Patient Advocacy and Informed Decision-Making

 
ANNOUNCEMENTS
 
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You should complete Dairy 6 today
b.
Diary Write Up will be explained on Tuesday April 16
 
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Everything from Midterm to final lecture.
 
50 multiple choice + 4 Extra Credit questions
 
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Quiz 2 Performance
 
Ave. Score = 81%
Review Question 1
For patients, hospital garb has what negative effect?
____  An added expense most can’t afford
____ There is little choice in color or design, offending personal style
____ Imposes childish, infirmed, low-status identity
____ Rarely allowed to take garb home, as souvenir of important event
____ None of the above
 
X
Review Question 2
Why do patients often fall into “good patient” role?
____  Hospitals place them in role of dependent child, who seeks to please.
____  Hospitals have legitimate needs for them to cooperate
____  Patients try to win the favor of staff to get better attention
____  Patients’ superstitious belief that MDs have god-like healing powers
____  All the above
 
X
 
Class 22
 
Being a Patient (finish)
 
Patient / Provider Communication (start)
 
Should MDs Inform Patients?
If So, How Much?
 
What are problems with informing patients?
 
What are problems with not informing patients?
 
What about uncertain diagnoses?  “You have a 40% chance of X illness”.
The Informed Patient
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    Janis redefines situation: Some anxiety is good.  Why?
 
No anxiety
 – person not prepared for difficult outcomes.
Too much anxiety
 – person is flooded, can’t take in information.
Recommends providing pats. with enough info to emotionally prepare.
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Patients either told / not told what to expect post-surgery (pain,
 
recovery, severity, etc.)
 
Result
: Informed pats need less narcotics, leave hospital sooner.
 
Highly replicated finding.
1918-1990
 
Social Support and Surgical Recovery
 
You are about to undergo surgery.  Would you prefer:
 
____ Private room (no roommate)
 
____ Roommate who is 
about to undergo 
same/diff surgery
 
____ Roommate who is 
in recovery 
from same/diff surgery
 
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Patients pared with roommate who is:
 
 *  Undergoing same / different surgery
 
 *  Pre-operative / post-operative
 
What matters in terms of patients’ recovery?
 
Social Support and Surgical Recovery:
Roommate Same or Different Condition
Kulik, Mahler, and Moore (1996)
 
Yards Walked
 
Walking Post-Surgery
 
Days in Hospital Post Surgery
 
Paired with post-op: Less anxious
Responsibility and Care-Giving on Patient Outcomes
Rodin & Langer, 1977
Subjects are nursing home elderly.
Cond. 1
: Reminded of their own responsibilities,
and given a plant to care for.
Cond. 2
:  Reminded of staff responsibilities to them, 
 
and given a plant that staff cares for.
18 months later:  Staff ratings, mortality.  Who does better?
Cond ___ :   * More positive staff ratings (happier, more sociable) 
  
 
        * Lower mortality (more likely still alive)
 
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       1.  Informed about condition:  Diagnoses, discomfort
       2.  Roommate who can help interpret treatment, foresee outcomes.
       3.  Given responsibility, meaningful tasks.
 
Animal Assisted Therapy (AAT):
 
Specially trained animals plus handlers
 
visit hospitalized patients.
 
Dog lies on patient's bed, is petted.
 
Cute, but does it work?
 
Experiment by Kathie Cole, RN, UCLA Medical Center
 
77 heart-failure patients (ave. age = 57) receive 12 minute visit
 
from either:
   
a.  Dog
   
b.  Human volunteer
   
c.  No visit
 
Animal Assisted Therapy
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Dog:
   
Down 24 pts
 
Human:
  
Down 10 pts
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Dog:
   
Down 17%
 
Human:
  
Down 02%
 
Control:
  
Up 07%
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Dog:
   
Down 10%
 
Human:
  
Up 03%
 
Control:
  
Up 05%
Results of AAT Study: The Paws that Refreshes
 
Why are dogs better
than humans?
 
