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1. •Medical workers encounter difficult patients daily.
•Difficult patients attend health facilities only
because they must and are at times forced to visit
health facilities.
•They bring along their:
Different personalities
Cultural background and
Current emotional state.

2. •Such patients are afraid of losing control.
•A patient may seem difficult because of the illness
or stress at losing to the health workers who seem
to take over immediately the patient enters a health
facility.
The health worker needs to be a skilled
communicator to compel the patient to open up.

3.  The following may result in difficultsituations
•The silent or reticent patient
•The talkative or rambling patient
•The vague patient
•The angry patient
•The depressed or sad patient
•The denial patient
•The anxious patient

4. •Patient with somatization
•The dependent and demanding patient
•Dramatic or manipulative patient
•Long suffering and masochistic patient
•The orderly and controlled patient
•The manic, restless patient
•The guarded paranoid patient
•The superior patient

5. The physician should consider what could be
precipitating or causing the difficulty. It could be:
•System or environmental problems
Problems such as with transport
At the front desk
•The illness
•The patient
Problems with depression, loss, previous
experiences, etc.

6. •The physician
Problems with perception, workload, empathy
communication, expertise.
Following are examples of difficult encounters
adapted from Corenzetti (2013).

7. Patient typeCharacteristics
of the clinical
encounters
Approach
Dependent
clinger:
Insecure
Desperate for
assurance
Worried
about
abandonment
Patient initially
plays to
physician's
sympathies and
praises health
worker making
the physician
feel special.
As the
relationship
develops,
Maintain a
professional outlook
Establish boundaries
early and consistently
maintain them.
Involve the patient in
decision-making.

8. Patient typeCharacteristics of
the clinical
encounters
Approach
Dependent
clinger
the patient becomes:
Needy
Wantsor demands
increasing personal
time from the
physician; the
physician may feel
resentful.
Assure the patient
that you will not
abandon them.
Schedule regular
follow-up
appointments.

9. Entitled
demander:
Often angry.
Does not want
to go through
necessary
steps of
assessment or
treatment.
Patient is
aggressive and
intimidating.
Forges a
negative
relationship with
the physician.
Suspend judgment
and examine your
own feelings.
Recognize that the
patient's hostility
may be to maintain
self-integrity
during a
devastating illness
or other trauma.
Address any
specific emotion
that is evident with
the patient.

10. Entitled
demander:
Often angry.
May be
reacting to
fear and loss.
Sees physician
and health
system as
barriers to their
needs.
Physician may
feel anger, guilt,
doubt, or
frustration.
Do not react
defensively when
the patient
expresses concerns.
Reinforce that the
patient is entitled
to good medical
care, but that anger
should not be
misdirected at
those trying to
help.

11. Manipulative
help-rejecter:
Wants
attention.
Mighthave
been rejected
previously.
Patient
subconsciously
manipulates
doctor:
Returns to the
office often in
cycles of help-
seeking,
rejecting
treatment and
does not
improve despite
appropriate
intervention.
Recognize that the
patient wants to
stay connected to
the physician, not
necessarily to
recover.
Engage the patient
by sharing
frustrations over
poor outcomes.

12. Manipulative
help-rejecter:
Has difficulty
with trust.
Often has
undiagnosed
depression.
Confident that
his or her health
cannot improve.
Physician may
be concerned
about
overlooking a
serious illness.
Work with the
patient to set limits
on expectations.
Reformulate the
health plan with
the patient to focus
on alleviating
symptoms rather
than curing the
condition.

13. Self-
destructive
clients who
deny illness:
Feel hopeless
about
changing the
situation.
Unable to help
themselves.
Fear failure.
Health
problems
persist despite
adequate
counselling and
treatment.
Patient
continues self-
destructive
habits.
Recognize that
complete
resolution of
issues is limited.
Set realistic
expectations.
Redirect patient's
behaviour to
identify causes of
nonadherence
(e.g., money, time,
access to medical
care

14. Self-
destructive
clients who
deny illness:
May have
untreated
anxiety or
depression.
Physician may
feel ineffective
and responsible
for lack of
progress.
or appropriate
treatment).
Celebrate success

15. •Generally, given the high suicidal risks among
depressed clients, the physician should watch their
nonverbal and verbal behaviors by:
Not showing boredom, frustration or anger.
Using the body to empathize, encourage and
facilitate discussions.
Explain details and promote disclosure.

16. Use listening, paraphrasing, reflecting, questioning,
etc. skills to facilitate communication and
understanding.
With an anxious patient, retain calmness and make
them understand that anxiety is common among
some patients.
Be specific about instructions

17. •With the angry patients, be watchful for these signs:
Speaking louder and quicker or becoming quiet.
Changing, flushed facial expression with loss of eye
contact.
Impatience and non-compliance.
Sudden movements or invading your space.
•In response,
Do not show fear.
Be willing to talk and listen.

18. Acknowledge their anger.
Do not invade their space.
Keep a safe distance
Do not talk to them from behind. Face them.
Encourage them to talk.
Do not interrupt or issue threats.
State the facts.
Do not make statements/promises you cannot fulfil.

