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Plab 2 Notes Day 2
Plab 2 Notes Day 2
Fourth, after you have given the patient a brief period of time to express his or her
feelings, let the patient know that you have connected the emotion with the reason
for the emotion by making a connecting statement. An example:
1. Doctor: I'm sorry to say that the x-ray shows that the chemotherapy doesn't seem
to be working [pause]. Unfortunately, the tumor has grown somewhat.
2. Patient: I've been afraid of this! [Cries]
3. Doctor: [Moves his chair closer, offers the patient a tissue, and pauses.] I know
that this isn't what you wanted to hear. I wish the news were better.
In the above dialogue, the physician observed the patient crying and realized that the patient
was tearful because of the bad news. He moved closer to the patient. At this point he might
have also touched the patient's arm or hand if they were both comfortable and paused a
moment to allow her to get her composure. He let the patient know that he understood why
she was upset by making a statement that reflected his understanding. Other examples of
empathic responses can be seen in Table 2⇓.
Table 2.
STEP 6: S—STRATEGY AND SUMMARY
Patients who have a clear plan for the future are less likely to feel anxious and uncertain.
Before discussing a treatment plan, it is important to ask patients if they are ready at that time
for such a discussion. Presenting treatment options to patients when they are available is not
only a legal mandate in some cases, but it will establish the perception that the physician
regards their wishes as important. Sharing responsibility for decision-making with the patient
may also reduce any sense of failure on the part of the physician when treatment is not
successful. Checking the patient's misunderstanding of the discussion can prevent the
documented tendency of patients to overestimate the efficacy or misunderstand the purpose
of treatment.
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Clinicians are often very uncomfortable when they must discuss prognosis and treatment
options with the patient, if the information is unfavorable. Based on our own observations
and those of others we believe that the discomfort is based on a number of concerns that
physicians experience. These include uncertainty about the patient's expectations, fear of
destroying the patient's hope, fear of their own inadequacy in the face of uncontrollable
disease, not feeling prepared to manage the patient's anticipated emotional reactions, and
sometimes embarrassment at having previously painted too optimistic a picture for the
patient.
These difficult discussions can be greatly facilitated by using several strategies. First, many
patients already have some idea of the seriousness of their illness and of the limitations of
treatment but are afraid to bring it up or ask about outcomes. Exploring the patient's
knowledge, expectations, and hopes (step 2 of SPIKES) will allow the physician to
understand where the patient is and to start the discussion from that point. When patients
have unrealistic expectations (e.g., “They told me that you work miracles.”), asking the
patient to describe the history of the illness will usually reveal fears, concerns, and emotions
that lie behind the expectation. Patients may see cure as a global solution to several different
problems that are significant for them. These may include loss of a job, inability to care for
the family, pain and suffering, hardship on others, or impaired mobility. Expressing these
fears and concerns will often allow the patient to acknowledge the seriousness of their
condition. If patients become emotionally upset in discussing their concerns, it would be
appropriate to use the strategies outlined in step 5 of SPIKES. Second, understanding the
important specific goals that many patients have, such as symptom control, and making sure
that they receive the best possible treatment and continuity of care will allow the physician to
frame hope in terms of what it is possible to accomplish. This can be very reassuring to
patients.
Dr: Hello Mr and Mrs Pilmore ? ….. I am Dr ….. one of the junior doctor in the
Paediatric department. Are you the parents of Joshua ? Parents: Yes doc
Dr: I am one of the team of doctors looking after your son.
Parent: Oh, How is he doctor ?
Dr: Joshua is in the resuscitation room now. Our team is taking care of him.
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I have come here to talk to you about him. Before that – Mr Pilmore, I was told that he
met with an accident. Can you please tell me more about ii?
Parent: Doctor we were about to go to a restaurant and Joshua suddenly ran to cross the
road and the next thing I heard he was calling me Papa Papa. When we saw him he was
under the car. We called the ambulance immediately. They brought him here.
Dr: I am very sorry to hear that. When did this happen ?
Dr: As I mentioned our team will try to do the best for Joshua. As I told you before, most
of the time children do recover from the problem once we do the operation and remove
the blood clot from inside his head. However, there is slight chance that he may not
make it. I am sorry to say this.
Mother may cry – console her and dad. ( tissues – glass of water to drink).
