explore how the communication encounter might be optimised through selecting the appropriate mode of discussion (e.g. face-to-face or virtual), avoiding interruptions and incorporating communication aids or adjuncts as necessary.[12] Fourthly, especially when junior or less experienced doctors are involved in the clinical communications, it is important to spend time comprehensively reviewing the patient’s case notes, developing a good grasp of the patient’s clinical situation and anticipating questions that may arise during the discussion. The questions may pertain to the disease aetiology or precipitants (e.g. cause of deterioration), rationale for various investigative and treatment decisions, and expected clinical trajectory or prognostication.[12] To be adequately prepared to address these queries, physicians should review current literature or clinical evidence beforehand, obtain proper handovers from previous teams or seek clarification from senior members of the healthcare team.[12] Lastly, especially when a challenging clinical encounter is foreseen, physicians should ensure that they are in a good physical and mental state (e.g. not post-call, exhausted or fatigued, in a rush, hungry or emotional) and select an appropriate time and venue that is conducive for discussions and free from interruptions. Acknowledge emotions and difficulty of the situation In difficult clinical encounters, it is advisable to address the ‘elephant in the room’ and directly acknowledge the challenging situation, as this often helps to defuse a tense situation.[1,10,11] By doing so, patients or their family members may be more willing to share or vent their pent-up grievances, thereby revealing underlying concerns, agendas and perspectives of the situation.[1] Physicians should practise active listening and, when appropriate, name the relevant emotions, acknowledge tensions and discrepancies, gently correct misconceptions and attempt to guide the other party to reach reasonable and amicable common ground. There are, however, contextual nuances in acknowledging difficult situations. For example, a neglectful child acting out of guilt may demand aggressive interventions for a parent; it is important to name, validate and reflect their emotions while gently guiding them towards cognitive reframing to avoid maladaptive actions that may prolong the parent’s suffering. Additionally, acknowledging a medical error focuses on being upfront about admitting and rectifying the mistake, empathising with the natural emotions felt and working towards rebuilding trust in the patient–physician relationship. Targeted and empathic communication strategies Communication techniques adopted by the physician can greatly affect how the recipient perceives the conveyed information, attitudes and character of the provider and the entire clinical encounter. From the literature, there are several communication models developed for specific challenging clinical scenarios [Box 2]. The SPIKES (setting up, perception, invitation, knowledge, emotions, summary) model[17] is perhaps the most well-known communication framework traditionally taught for breaking bad news in clinical settings. More recently, frameworks such as the SPEAR model (select the target patients, explore patient or family perspectives, educate on disease prognosis and resuscitation outcomes, acknowledge expressed emotions and demonstrate empathy, make a medical recommendation)[13] or the Ariadne Labs Serious Illness Conversion Guide[22] have been described for use in clinical goals-of-care discussions. The AEIOU technique (apologise for the situation, empathetic response upfront, information giving with pacing, openness and transparency, understanding concerns)[14] was developed as a tool to disclose medical errors in an effective and culturally sensitive manner. Interestingly, the authors who described the AEIOU technique cautioned about poor clinical experiences related to inappropriate application of the SPIKES framework for breaking bad news (e.g. of terminal diagnoses) to disclosure of medical errors,[14] suggesting that nuanced, targeted communication frameworks are required for specific types of ‘difficult conversations’.Box 2: Communication techniques for specific difficult clinical scenarios.In addition, evidence-based empathic communication techniques [Box 3] are highly important in navigating all types of difficult conversations. These include the NURSE acronym (naming, understanding, respecting, supporting, exploring),[23] validating statements,[23] normalising statements[23] and reflective statements.[24] For example, reflecting the emotional content of what is said is a simple yet effective communication technique that can be adopted in many challenging clinical situations, where the listener merely acknowledges the expressed emotion and demonstrates reciprocal empathy without offering any solutions or new information at that juncture. For patients who are argumentative or tangential in speech, ‘turning the receipt’[21] is a potentially useful technique that actively acknowledges the patient’s viewpoint before steering back to the consultation agenda. Lastly, non-verbal cues such as maintaining eye contact, appropriate gesturing, body posture and active listening, are important aspects of effective communication.