19. Do not take offence at their verbal abuse or threat.
If possible, switch the conversation to something
else.
•Disability such as hearing impairment,
developmental or cognitive disability might lead to
difficult situations.
Attempt to understand where the patient is coming
from.
Adapt situations to minimize stress on client.

20. •Difficult situations may also arise during:
Breaking bad news.
Caring for the dying patient.
Solving conflicts.
Conflicted roles.
A skilled and competent communicator can
manage such situations without placing undue
stress on the situation or client.

21. ‘Nothing travels faster than the speed of light with
the possible exception of bad news, which obeys
its own special laws’ (Douglas Adams).
•Bad news refers to situations where there is:
A feeling of no hope.
A threat to a person’s wellbeing.
Risk of destabilizing established lifestyle.
A message which conveys a picture of fewer
choices in life

22. •Examples:
Life threatening illnesses –cancer, HIV.
Degenerative conditions –Alzheimer.
Chronic illnesses-rheumatoid arthritis.
Mental retardation in children –Down’s syndrome.
Disease's recurrence or spread and treatment failure.
Irreversible side effects.
Issue of palliative care and resuscitation.
•

23. •Breaking bad news has become:
A part of clinical practice.
A skill to be learned and applied
An aspect of care that clients and relatives
appreciate.
Nondisclosure is unethical.
Breaking bad news provides better psychological
adjustment in patients.

24. Reduces stress in doctors.
Facilitates open discussions among concerned
parties.
Empowers patients-allows a greater say in
treatment.
•Bad news is based on a patient’s views and reaction
to news. It depends on:
A patient’s real situation and
Perceptionabout the situation.

25. •Patient’s perspective
Patient’s memory -negative reports have lasting
effects
•Yet, breaking bad news can:
Facilitate adaptation and
Foster doctor-patient relationship

26. •Health worker’s perspective
Fear of causing pain, being blamed, upsetting the
client’s family structure or therapeutic failure.
Emotional engagement.
Lack of training in breaking bad news.
Lack of time or support from colleagues and
system constraints.
•Cultural or language constraints.

27. •Certain legal and ethical principles in clinical
practice forbid withholding personal and
important information from patients.
•Who breaks the news?
Must have knowledge and information about
the case.
Discuss with colleagues/team
Specific situations require considering
otherwise –psychotic patients, children.
May be more appropriate for another doctor,
at times, to break the bad news.

28. •It depends on situations. Consider the effect on the
client.
•At times withholding bad news could be disastrous
–HIV.
•It is not appropriate to break bad news at the end of
a shift because of time factor.
•Breaking bad news is a process, not one-off event.

29. •During breaking bad news, the patient desires a
doctor who:
Shows empathy, cares.
Have time to talk with them.
Providesadequate information.
Is confident.
A familiar face.

30. SPIKES Model
Setting up the interview
•Arrange for privacy
•Involve significant others
•Sit down (unhurriedly)
•Make connection with the patient
•Manage time constraints or interruptions –hand off
your pager, if possible.

31. Perception of the patient
•Before you tell, ‘ask’. Use open-ended questions to
assess the patient’s and family’s perception of the
disease. Do not talk down!
Examples:
What have you been told about your condition?
Why did we carry out an MRI?
•Such questions will help determine if patient is in
denial and their expectations.

32. Invitation by the patient
•Explore how the patient would want the
information –whether they need a family member
involved.
Knowledge to the patient
•A warning shot is necessary-could help lessen the
shock. ‘Unfortunately, I have some bad news …

33. •Avoid using jargons, and do not appear blunt –‘your
results show you have full blown AIDS and there
is nothing we can do about that.’
Emotions of the patient: Expect anything ranging
from silence, disbelief, crying, denial, anger, shock.
•Respond to the patient’s emotion with empathy.
•Acknowledge the emotion.
•Identify reasons for the emotion.
•Connect with the patient.

34. Strategy and Summary
Patients who have a clear plan are less likely to
feel anxious.
•Check with the patient if they are ready to discuss
‘next steps’
•Explore patient’s agenda (ICE)
Ideasthat may help
Concerns: what is worrying them?
Expectations: what are their hopes for the future?

35. Use the C-O-N-E-SProtocol when:
• Disclosing that a medical error has occurred.
• There is a sudden deterioration in the patient’s
medical condition
•Context
Prepare for what to say and anticipate the
client/family reaction.
Have the conversation in a quiet area.
Seat the patient closest to you
Sit down, try to be calm, maintain eye contact.
Have a box of tissues available.

36. •Opening Shot:
Alert the patient/family of important news.
‘This is hard, but I have some information to give
you that is important.’
‘Thanks for coming in. I must tell you what is
going on with your mother.’
•Narrative approach:
Explain the chronological sequence of events.
‘As you know, your mother visited us in…’
‘Then, we gave her… and there was little
improvement.’
‘Yesterday, we found out that …’

37. Avoid assigning blame or making excuses.
Emphasize that the clinic is investigating how the
error occurred.
‘We started investigations and by the end of today I
hope to answer your questions as clearly as
possible.’
‘I hope by the end of today she will start
improving.’
Offer a clear apology -‘I am really sorry that this
has happened.’

