Station 4: Ethics and Communication Skills
HINTS FOR THE ETHICS AND COMMUNICATION SKILLS STATION
I’ ve learnt that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.
Maya Angelou
•Always remember the above quote in all your interactions in practising medicine and especially when dealing with difficult and sensitive situations.
•In this station, your communication skills are being thoroughly evaluated.
•It is not just your ability to speak that is being assessed, but also your ability to listen to the concerns that your patient presents, and how you empathize with them.
•Read the scenario you are given carefully. Look at what is being asked. The range of tasks in this station is wide, from breaking bad news to explaining a new diagnosis and addressing the related issues.
•Make good use of the time before entering the station to think through how you are going to tackle the scenario. Make a list of the issues to be addressed so that you do not forget them under the time pressure.
•Start with an open question. Give the patient as much time as they need to talk and allow them to finish before speaking.
•If this is an angry relative/patient that you are dealing with, always take on board their frustrations and apologise for any wrongdoing (regardless of what your assessment is of the complaint). Never disregard their concerns, as the matter will be of significant importance to them.
•Always try to empathise with the patient’ s situation.
•As the consultation progresses, use more closed questions to help guide the consultation.
•Summarise the main points discussed and addressed as you are going along, to act as a prompt to both you and the other individual for any other issues yet to be discussed.
•Remember that your ability to give accurate factual information and the way in which you relay this are both being assessed.
•Be clear and concise with your answers to any questions. Do not use jargon.
•During your discussion, remember the four main ethical principles and use them to help guide your approach to any ethical dilemma:
•Autonomy: Respect for the individual and the choices they make.
•Justice: Equality in the distribution of healthcare resources.
•Beneficence: To act in the best interest of the patient.
•Non-maleficence: Actions should not harm the patient (based on the principle of primum non nocere : first do no harm).
•Remember the issue of confidentiality in this station. Confidentiality may be breached in certain situations, such as child protection, notifiable diseases, fitness to drive and serious crimes.
BACKGROUND INFORMATION
You are asked to see a 64-year-old lady in the respiratory outpatient clinic with the results of her staging CT. The patient was referred with a history of a persistent cough unresponsive to several courses of antibiotics. A CXR requested by the general practitioner (GP) prior to the referral showed a probable mass in the right upper lobe. The CT confirmed the mass in the right upper lobe, with mediastinal and subcarinal lymph nodes, a small pleural effusion and multiple liver metastases. The current radiological staging is T3 N2 M1b, making this cancer inoperable.
KEY POINTS FOR THE PATIENT
•You have been seeing your GP over the past 2 months with a persistent cough.
•You have come to clinic to get to the bottom of this and don’ t want anyone else to be here with you.
•You have been given several courses of antibiotics which have not cleared the cough.
•You have been getting progressively more breathless over the past 1 month.
•Your children have noticed a change in your voice and you have lost a stone in weight recently.
•You smoked 10 cigarettes a day for 40 years but stopped 2 years ago.
•You have had pain in your right arm and difficulty raising it.
•The GP recently started you on blue and purple inhalers and a course of steroids.
•You are annoyed that your GP has not taken you more seriously.
•You have a strong suspicion that you have cancer, and this is keeping you awake at night.
•The main concern you have is that your father died of lung cancer and was in a lot of pain towards the end.
•You want to be offered all possible treatments available and are angry and upset when you are told that the treatment will be palliative and not curative.
•Other than smoking, you have always been very healthy, and so you understand that treatment will only be palliative.
•You worry how you will break the news to your family.
•You ask if the cancer may have been treatable if you had been referred earlier.
•You want to lodge a formal complaint against your GP, as things may have been different if you had been referred sooner.
SUGGESTIONS FOR THE CANDIDATE
•Introduce yourself to the patient and ask the patient their understanding of why they have been referred to the clinic.
•Ask them if they have come with anyone today and if they would like anyone else present.
•Ask the patient about the symptoms they have been having, what prompted them to see their GP and about any treatments they have had.
•Ask about their main concerns and what they think might be the underlying cause.
•Recap the history to the point where investigations began and tell the patient that you have all the results.
•Explain that you have some bad news and ask again if the patient would like anyone present with her.
•The main reason for investigation was to exclude a malignancy.
•Unfortunately, the results show that there is a tumour in the lung involving lymph nodes and lesions in the liver; the diagnosis is likely to be cancer.
•Pause for the patient to take the information in and give them as much time as they need.
•Ask the patient if they have understood what you have told them before proceeding.
•Explain that the case has been discussed at the lung cancer multidisciplinary team (MDT) meeting.
•Explain that because of the spread, the cancer cannot be surgically resected and that treatment options will be limited to disease control and not cure.
•Ask the patient what their main concerns are and acknowledge them.
•Try to acknowledge each concern and offer help.
•Gauge how much information the patient would like to be given.
•Reiterate that although it is not possible to treat the underlying cause, there are other services and support that can help the patient to cope with the diagnosis and the disease.
•Acknowledge the patient’ s anger and frustration with the GP, and that they ought to contact the GP to discuss the issues.
•Advise that it would be difficult to say if the cancer could have been caught earlier, as you don’ t know how aggressive it is.
•Tell the patient that there is a lung cancer specialist nurse that will see them today before they go, and that they will be a regular point of contact.
•Offer the patient to help break the news to the family.
•Recap the information given and ask if the patient has any questions.
•Explain that you will see them in clinic next week and ask if they would like to bring any family or friends along with them to discuss the diagnosis again.
THEMES EXPLORED
BREAKING BAD NEWS FOR AN INCURABLE CONDITION
•This is often difficult due to the emotions involved and the range of patient responses that one may encounter. Remain calm yourself and make sure that you listen to the patient.
•Ensure that you ask the patient about their understanding of the current situation before proceeding to give them the news.
•Do not use any euphemisms or jargon and make sure that you are being clear with the diagnosis.
•If the patient has a diagnosis of cancer, use the word cancer .
•Make sure that you have all the correct/relevant information to hand.
•Appear empathic and ensure that the patient has time to digest the information given.
•Remember to summarise the key points at the end of the consultation and offer to see them again in clinic.
•Offer the relevant support: specialist nurses, palliative care teams, information leaflets and contacts for support groups.
DEALING WITH AN ANGRY PATIENT
•Acknowledge that the patient is angry or upset and let them know that you are aware and that it is a normal response.
•Allow them to voice their anger and do not react to the situation.
