Patient Centred Care Case Study

Original Editor - Ewa Jaraczewska based on the course by Marissa Fourie

Top Contributors - Ewa Jaraczewska, Jess Bell and Kim Jackson

Introduction

Patient-centred care is an important dimension of high-quality healthcare delivery that focuses on the partnership between patients and healthcare professionals. Patient-centred care is achieved when clinicians actively engage patients in healthcare discussions and decision-making, creating care plans that align with patients' values, needs, and preferences. The concept of person-centred care has emerged from patient-centred care. Patient-centred care focuses on people achieving functional outcomes while person-centred care focuses on a person achieving a meaningful life.

If you would like to learn more about patient-centred care, please see: Patient Centred Approach to Care.

Abstract

This fictional case study analyses the role of patient assessment and medical care through the lens of patient-centred and person-centred care.

Client Characteristics

The patient is a 65-year-old woman living in a rural village in sub-Saharan Africa. She was admitted to hospital via the emergency room, with a painful right forefoot, fever, chills, and tachycardia. The patient had stubbed her toe two months ago, but it did not heal as expected.

The patient has a history of bladder prolapse, occasional urge incontinence, painful varicose veins and recent onset of eyesight regression. She was diagnosed with high blood sugar at her local primary healthcare clinic one year ago and prescribed medication. The patient's mother also had diabetes and had to have her right leg amputated some years ago. After her diagnosis, the patient visited a traditional healer who linked the patient's condition to a generational curse. The healer performed a ritual and claimed the curse was lifted, so the patient discontinued the clinic-dispensed medication.

Examination Findings

Upon examination, the patient's right foot appeared red (erythema) and swollen (oedema) and was warmer (increased temperature) than the other foot. She also had a necrotising ulcer on her right big toe. She had been unable to weight bear on her foot for one week and had a fever, chills and general malaise for the 48 hours prior to admission. She also had superficial incisions on her right calf - the patient had visited a traditional healer three weeks prior to admission and these were part of the treatment she received. These incisions were not healing well and were quite painful. The patient's blood glucose level was also elevated, at 26 mmol/L.

Clinical Hypothesis

The patient presented with a necrotising right foot ulcer, poorly controlled diabetes with significant hyperglycaemia, risk of sepsis and progressive tissue necrosis, additional wounds from traditional treatment and a limited understanding of diabetes management.

Patient-Centred Care Intervention

This section focuses on the interaction between the admitting doctor and the patient to highlight the role of patient- and person-centred care in treatment.

Doctor-Patient Interaction

The patient was assessed by a doctor who was doing an elective internship in the patient's country.

The doctor introduced himself and explained that he would take a history and complete a medical examination. He asked if the patient wanted a family member to be present. She agreed that she would like her son to be present, noting he could help if she struggled speaking English.

While waiting for the son, the doctor consulted with a nurse from the patient's ethnic group about cultural factors that might affect her care. He gained important information on the importance of traditional medicine, deference to authority figures and those with tertiary education, and the important role of the grandmother in childcare.

Once the son was present, the doctor started to take the patient's history. During their interaction, he learned that the patient stubbed her toe two months ago. Initially, she just had a minor bruise and was able to resume normal activities. However, her toe wound worsened, and pain and swelling started to spread. She visited a traditional healer three weeks before her admission, who made the superficial incisions in her calf.

The doctor became aware that he was feeling annoyed about the traditional healer's intervention, which he considered unethical and exploitative. However, he remained respectful of the role of traditional medicine in the patient's culture.

The doctor continued his interview and found out that the patient is usually an active, busy mother and grandmother. She helps to look after six grandchildren and she values her role as a caregiver. She enjoys cooking for her family and described herself as a generally happy and healthy individual.

When the patient discussed the importance of her role as a grandmother, she became tearful. The doctor gave the patient and her son privacy for a moment to allow them to negotiate these emotions. On his return, the doctor assured the patient that she could share any concerns. Her son explained the patient feared being a failure to her family and community, and that she would lose her limb like her mother had.

The doctor expressed empathy for the patient's fear and uncertain situation and assured her of the medical team's commitment to her recovery. He offered a medical explanation of the patient's situation. He acknowledged the healer's suggestion that the patient's illness was passed on from the previous generation was probably valid. However, it may not be a curse, but an inherited condition. He also provided education on how our body may change the way it breaks down food as we age, increasing the sugar in our blood. He highlighted that her blood test confirmed she still had high levels of sugar in her blood, so the healer's treatment might not have entirely cured the disease.

The doctor also highlighted that the patient's active lifestyle was very helpful, but that diet management and medication use were important to manage symptoms.

While the patient said she would follow this advice, the doctor felt she was still apprehensive. However, he realised she may not have felt able to ask questions or challenge his view. After another conversation between mother and son, the son explained that his mother was scared she would eventually lose her leg, like her mother.

The doctor acknowledged the patient's fears and reiterated that the medical team would do their best to prevent that from happening. He also noted that a skilled surgeon would be involved in her care. Acknowledging the uncertainty of outcomes, the doctor proposed a stepwise approach to treatment with progressive, smaller goals.

