Why is it Important? 

Communication is massive part of day to day life in the work place. It's both verbal and non verbal, and is key for transferring information about patient care;

• Between medical teams - for advice, escalation or handover 

• Between the MDT - again for advice, escalation, ongoing care planning and handover 

• Between the MDT and patients - for reviews, updates regarding care and can include difficult conversations 

How we communicate with patients also plays a really important part in their healthcare journey. It's a very vulnerable experience on the other side of healthcare, and this can be upsetting and / or stressful. Poor communication is also a huge contributer to complaints within the service. 

Civility: 

Civility plays a huge part in how we communicate. Incivilty within the work place can reduce an individuals ability to do their job to the best of their ability and can reduce performance of the individual involved by 80% and bystanders by 20%. It reduces the likeliood of concerns being raised appropriately, and so you will probably come across this in human factors training and various camplaigns targeting communication in the work place. 

Team work: 

Again huge part of our day to day work and good communication between members of the team allows for optimal patient care to be delivered. Utilise closed loop communication styles, and always be polite and clear in your communication. Default to SBAR as a structure as it really is useful and try to communicate in a clear and consise manner. 

If you're even unclear about information, it's ok to ask follow up questions or to clarify. 

Handover: 

Handover is a vital part of patient care and allows for patient details, medical background, current issues and management plans to be discussed. This can be when seeking advice for a patient, requesting a review or related to transfer of care between teams. 

Utilise an SBAR approach (covered previously) to make sure you cover the key aspects.

• Introduce yourself and your role. 

• Explain the situation 

• Highlight relevant medical background and history. 

• Summarise your assessement of the patient and flag key finding - eg 'The ECG shows ST depression in the lateral leads' or 'the patient is febrile at 39' 

• Summarise any actions taken and clearly state why you are calling - is it for a review, advice or something else. 

Try to keep handover's concise. A clear handover makes it easier for seniors to address your concerns. 

It can be helpful to have a patients notes, observations and recent investigations open in front of you so that you can answer any follow up questions the person you've called may have. You might not know the answer and that's ok, let them know and ask if they would like you to find out.

Top Tips before you call​

• What is the main problem?​

• What evidence is there for this? ​

• What is relevant?​

• What do you want to happen?​

• Timeframe?​

• Get the patient notes and investigation results out in front of you ready ​

• Has someone thought about treatment escalation plans/DNACPR – if so, what is their ceiling of care ​

DNAR and Treatment Escalation: 

As an F1 it is not your responsibilty to make these decisions and if you are asked by the MDT regarding issues like this, I would suggest discussing with your senior. 

However, I would recommend that you sit in on discussions around DNAR and treatment escalation both within the team and with the patient as everyone will take a different approach and it's good to see different strategies so one day you can build your own. 

Although you aren't expected to make these decsions it, you may be clerking a patient and be exploring if they have any pre-existing wishes. Some patients who are frequently in hospital may openly declare that they have an advanced care plan, or that they have DNAR paperwork. Others may already have DNAR paperwork in place from previous admsisions so it's always useful to look on the system at previous dishcarge paperwork to see. 

Regarding DNACPR(1) 

• It is a clinical decsion made by the treating medical team but should be discussed with patients or their relatives 

• Forms should be countersigned by a consultant within 24 hours

• Is there an optimal time to discuss?

  • The answer is probably yes. 

  • Aim is to try and discuss / decide at the time of admission but may not be feesible and the team may need to gradually introduce the topic in some instances 

• From your perspetive do try to sit in on these conversations 

  • Important that you are clear with what you mean. DNACPR is commonly misunderstood by patients and their relatives to assume we are giving up. Explain clearly that it doesn't prevent any other active treatment. 

• Sometimes repeat conversations are necessary. If a patient is getting upset and the decision is not immediate, these delicate conversations may take time and sometimes are best revisited later on. 

• You may be responsible for documenting these discussions within the notes so clearly document;

  •  Who has discussed the decision 

  • Who was present for the discussion - Medical / Nursing staff / Patients / Relatives 

  • The reasons for the discussion 

  • The patients point of view 

  • The outcome of the discussion 

Challenging Conversations 

Lots of the communication we undertake can be challenging. You may know early that a conversation is likely to be challenging or it may become challenging at any point. 

This may include discussions regarding;

• poor prognosis 

• Cancellation of procedures 

• Test results 

• Mistakes / errors / harm 

• complaints 

When adressing these convesations the key thing is to start with open questions. Allow the patient to voice their concerns to begin with so you can tailor the conversation to address this. Try to explain the situation or rationale where possible. For example with an on the day cancellation in theatre it's ok to explain that they have to be cancelled due to theatre acuity, but make sure you also apologise and acknowledge the frustration / disappointment this is going to have caused. 

Take the time to listen to concerns and explain ongoing actions but be careful not to make any promises as this can often worsen frustration if they are expecting one thing and another thing happens instead. 

When it comes to incidents involving errors / harm or potential harm we do have a duty of candour. Treat any issues first and then explain openly and honestly to patients what has happened. Apologise and explain incidents are treated seriously with well established pathways to assess how errors occured and outcomes include ways of preventing similar mistakes in the future. 

Always remember to reassure the patient we are taking these things seriously, and that we will monitor them to ensure there has been no negative impact medically to their health. However we need to be aware this can be an upsetting situation for the patient with an acute increase in stress levels, so always take the time to listen and reassure. Signpost them to the Nurse in charge / your senior to discuss further as well as PALS. 

De-escalation in challenging conversations

My advice with challenging conversations is to go with another staff member to start with. If a conversation is becoming fraught it's important to try and descalate, and there are a number of strategies you can use for this. (2)

• Acknowledge the patient or relative  and their concerns - NB Rember to Think – confidentiality – is this patient happy for you to talk to their relatives?

• Consider if Face-to-face better if phone call communication is difficult as it can be hard to read reactions / tone over the phone

• Listen to concerns, enable them to feel heard   

• Explain events and plan if able, offer opportunities for questions 

• Build rapport  and ease into conversation 

• Use of pauses, silences 

• Body language - keep it open 

• Give the time and listen . See if another Doctor can hold your bleep so you aren't disturbed. 

• It is easy to get caught up in the emotion of a situation, but try to stay calm 

• Listen – show this, paraphrasing 

• Space – pauses, physical space 

• Lower voice, measured speech 

• Avoid interruptions 

• Empathy and acknowledgment 

Try to keep the conversation moving towards solutions and be factual – challenge incorrect information if it presented to you as misunderstandings can cause worsenig issues. 

Remember though; 

If you feel unsafe or things are going in circles, leave - at this point it's likely better a senior speaks with them 

Don’t feel pressured into having to put up with verbal abuse 

Disclaimer:

This is a not for profit education resource designed for new resident doctors. All information serves as a guide to help doctors approach day to day life as an F1. It is not intended as a guide to patient care and should never be used as such or in place of advice of treating clinicians or published clinical guidelines. All cases are fictional and any resemblance is purely coincidental. Additionally all images are AI generated unless otherwise stated. 

References: 

1. Guidance: DNACPR and CPR decisions. (n.d.). Resus Council. https://www.resus.org.uk/additional-guidance/guidance-dnacpr-and-cpr-decisions

2. Dapaah-Afriyie, K. (2025). Navigating Difficult conversations in the Inpatient setting: A framework for Hospitalists. In Journal of Brown Hospital Medicine (Vol. 4, Issue 3, p. 141104). https://doi.org/10.56305/001c.141104

3. Civility saves lives. (n.d.). Civility Saves Lives. https://www.civilitysaveslives.com (resource)