38. •Emotions: address strong emotions with empathic
responses. (Use E-V-Eprotocol for strong
emotions).
‘I know it’s upsetting for you. It’s awful for me
too.’
‘It’s very rare, but it does happen and I’m sorry
that it did.’
Do not allow yourself to be pushed into making
promises you cannot deliver.
Avoid reassuring the person that there is going to
be a good outcome or that no harm was done.

39. •Strategy and Summary
Summarize the discussion and make specific plans
for follow up.
Let your clients know the situation is a priority.
‘I am the doctor responsible for your mother, so it is
important that I find out what happened.’
‘I’ll be open and honest with you when I have all the
facts.’
‘I can guarantee that we will do our best.’

40. If you do not know the answer, say so and that you
will attempt to find out.
Disclosing medical errors is now a standard. It is
not optional. Sensitive disclosures have a favorable
impact on malpractice claims
E-V-E protocol: use when strong emotions occur
•E-Explore
Explore and identify the emotion (anger, sadness,
etc.).
Find out more about the emotion and what causes it.
‘Can you tell me more about how you feel?’
Acknowledge the emotion: ‘I understand it made
you sad’

41. •V-Validate : Let the person know you understand
the emotion was appropriate.
‘I can understand how that would make you sad.’
•E-Empathic Response : Respond in a way that
shows you have seen the emotion and that you can
understand it.
‘I’m sorry this has happened, and I understand
how it would make you feel that way.’
‘I get your point. It was obviously very upsetting.’

42. Use the protocol to hold your emotions in check
•Be Prepared
Expect emotions (your own and client's)
Have a plan for how you will do it (especially if
you must give bad news).
Monitor what you think and feel
Practice self regulation –Keep your own emotions
in check when you are pushed.
Aim to turn the confrontation into a conversation.
Know when NOT to have a conversation (when
emotions are intense or high).

43. Use Non-Judgmental Listening
•Remember the emotion is not about you, but about
the other’s disappointments, fears, anxiety, etc.
which often underlie the anger, blame or denial
•Maintain eye contact.
•Listen without interrupting only making clarifying
statements and paraphrasing.
‘So let me see if I understand…’
•Put your own agenda aside until the other person
has finished
•Avoid trying to make a situation better when it is
grave. ‘I’m sure things will not be as bad as you
think’ -wrong

44. Six-Second-Rule
•Avoid escalation of conversation.
•When your own emotions start to boil (especially
in response to anger or blame), wait at least 6
seconds or more if needed for them to calm down.
•Avoid being defensive/blaming -‘Well it didn’t
work because you waited too long to get help.’
•Gather your thoughts and use skills such as ‘tell me
more’ or empathic/validating responses.
Tell Me More
•Invite the person to expand on what they are saying.
‘Tell me more about your sister.’ ‘What happened
after that?’‘What are your other concerns?’

45. Empathizing and Validating to acknowledge and
diminish emotions.
•Acknowledge emotions by empathizing:
‘I can see you weren’t expecting this.’
‘It must be hard to come here every week.’
Respond with a wish statement.
•Let the other person/client know you hear them and
acknowledge that the goal may be desirable, but…
‘I wish I had better news…’
‘I wish we had a more effective treatment.’

46. At referral stage
Planning the assessment
Undertaking assessment
Analysis of information
Forming judgements
Reaching decisions
Formulating plan
Setting goals
Agreeing timescales
Reviewing progress

47. •Communication enhances health care practices,
thereby helping in achieving the goals of the health
sector as they relate to the clients, the community,
the government and the health workers.
•Effective clinical practice cannot focus on
technical aspects only but must include human
factors.
•Good communication encourages collaboration
and helps prevent errors.
•To be an effective health worker, it is vital to learn
and practice effective communication skills.

48. BaileWF, BuckmanR, LenziR, GloberG, Beale EA, Kudelka
AP. 2000. SPIKES-A six-step protocol for delivering bad
news: Application to the patient with cancer. The Oncologist
5(4):302-11.
Bor, R., Miller, R, Goldman, E & Scher, I. 2007. The meaning of
bad news in HIV disease: Counselling about dreaded issues
revisited Counselling Psychology Quarterly, 6(1), pp. 69-80.
Dept. of Health and Dept. for Education & Skills. 2007. Good
Practice Guidelines in Working with Patients with
Learning Disabilities. Available at: http://dh.gov.uk
Pinner, D., & Pinner D., 1998,Communication Skills, 4
th
Edition,
Addison Wesley Longman, Auckland.
Smith, M. 2006. Getting started: communication with the
elderly. The Geriatric Mental Health Training Series.
University of Iowa: College of Nursing.
The GerontologicalSociety of America. 2012. Communicating with
Older Adults.