Parent: Doctor I can’t believe this !
Dr: I can’t even imagine how you are feeling now. We will do everything possible from
our side.
Parent: Thank you doctor
Parent: Can we see him?
Dr: I can understand you want to see him. As you know at the moment we are
resuscitating him. You may not be able to see him for long time because we need to
operate on him as soon as possible. May be you can have a quick look at him now
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and you can see him properly after the operation, is that OK Mr and Mrs Pilmore.
Parent: Ok doctor. Will there be any damage to the brain after the operation ?
Dr: Hopefully he will not have any brain damages. However, we can’t say much about it
now. We may know that only after the surgery.
Dr: Any other concerns Mr and Mrs Pilmore? Parents : No doctor.
Dr: Thank you. I need to ask you few questions about his health ? Is that OK?
Parents : OK
Dr: Can I ask you how was Joshua’s health before this happened
? Parent: He was completely fine.
Dr: Did he have any medical conditions at all ? Parents: No
Dr: Is he on any medications? Parent: No
Dr: Is he allergic to anything you know? Parent: Strawberries
doctor.
Dr: I see. It is good that you told me about it. I will make a note of
this in his notes and let everyone know about this so that no one
gives him strawberries here. Can I ask is he allergic to any
medications at all? Parents - No
Dr: Any medical conditions in the family members ? Parent: No
Dr: When did he last eat or drink? Parent: Just before this happened / in the morning.
Dr: How many hours ago is that? Parents … hours ago.
Dr: Thank you very much for the information. Is there any other questions? Parents:
No
Dr: Thank you very much Mr and Mrs Pilmore, once again I am very sorry to give this
news.
Dr: Hello Mr and Mrs Martin ? ….. I am Dr ….. one of the junior doctor in the
Paediatric department. Are you the parents of Joshua ? Parents: Yes doc
Dr: I am one of the team of doctors looking after your son.
Parent: Oh, How is he doctor ?
Dr: Joshua is in the resuscitation room now. Our team is taking care of him.
I have come here to talk to you about him. Before that – Mr Martin, I was told that he
met with an accident. Can you please tell me more about ii?
Parent: Doctor we were about to go to a restaurant and Joshua suddenly ran to cross the
road and the next thing I heard he was calling me Papa Papa. When we saw him he was
under the car. We called the ambulance immediately. They brought him here.
Dr: I am very sorry to hear that. When did this happen ?
condition.
Usually that controls the bleeding. Also we may need to give him blood transfusion
because he would have lost lot of blood. Is that OK for us the give the blood
transfusion ?
Dr: As I mentioned our team will try to do the best for Joshua. As I told you before, most
of the time children do recover from the problem once we do the operation and fix the
broken bones.
However, there is a very slight chance that he may not make it.
Mother may cry – console her and dad. ( tissues – glass of water to drink).
Parent: Doctor I can’t believe this !
Dr: I can’t even imagine how you are feeling now. We will do everything possible from
our side.
Parent: Thank you doctor
Can we see him?
Dr: I can understand you want to see him. As you know at the moment we are
resuscitating him. You may not be able to see him for long time because we need to
operate on him as soon as possible. May be you can have a quick look at him now
and you can see him properly after the operation, is that OK Mr and Mrs Martin.
Dr: Any other concerns Mr and Mrs Martin ? Parents : No doctor.
Dr: Thank you. I need to ask you few questions about his health ? Is that OK?
Parents : OK
Dr: Can I ask you how was Joshua’s health before this happened
? Parent: He was completely fine.
Dr: Did he have any medical conditions at all ? Parents: No
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Dr: Thank you very much for the information. Is there any other questions? Parents:
No
Dr: Thank you very much Mr and Mrs Pilmore, once again I am very sorry to give this
news.
Dr: I am one of the junior doctors in the medical department looking after your
husband Mr Mohammed Ali. I am here to talk to you about his condition.
Dr: Do you know anything about his
condition? Wife: He had headache and he
collapsed at home. Then we brought him in
here doctor.
Dr: I am sorry to hear about that.
Dr: Can I ask you few questions about his health? Wife: Yes doctor.
Dr : Did he have any medical conditions at all? Wife - No
Dr: Like High blood pressure ? Diabetes? Any heart conditions or kidney problems?