Outcome

The doctor's initial treatment goal was to improve the patient's systemic symptoms, which would also reduce her emotional distress. The first step of treatment would focus on managing inflammation, infection, and acute wound care. At this stage, the patient would focus on resting and following mobility and wound management instructions. The patient acknowledged this would be challenging for her, but stated that she was willing to do her best to achieve the best outcome. Both parties acknowledged the uncertainty of the outcome but agreed on these immediate actions. Rapport had been established between the doctor, patient, and her family, and this had paved the way for further patient-centred care.

Discussion

The following discussion uses this case study to describe doctor-patient interactions in patient-centred care. It provides a brief description of important aspects of patient-centred care and explains how the doctor applied them during his interaction with the patient.

Cultural Competence

Cultural competence is the ability to understand, appreciate, and interact with people from cultures or belief systems different from one's own.

The doctor demonstrated cultural competence by consulting with nursing staff from the same ethnicity as the patient. Through this consultation, he was able to gain valuable information on cultural health beliefs, traditional healing, attitudes toward authority figures, and family dynamics. He realised that he felt annoyed about the traditional healer's interventions, but he suppressed criticism. He even validated the patient's traditional beliefs by acknowledging the healer "had a valid point" about intergenerational illness. This helped to enhance the doctor-patient therapeutic relationship.

Understanding the Whole Person

Whole-person care "describes care that is patient-centred and takes into consideration the optimal physical, behavioural, emotional and social wellness and outcomes of every individual."

The doctor demonstrated whole-person care by exploring the patient's life beyond her medical condition. He explored her role as a caregiver to six grandchildren and her enjoyment of cooking and household activities. He also sought to understand her as a person and her personal values.

Exploring the Patient's Experience of Health, Disease, and Illness

Exploring the patient's experience of health, disease, and illness means clinicians look beyond presenting symptoms to understand how illness affects a person's life and circumstances.

The doctor sought to understand the patient's concept of health, disease and illness by listening to her narrative about how her injury occurred, the progression of her symptoms, her medical history, her diabetes diagnosis, her decision to discontinue medication, and her experience with traditional healing.

Enhancing the Patient-Clinician Relationship

"Patient-centred care requires health care professionals to have the ability to form therapeutic interpersonal relationships that elicit patients' true wishes and recognise and respond to their needs and emotional concerns."

The doctor worked to create a strong patient-clinician relationship by properly introducing himself, asking the patient about her communication preferences and accommodating her son's presence. He also recognised potential language barriers and included her son in discussions to uncover unspoken concerns. He created a space for the patient to express her emotions, ask questions and raise any concerns.

Empathy and Compassion

Empathy is the ability to understand the patient’s situation, perspectives, and feelings; communicate that understanding and check its accuracy; and, then act on that understanding with the patient.

The doctor demonstrated empathy in a number of ways. He recognised the patient's emotional distress when she felt her role as a grandmother could be impacted by her health condition. He also acknowledged her fear of an uncertain outcome and potential amputation stating, "I can imagine how scared and uncertain you must feel".

Finding Common Ground

Finding common ground with a patient helps prevent a potential misalignment between patient and practitioner expectations.

The doctor engaged in a process of mutual understanding and agreement by bridging traditional and medical explanations. He was able to reframe the concept of a "generational curse" as a genetic predisposition. He acknowledged the value of the patient’s active lifestyle while suggesting clinical interventions and established a stepwise approach to treatment with smaller, short-term goals. Through this approach, the doctor and patient were able to agree on the immediate focus of treatment.

Shared Decision-Making

Shared decision making is a collaborative process where patients and healthcare professionals make decisions about the patient’s health together after discussing available options.

The doctor involved the patient in making healthcare decisions by asking if she wanted to hear medical explanations and action plans. He also discussed her role in recovery (initial rest and following wound care and medication advice). Both the doctor and patient acknowledged the challenges she might face following this advice, but both agreed on the immediate treatment goals.

The doctor helped develop a partnership with the patient to collaborate on decisions by including her family in the care process. He also clarified his responsibilities and the patient's role. Together, they set goals that focused on recovery and a return to meaningful roles. The doctor continuously recognised the patient's active role in her recovery.

Communication

Communication in healthcare is defined as the exchange of information between a patient and a clinician, and this will include the family or caregivers where applicable.

The doctor navigated difficult topics with the patient by addressing her fears about amputation without making false promises. He was careful to discuss the patient's previous decision to stop taking medication without judgement.

He also made sure that he managed his emotional response to the traditional healer's intervention and was able to work with the patient's son to help navigate sensitive discussions. Please note that sometimes it may not be appropriate to use family as translators. If you are interested, you can find out more about using interpreters here.

The doctor provided education by explaining diabetes in accessible terms (e.g. "breaking down of food becomes faulty"). He connected the patient's symptoms to pathophysiology ("too much sugar in the blood") and explained how seeing a dietitian could help. He also reinforced the importance of adhering to prescribed medication.

Summary

This case study demonstrates how a doctor can enhance outcomes by adopting a patient-centred approach. The doctor in this case study took the time to understand the patient as a complete person before forming his treatment plan. In doing so, he was able to create a personalised care plan with the patient that addressed her needs and concerns.