•Ask them what specific things are making them angry and offer them potential solutions to help overcome these issues.
CARE IN THE DETERIORATING PATIENT
You are the registrar covering the medical wards for the evening. You have received a call from one of the nurses on a respiratory ward to speak to a patient’ s son. The patient is a gentleman with bowel cancer with liver and lung metastases. He was admitted to hospital with dyspnoea and has been treated for a lower respiratory tract infection with intravenous antibiotics. Despite this, he has deteriorated in the 5 days since admission. The patient himself recognised this on the registrar ward round today, and following a discussion, antibiotics were stopped with a decision being made to commence morphine for dyspnoea and refer the patient to the palliative care team. The ward team were asked by the patient about his prognosis today, and thought this would likely be measured in ‘ days to weeks’ . The family were not on the ward for afternoon visiting, and the nurse had called the son, asking him to come in for the consultant ward round tomorrow. Following the call, he has visited this evening and is angry that his father is ‘ being left to die’ . You have gained consent from the patient to speak to his son.
KEY POINTS FOR THE SON
•You have come to the hospital to see your father, following a call from the nursing team. You are the patient’ s only child.
•Your father has had bowel cancer for a few years. During that time, he has had surgery and a few courses of chemotherapy.
•During your father’ s last trip to the oncologist, they felt he was not fit for more chemotherapy. You still hold out hope that he will be offered further treatment.
•You know that your father was admitted to hospital a few days ago and has been treated for a ‘ chest infection’ with antibiotics.
•You were hopeful that he would improve while in and be discharged back to his house where he lives alone. You are aware that he’ s been bedbound since admission.
•On receiving a call from the nursing team, you came straight to hospital. On hearing antibiotics have been stopped, you feel like the hospital is ‘ giving up’ on your father.
•You have also been told by the nurse that your father has been started on morphine. You have been told this was started to help his breathing, although you think it is being used for ‘ euthanasia’ .
•You have not spoken to your father about this since you came in, but you are worried that he’ s ‘ lost his fight’ .
•You find it hard to accept that your father is deteriorating. On direct questioning, you admit that you are lacking support (you don’ t have any other family). You don’ t want your father to die, as he is ‘ all you have’.
•If all the above issues are covered, you will feel supported, be accepting of the plan and come to the ward round tomorrow to meet the consultant and discuss future plans.
•If you are not given appropriate information or feel you are not listened to, you will get angrier and leave the conversation.
SUGGESTIONS FOR THE CANDIDATE
•Note that you are dealing with an angry relative.
•Allow the son to voice his concerns, providing adequate time for him to do so.
•Do not interrupt him.
•Acknowledge the son’ s distress.
•Talk through his understanding of his father’ s condition. This could include his father’ s likely prognosis.
•Explain that adequate treatment has been given for the lower respiratory tract infection.
•Explain that much of his father’ s dyspnoea could be related to lung metastases, and the general fatigue related to advanced cancer.
•Explain that oncological treatment will not be possible, but there is much that can be done to improve his father’ s symptoms.
•Explain that morphine is now used regularly to treat dyspnoea in advanced illness. This will be started at a low dose and prescribed safely. It is usually very well tolerated.
•Explain that a referral to the palliative care team has been made to optimise symptom control measures, but also to help with future plans (rapid discharge home may be possible).
•Reassure the son that the plan was discussed with his father, who was in agreement.
•Explain to the son that the medical and nursing teams on the ward, along with the palliative care team, will try to support him psychologically while his father is in hospital. Further support for the son could be offered from the hospital chaplaincy team if he were in agreement.
•Reassure the son that if he has further questions after this meeting, these could be discussed on the consultant ward round tomorrow.
THEMES EXPLORED
SUPPORTING AN ANGRY RELATIVE
•It is important to both acknowledge the relatives’ distress and find out why they are angry.
•Talk through their concerns one by one, first by listening and then by offering whatever information you can.
•Offer follow-up to the conversation, including a further opportunity to ask questions after this discussion.
•Recognise anticipatory grief (grief occurring before a patient has died) as a cause of distress in the families of unwell patients.
RECOGNITION OF A DETERIORATING PATIENT
•Recognition of a deteriorating patient is important for many reasons. First, it allows an appropriate treatment plan to be constructed. Additionally, it allows clinical teams to keep patients and families updated, and to help them plan for the future (such as the patient’ s preferred place of death).
•Signs that a patient is in the last weeks of life include fatigue, decreased mobility, loss of independence in activities of daily living (ADLs), decreased appetite and impaired cognition.
•Signs that a patient is in the last days of life include decreased fluid intake, impaired swallowing, decreased conscious level and changes in breathing pattern.
•While this case did not cover this specifically, it is important to have an understanding of the ‘ priorities of care for the dying person’ .
•It is also important to be aware of recent developments in decisions about cardiopulmonary resuscitation.
REFERENCES
Leadership Alliance for Care of Dying People. (2014) One chance to get it right. Available from https://www.gov.uk/government/publications/liverpool-care-pathway-review-response-to-recommendations. Accessed 4 August 2016.
Resuscitation Council (UK). (2014) Decisions Relating to Cardiopulmonary Resuscitation . 3rd ed. Available from https://www.resus.org.uk/dnacpr/decisions-relating-to-cpr/. Accessed 4 August 2016.
Mr David Clegg has come to see you in the sleep clinic. He is a 55-year-old gentleman who has been complaining of symptoms of tiredness over the past year. He has been investigated by his GP, and recent thyroid function tests (TFTs) and a full blood count (FBC) have been normal. The patient is complaining that his symptoms are interfering with his work and he is falling asleep inappropriately. The GP is concerned that the patient may have obstructive sleep apnoea/obesity hypoventilation syndrome. The patient weighs 144 kg and is 1.65 m tall. Discuss the diagnosis and related information with the patient.
KEY POINTS FOR THE PATIENT
•You have been referred to the clinic by your GP to investigate the cause of your sleepiness.
•All your blood tests have been normal.
•Your GP thinks that the tiredness may be related to the fact that you are overweight.
•The tiredness is having a significant impact on your life.
•You have fallen asleep in several important meetings at work, which was rather embarrassing.
•You are concerned as you have found yourself falling asleep at the wheel of your car. You nearly crashed into a barrier the other day.
•Your wife sleeps in a separate bedroom, and this is affecting your sex life as well.
•You have tried losing weight, but you are not getting very far.
•You drink up to three pints of beer most nights.
•You wake up most mornings complaining of a headache.
