Patients with special needs (mentally unstable patients, aggressive patients, anxious patients, depressive patients, socially

disadvantaged patients, patients with permanent damage/disability);

The doctor calls up the patient and says, "I havesome bad news and some worse news. The badnews is that you have only twenty-four hours leftto live."The patient says, "That is very bad news.What could be worse?"The doctor says, "I've been trying to reach yousince yesterday."

Doctor – patient communication

Prefer to expect:• Patient comes unprepared;• Patient monitors care, which he/she (not)receives;• Patient recognizes (criticizes) treatment, which

he/she got, physician´s and nurses mistakes and faults;

• Patient talks about these mistakes and faults (it is usually out of a physician´s office so he/she creates a favourable or unfavourable reputation).

Doctor – patient communication

The physician must be good:• Psychologist;• Sociologist;• Philosopher;• Expert (his/her approach must be both

professional (trained) and creative – made to the patient and his/her problems measure – individualized).

Doctor – patient communication

Advice to patients in verbal communication:• Ask about everything you want to know and

what you are unsure;• Talk to your doctor, what, where and how it

hurts you;• Tell all the problems at once;• Tell your doctor about all your doubts and

what you don´t believe.

Doctor – patient communication

Advice to patients in non-verbal communication:• Patient should look into physician´s eyes;• Patient should respect physician´s privacy;• Patient should respect other patient´s privacy;• Truthfulness.Tricky question is whether it is possible to orderpatients to believe their physicians. TRUST issomething what is created by repeated contactswith physicians.What do you think is the most important thing forpatient?

Doctor – patient communication

Questions, which patient wants to usually know:• Cause of his/her pain or problem;• How it is possible to change this pain or problem;• For how long it can be solved;• What should he/she do if his/her condition doesn´t

change in hour, three days, a week;• What are the side effects of recommended

treatment;• What limits does the treatment cause;

Doctor – patient communication

That is why a physician should develop the habit of repeat these types of sentences:

• Do you want to ask a question?• Could you repeat what I have said.• What will (not) you do?• As I understand it, you say that…• Could you repeat how you will take the

medicine.

Doctor – patient communication

Patient around the world are the same. Tate´s so called Rule of one third:

• 1/3 accepts the physician recommendation and follows it.

• 1/3 follows physician recommendation, but inconsistently and inefficiently.

• 1/3 ignores physician recommendation.

Doctor – patient communication

Mentally unstable patient:• Matter of specialized facilities.• Must be respect of human dignity.• „You´re crazy. You´re a freak. You belong to a

madhouse. You're paranoid - humiliating insults.“

• It goes for these patient that they must agree with treatment and hospitalization.

Doctor – patient communication

In the past these people were chained to the wall or they were exposed in an iron cage. But there was one case in the Czech Republic at the beginning of 90s´. One physician was so rude to a mentally unstable woman – he applied an injection so violently she lost the ability of walk alone and meaningful speech. After that she was pushed into the emergency car against her will and she broke fingers on her hand.

Doctor – patient communication

• To be considerate;• To listen to what they say;• Try to understand what they say;• Verify their information, message.

Emotional health is more fragile and more tricky. (Tate, 2005)

Doctor – patient communication

Aggressive patient:• Aggression is considered to be a natural

behaviour even at the civilized man. We carry it inside as a remnant of the historical period.

• Aggression means low tolerance to mental stress.

• It is manifested by affective up to violent and life-threatening behaviour.

Doctor – patient communicationWho can be aggressor?• Patient who suffers from persistent conduct disorder;• Patient who perceives too sensitively unfavourable

diagnosis;• Patient who is disappointed by the few hopeful

predictions;• Patient who is disappointed by limited treatment

possibilities;• Patient who suffers from severe pain;• Patient who waits for too long (in the morning with

an empty stomach).

Doctor – patient communication

Rarely the patient is aggressor for himself/herself:• Self-harm;• Refuses food;• Prevents nurse to treat him/her (knocks out

syringe, pulls out infusion or probe, attempts to commit suicide);

Why do you think they do these things?

Doctor – patient communicationAggressive patient manifests increased unrest:• Tapping feet;• Walking nervously;• Kicking into the space and objects;• Beating with objects;• Using strong gestures;• Breathing loudly and irregularly;• Increasing excitement on his/her face and increasing

tone of voice;• Using of profanities, insults and threats.

Doctor – patient communication

How to react from a position of physician?

What is the best way how to react?

Doctor – patient communication

• A physician should immediately find out what was the starting torque.

• It is appropriate to react with fast questions to find out what was the cause of inadequate emotions (because doctor gets time to think).

