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The advisory techniques go beyond what is required by the individual success criteria and allow authors to better address the guidelines. Some advisory techniques address accessibility barriers that are not covered by the testable success criteria. Where common failures are known, these are also documented. All of these layers of guidance principles, guidelines, success criteria, and sufficient and advisory techniques work together to provide guidance on how to make content more accessible.
Authors are encouraged to view and apply all layers that they are able to, including the advisory techniques, in order to best address the needs of the widest possible range of users. Note that even content that conforms at the highest level AAA will not be accessible to individuals with all types, degrees, or combinations of disability, particularly in the cognitive language and learning areas.
Authors are encouraged to consider the full range of techniques, including the advisory techniques, as well as to seek relevant advice about current best practice to ensure that Web content is accessible, as far as possible, to this community.
Metadata may assist users in finding content most suitable for their needs. Other documents, called supporting documents, are based on the WCAG 2.
Techniques for WCAG 2. Additional resources covering topics such as the business case for Web accessibility, planning implementation to improve the accessibility of Web sites, and accessibility policies are listed in WAI Resources. Each of these is introduced briefly below and defined more fully in the glossary. It also includes the increasingly dynamic Web pages that are emerging on the Web, including "pages" that can present entire virtual interactive communities.
For example, the term "Web page" includes an immersive, interactive movie-like experience found at a single URI. For more information, see Understanding "Web Page". Programmatically Determined Several success criteria require that content or certain aspects of content can be " programmatically determined.
For more information, see Understanding Programmatically Determined. Accessibility Supported Using a technology in a way that is accessibility supported means that it works with assistive technologies AT and the accessibility features of operating systems, browsers, and other user agents. Technology features can only be relied upon to conform to WCAG 2. Technology features can be used in ways that are not accessibility supported do not work with assistive technologies, etc.
The definition of "accessibility supported" is provided in the Appendix A: It is not hard to imagine that these factors may operate when bad news must be given to cancer patients [ 4445 ].
The participants in our previously mentioned ASCO survey identified several additional stresses in giving bad news. From this information and other studies we may conclude that for many clinicians additional training in disclosing unfavorable information to the patient could be useful and increase their confidence in accomplishing this task. Moreover, techniques for disclosing information in a way that addresses the expectations and emotions of the patients also seem to be strongly desired, but rarely taught.
When physicians are uncomfortable in giving bad news they may avoid discussing distressing information, such as a poor prognosis, or convey unwarranted optimism to the patient [ 46 ].
A plan for determining the patient's values, wishes for participation in decision-making, and a strategy for addressing their distress when the bad news is disclosed can increase physician confidence in the task of disclosing unfavorable medical information [ 4748 ].
It may also encourage patients to participate in difficult treatment decisions, such as when there is a low probability that direct anticancer treatment will be efficacious. Finally, physicians who are comfortable in breaking bad news may be subject to less stress and burnout [ 49 ]. Previous Section Next Section A Six-Step Strategy for Breaking Bad News The authors of several recent papers have advised that interviews about breaking bad news should include a number of key communication techniques that facilitate the flow of information [ 31350 - 54 ].
We have incorporated these into a step-by-step technique, which additionally provides several strategies for addressing the patient's distress. Complex Clinical Tasks May Be Considered as a Series of Steps The process of disclosing unfavorable clinical information to cancer patients can be likened to other medical procedures that require the execution of a stepwise plan.
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In medical protocols, for example, cardiopulmonary resuscitation or management of diabetic ketoacidosis, each step must be carried out and, to a great extent, the successful completion of each task is dependent upon the completion of the step before it.
Goals of the Bad News Interview The process of disclosing bad news can be viewed as an attempt to achieve four essential goals. The first is gathering information from the patient. This allows the physician to determine the patient's knowledge and expectations and readiness to hear the bad news.
The second goal is to provide intelligible information in accordance with the patient's needs and desires. The third goal is to support the patient by employing skills to reduce the emotional impact and isolation experienced by the recipient of bad news. The final goal is to develop a strategy in the form of a treatment plan with the input and cooperation of the patient. Meeting these goals is accomplished by completing six tasks or steps, each of which is associated with specific skills.
Not every episode of breaking bad news will require all of the steps of SPIKES, but when they do they are meant to follow each other in sequence. This can be accomplished by reviewing the plan for telling the patient and how one will respond to patients' emotional reactions or difficult questions. As the messenger of bad news, one should expect to have negative feelings and to feel frustration or responsibility [ 55 ].
It is helpful to be reminded that, although bad news may be very sad for the patients, the information may be important in allowing them to plan for the future.
Sometimes the physical setting causes interviews about sensitive topics to flounder. Unless there is a semblance of privacy and the setting is conducive to undistracted and focused discussion, the goals of the interview may not be met. Arrange for some privacy.
SPIKES—A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer
An interview room is ideal, but, if one is not available, draw the curtains around the patient's bed. Have tissues ready in case the patient becomes upset. Most patients want to have someone else with them but this should be the patient's choice. When there are many family members, ask the patient to choose one or two family representatives. Sitting down relaxes the patient and is also a sign that you will not rush. When you sit, try not to have barriers between you and the patient.DE'ARRA & KEN 4 LIFE ✨COUPLE GOALS ❣️😍💋
If you have recently examined the patient, allow them to dress before the discussion. Make connection with the patient.
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Maintaining eye contact may be uncomfortable but it is an important way of establishing rapport. Touching the patient on the arm or holding a hand if the patient is comfortable with this is another way to accomplish this. Manage time constraints and interruptions. Inform the patient of any time constraints you may have or interruptions you expect. Set your pager on silent or ask a colleague to respond to your pages.
Based on this information you can correct misinformation and tailor the bad news to what the patient understands. It can also accomplish the important task of determining if the patient is engaging in any variation of illness denial: When a clinician hears a patient express explicitly a desire for information, it may lessen the anxiety associated with divulging the bad news [ 57 ]. However, shunning information is a valid psychological coping mechanism [ 5859 ] and may be more likely to be manifested as the illness becomes more severe [ 60 ].
Discussing information disclosure at the time of ordering tests can cue the physician to plan the next discussion with the patient. Would you like me to give you all the information or sketch out the results and spend more time discussing the treatment plan? If patients do not want to know details, offer to answer any questions they may have in the future or to talk to a relative or friend. Giving medical facts, the one-way part of the physician-patient dialogue, may be improved by a few simple guidelines.