•You feel as though you have not had a good night’ s sleep for months.
•You are beginning to feel depressed about this now.
•You want to know what can be done.
SUGGESTIONS FOR THE CANDIDATE
•Start by asking the patient if he knows why he has been referred to the sleep clinic.
•Ask him specifically how the tiredness is impacting on the various aspects of his life. Ensure that you ask about work and home.
•Ask about a bed partner and if they have reported the patient snoring at night or having periods where they stop breathing.
•Ask the patient what they understand about the terms obstructive sleep apnoea and obesity , and whether the GP has explained anything about the potential diagnosis.
•Go on to explain the potential diagnosis.
•Explain to the patient that further tests will have to be carried out before confirming this.
•Initially, the patient will be asked to complete an Epworth Sleep Score and then further tests will include blood tests (FBC, urea and electrolytes [U&Es], liver function test [LFTs], TFTs and ferritin levels), overnight oximetry and possibly limited/full polysomnography.
•Advise the patient on lifestyle factors: cut down on alcohol intake and attempt to lose weight.
•One of the main issues that will need to be covered here is that the patient is falling asleep at the wheel of his car.
•You must advise him that he has a condition that is affecting his ability to drive, and he will need to stop driving and has a legal duty inform the Driver and Vehicle Licensing Agency (DVLA). The regulation for group 1 drivers is that they need to stop driving until satisfactory control of symptoms has been attained.
•Ask the patient if they have any questions.
•Summarise the above information for the patient before ending the consultation and offer to give them some information leaflets prior to leaving.
THEMES EXPLORED
•The main points to cover in this case are to give the patient information regarding the potential diagnosis and also about what investigations may be required.
•The patient has specifically mentioned that he is falling asleep while he is driving. This needs to be taken seriously, and it is the responsibility of the medical practitioner to advise the patient to stop driving and inform the DVLA immediately. This must also be documented in the patient’ s notes.
•There are many medical conditions about which the patient needs to inform the DVLA and may also need to stop driving.
•Once you have discussed this with the patient, it is their responsibility to inform the DVLA. If the patient continues to drive against medical advice, you will need to urgently contact the DVLA and disclose the relevant medical information in confidence. Remember that you must inform the patient that you are going to do this and you should confirm this in writing to the patient and their GP once you have informed the DVLA.
Driving Regulations for Selected Medical Conditions
Condition |
Group 1 regulations |
Group 2 regulations |
First unprovoked/isolated seizure |
6 months off driving from date of first seizure (or factors to suggest increased risk of further seizures, then cannot drive for 12 months) |
5 years off driving from first seizure and must be on any treatment for epilepsy in that time |
Epilepsy or multiple unprovoked seizures |
Review licence may be issued if no seizures for 5 years (with medication if required) |
Must remain seizure-free for 10 years with antiepileptic medication |
Stoke/transient ischaemic attack (TIA) |
No need to notify DVLA (but stop for 1 month) unless residual neurological defect beyond 1 month (especially if visual field defect or cognitive defect and limb function impairment) |
Licence revoked for 1 year If recurrent TIAs/stroke, must undergo functional cardiac testing first |
Acute coronary syndrome |
Cannot drive for 1 week after successful coronary angioplasty |
Cannot drive for 6 weeks until exercise test requirements ful?lled |
Pacemaker insertion or box change |
Do not drive for 1 week |
Do not drive for 6 weeks |
Permanently barred |
Implantable cardioverter defibrillator (ICD) implantation (prophylactic) |
Cannot drive for 6 months from the date of insertion |
Source:Adapted from Driver and Vehicle Licensing Agency, Assessing fitness to drive – A guide for health professionals’ document, DVLA, Swansea, 2016. Available from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/517268/Fitness_to_drive.pdf.
Note:Group 1 includes cars and motorcycles. Licences are valid until 70 (unless restrictions applied for medical conditions), after which renewal is every 3 years.
Group 2 includes large lorries (Category C) and buses (Category D). Licence valid for a maximum of 5 years only and must be renewed every 5 years (or at 45 years if issued before 19 January 2013) until aged 65 years, following which there is an annual review.
General Medical Council (GMC) guidance. The driver is legally responsible for informing the DVLA about any condition or treatment that impairs the patient’ s fitness to drive.
Driver and Vehicle Licensing Agency. (2016) Assessing fitness to drive – A guide for health professionals’ document. Available from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/517268/Fitness_to_drive.pdf. Accessed 20 April 2016.
You are the medical registrar in a rheumatology outpatient clinic. Mrs Patel is a 52-year-old lady who has a history of severe rheumatoid arthritis. She has tried several disease-modifying drugs (including methotrexate and anti– tumour necrosis factor [TNF] therapy) without significant reduction in disease activity. She has come to see you in clinic today as you wish to start therapy with rituximab.
KEY POINTS FOR THE PATIENT
•You have suffered with severe rheumatoid arthritis for many years now.
•You have active disease which is proving difficult to control and is affecting your quality of life and ability to work as a shop assistant.
•Steroids have caused significant thinning of your bones, so you are reluctant to have the dosage increased.
•You have tried several disease-modifying antirheumatoid drugs (DMARDs), including methotrexate, which caused a problem with your liver tests and so had to be withdrawn. You have also been treated with anti-TNF therapy with infliximab, but your disease remains active.
•You are frustrated with repeated trials of medications which either do not work or cause more problems due to side effects, and have read about MabThera (rituximab) on the Internet and insist that you are treated with this.
•You understand this is an expensive treatment but insist that this is the treatment you want.
•You want to know more about how this drug works. Will it cure you?
•You want to know what the potential effects of the drug are. Importantly, will it damage your liver like methotrexate?
•You are afraid of the immunosuppressive effects of the drug, as you had a tuberculosis (TB) scare about 20 years ago, back in India, when a lump was found in one of your neck glands not long after your mother was diagnosed with TB.
•You do not recall whether you received any treatment at the time, only that you had a biopsy taken.
•You are concerned that the history of TB will affect your eligibility for treatment with rituximab and want to know what can be done to ensure that initiation of treatment is not delayed.
SUGGESTIONS FOR THE CANDIDATE
•You have a very knowledgeable patient in clinic with you, who is very well read about her condition.
•You ask how she is managing at present with her condition, and how it is affecting her life.
•Listen to and empathise with the patient’ s concerns regarding the effects of the condition and the impact it has on her.