Elephant-Assisted Therapy:
South Africa
 
Dolphin-Assisted Therapy:
Israel, Florida, Ukraine
 
 
Therapeutic Riding and
Cerebral Palsy
Veronic Skoczek and MacGuyver:
 
Skoczek suffers from cerebral palsy, affects walking and
 
other motion.
After years of “therapeutic riding” walks unassisted.
Rhythm of horse’s gait mimics pelvic movement during walking.
Improves alignment, muscle symmetry, postural control
 
https://www.nsarco.com
 
https://www.esaregistration.org/ther
apy-dog-and-animal-info/
 
Emotional
Support Animal
Registry
Children in Hospitals
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a.  Place associated with pain
b.  Sad/Scary looking patients
d.  Parents are not in control
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a.  Fear, anxiety
b.  Anger, rebellion
c.  Shame (esp. at adolescence)
 
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              a.  "Setting" anxiety
              b.  Age 3-6: fear rejection
 
c.  Age 4-6 develop new fears (e.g., darkness)
              d.  Age 6-10 free-floating anxiety
              e.  Separation anxiety:  deserted? punished?
 
Social-Psychological Tx for Hospitalized Children
 
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a.  Parental visits study (Branstetter, 1969)
  
Cond 1.  Mom at visiting hours only
  
Cond 2.  Mom for extended periods
  
Cond 3.  Surrogate mom
 
b. Kids in Cond 2 & 3 do better than Cond 1
 
c. Hospitals now let parents stay with kid all times
 
d. Story telling
 
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a.  “Kid in Hospital” movie --> less anxiety
 
b.  In gen., informed kids show less anxiety
 
c.  Encourage kids to ask questions
 
d.  Provide kids with coping skills
  
*  Self-talk
      
*  Relaxation skills
 
Story Telling for Hospitalized Children
 
https://storynet.org/groups/hsa/healing-
story-alliance-hsa/
 
Story telling an ancient part of human
civilization.
 
Our minds are soothed by stories.
Provide meaning and order;
a beginning, middle, end.
 
Hospitals include storytelling to children-patients.
 
Eases anxiety and fear.  Provides a “mental vacation”.
 
May reduce pain.
 
Class 24
Patient / Provider Communication
 
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Communication and compassion not emphasized
 
Communication skills not modeled.  MD training is itself inhumane.
 
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Motives for becoming MD sometimes contrary to compassion/listening
  
prestige, wealth, status, authority
 
Some MD skills contrary to compassion/listening:
  
Detachment
  
Analytic / time-efficient / detail oriented
 
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Competitive:
 
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Technical
 
Why Providers Are Often Poor Communicators
MD Failure to Listen
Beckman & Frankel (1984) study of MD initial response to patients
MDs know they are  being observed, 74 patient visits
Patient given opportunity to explain problem:
MD interrupts, directs pat. to particular disorder:
MD interrupts pat. after _____________  of elapsed time.
 
23%
 
69%
 
18 seconds
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?
 
1.  Patients don’t get a chance to fully explain symptoms, concerns.
2.  MD doesn’t get all vital information
 
MD Communication Problems
 
1.  Failure to listen
2.  Use of jargon:
 
Hmm.  Seems you have Ulag's
 
Syndrome, which voraciously perturbs
 
the ipsilateral medulla of the flataboig.
 
Arnold of Villanova 
(1235-1311):  
[Tell the
patient that] he has an obstruction of the liver,
and particularly use the word obstruction because
patients do not understand what it means.
 
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MD sees pat. as condition, not a person
  
Refer to pat. in third person, in front of pat.  “Need to get
  
his name and address, and what’s his primary symptom”
 
  
 
Functions:
 Manages pat., improves efficiency in emergency
 
Effect on Pat:
  
Can calm:  Help dissociate from fearful situation
  
Can alarm: 
“I see this condition terminating in negative
    
status”
 
MD Communication Problems (contin.)
 
Inappropriate Emotions
 
MD  looks frightened, distressed,
 
frustrated.
 
“Holy Toledo, look at that spot on
 
your X-ray!!!!”
 
