Remembering the personBMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k2512 (Published 18 July 2018) Cite this as: BMJ 2018;362:k2512
All rapid responses
There is at times a great deal of overlap in how we as physicians interact with patients on the extreme ends of the age spectrum. Both cohorts may lack capacity to consent, may not be able to understand our questions or be able to communicate an appropriate response. Yet, that does not (and certainly should not) stop us from including them in the process.
As an example of the author’s routine practice of choice, paediatric history taking should begin from the child, even if their parents are present. Depending on the individual child’s age, it may not be possible to obtain information from them. However, this is a key opportunity to build rapport with that child. This also helps gauge several aspects of care e.g. interaction with parents, level of understanding and mental age versus chronological age, likely compliance with any suggested treatment. Furthermore, this allows additional opportunity for one to determine whether if the child is ‘sick’ or not.
Following this, the author will then seek additional information from the parents. It is to the author’s belief that this is a model that should be adopted as standard when interacting with patients with cognitive decline and their carers whenever possible.
In reference to ‘giving information clearly and in detail can be done even better when combined with sympathy’ the Calgary Cambridge model as well as providing a clear and structured approach to consultations takes into account the ICE section namely the ‘ideas’ ‘concerns’ and ‘expectations’. Those concerns and expectations of the carers are at least as important in patients with cognitive decline. I prefer to include ICE once the presenting complaint and history of presenting complaint are established as this sets out creating a good rapport and asking further questions will not sound too intrusive.
Cognitive decline usually starts at the higher executive function and gradually works its way to the most basic needs and functions of the human body. It is important to note that expression and reception of emotion is deeply engrained in humans and is probably one of the last functions that the brain will lose. Showing affection, verbal and physical inclusion and communication may in fact be one of the only methods of communication left with those suffering from significant cognitive decline irrespective of life expectancy.
On a final note quis custodiet ipsos custodes? Literally translated from latin meaning who will guard the guardians. In reference to the above appropriate interaction , education and inclusion of the carers is at the core of providing holistic care for the patient.
Competing interests: No competing interests