•You note that the patient has tried several DMARDs and anti-TNF therapy in the past without much benefit (and with lots of complications).
•You explain that abnormalities with liver function tests are a well-documented effect of treatment with methotrexate, and unfortunately, osteoporosis is one of the long-term effects of treatment with steroids (as well as other effects, such as hypertension, diabetes, fluid retention, stomach ulcers and eye problems).
•You enquire where the patient read about MabThera – an official evidence-based website or from a general Internet search.
•You explain that rituximab is a treatment that works on the B-cells of the immune system to reduce inflammation and improve your symptoms, and that there are strict criteria for eligibility; however, she appears to have met the criteria, having failed DMARDS, including methotrexate and at least one anti-TNF agent.
•Explain that the medication works by reducing inflammation but cannot cure the disease.
•Give the patient time to take this in and ask any questions.
•Explain that the treatment is given as an infusion in hospital (usually as a day case procedure) and can take up to 6 hours to complete.
•Occasionally, people can feel unwell during the infusion and develop a fever and/or wheeziness or feel dizzy/light-headed (due to a drop in blood pressure), but usually measures can be taken to overcome these, such as slowing the rate of the infusion (but in severe cases, it may have to be stopped).
•The main risk of the treatment is of infections, as rituximab works by dampening down the immune system, so if you develop a sore throat, fever or other signs of infection, then they must contact a doctor immediately. Rituximab can also be associated with serious infections, such as TB. Enquire about past TB exposure.
•Before initiating therapy, TB needs to be excluded with a chest radiograph. If it is positive, and as there is uncertainty whether the TB was adequately treated previously, she will need chemoprophylaxis before treatment with rituximab, but this should have been addressed prior to treatment with anti-TNF therapy. In addition, she will need to have an influenza vaccination and ensure that she is up to date with pneumococcus vaccination.
•Reassure her this is usual practice, that it is safer to delay starting rituximab for a short time to prevent potential life-threatening infection with TB, and to ensure that she is well-vaccinated to reduce risk of infections, and that this does not mean she will be precluded from receiving treatment.
•Make sure you listen to and address the patient’ s concerns. Summarise and ask if there are any questions.
•Offer an information leaflet about rituximab and schedule another appointment to discuss any concerns and initiate the treatment pathway.
THEMES EXPLORED
•Autonomy: The main theme explored in this case is how to counsel a patient effectively regarding a new treatment with potentially serious side effects, without coercion, to enable them to make an informed decision as to whether to proceed with the treatment.
•Beneficence: With novel/biological therapies, there is a risk– benefit balance between potential adverse effects of the drug versus the desired benefits, which is often difficult when the long-term effects of such medications are often not fully known.
•Justice: National Institute for Health and Care Excellence (NICE) guidelines suggest that patients with active rheumatoid arthritis who had an inadequate response to, or are intolerant of, other DMARDs, including at least one TNF inhibitor, should be considered for rituximab (and methotrexate). This would justify the need to give such potentially harmful treatments.
•Do no harm: Prior to treatment with anti-TNF therapy, patients should be screened for TB, and active TB must be adequately treated, as therapy carries an increased susceptibility to developing TB. They should also be up to date with other vaccines, such as pneumococcus and receive influenza vaccine.
•Patients with a past history of extra-pulmonary TB or abnormal CXRs require close monitoring on treatment.
•Patients with previously inadequately treated TB require chemoprophylaxis before commencing treatment.
•Patients require close monitoring for symptoms of TB while receiving biological therapy and for 6 months after stopping.
•If patients develop symptoms suggestive of TB on biological therapy, they will require full treatment with chemotherapy.
REFERENCES
Buch MH, et al. (2011) Updated consensus statement on the use of rituximab in patients with rheumatoid arthritis. Ann Rheum Dis 70(6): 909– 20.
Bukhari M, et al. (2011) BSR and BHPR guidelines on the use of rituximab in rheumatoid arthritis. Rheumatology 50(12): 2311– 3.
National Institute for Health and Care Excellence. (2010) TA195. Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor. Available from https://www.nice.org.uk/guidance/ta195. Accessed 24 April 2016.
You are the registrar in the renal outpatient clinic. You are seeing a 32-year-old female patient who has recently been given a diagnosis of autosomal dominant polycystic kidney disease (ADPKD). She has come back to clinic today wanting more information regarding her diagnosis and the implications it may have for her future. Her mother also has the condition and may be starting dialysis in the near future. She has a young daughter and is planning to expand her family.
KEY POINTS FOR THE PATIENT
•You were recently seen in the renal clinic when you were given a diagnosis of polycystic kidney disease.
•You have had some time to digest the information given to you previously and you now have several concerns that you would like to discuss with the doctor today.
•You are extremely anxious regarding the diagnosis.
•You have a three-year-old daughter and had been planning to expand your family.
•You are concerned regarding the prognosis of the condition and associated complications.
•You enquire if there are any alternative treatments or surgical options available to help prevent any complications and decline in renal function.
•Your mother also has the disease, and her doctors are considering starting her on dialysis in the near future.
•You wish to know whether this might be the case for you in the future and, if so, when might this be and whether you require a kidney transplant at some stage.
•You wish to know if there is anything that can be done to prevent yourself from getting to the stage your mother is currently at, i.e. requiring long-term renal replacement therapy (RRT).
•As your family is not yet complete, you wish to know if this diagnosis would prevent you from having any more children and what are the risks involved.
•If you were to become pregnant, would pregnancy affect the progress of the disease?
•Since both you and your mother have the condition, you are extremely concerned about the inheritance of the condition and whether you could have passed on the disease to your daughter.
•You want to know if your daughter can be tested and if there is anything that can be done to prevent her from developing the condition.
SUGGESTIONS FOR THE CANDIDATE
•It is important first to establish the amount of information the patient received during the previous consultation and how much she has retained.
•Summarise the key points and offer to discuss the diagnosis again, and clarify any points that she may not have fully understood.
•Ascertain the patient’ s main concerns by asking if she has any specific questions in mind that she would like answered.
•Attempt to alleviate some of the patient’ s anxieties by reassuring her that you and the team are there to help and provide whatever support she requires.
•Explain again to the patient that ADPKD is an inherited condition (autosomal dominant) and that the inheritance pattern of the condition means that there is a 50% chance that she has passed it on to her daughter.
•Explain that as it is a cystic condition, the cysts could develop in other organs (liver, pancreas), as well as the kidneys. Problems she might experience include recurrent urinary tract infections, infection or bleeding within a cyst, pain due to the size of the cysts and high blood pressure, all of which are treatable.
