| Avoiding Panic With Empathy and Education |
Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
Joined Mountain View
Medical & Surgical Associates
of Madras, Oregon July 2008 |
ast week, I met a 93-year-old lady with severe RA, pedal deformities, and a painful second toe ulcer with underlying osteomyelitis.The family had already been told by the surgeon who referred her to me that she would likely require an amputation. The family presented to me with the desire to avoid surgery. What would you do in this situation?
Discussing the need for an Amputation is the podiatry version
of telling a patient she has cancer. |
I'll bet very close to 100% of practicing podiatrists have, at some time in their careers, told a patient she would need an amputation. I'll also wager that at some point, all of us have had a patient react poorly to the news. Discussing the need for an amputation is the podiatry version of telling a patient she has cancer. Nothing is as grave or serious to our patients as this news. How do we tell our patients this news and avoid panic?
Practice Perfect now features brand new lectures on podiatry.com – viewable for CME Credit.
Take advantage of our limited-time 20/20 Offer, where you can get CME Credit for FREE.
Although today's lecture is courtesy of Coloplast, at no cost to you.
Details are provided at the conclusion of the eZine. |
|
In my short career, I have had ample experience telling patients they'll need an amputation. So, although I'm not a psychologist, I'll speak with some authority on the topic. I argue this based on two factors. First, I’ve done many various types of foot amputations and counseled patients preoperatively. Second, thus far, my patients have universally been satisfied with their overall experience. For those of you with experience with this topic, please write in and discuss your methods. Appropriately counseling our patients is perhaps the most important aspect of what we do, and I've seen a good number of doctors who seem completely incapable of helping their patients through an arduous emotionally draining process. I think this is an under-considered topic in residency that requires some discussion — perhaps even more training than we currently receive.
Here's a basic framework for discussing the need for an amputation (Obviously, the details differ depending on the situation):
- Do not be in a hurry or look like you're in a hurry.
- Sit down at eye level with the patient and look him/her in the eye when speaking.
- Speak clearly and don't use jargon. I also don’t use the word "amputation", "amputate", etc. I prefer euphemisms like "remove."
- Speak with and feel compassion. How would you feel if you or your parents were in this situation?
- Answer every question completely and honestly.
- It is abnormal for a patient to have no questions. If they don’t, ask, “Are there any questions I can answer for you?” Wait quietly for a response. If they say “no”, this is your chance to answer questions they might not think to ask.
- Here are some common questions patients ask.
• If it doesn't come up I answer for them: Am I going to walk again?
• Will this affect my balance?
• Am I going to lose my leg?
• How long will it take to recover?
• When can I start walking on it?
- I discuss very honestly the following issues: risks of surgery, potential complications (emphasizing that this is limb salvage surgery and further amputation is possible), benefits, detailed postoperative recovery and need to strictly adhere to my orders, and improving their health (smoking cessation, blood sugar control, etc.).
- Get the family involved. I have the same conversation with them, emphasizing how they can help their family member. Nothing improves compliance like a wife hovering over her husband while he heals his amputation.
|
To those residency directors who do not address communication issues, I would strongly recommend a short course or module on appropriate patient education. You can include roll-playing situations to build physician skills and attitudes. Podiatrists must have the skills to discuss difficult issues appropriately with patients.
With empathy and education,
patients suffer less and
have better outcomes. |
Let’s return to my 93-year-old ulcer/osteomyelitis patient. As of this editorial, she has not yet undergone any surgery yet. The first visit consisted of evaluation and a discussion of all the “possibilities” with the several family members that were present. This conversation included a discussion of the surgical and nonsurgical options. I emphasized the need for a full medical evaluation prior to surgery. We ordered radiographs (showing osteomyelitis of the proximal phalanx 2nd toe) and noninvasive vascular testing (which was essentially normal). At her next appointment, we will again discuss the options, although I will be pushing for an amputation (assuming she’s healthy enough for surgery). I will educate the patient and family as much as possible so they will make the best decision. No one has panicked. The family has listened seriously during our discussions and will make an appropriate decision now that they are fully educated.
With empathy and education, patients suffer less and have better outcomes. Good luck with your next patient experience.
Keep writing in with your thoughts and comments or visit eTalk on PRESENT Podiatry and start or get in on the discussion. We'll see you next week. Best wishes!
Jarrod Shapiro, DPM
PRESENT New Docs Editor
[email protected]
|
.jpg)
