Communicating Risk

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Communicating Risk

• Dr J Dixon October 2004
• Bradford

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Example

• 87 yr old, new onset Atrial Fibrillation, history
  of IHD, hypertension, and previous history of
  peptic ulcer disease and acute GI haemorrhage.
• Evidence suggests should be anti-coagulated, but
  clearly risks with this, and aspirin probably
  CId. Hx of falls would probably mitigate against
  starting either, but there are clear survival
  advantages to cardioversion (5 cva per year)
• What does the patient think???

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Communicating Risk

• Why is this important?
• Enhances concordance with chosen treatment
• Shares responsibility and reduces reliance on GP
• Allows for greater honesty and ultimately reduces
  complaints / litigation.

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Challenges to communicating risk

• Knowing the risks
• Knowing how much to communicate
• Knowing how best to communicate them

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When should we carefully communicate risk?

• When outcomes differ dramatically between
  different choices of treatment both in terms of
  severity and likelihood (medical or surgical Rx
  for BPH)
• Choices involve tradeoffs between short term and
  long term consequences (shoulder cortisone
  injection)
• One choice involves a grave outcome even if
  probability is low (aspirin in under 14s for
  suspected Kawasakis)
• The patient is particularly risk averse (pregnant
  mum, severe migraine.)
• Certain outcomes have great importance for this
  patient (stopping antiepileptic medication in a
  fit free milkman)

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3 patient types

• Deferrers simply defer to their doctor and accept
  whatever the doctor feels is best for them
• Delayers will prolong the decision making briefly
  until they hit upon a decision strategy or rule
  of thumb and grasp the decision
• Deliberators carefully appraise all of the given
  information, including the doctors preferred
  option and take time before making up their minds.

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Doctor factors that block effective risk
communication

• We dont know all the facts
• We dont know the risks or their likelihood
• We have hidden agendas- reduction of costs,
  prescribing or referral targets
• We assume patients dont want to know on basis of
  age, ethnicity , perceived intelligence
• It undermines our authority
• We have no time, or there is too much information
• This person would never complain
• Influencing the patient into taking the easiest
  option (doing nothing?)
• Weve always done it this way

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Patient factors that block effective risk
communication

• Hypochondrias
• Information overload
• Seeking compensation
• Intimidation by perceived unequal relationship
  with health professionals
• Cultural, ethnic, sexual differences

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Suggested framework for discussion of risk

• Appreciate interpersonal dynamics and help people
  move on- i.e. dont let emotions or experiences
  dominate the discussion- reach to understand
  patients prejudices then separate the people from
  the problems
• Consider every option minimising judgement
• Agree on criteria and principles on which to
  judge each option- if an impasse occurs- discuss
  which criteria takes precedence

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Decision aids

• Care! Need to be well presented and carefully
  explained.
• Research shows that they dont actually improve
  patient satisfaction at outcome of a discussion.
• They can improve knowledge (both GP and patient)
  and involvement- e.g. PSA testing (most decline
  routine testing when situation fully explained)

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When it all goes wrong- adverse outcomes

• Document everything including risk communication
  discussions
• If time permits- approach trainer/MDU to ask how
  to approach situation BUT
• Without delay seek out patient/family and face
  problem openly and honestly- delay suggests cover
  ups-
• Ask patient about what setting they would like
  this to take place in- preserve dignity
• Set the stage (you will remember the discussion
  we had about risks of X)
• Explain what went wrong
• Explain new management plan /options