•Explain that end-stage renal disease is a potential complication that may occur some years after diagnosis. If her renal function were to decline over the course of time, then she would be prepared for dialysis in advance of needing it. An alternative possibility would be transplantation when a kidney became available, ideally before she needed to start dialysis; however, if this were not possible, then she may require dialysis initially prior to transplantation.
•Explain that the mainstay of treatment is trying to preserve kidney function for as long as possible by reducing complications and treating them aggressively, i.e. good blood pressure control, treating infections, etc.
•Explain to the patient that she will be closely monitored over the coming years with regard to her renal function.
•Explain that newer treatments are being developed, such as tolvaptan, which has recently been approved by NICE for rapidly progressive PKD, but the treatment, as with any treatment, is associated with some side effects, such as polyuria and risk of liver injury. However, she would not currently be eligible for this.
•Reassure the patient that this disease will not prevent her from having more children, but that in future pregnancies, she will be monitored more closely and may have an obstetrician-led pregnancy with close monitoring of her renal function.
•Explain that this may mean more frequent prenatal visits to the hospital and scans to ensure that she and her baby are both doing well. In addition, she may be more closely monitored during and after delivery.
•Explain that pregnancy per se will not affect disease progression currently.
•Explain that the main way of screening for this disease is using ultrasound imaging to look for the presence of cysts within the kidney. This is usually done when the patient is in their 20s.
•When asked about genetic testing, explain that there are many genetic mutations that can give rise to the disease, so it may not be possible to identify the specific one causing her disease. Assure her that her daughter can be screened when she is older. You can offer for her to be referred to a geneticist if she is keen to do so.
•Summarise that although PKD is a chronic/lifelong condition, it will not prevent her from leading a full and active life. She will be closely monitored throughout with specialist services when needed. It will not prevent her from completing her family, and should she progress to needing dialysis, she will be thoroughly supported and helped through this.
THEMES EXPLORED
•When discussing a new diagnosis of a chronic/life-limiting condition, it is important to ascertain the level of information the patient has received beforehand, and their understanding.
•Respecting the patient’ s autonomy is crucial, and it is important to gauge the level of information the patient would like to receive. Be open and honest. Try not to use jargon and use language that the patient can understand.
•Offer the patient details of support groups where they can obtain further advice in dealing with the diagnosis, and provide information leaflets that explain the condition.
•Explain that having a chronic disease does not mean that she cannot complete her family.
•She must be informed that 50% of her offspring may also be affected with the condition due to the pattern of inheritance. She will not be expecting (or wanting) to hear this, so be cautious in your approach.
•The importance of reducing complications must be emphasised.
•If renal decline is progressive, then development of end-stage renal disease may be unavoidable, although there are options of renal replacement therapy and the need for RRT will not be imminent. Reassure her that new therapies are always emerging.
•Offer a further consultation to discuss any points and referral to an obstetrician, if desired, for future pregnancy planning and a geneticist for further genetic counselling if she so desires.
National Institute for Health and Care Excellence. (2015) Guidance TA358. Tolvaptan for treating autosomal dominant polycystic kidney disease. Available from https://www.nice.org.uk/guidance/ta358/resources/tolvaptan-for-treating-autosomal-dominant-polycystic-kidney-disease-82602675026629. Accessed 24 April 2016.
You are the registrar covering the medical wards for the weekend. You have received a call from one of the nurses on the elderly care ward to speak to a patient’ s daughter. The patient’ s daughter is an ITU nurse and is very concerned about the fact that her mother had appeared quite drowsy on her arrival. She alerted the nurses, and they checked her finger-prick blood glucose level, as she is on insulin, and found her to be hypoglycaemic. It further transpired that the dose of insulin that was prescribed on the chart was incorrect, and as a result, she was given a much higher dose of subcutaneous insulin than normal for her.
KEY POINTS FOR THE DAUGHTER
•You have come to the hospital to see your mother, who was admitted with an acute coronary syndrome.
•You are very distressed, as when you arrived, she appeared to be drowsy and not responding to you.
•You alerted the nursing staff and asked them to check her blood glucose level, as she has diabetes treated with insulin, and to check the rest of her observations.
•Your mother was found to have a very low blood glucose level, and this was the likely cause of her drowsiness. She was given glucogel, and this improved her symptoms.
•The nursing staff had informed you that your mother had recently had a sliding scale of insulin stopped and was given her regular dose of insulin. The nurses tell you that she was prescribed and given 30 units of Novomix 30. You tell them that her regular dose is only 10 units of Novomix 30 BD.
•You are very angry and upset that this has happened and want to see the doctor on call.
•You ask the doctor why the insulin was prescribed incorrectly when your mother’ s list of medication was brought in with her.
•You want to know why this was not double-checked by the pharmacist.
•You feel that it is completely unacceptable that this has happened when there should be procedures in place to prevent prescribing errors such as this. You are relieved that your mother has recovered, but still disappointed in the lack of care.
•You want to speak with the consultant in charge of your mother’ s care and make an official complaint about the incident, as you are concerned that it was a case of bad practice.
•You also insist that an incident form is completed regarding the event to ensure the matter and the individuals involved receive feedback and training.
•Note that you are dealing with an angry relative who is a fellow health professional.
•Allow the relative to voice all their concerns and provide adequate time for them to do so.
•Do not interrupt.
•Acknowledge the daughter’ s concerns.
•Acknowledge what has happened and apologise for the error.
•Address each of the concerns that the patient’ s relative expresses.
•Be open and honest and acknowledge the fact that a prescribing error has been made resulting in harm to her mother.
•Assure the daughter that all junior doctors are given training in insulin prescribing and that you will ensure that it is correctly prescribed on the drug chart now.
•Assure the daughter that you will regularly review her mother to ensure that her blood sugars remain stable.
•Offer to arrange a time for the daughter to speak with her mother’ s consultant.
•Reassure her that you will fill out an incident report regarding the matter, and this will be escalated to the ward manager and the consultant in charge of the patient.
•Advise the daughter that if she or her mother would like to take the matter any further, they can contact the patient liaison office and write a formal complaint, which would be addressed in accordance with hospital policies.
•Once again, apologise for any distress caused to the patient and assure the daughter that you will relay her concerns to the various parties involved.
THEMES EXPLORED
•The main ethical principle addressed in this case is non-maleficence (first do no harm). The other theme explored is the duty of candour.
