Communicating Risk

1. Communicating Risk Dr J Dixon October 2004 Bradford

2. 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 CI’d. 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???

3. 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.

4. Challenges to communicating risk • Knowing the risks • Knowing how much to communicate • Knowing how best to communicate them

5. 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 14’s 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)

6. 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.

7. Doctor factors that block effective risk communication • We don’t know all the facts • We don’t know the risks or their likelihood • We have hidden agendas- reduction of costs, prescribing or referral targets • We assume patients don’t 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?) • We’ve always done it this way

8. Patient factors that block effective risk communication • Hypochondrias • Information overload • Seeking compensation • Intimidation by perceived unequal relationship with health professionals • Cultural, ethnic, sexual differences

9. Suggested framework for discussion of risk • Appreciate interpersonal dynamics and help people move on- i.e. don’t 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

10. Decision aids • Care! Need to be well presented and carefully explained. Research shows that they don’t 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)

11. 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