Communication is about more than providing information. It has a key role in establishing good therapeutic relationships and in acknowledging the humanity of patients. Here we identify the factors contributing to good communication.
What is good communication?
- involves recognising the individuality of patients and will, ordinarily, be a necessary first step to the provision of holistic or ‘whole person’ care
- is critical to exploring and understanding the extraordinary range of cultural expectations that patients and health professionals bring to modern health care
- is a pre-requisite for valid patient consent.
Poor communication plays a part in the majority of complaints against doctors and health care services.
Certain groups, such as the elderly, children, the young, people with learning disabilities and those who do not have English as a first language can sometimes struggle to be heard. People from these groups can be offered less information and can be at risk of having decisions made on their behalf without their full involvement.
Particular care is therefore needed here and it is vital that doctors avoid unfounded assumptions about the wants, needs or abilities of individuals on the basis of categories that are not relevant to the therapeutic relationship.
'Elderspeak' and the autonomy of the older patient
It is widely recognised that some health professionals working in institutions can develop the habit of ‘talking down’ to older patients. This has come to be known as ‘elderspeak’. It is similar to baby talk and is frequently characterised by slow, loud speech using exaggerated intonations, a repetitive and simplistic vocabulary as well as diminutives and intimate terms of endearment. Although intended to be clear and sympathetic it is both patronising and demeaning. Older patients are said to respond to it "with lowered self-esteem, depression, withdrawal from social interactions and even dependent behaviour consistent with their own stereotypes of elderly individuals." William K et al. J Gerontol Nurs 30(10):17-25.
What factors contribute to good communication?
Good communication involves both the exchange of relevant information and the development of positive therapeutic relationships.
According to GMC guidance, doctors must:
- listen to patients, ask for and respect their views about their health and respond to their concerns and preferences
- share with patients, in a way they can understand, the information they want or need to know about their condition, its likely progression, and the treatment options available to them
- respond to patients’ questions honestly and keep them informed about the progress of their care
- make sure that patients are informed about how information is shared within teams and among those who will be providing their care.
In addition, in our view, the following are important aspects of good communication:
- Information should not be limited to that necessary to enable patients to provide consent for discrete interventions. Where appropriate, information should be provided in a supportive manner that enables patients to protect and promote their health in the longer term
- The role of the doctor is both to advise patients and to facilitate, as far as possible, their active involvement in decision making. Doctors should therefore be sensitive to patients’ information needs.
- All health professionals should be properly trained to communicate unwelcome news in an honest and supportive manner.
What’s the moral problem?
Can patients refuse to receive information?
Ethically, the requirement to provide patients with sufficient information in order to make an informed decision is linked to the strong requirement to respect patient autonomy. A refusal of relevant information causes concern because it looks as if patients are voluntarily surrendering their autonomy. It also raises practical concerns about whether the conditions for consent have been met and therefore whether doctors may be acting unlawfully, raising the possibility of complaints or litigation later.
In our view, where patients make it clear that they do not want to receive information, it should not be forced upon them. In order for consent to be valid, however, they do need to know the core facts about what is proposed. Competent patients should therefore be encouraged to receive information that is essential to maintaining their health, as well as information relevant to assessing the risks and benefits of the proposed intervention or course of treatment.