•The patient has directly suffered harm as the result of a wrong prescription of insulin.
•The duty of candour is a legal duty which entails all healthcare providers to inform patients (or their representative) and to apologise to them if there has been a mistake made in their care which has resulted in harm. This ensures that patients are given accurate and honest information.
•When addressing any form of complaint, it is important that you have on hand as much information as possible to give to the patient or their relatives.
•You should acknowledge any error that has been made, and you must apologise for this.
•Offer to answer any questions that the patient or relative may have in relation to their concerns to help alleviate the situation.
•Do not try to conceal any information which may later come to light.
•If they are not happy with your explanation, offer to arrange for them to speak with the consultant in charge of the patient’ s care.
•Offer them other sources of support regarding patient welfare, such as patient advice services, which are available in all hospitals.
•Reassure them that the matter will be taken seriously and dealt with appropriately.
•All hospitals will have processes in place to report adverse incidents that have taken place and to learn from the outcome of these reports.
Care Quality Commission. (2015) Duty of candour: Information for all providers: NHS bodies, adult social care, primary medical and dental care, and independent healthcare. Available from www.cqc.org.uk/sites/default/files/20150327_duty_of_candour_guidance_final.pdf. Accessed 4 August 2016.
National Health Service. (n.d.) Report a patient safety incident. Available from www.nrls.npsa.nhs.uk/report-a-patient-safety-incident/. Accessed 4 August 2016.
You are the medical registrar on call covering the weekend. You have been asked to speak to a relative on one of the medical wards, who wants her husband discharged against medical advice. The patient has a background history of Parkinson’ s disease, epilepsy and vascular dementia. The patient was admitted on this occasion with a lower respiratory tract infection and a UTI. He is currently being treated with intravenous fluids and antibiotics and has systemic signs of sepsis. The patient’ s wife is adamant that she wants him discharged him from hospital and sent home. You try to speak to the patient, but he is too confused to communicate.
KEY POINTS FOR THE PATIENT’ S WIFE
•You are the patient’ s main carer and have looked after him for many years now.
•You are adamant that he should be discharged, albeit against medical advice.
•You feel that his condition is worsening, as he is not in a familiar environment.
•You also feel that there is no point of him being in hospital, as he is not getting the one-to-one care which he would be getting at home.
•You question the doctor as to why the patient cannot just have antibiotics at home.
•You know that the patient has signed an advance directive stating that he should not get treatment that would unnecessarily prolong his life.
•You feel that the patient is not sleeping at night as it is too noisy on the ward.
•You know that you do not hold lasting power of attorney status, but you know the patient best and this is what he would have wanted.
•You are angry at the doctor because you think nothing is being done as it is the weekend.
•You question the doctor as to what he can do to stop you from taking your husband off the ward.
•You feel that keeping him in hospital is not in his best interests.
•You can give him antibiotics orally and make sure he drinks plenty of fluids at home.
•You are frustrated, as you feel that your views are not being taken into consideration.
SUGGESTIONS FOR THE CANDIDATE
•You are approached by a very angry and frustrated relative.
•Make sure you listen and address the relative’ s concerns. The best way to counter this discussion is to approach the relative with empathy and kindness to diffuse the situation.
•Ask her what is worrying her regarding the patient’ s stay in hospital.
•Reiterate that the patient is suffering from a urinary tract infection and a chest infection, and is currently having intravenous antibiotics and fluids. Explain that the patient is not well enough for treatment with oral antibiotics as yet, as evidenced by his ongoing signs of sepsis.
•Explain that you are part of a team and that you are all acting in the patient’ s best interest.
•When the relative tells you about the advance directive, you can tell her that this infection is a treatable condition and you are actively treating her husband and are not preparing for end-of-life care currently.
•Explain to the relative that you will try to ensure that everything possible will be done to make the patient more comfortable, such as moving him to a side room or a quieter area of the ward where he should be able to get more rest.
•When the patient’ s relative asks what you can do to stop her, tell her that you would hope to resolve the situation before this happened, but if the need arose, you would have to involve hospital security.
•Explain that you have tried to assess the patient’ s mental capacity, but he is too confused to understand what you are saying.
•Ask the relative if she has lasting power of attorney.
•Explain that as she does not have this status, as the healthcare professional, you are acting in the patient’ s best interest by keeping the patient in hospital.
•You would be going against your duty of care by allowing the patient to leave.
•Summarise what you have discussed and ensure that you convey an empathic tone throughout to the relative and acknowledge her concerns.
•Suggest that the relative could speak to the consultant in charge of the patient’ s care, after the weekend.
•Reiterate that you are doing your best to treat the patient.
THEMES EXPLORED
•The main theme explored in this case is the issue of mental capacity. The Mental Capacity Act came into force in 2007 in England and Wales, and it helps provide a framework to empower and make decisions for people who are unable to do so for themselves.
•Every adult has the right to make their decisions and must be assumed to have capacity unless proven otherwise. People should be supported to make their own decisions, unless deemed to lack capacity, and any individuals with capacity who make seemingly unwise decisions should be respected.
•To assess whether a patient has capacity, they must be able to understand and retain the information presented to them, weigh up that information and communicate the decision back to you.
•If a patient does not have capacity, then as the healthcare worker responsible for the patient, you can take decisions regarding the patient’ s medical care. It is also important to involve the family and carers and seek their views and opinions as to what the patient may have wanted.
•Any intervention made should be the least restrictive intervention and should always be in the patient’ s best interest.
•Patients can sign advance directives refusing specific treatments that they would not want should the situation arise. These are legally binding documents that need to be signed in the presence of a witness. They should also contain a statement that the decision should be enforced even if life is at risk.
•If there is any issue regarding the validity of an advance directive in an emergency situation, the appropriate treatment can be given until the validity of the document is verified.
•The patient can also appoint a lasting power of attorney who can make medical (and other) decisions on behalf of the patient who lacks capacity. This document needs to be registered with the Office of the Public Guardian for it to be valid.
•In a situation where a patient lacks capacity and has no representative to discuss their medical treatment, an independent mental capacity advocate (IMCA) can be appointed to act as an advocate for the patient in the decision-making process. An IMCA is not needed if it is an emergency treatment or if the patient is detained and being treated for a mental illness under the Mental Health Act.
REFERENCE
Office of the Public Guardian. (2014) Mental Capacity Act: Making decisions. Available from https://www.gov.uk/government/collections/mental-capacity-act-making-decisions. Accessed 5 August 2016.
