by Charly Miller, EMT-P

This page was originally published in’s June, 1999 issue.

Emergencies cause people to experience the devastating sensation that they've "lost control" over their "world." As long as a patient perceives a loss of control she/he'll suffer increased stress, anxiety, and pain – as well as decreased ability to cooperate with, or positively respond to, the treatment we provide.

To arrest and repair such negative effects, we must speak and act in specific ways that help restore a patient's sense of control. In addition to practicing the "simple" methods of restoring a patient's sense of control (as discussed in Parts 5 and 6) we should:

Remember the "THREE DIVINE SECRETS" to restoring a patient's sense of control with choices or by asking permission (initially discussed in Part 8):

  1. Only give a patient a Choice when you Don't Care what she/he might answer!
  2. Never ask Permission to do something that Must be done.
  3. When Choice or Permission is not an option:
    a) Positively Explain What Will Happen, then
    b) Find Something You Don't Care About to Offer as a Choice.

When practicing these control-restoration methods, you'll quickly discover that:

Offering Choices and Asking Permission can actually assist in diagnosis and care decisions!

When a patient doesn't require spinal immobilization, offering a choice of transportation position is a marvelous opportunity to help restore the patient's sense of "control."

Do I care whether the patient chooses to sit up or lie flat? Nope - not as long as the patient's blood pressure is over 100 systolic. If it's below that, however, I do care. (See Part 8.)

But, what about a medical patient who is seriously Short of Breath?

Do I CARE whether the Short of Breath patient chooses to sit up or lie flat?
Nope – not as long as the patient's blood pressure is over 100 systolic.

Wait a minute! What?!

Of course, we all prefer Short Of Breath (SOB) patients to sit up nice and tall! We know that such a position should help them breath better. Unfortunately, knowing that, we often put them in an upright position without even discussing it with them.

Additionally, we frequently wrestle with the difficult decision of whether or not to intubate the SOB patient.

Especially when an SOB patient is elderly, endotracheal or nasotracheal intubation can increase their length of hospital stay and increase their potential for developing nosocomial infections. ("Nosocomial infections" are infections acquired in the hospital!" If you weren't in the hospital, you wouldn't get them.)

Intubated patients can develop ventilator-dependency, making it difficult to "wean" them off of a ventilator. Having an access route leading directly into the wet, warm, dark recesses of a patient's lungs, increases the likelihood that germs present in the hospital (from other patients) will seriously infect the patient. Both of these things are serious concerns to the SOB patient intubation decision.

Wouldn't it be nice if our SOB patients told us whether or not they needed to be intubated?

Guess what? If you give Short Of Breath patients the option of lying flat – give them a choice – not only will you increase their sense of control, decrease their anxiety and pain, you'll also allow them to tell you how aggressively they need to be treated.

Bingo. We've given the patient a choice and then complied with the patient's wishes. By doing so, we've significantly restored the patient's sense of control – improving their condition. We even interjected a positive-response suggestion for the transportation position they chose (making it more effective than it would be had we not discussed it).

But, perhaps even more importantly, our patient's choice to sit up provided us with valuable information about her/his condition, and what kind of treatment is required.

By choosing to sit up, the patient showed us that she/he still has the energy and desire to fight to breathe! Does this patient need to be endotracheally or nasotracheally intubated? Probably not. Likely, upright positioning, lots of supplemental oxygen, a breathing treatment, and plenty of positive-treatment-response suggestions will vastly improve this patient's condition.

But, what if the patient answered differently?

This patient chose to lie down, indicating that she/he is too fatigued to continue fighting to breathe. This patient is only moments away from respiratory failure or arrest, and needs aggressive airway management, positive pressure ventilation with 100% oxygen, and in-line-nebulized albuterol.

This patient has told you that she/he needs to be intubated.

If you didn't offer this transportation position choice, you might not appreciate the patient's state of extreme fatigue. If you simply kept the patient sitting up, you might have wrestled with the "intubation decision" and made the wrong plan.

Instead, you offered a choice, and the patient made it. You complied with the patient's choice, increasing the patient's sense of control, increasing the patient's ability to cooperate with intubation, and significantly improving the likelihood that the patient will positively respond to treatment.

Best of all, you were able to rapidly identify the need for aggressive treatment, with a minimum of worry about having made a wrong decision.

Offering Choices and Asking Permission not only improves patient condition by restoring a patient's sense of control over her/his world, offering choices and asking permission can assist you to make better, more-comfortably-arrived at, diagnoses and care decisions.

In the next Foundation of Patient Communication installment, we'll discuss avoiding arguments while offering choices and asking permission!

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"Feedback About The Foundation of Patient Communication – Part 9"

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