Women who get mammogram, if
MD appears worried, they:
 
      
 
a.  Remember less
 
b.  See situation as worse
 
c.  Higher pulse rates
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Understanding the importance of patient information in healthcare, this announcement covers topics such as the impact of hospital garb on patients, reasons why patients adopt certain roles in healthcare settings, patient-provider communication dynamics, the debate on how much information doctors should disclose to patients, and the benefits of informed patient care according to a study by social psychologist Irving Janis. It also touches on the significance of social support in surgical recovery scenarios.


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  1. ANNOUNCEMENTS 1. Diary Study a. You should complete Dairy 6 today b. Diary Write Up will be explained on Tuesday April 16 2. Final Exam: May 7, 11:45 to 1:15 Everything from Midterm to final lecture. 50 multiple choice + 4 Extra Credit questions 3. Quiz 2 Results: Classdid well. Average 81% correct. Grades on Canvas

  2. Quiz 2 Performance Ave. Score = 81%

  3. Review Question 1 For patients, hospital garb has what negative effect? ____ An added expense most can t afford ____ There is little choice in color or design, offending personal style ____ Imposes childish, infirmed, low-status identity ____ Rarely allowed to take garb home, as souvenir of important event ____ None of the above X

  4. Review Question 2 Why do patients often fall into good patient role? ____ Hospitals place them in role of dependent child, who seeks to please. ____ Hospitals have legitimate needs for them to cooperate ____ Patients try to win the favor of staff to get better attention ____ Patients superstitious belief that MDs have god-like healing powers ____ All the above X

  5. Class 22 Being a Patient (finish) Patient / Provider Communication (start)

  6. Should MDs Inform Patients? If So, How Much? What are problems with informing patients? What are problems with not informing patients? What about uncertain diagnoses? You have a 40% chance of X illness .

  7. The Informed Patient Irving Janis ideal anxiety approach (1958) 1918-1990 Hospital hires Janis (social psychologist) to reduce patient stress Janis redefines situation: Some anxiety is good. Why? No anxiety person not prepared for difficult outcomes. Too much anxiety person is flooded, can t take in information. Recommends providing pats. with enough info to emotionally prepare. Egbert study (1964): Works with pats. undergoing abdominal surgery Patients either told / not told what to expect post-surgery (pain, recovery, severity, etc.) Result: Informed pats need less narcotics, leave hospital sooner. Highly replicated finding.

  8. Social Support and Surgical Recovery You are about to undergo surgery. Would you prefer: ____ Private room (no roommate) ____ Roommate who is about to undergo same/diff surgery ____ Roommate who is in recovery from same/diff surgery Kulik & Mahler study (1996) Patients pared with roommate who is: * Undergoing same / different surgery * Pre-operative / post-operative What matters in terms of patients recovery?

  9. Social Support and Surgical Recovery: Roommate Same or Different Condition Kulik, Mahler, and Moore (1996) Walking Post-Surgery 300 Yards Walked 250 200 150 100 50 0 No Roomate Roommate Different Condition Roommate Same Condition Days in Hospital Post Surgery 12 10 8 6 4 2 0 No Roomate Roommate Different Condition Roommate Same Condition Paired with post-op: Less anxious

  10. Responsibility and Care-Giving on Patient Outcomes Rodin & Langer, 1977 Subjects are nursing home elderly. Cond. 1: Reminded of their own responsibilities, and given a plant to care for. Cond. 2: Reminded of staff responsibilities to them, and given a plant that staff cares for. 18 months later: Staff ratings, mortality. Who does better? 1 Cond ___ : * More positive staff ratings (happier, more sociable) * Lower mortality (more likely still alive) Key Points Slides 6-9: Pats. do better when autonomy, efficacy restored. 1. Informed about condition: Diagnoses, discomfort 2. Roommate who can help interpret treatment, foresee outcomes. 3. Given responsibility, meaningful tasks.

  11. Animal Assisted Therapy Animal Assisted Therapy (AAT): Specially trained animals plus handlers visit hospitalized patients. Dog lies on patient's bed, is petted. Cute, but does it work? Experiment by Kathie Cole, RN, UCLA Medical Center 77 heart-failure patients (ave. age = 57) receive 12 minute visit from either: a. Dog b. Human volunteer c. No visit

  12. Results of AAT Study: The Paws that Refreshes Anxiety: Dog: Human: Down 24 pts Down 10 pts Epinephrine Dog: Human: Control: Down 17% Down 02% Up 07% Blood pressure Dog: Human: Control: Down 10% Up 03% Up 05% Why are dogs better than humans?