You are the registrar in the gastroenterology outpatient clinic. Your next patient is a 19-year-old man who has recently presented with several episodes of bloody diarrhoea. The patient has had a recent colonoscopy which confirms the diagnosis of ulcerative colitis (UC). Discuss the diagnosis with the patient and the implications of the disease.
KEY POINTS FOR THE PATIENT
•You have come to clinic today to find out the results of a colonoscopy that was undertaken to investigate the cause of the bloody diarrhoea you have been having.
•Previously, you have been fit and well with no other health problems. Over the past 6 weeks, you have had multiple episodes of bloody diarrhoea daily.
•When you were previously seen in clinic, the doctor mentioned that they were looking to see if there was any inflammation of your bowels that could account for your symptoms. However, you did not really understand the explanation given.
•When you are given the diagnosis of ulcerative colitis, you ask the doctor to fully explain this and any problems that are associated with the disease.
•You are worried, as you have just finished your gap year and are due to start university soon and wonder how this will affect your social life.
•You want to know what medication you will need to take.
•You want to know if you will still be able to drink alcohol and go out with your friends and lead a ‘ normal’ life. You hope to go on to university – will this still be possible?
•You want to know how often you will need to see a doctor.
•You read an information leaflet in the waiting room and you want to know if you will need to have an operation and, more importantly, if you will end up with a stoma.
•When pressed by the doctor, you tell them that you are very concerned about this problem, as your dad died at a young age from bowel cancer and you wonder if this is something that you should be worried about, now that you have this diagnosis.
SUGGESTIONS FOR THE CANDIDATE
•Recap the history for the patient and initially gauge their understanding of why they have come to clinic and why they have had the procedure done.
•Ascertain the amount of information previously given and their level of understanding.
•Summarise the previous information.
•Explain that colonoscopy is the usual investigation to look for any active inflammation of the bowel that could be causing his symptoms.
•Explain that biopsies were also taken at the same time to help clarify the underlying disease/inflammatory process.
•Explain that all the results are now available and are consistent with a diagnosis of ulcerative colitis, which is an inflammatory condition affecting the bowel.
•Give them time to absorb the information that they have been given and then wait to see if they have any questions.
•Ask if they have heard of UC or any other inflammatory bowel condition before and, if so, what is their understanding of this.
•Offer to give them an overview of the disease. Do not use jargon.
•Explain that UC causes inflammation of the bowel wall. It is restricted to the large bowel and therefore results in bloody diarrhoea, so his presentation was not unusual or atypical.
•Although the disease mainly affects the bowel, there can be other manifestations outside the bowel with symptoms such as joint aches, rashes, mouth ulcers and sore eyes, but bowel symptoms are most common.
•Empathise with the patient and reassure him that with treatment, there is no reason why he cannot lead a normal life and pursue his studies, and that the condition could be looked after by a specialist in his university town if needed, or he could continue to come and see you and his appointments could be worked around his studies.
•Treatment aims are to control active disease, improve quality of life and maintain remission.
•Treatment decisions will always take into account the patient’ s individual needs and preferences.
•As he has only bowel symptoms, treatment would initially be local therapy with oral aminosalicylic acids (ASAs) and/or steroids if symptoms persist.
•If symptoms are still not well controlled, stronger therapies to dampen the immune system could be added at that point.
•Explain that the amount of alcohol he can drink will depend on the treatment he is taking; if on stronger immunosuppression, it would not be recommended, but he should only drink in moderation (and not exceed the current weekly maximum recommendation of 14 units per week spread over 3 or more days)
•Explain that initially he will need a more regular review (every couple of months or so) until the disease is under control, but thereafter, the intervals between clinic reviews would be increased.
•Reassure him that in between visits, there is always a specialist nurse available who he can contact for further advice or earlier review if required.
•Regarding surgery, reassure him that this is undertaken only in severe cases of colitis when the inflammation cannot be controlled with medical therapy, or in emergency circumstances. However, there are now many new treatments available (biological) that can help avoid surgical intervention altogether, even in circumstances where it might have been unavoidable in the past.
•Ask the patient if they have any other specific concerns or if there is anything at all they are worried about. Tell them it is quite natural to be frightened and worried about the new diagnosis, and that you are here to help/address any concerns they may have.
•When bowel cancer is mentioned, be honest and tell him that in patients with UC, there is a slightly increased risk of bowel cancer after having the condition for many years. The risk, however, is still small. Emphasise that all patients are closely monitored and there are surveillance measures with colonoscopy (as recommended by NICE) to pick up any disease early.
•Summarise the main points and emphasise that there is plenty of support available to help him cope with the condition, and the aim of treatment is to help him lead as normal a life as possible.
THEMES EXPLORED
•When giving the diagnosis of a new/chronic/life-limiting condition, the patient has the right to know the full facts regarding the diagnosis and all treatment options available.
•The patient’ s autonomy regarding their treatment decisions must be respected if they are of sound mind, especially any refusal of treatment.
•The individual must be allowed to use their own judgement in weighing the pros and cons of available options. They should never be coerced into making any choices.
•It is crucial for the information giver to not allow any preformed judgements about the patient to cloud the information given to the patient.
•If there are any errors or delays in getting to the underlying diagnosis, these should not be hidden and any apologies should be made to the patient and their family.
•In this scenario, it is a young patient who is clearly frightened as to what the future holds with this condition (regarding treatments including surgery, the possibility of cancer and whether he will still be able to lead a normal life). Reassure the patient constantly and give them plenty of sources of further information. Allow them time to digest the information and address their concerns as they arise.
•Remember his concern about the risk of cancer and be aware of the family history and with this, he is at increased risk and so should be offered ongoing annual colonoscopic surveillance. The benefits of such would be prevention of colorectal cancer with early detection, but the psychological impact of having this must also be considered with the patient’ s wishes.
•Remember to offer further ongoing support with use of the multidisciplinary team by offering their contact details, and arrange another follow-up appointment where the patient can go through the diagnosis and rediscuss any concerns they have or anything they did not understand.
REFERENCES
National Institute for Health and Care Excellence. (2011) Guidance CG118. Colonoscopic surveillance for preventing colorectal cancer in adults with ulcerative colitis, Crohn’ s disease or adenomas. Available from https://www.nice.org.uk/guidance/cg118/resources/colonoscopic-surveillancefor-preventing-colorectal-cancer-in-adults-with-ulcerative-colitis-crohns-disease-oradenomas-35109396155077. Accessed 24 April 2016.