Wife : No
Dr: Any stroke or mini strokes before ? Wife: No
Dr: Mrs Ali, we did a CT scan of his head and we got the result. Did anyone discuss
the CT scan result with you ?
Wife: No doctor ?
Dr: Before I tell you the result MRs Ali can you please tell me - Do you have any
idea what may be happening to him ?
Wife: No doctor.
Dr: I am very sorry to say this - it is not a good news. He has a very serious
condition. Do you want to know about it?
Wife: Yes doctor.
Dr: Do you want any of your family members to be with you when we discuss this?
Wife: No it is OK doctor.
Dr: Mrs Ali, CT scan of his head showed there is massive bleeding inside his head.
This is a very serious condition.
Wife: But don’t you have any treatment for that?
Dr: Sometimes we can do surgery to treat this condition. We have discussed his
condition with the Neurosurgeon but he thinks the surgery or any other treatment
will not help for your husband’s condition because the bleeding is very huge.
Dr: I really wish I could say it is not true. But unfortunately Mrs Ali that is
Dr: Mrs Ali There are various reasons this condition can happen. In his case he had
some abnormal blood vessels in his head which were kind of swollen and thin and that
blood vessel suddenly ruptured and caused this heavy bleeding. Also since he had
high blood pressure sometimes the high blood pressure can contribute to this problem.
Sometimes this condition can run in the family members.
Mrs Ali as you may know he is still unconscious but breathing on his own at the
moment.
I really wish we could keep him in the ITU and treat him. But we keep only such
patients in the ITU to treat - with whom we expect them to recover from the
condition. Unfortunately, we are not expecting that Mr Ali will recover from his
condition.
Keeping him in the ITU even if he stops breathing is not going to help him.
My consultant will discuss these things with you because your opinion is also
very important for us. What do you think Mrs Ali ?
Wife: I can understand. Are you not going to do anything at all for him ?
Dr: Mrs Ali, However we are going to do everything possible from our side to keep
him comfortable. We will provide him palliative care – that is we will be providing
all types of care to keep him comfortable.
Wife: When do you think he may die?
Dr: I really wish that I could say that he can live very long
and healthy life but Mrs Ali he may not live very long. He
may die any day.
Wife: I have 2 sons. Should I tell them to come here ?
Dr: Mrs Ali I think you should tell them to come here
because as I mentioned it is a very serious condition now.
Wife: Can I take him home doctor ?
Dr: Yes surely Mrs. Ali. We will make all the arrangements so that you can take
him home and we will provide all types of care and support you may need to look
after him as long as he lives.
Dr: Is there any other
concerns?
Wife: No doctor.
Dr: Once again I am very sorry to give you this bad news.
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Dr: Hello Mr I am Dr…. one of the junior doctor in the surgical department.
How are you doing?
Pt: I am OK
Dr: I am one of the team of doctors looking after your wife Mrs.
I am here to talk to you about her condition. Do you know anything about how her
condition is now?
Pt: She had a surgery. I just came to see her now. I don’t know doctor how she is now.
How is she doctor?
Dr: I really wish I had a good news for you. But Mr..I am very sorry to say this she is in a
very critical condition now.
Pt: Why doctor what happened ?
Dr: After the surgery she was moved to the ward then we noticed that she started
bleeding heavily. We already transfused her 6 bags of blood. Unfortunately bleeding
has not stopped. So we have shifted her to the operation theatre again to try to stop
the bleeding. My Consultant is with her in the theatre. Our whole team is trying our
best to stop the bleeding.
Pt: OK. I need to go for my work now. Shall I come back after she is back from the
theatre?
Dr: Mr. I am very sorry to say that this condition is very serious because we may not
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Pt: I think you did the operation unnecessarily and you are giving me my wife’s dead
body now.
Dr: I am really sorry if I made you feel that way. I can imagine why you are feeling that
way. It was essential at that time to do the surgery to save her leg.
Pt: Why is that you say it is difficult to stop the bleeding? Where is she bleeding from?
Dr: Let me explain her condition and what operation we did on her and you can
understand where she is bleeding and why it is difficult to stop the bleeding.
We all have a big blood vessel in our tummy called Aorta which branches out into
smaller branches and it continues in to the leg as femoral artery which supplies blood
to the leg. She had blockage in the femoral artery in the top part of her thigh so the
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