  13. Elephant-Assisted Therapy: South Africa Dolphin-Assisted Therapy: Israel, Florida, Ukraine

  14. Therapeutic Riding and Cerebral Palsy Veronic Skoczek and MacGuyver: Skoczek suffers from cerebral palsy, affects walking and other motion. After years of therapeutic riding walks unassisted. Rhythm of horse s gait mimics pelvic movement during walking. Improves alignment, muscle symmetry, postural control https://www.nsarco.com Emotional Support Animal Registry https://www.esaregistration.org/ther apy-dog-and-animal-info/

  15. Children in Hospitals Hospitals are frightening to children. a. Place associated with pain b. Sad/Scary looking patients d. Parents are not in control Emotional reactions a. Fear, anxiety b. Anger, rebellion c. Shame (esp. at adolescence) Being left overnight in hospital esp. upsetting. a. "Setting" anxiety b. Age 3-6: fear rejection c. Age 4-6 develop new fears (e.g., darkness) d. Age 6-10 free-floating anxiety e. Separation anxiety: deserted? punished?

  16. Social-Psychological Tx for Hospitalized Children Social Support Psychological Control a. Kid in Hospital movie --> less anxiety b. In gen., informed kids show less anxiety c. Encourage kids to ask questions d. Provide kids with coping skills a. Parental visits study (Branstetter, 1969) Cond 1. Mom at visiting hours only Cond 2. Mom for extended periods Cond 3. Surrogate mom b. Kids in Cond 2 & 3 do better than Cond 1 c. Hospitals now let parents stay with kid all times d. Story telling * Self-talk * Relaxation skills

  17. Story Telling for Hospitalized Children Story telling an ancient part of human civilization. Our minds are soothed by stories. Provide meaning and order; a beginning, middle, end. Hospitals include storytelling to children-patients. Eases anxiety and fear. Provides a mental vacation . May reduce pain. https://storynet.org/groups/hsa/healing- story-alliance-hsa/

  18. Class 24 Patient / Provider Communication

  19. Why Providers Are Often Poor Communicators Situation: Time pressed, competing demands ( Jerusalem to Jericho ) Medical Training: Communication and compassion not emphasized Communication skills not modeled. MD training is itself inhumane. Self Selection Motives for becoming MD sometimes contrary to compassion/listening prestige, wealth, status, authority Some MD skills contrary to compassion/listening: Detachment Analytic / time-efficient / detail oriented Personality qualities needed to get into med school Competitive: Cerebral Technical

  20. MD Failure to Listen Beckman & Frankel (1984) study of MD initial response to patients MDs know they are being observed, 74 patient visits Patient given opportunity to explain problem: 23% MD interrupts, directs pat. to particular disorder: 69% MD interrupts pat. after _____________ of elapsed time. 18 seconds Consequences? 1. Patients don t get a chance to fully explain symptoms, concerns. 2. MD doesn t get all vital information

  21. MD Communication Problems 1. Failure to listen 2. Use of jargon: Hmm. Seems you have Ulag's Syndrome, which voraciously perturbs the ipsilateral medulla of the flataboig. Arnold of Villanova (1235-1311): [Tell the patient that] he has an obstruction of the liver, and particularly use the word obstruction because patients do not understand what it means.

  22. MD Communication Problems (contin.) 3. Baby talk: Is you got a boo-boo on your spleen? Might especially be a problem for older patients (e.g., Giles, 1991). 4. Depersonalization: MD sees pat. as condition, not a person Refer to pat. in third person, in front of pat. Need to get his name and address, and what s his primary symptom Functions: Manages pat., improves efficiency in emergency Effect on Pat: Can calm: Help dissociate from fearful situation Can alarm: I see this condition terminating in negative status

  23. Inappropriate Emotions MD looks frightened, distressed, frustrated. Holy Toledo, look at that spot on your X-ray!!!! Women who get mammogram, if MD appears worried, they: a. Remember less b. See situation as worse c. Higher pulse rates

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