[1]Box 3: Empathic communication techniques.Conflict resolution strategies If a full-blown conflict develops from a challenging conversation, several conflict resolution approaches may be adopted. The Thomas–Kilmann conflict management model (1974)[25] outlines five key strategies—competing, avoiding, accommodating, collaborating and compromising—determined by the individual’s degree of assertiveness and empathy, with each having its pros and cons [Table 1]. In our view, competing in the form of assertiveness or firmness is useful in specific situations where physicians must not relent to medically inappropriate requests or tolerate abusive behaviours. Rarely, avoiding may be necessary when the other party is clearly abusive or unreasonable, or when a productive conversation is not possible at that juncture. Accommodating may be acceptable in areas that afford leeway for clinician discretion, e.g. relaxing visitation rules in a non-pandemic situation for a patient who is at high risk of deterioration. Collaborating is usually ideal in situations involving shared decision-making between physicians and patients or families. Compromising is sometimes acceptable when the clinical decision pertains to a contentious area, for instance, allowing a continued but limited trial of antibiotic treatment in a severely ill patient with poor premorbid medical or functional status who shows little response to the initial treatment.Table 1: Applying the Thomas–Kilmann conflict resolution model to patient or family–physician conflicts.Ask for help For clinical encounters that may be too difficult for a physician to manage alone, help should be sought and readily available. In the local setting, a family conference[19] is usually held when there are significant disagreements or conflicts between patients or families and their medical team. Broadly, the goals of a family conference are to elicit, acknowledge and address underlying concerns, clarify misunderstandings, set appropriate professional boundaries and expectations with regard to behavioural conduct, and ideally, reach common ground in working together for patient care. Usually, the family conference should involve the primary medical care team, including a senior member (e.g. attending consultant), as well as other relevant members of the healthcare team, including nursing staff, allied health professionals and subspecialty referral teams. Prior to the family conference, the healthcare team should meet in a pre-conference huddle to discuss the clinical case and discussion agenda, and reach consensus on medical recommendations and proposed interventions to ensure consistency in messaging conveyed to the recipients.[19] At the hospital level, relevant personnel from hospital management or the patient relations office should be involved early whenever there are conflicts or complaints related to patient care that cannot be resolved after a family conference or ‘clear the air’ discussion between the medical team and the patient or family. In situations where there are potential ethical conundrums (e.g. contention over medical futility and withdrawal of life-sustaining treatment), the clinical ethics committee should be consulted. In cases of medical errors, adverse clinical events and/or any concerns of an impending lawsuit filed by patients or family members, it is prudent to involve the hospital’s legal advisers in a timely manner. CLINICAL DOCUMENTATION Good clinical documentation of communication encounters is important to ensure that all members of current and future healthcare teams are kept abreast of the challenges faced in patient or family–provider interactions and to serve as a point of reference in the event of medicolegal disputes.[12] It is important to ensure that documentation is clear, concise, accurate and objective. Content that should be documented include the date, time and personnel involved in the encounter, a summary of the content discussed, conflictual opinions or stances and follow-up actions.[12] Emotionally charged conversational content must be documented objectively, based on factual recall of actual statements made, without making insinuations about the person’s intent or character.[12] PEDAGOGICAL AND PSYCHOLOGICAL INTERVENTIONS As challenging patient encounters are part and parcel of frontline clinical practice, communications skills training on managing difficult or unpleasant clinical communications should be mandatory in medical education. Simulated practice through standardised patients may be an effective way to build competency and resilience in dealing with challenging clinical encounters in a safe environment. In addition, psychological interventions are important to help clinicians deal with the emotional aftermath of difficult or emotionally charged clinical encounters. For example, cognitive behavioural techniques can help clinicians through engaging in cognitive reframing or restructuring to promote accurate appraisals of perceived threat and coping resources, avoiding catastrophic thinking and maladaptive behaviours.[26] Furthermore, mindfulness interventions can be practised in emotionally charged clinical encounters to help clinicians process the situation in a non-judgemental fashion with objectivity, kindness and emotional acceptance.[27] Lastly, clinical debriefing, traditionally used in reducing psychological distress after a traumatic clinical event (e.g. failed resuscitation),[28] can also be adopted by senior members of the medical team after conflictual or challenging patient encounters to help address negative emotions and provide support for junior staff. CONCLUSION Difficult clinical communications are prevalent in frontline medical practice due to a variety of patient, physician and systemic factors. The ‘PATCH’ model of communication and adjunctive strategies may help clinicians navigate the challenging clinical encounters of real-world practice. Psychological interventions are also necessary to strengthen the emotional resilience of physicians who have to manage unpleasant clinical encounters and conflicts. TAKE-HOME MESSAGES Difficult clinical communications are common in clinical practice; when poorly handled, they can lead to complaints, reduced patient satisfaction and negative effects on physicians’ mental health and well-being. Causes of difficult clinical communication can be classified as patient- or family-related, clinical or situational, physician-related, or systemic factors. 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