Lupine Publishers | Collateral Histories taken from Patients’ Relatives: Processes, Requirements and Evidence of Discrimination
Lupine Publishers | Journal of Clinical and Community Medicine
Abstract
Aim: The purpose of
this study was to identify whether appropriate consent was obtained for taking
collateral histories and whether there was evidence of differences between two
ethnic groups.
Method: Case records of
in-patients were reviewed. A sampling framework was established for the
identification of 20 in-patients aged over 65 years. Five English and Asian
men, as well as 5 English and Asian women were selected from 4 medical wards.
Results: The average age of
men and women and of English and South Asian patients was comparable at about
80 years. The lowest standards were achieved in scoring cognition and
identification of the source of any collateral history. For South Asian
patients the preferred language of the patient was only noted on three
occasions When score rates were compared the average standard score for English
patients was 4.1out of 6 compared to 2.8 for South Asians.
Conclusion: We
need to provide staff with detailed guidance at induction and during junior
training sessions as to when and how collateral histories should be taken and
the legal requirement to document such details.
Introduction
The need to obtain a
collateral history places an additional burden on busy clinical staff and is
even the subject of Twitter discussions. Sommer [1] Questions as to patient
confidentiality can raise additional difficulties. When the patient does not
feel at home in English it is easier to accept a simple Yes or No to a series
of questions and to believe the responses are correct, than to seek out a translator
who will appreciate the subtleties of patient confidentiality. Such
communication problems make any formal assessment of cognition difficult and
why should someone who grew up outside of Europe know the exact dates of World
War II when the partition of India and Pakistan is of considerably more
personal relevance?
Against this background
we should question whether collateral histories are of value. Research has
shown that they can:
Nevertheless, the
patient’s consent to obtaining such information should be sought and documented
in the notes. Beedle [2] Such discussions with caregivers are also likely to
identify stress to which they are subject and may have a direct impact on the
clinician’s ability to discharge a patient.
Method
In addition, details
were collected on who took the collateral history and where the preferred
language was not English was a translator used and if so, who was that
translator.
A sampling framework was
established for the identification of 20 in-patients aged over 65 years. The
selection of cases was for 5 English and 5 Asian men, as well as 5 English and
5 Asian women. Medical wards were visited in turn and pro-forma completed. As
soon as a quota was reached no further notes were reviewed in that category.
The day of review was midweek and 4 medical wards were visited in succession.
In each ward appropriate patients were identified in sequence and pro-formas
completed.
Subsequent to the audit
an educational program was delivered to doctors working on these medical wards
with the intention of improving the methods of obtaining collateral information
and its quality. The educational program consisted of unit meetings and
lectures. Six weeks after the initial assessment and educational program a
repeat audit was initiated on the same medical wards using the same methods of
data collection.
Results
Eight men were
identified on Ward A, 4 women on Ward B, 0 patients on Ward C, 2 men and 6
women on Ward D. The average age of men and women and of English and South
Asian patients was comparable at about 80 years. Eight of the English patients
and 8 of the South Asian patients were over 75 years old.
The lowest standards
were achieved in scoring cognition and the identification of the source of any
collateral history. (Tables 1 & 2) Both of these failures call into
question the validity of both patients provided histories and any collateral
history that was obtained. This is especially true for South Asian patients
where the preferred language of the patient was only noted on three occasions
and a translator only made available in two cases. (Table 1) The inadequacy of
such assessments in most cases was emphasized by comments made by nurses who
often stated that patients for whom these details were not recorded had a
limited knowledge of English or none at all.
Table 1: A Spot Audit of Collateral Histories taken on the Medical Wards at Leicester Royal Infirmary.
Table 2: Recording of individual standards achieved during audit of collateral history: * It was assumed that for all English patients English would have been the preferred language.
Table 3: A Spot Re-audit of Collateral Histories taken on Medical Wards at Leicester Royal Infirmary.
Table 4: Recording of individual standards achieved during re-audit of collateral history.
Discussion
The standard of
collateral histories needs to be improved. The main changes that should be
incorporated into future clinical histories should include:
In order to achieve
these outcomes, we need to provide staff with detailed formal guidance at
induction and during junior training sessions. Simple educational programs and
talks at unit meetings are not effective. There is a need to introduce
mandatory e-based training programs with formal assessments. There may also be
a place to encourage junior doctors to use formal pictograms which would cover
items such as the nature of housing, mobility and the provision of food
together with the role of careers. Pictograms have been popularized through use
on the worldwide web and in software. Better known as “icons” they are
displayed on a computer screen in order to help the user navigate a computer
system or mobile device. Otto Neurath, Austrian philosopher of science, was one
of the influential minds behind graphic representation of data. A strong
believer in visual education, he held the view that by using simplified symbols
(pictograms or icons), viewers could, at a glance, understand complex
information regardless of their education.
Their introduction into
the clinical record could have significant benefits for conveying vital
information about housing, mobility and dependence. The introduction of a
limited number of specific pictograms covering these aspects of social history
could ensure uniformity through a shared understanding by clinicians of what
each sign means.
The second issue which
emerged clearly from these studies was the inadequacy with which elderly
patients from ethnic minorities were assessed. Leicestershire has a large South
Asian population, mainly of Gujarati and Punjabi origin. Most families came to
the area in the 1970s. However, amongst the older population there are a
substantial number of people whose language of choice is still Gujarati, Punjabi
or Urdu. Despite a long-standing commitment to improved patient communication
in these communities [3,4] the current situation is inadequate. The belief of
the Care Quality Commission during its in-depth inspection of University
Hospitals of Leicester NHS Trust in 2014 [5] that cultural diversity and social
deprivation of the community is well served appears to be illfounded. Its
report states:
“We spoke with staff
about how they communicated with people whose first language was not English.
They told us they had access to a telephone interpreter service (Language Line)
and that many staff were bilingual or multilingual and could be used to
interpret. We did not see evidence that communication was an issue at this
trust.”
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