Case scenario 1 Initial communication Role play script
Learning objectives

Initial Communication on admission
Aspects of effective communication will be highlighted in the script
– The wrong way and The right way.
The Wrong Way•Improper setting
•Did not introduce himself or ask relative to introduce himself
•Did not obtain background knowledge or history
•Medical jargon
•Not allowing relative to speak, not acknowledging emotion
•No empathy throughout
The Right Way•Gather all information about clinical status before communication
•Introduce yourself, create appropriate setting
•Put the relative/surrogate at ease with initial introduction. Assess
language ability
•Let the surrogate narrate history without interruption
•Direct the conversation if necessary
•Provide information in lay person language
•Acknowledge emotion, provide support
•Give enough time, listen and be empathic
•Sum up discussion, set a time for next meeting
Case Scenario• A 76 year old male with history of DM & HT is admitted to ICU with CAP with
ARDS with shock and AKI.
• He has been transferred from a peripheral hospital where he has been treated
for 4 days
• Initial assessment by Emergency medical officer in the emergency department
–Pulse 120/min, RR 36/min, Cold extremities, B.P 90/68, 02 Saturation 88% on
Venturi mask 60%
–Call to ICU for further management
• You as the ICU consultant complete your assessment
• Plan: ICU admission, Intubation, CVP line insertion, Arterial line, Fluids
Empirical higher antibiotics, Blood investigation, cultures, ABG etc. May need
dialysis.
ScriptThe wrong way
You ask for the relatives.
(You speak to them standing in the corridor)
Doctor: Are you the relative. Come here. Your patient has a pneumonia with
multi-organ failure. He is very serious and requires ventilation. He needs
inotropic support and may also need dialysis.
Relative: Doctor, I am not understanding anything. what do you mean patient is
serious, is he going to die? I am very scared. Already we have spent Rs. 50,000/in the other hospital.
Doctor: I have no time to explain in detail. Don’t you understand his heart and
lungs are failing. He has hypotension and severe hypoxia, he is also going to need
dialysis. Such patients are very serious. You have brought him so late. We have to
start the treatment immediately otherwise he is going to die. Cost also is going to
be very high.
Relative: Doctor, don’t think about cost. We will arrange for whatever money is
required. If necessary we will sell our land. But our patient must survive.
Doctor: Ok, ok. Arre Somnath (the emergency medical officer) get the patient
quickly to ICU. Make sure he pays deposit and signs high risk consent.
Narrator: Now let us see how to do this right.
The right way
(Introduction, proper setting, establishing personal contact)
Doctor: Are you the relative of this patient? Come, Come with me let us sit in our
office. My name is Dr. Anand, I am the ICU consultant and am going to look after
your patient.
Doctor: Can I get you some water? How are you related to Mr. X?
Relative: I am the patient’s son, Mr. Raju. Is he very serious? Is he going to die?
Doctor: Don’t worry Mr. Raju, we will try to do our best for your father. I hope
you are comfortable to speak in English. Or should I explain in Hindi.
Son: I understand English and can speak a little. Please explain slowly.
(First Principle Ask-Tell-Ask)
Ask
Doctor: Ok I will talk slowly. Just tell me how long has he been ill and when did
he get worse. What has been explained to you.
Son: We took him to the other hospital 2 days ago for cough and fever. He also
has DM, HT. He was kept in their ICU. He was started on antibiotics. The doctor
there told us he has pneumonia and kept saying he was getting better. Today
morning we were suddenly told that we need to shift him for ventilator
treatment.
Doctor: How long did he have cough and fever? How long has he had DM, HT. Has
he any heart problem, previous eye problem or kidney problem. Has he been
regular with meds, is the DM, HT well controlled?
Son: He was having high fever, cough for three days and was not eating well. The
night before admission he complained of breathlessness, so we took him to
hospital. He was regular with his tablets but his diet was not controlled. Sugars
were always 200 +. He has not had any check up for last one year. No other
problem as far as I know. Doctor have they not treated properly at the other
hospital?
Doctor: As far as I can see they have started all the treatment initially. What
about your mother, is she also here?
Son: No she is at the village, where she stays with my father. I stay here in the
city.
Doctor: You need to call her just for us to get some more details. She also needs
to know about his condition.
Son: Why, why doctor is he very serious, is he going to die? My mother won’t be
able to take it? I am very scared.
Doctor: I see that you are very concerned about your mother but she also needs
to be told and prepared. (Reflective statement Principle 3)
(Tell)
Doctor: (places hand on patients shoulder)I can understand your concern.
(Acknowledging emotion Principle 4) I have reviewed the reports and x-rays
from the other hospital. He has an infection of the lungs. You understand
pneumonia, that is why he has cough and sputum. The breathlessness has
increased because the pneumonia has involved both lungs with swelling of the
lungs. He is not getting enough oxygen. Also because the infection has spread
through blood the heart has become weak, BP is on the lower side. Also urine
formation is also less because of the low BP and the infection. He is going to need
to be in ICU. He will require support for breathing with ventilator and medicines
to maintain BP. If his urine remains less we may require support for that as well.
If necessary we will call in the nephrologist and other specialists.
All this is going to take time and he will need to stay in ICU for at least 7-8 days.
There are costs involved as well. Where do you work?
Son: I work in the municipal corporation. Doctor is he going to die? I am very
worried. And doctor, don’t worry about costs. I will arrange whatever is
required. You please start treatment.
(Ask)
Doctor: ( holds patient’s hand). His condition is serious. We have already started
his treatment and are making arrangements to shift him to ICU for further
treatment. When patients of this kind require breathing support and BP support
they are very serious and there is risk to life but we will do our best. Also we
have all the necessary facilities and specialists. I will ask our nurse to guide you
to our admission desk so that you can complete the paper work. In the
meanwhile I request you to sign the consent for the breathing support and ICU
treatment that we need to start. You must understand that for providing this
support we need to insert a tube through the mouth into the wind pipe so we can
provide oxygen properly. With the tube in place he may not be able to speak
temporarily and will also be on medicines that will put him to sleep and keep
him comfortable on the ventilator. However as he recovers we may expect
everything to come back to normal. You must understand the first 48-72 hours
there is a substantial risk to his life. Do you want to know anything more?
Son: Doctor I am very scared. I don’t know what to do. I can’t understand what
you are saying. Please help me.
“Tell me more” principle
Doctor: (holds hand again, pauses for a few seconds) I can see you are very
worried (acknowledging the feeling). What does this mean for you? Are you the
eldest in the family? (trying to gauge what it means for him)We are here to help
you. Can you get other senior members of your family for support. Maybe I can
talk to your family doctor or if there is some medical person in the family, we can
call that person. I will explain things once more when he is shifted to ICU.
Son: I have already spent 50,000 in that other hospital. I don’t know how I am
going to manage.
Doctor: Don’t worry we will do our best. Find out from the corporation what
kind of financial help you can get. I will also get our social worker involved. Who
else has come along with you? I can see that you are going to need support.
Dr. Somnath, please make arrangements to shift Mr. X safely to ICU. Please
provide whatever assistance his son needs. Call me if anything is required.
Mr. Raju we have already started treatment, I will speak to you once more as
soon as we have shifted to ICU and started all the treatment. Please try and get
your mother and other senior family members to meet me.