Doctor – patient communication 1) We express our participation verbally:• I understand you well.• I share your outrage.• I'm sorry…• Unfortunately, it sometimes happens.• Please, sit down. We can talk about it right now.• Don´t give up. We can advise on how to proceed.• What do you think I should do now?• Do you think we can solve this situation? - using

questions we for patient to answer, to rational thinking which can calm the patient).

Doctor – patient communication

Voice:• calm, gentle, lower-pitched and quieter voice.Postures, gestures:• slow movements, slow gestures, friendly

hand, use of touch (grasping arm).

Doctor – patient communication

2) We should be o the same wavelength:• Energy are not passing;• Communication is on two different levels;• Patient's anger may increase; • It´s necessary to demonstrate authority;• To act/behave directively mirroring his/her

gestures.

Doctor – patient communication

„Well, Mr. Novák, could you sit down on a chair, please…“ (in doing that we either touch him/her to show the direction or denote the direction) and we encourage the patient – „just calm down slowly, take a deep breath and we try to relax - otherwise we can not continue and I couldn't help you. You came to my office and you want me to help you“.

Doctor – patient communication

Anxious patient:• Anxiety can be „in born“;• Based on exaggerated fears about their health;• Disappointed expectations of himself/herself or

others – the patient failed;• For these patients is typical: anxiety and stress to get

through an illness… • Doctor plays the role of parents in this relationship.

Doctor – patient communication• Gentle but persuasive voice;• Slow and clear speech without an admonition;• Attentive listening ;• Kind but not reproving look;• Eye contact;• Mild gestures; • Detailed explanation of the problem; • Expressing of hope that they will try to find

solution together.

Doctor – patient communication

Examples for the beginning of the interview: • If I listen to you well, you suffer from…• Sit down and we are going to talk about…• I will help you if you tell me everything calmly.• I suggest first to do this and after…• Together we will solve your problem. • Perhaps we can find a solution.

Doctor – patient communication

Depressive patient: • Depression deprives man of joy, especially

from life.• sadness, indifference, helplessness,

indecisiveness, delayed speech and voice, talking about suicide, suicide attempt;

• these patients are very touchy.

Doctor – patient communication

• Physician should avoid these types of sentences:„Look, this man is blind and deaf, this man doesn´t have leg and both of them have the joy of life…“

• „You just make things up.“• „It won´t be better, only worse.“• „Do not focus on youself.“• It hurts pacient because he/she perceives it as

a criticism against himself/herself.

Doctor – patient communication

• Depressive patient records each unknown manifestation of the body as the disease (incurable);

• If you solve one problem they will come with another - endless string of problems;

• Vicious circle which heightens patient´s individual suffering.

• One recommendation: Make an agreement with the patient that he/she doesn´t attempt to commit suicide

Doctor – patient communication

Socially disadvantaged patient:• Homeless people;• Drunks;• Addicts;• Prostitutes;• Abused by another person;

Doctor – patient communication

• Special categories of social workers should take care of them.

• Specific problem is a long-term unemployment.

• Loss of the possibility of self-realization. • Absence of any ID.

Doctor – patient communication

Entrance interview:• Find out the current situation;• In the case of the woman in productive age we

ask about her family;• But there can be a problem that the patient is

unable to speak.• Orient on the basis of ID.• Act as in case of crisis and assume

responsibility for the patient.

Doctor – patient communication

Patient with permanent damage/disease:• Mental (anxiety, aggression, depression);• Sensory (blind, deaf, deaf blind);• Physical (wheelchair);• With reduced intelligence (mentally

handicapped);• Combination of these defects.

Doctor – patient communication

Professional approach:• Without bias;• Without prejudice;• Without aversion.

• UN – 20. 12. 1971 – Resolution of right of the physically and mentally handicapped.

Doctor – patient communication

Our society has decided to integrate disabled and handicapped people:

• barrier-free access to schools, public institutions, to shops, to public sanitation;

• installation of audio signal devices at crossings, guide strips on sidewalks.

Doctor – patient communication

Guidelines for communication with handicapped patients:

• Choose a communication which is adequate to form and patient´s individual disability;

• Always keep eye contact;• Speak to the patient (even if she/he is

accompanied, even if we are sure he/she can´t perceive us);

Doctor – patient communication

• Speak clearly, always use literary language without foreign or slangy medical terminology;

• Do not feel sorry about patient´s handicap, it decreases his/her psychological comfort;

• Talk with a patient appropriately to his/her age, not according to her/his mentality;

• Move tolerantly their moodiness, indiscretion, grain. • Talk with gentle, calm voice.

Doctor – patient communication

Have a nice day