Dr J Dixon Bradford www.bradfordvts.co.uk Communicating Risk Dr J Dixon Bradford www.bradfordvts.co.uk

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???

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.

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

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)

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.

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

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

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

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)

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