National Institute for Health and Care Excellence. (2013) Guidance CG166. Ulcerative colitis: Management. Available from https://www.nice.org.uk/guidance/cg166/resources/ulcerativecolitis-management-35109695126725. Accessed 24 April 2016.
You are a doctor working on the intensive care unit. You have been asked to discuss the possibility of organ donation with the family of a patient on ITU who has been pronounced brainstem dead. The patient is a young, fit and healthy 19-year-old girl who was involved in a road traffic accident. The patient’ s father is her next of kin, and you approach him to discuss the possibility of donation.
KEY POINTS FOR THE FATHER
•Your daughter has been involved in a road traffic accident, in which she was hit by a car.
•She suffered extensive head injuries and also had a ruptured spleen.
•You were informed by the consultant in charge of her care that her injuries were very severe and that she may not survive. You were naturally extremely upset, as your daughter was young, fit and healthy.
•You were informed that if she deteriorated clinically, tests would be carried out to assess the condition of her brainstem.
•The nature of the tests was fully explained to you, and subsequently, after two rounds of tests, your daughter was pronounced brainstem dead.
•As a family, you are all in shock, as the last time you saw your daughter before the accident she had been excited about her plans for her gap year.
•When asked by the doctor about the possibility of organ donation, you are initially taken aback that this has been raised at your time of loss.
•After some time to think, you ask what this would involve.
•You recall that your daughter had previously mentioned that she had ticked on her driving licence application that she would wish to be an organ donor.
•You want to know what the process of donation would involve and how long it would take.
•You ask which organs are likely to be taken.
•You ask who would receive the organs and whether you would be able to contact them.
•Your main concern is whether your daughter would experience any pain when the organs are removed.
•You are also worried about the appearance of her body after the organs have been taken.
•You ask if there is anyone else who can give you any further information about the process.
•You answer on the family’ s behalf that despite your loss, you are willing to give permission for your daughter to be an organ donor, as this was her wish.
SUGGESTIONS FOR THE CANDIDATE
•Initially offer your condolences to the family and empathise with their loss.
•When you bring up the subject of organ donation, acknowledge what a difficult time this must be for them, but explain that the possibility of organ donation is regularly addressed on the intensive care unit (ICU).
•Ask the family if they are aware of any wishes their daughter may have had concerning organ donation. Specifically ask about an organ donation card, or whether it was recorded on her driver’ s licence.
•Explain the process ahead. You will contact the organ transplantation team, who will coordinate the process of organ removal. There will be various teams from around the country who will come to obtain the organs, as this hospital is not a transplant centre.
•Advise that you will need to seek the permission of the coroner before organ retrieval can take place, as the patient was involved in an accident
•The organs will go to individuals on a transplant waiting list, who have been identified as being suitable and most urgently in need of an organ transplant.
•As the patient was previously healthy, all the major organs could be used, as well as other body parts, such as corneas, tendons and possibly bones.
•Reassure the family that the patient will not feel any pain, as she is brainstem dead and therefore unable to feel pain, but that she will also be given opiates prior to the procedure to ensure this.
•The surgeons will carefully close the body after removing the organs so the patient’ s appearance will not be significantly disfigured.
•The family will not be able to contact the recipients of the organs, but the transplant coordinator would be able to tell them some general information on who the organs have gone to.
•The transplant team/coordinator will also be available to answer any further questions that the family may have.
•Empathise with the family again regarding their loss and thank them all for considering this decision at such a difficult time.
THEMES EXPLORED
•Organ transplantation is an area which is often very difficult to address, as there is so much emotion involved when broaching the subject with relatives who have just lost a loved one.
•Any patient who meets the following criteria should be considered for organ donation, and their family or carers should be offered this option if
•The patient has suffered major and irreversible neurological damage leading to brainstem death or, alternatively, whose condition is such that continuing critical care is considered futile and withdrawal of treatment is being considered.
•The patient is HIV negative.
•The patient is not known or suspected to have Creutzfeldt– Jakob disease.
•If the next of kin disagrees with donation, despite the patient being on the organ donation register, it is current practice not to proceed with the donation regardless of patient autonomy.
•The legal aspects to remember are that the coroner’ s permission must be sought (if required) before going ahead with retrieval.
•In the case of determination of death by brainstem testing, medical practitioners must follow the code of practice issued by the Department of Health in 1998.
•Prior to brainstem death testing, three preconditions must exist:
•The patient’ s condition is due to irreversible brain damage of known aetiology.
•The patient is in unresponsive coma (potential reversible causes have been excluded).
•The patient is apnoeic and mechanically ventilated.
•If these conditions are met, the standard tests are carried out by two qualified doctors and are repeated after a short amount of time.
REFERENCES
Academy of Medical Royal Colleges. (2008) A code of practice for the diagnosis and confirmation of death. Available from http://www.bts.org.uk/Documents/A%20CODE%20OF%20PRACTICE%20FOR%20THE%20DIAGNOSIS%20AND%20CONFIRMATION%20OF%20DEATH.pdf. Accessed 19 August 2016.
Department of Health. (1998) A code of practice for the diagnosis of brain stem death. Available from http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4035462.pdf. Accessed 19 August 2016.
Department of Health. (2003) Saving lives, valuing donors: A transplant framework for England. Available from http://webarchive.nationalarchives.gov.uk/20031220221856/doh.gov.uk/transplantframework/. Accessed 4 August 2016.
ETHICS AND COMMUNICATION SKILLS STATION SUMMARY
•Thoroughly prepare for the range of themes commonly encountered in this station, and this will stand you in good stead.
•Remember that your communication skills are being challenged, and inadequate preparation will be evident to the examiners.
•Use the time before entering the station to plan a structure for your discussion and the topics to be addressed. This will help you organise your thoughts and think through the information to be gathered and given to the patient.
•Always bear the four main ethical principles (autonomy, beneficence, nonmaleficence and justice) in mind when approaching the task.
•Remember that there are other issues that may be the theme of discussion, such as
•Confidentiality
•Driving regulations/DVLA medical guidelines
•Breaking bad news
•Relaying a new diagnosis
•Organ transplantation
•Cardiac resuscitation orders
•Suitability for ITU transfer/care
•Allow plenty of time for pauses to give the individual enough time to take the information on board and ask any questions they might have.
•Summarise the key points of discussion as you go along.
•Always ensure that you are listening to the patient, empathise and remain calm at all times.