Time and patience

Table 1.4.1 Selected elements of metacommunication

What

How

Intonation

Should be congruent with content

Body language (kinesis)

Facial expression

Attentive, not "empty"

Serious but not "dramatic"

Encouraging

Head position (turn toward patient, not away)

Phatic signaling1

Hand gestures (modest but present)

Eyes

Look into patients' (not into distance)

Distance

Close enough without breaching privacy2

Physical contact

Holding/touching hand/arm/shoulder, done appropriately, conveys understanding, support3

As a general rule, there should be no contradiction

1 Empathically nodding: feedback signaling that the ophthalmologist remains connected to the patient.

2 Societal issues must also be taken into consideration: in certain societies a much larger physical distance ("personal space") is required than in others.

3 Societal issues must also be taken into consideration: certain religions discourage physical touch while other religions are neutral. Unwritten nonreligious rules also exist in this regard.

O Pearl

The "target" in the counseling process is never the eye: it is the patient, who must at the end have a reasonably good understanding of the eye's condition so that he can make an informed decision regarding treatment.

The initial counseling step is evaluation (see Chap. 1.9) of the patient and the eye to allow the ophthalmologist to have a decent understanding of the globe's condition. The actual counseling consists of:

• Providing information about the eye's condition

• Explaining to the patient and, preferably, to the family, the treatment options and the benefits and risks of each option (Fig. 1.4.2)5

• Answering the questions of the patient

• Arriving at a mutually acceptable decision regarding the choice of treatment

The ophthalmologist's presentation must be in a language and format that the patient can understand. This is especially difficult because the patient is under tremendous anxiety: worried about the long-term impact of the eye injury on his vision, on his own quality of life as well as on that of his family, on his future income, etc.

The ophthalmologist should not be "coaching" and should not force on the patient his own, preselected, preferred option6 (Fig. 1.4.3). The possibility of sympathetic ophthalmia must always be discussed (see Chap. 1.8).

Once the patient makes his choice, actual treatment follows. Counseling, however, does not end there: it should be continuous up to the last follow-up visit. Ideally, counseling is done in the presence of a witness (e.g., nurse) and a family member. A written record should always be taken, and taken simultaneously.

5 This should include details such as postoperative posturing.

6 Reasonable alternatives are almost always available.

Fig. 1.4.2 Counseling in real life. The patient (right) and her daughter listen to the ophthalmologist as he uses illustrations to explain the therapeutic options available for the patient's injured right eye.
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