Station 4 
Communication skills and ethics
CONTENTS
Introduction to communication skills
and ethics 616
Communication skills 616
Ethics 617
Cases 618
Discussing clinical management 618
4.1 Explaining a diagnosis 618
4.2 Explaining an investigation 619
4.3 Discussing treatment 622
4.4 Discussing management, prognosis
and possible complications in a patient
with multiple problems 625
4.5 Discussing diagnostic uncertainty 626
4.6 Discussing risk and treatment effect 628
4.7 Negotiating a management plan for
a chronic disease / long-term condition 631
4.8 Encouraging concordance with treatment
and prevention 633
Communication in special circumstances 635
4.9 Cross-cultural communication 635
4.10 Communicating with angry patients
or relatives 636
4.11 Communicating with upset or distressed
relatives 638
4.12 Discharge against medical advice 639
4.13 Delayed discharge 641
Breaking bad news 643
4.14 Cancer – potentially curable 643
4.15 Cancer – probably incurable 646
4.16 Cancer – patient not fit for active
treatment 648
© 2013 Elsevier Ltd
4.17 Chronic disease 650
4.18 Discussing an acutely terminal situation
with relatives 651
Confidentiality, consent and capacity 653
4.19 Legal points in confidentiality 653
4.20 Breaching confidentiality when a third
party may be at risk 654
4.21 Breaching confidentiality in the public
interest 656
4.22 Confidentiality when talking with
relatives and other third parties 658
4.23 Consent for investigation or treatment 660
4.24 Consent and capacity 663
4.25 Refusal of consent 668
4.26 Deliberate self-harm 670
End-of-life issues 673
4.27 End of life and palliative care 673
4.28 Advance decision making 681
4.29 Resuscitation status decision-making –
discussion with patient 683
4.30 Resuscitation status decision-making –
discussion with relative 688
4.31 Appropriateness of intensive therapy
unit transfer 690
4.32 Withholding and withdrawing
life-prolonging treatments – antibiotics
and drugs 692
4.33 Withholding and withdrawing
life-prolonging treatments – clinically
assisted nutrition and hydration 693
4.34 Percutaneous endoscopic gastrostomy
feeding 697
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 Station |4| Communication skills and ethics
4.35 Vegetative state 701
4.36 Brainstem death 705
4.37 Discussing live organ donation 707
4.38 Requesting an autopsy (post mortem) 709
Clinical governance 711
4.39 Critical incident 711
4.40 Managing a complaint and the question
of negligence 714
4.41 Fitness to practise – poor performance
in a colleague 717
4.42 Fitness to practise – misconduct in
a colleague 720
Introduction to communication skills and ethics
COMMUNICATION SKILLS
Effective communication
Effective communication in medicine means simply that
doctor and patient (relative, colleague, etc.) understand
each other. We could, broadly, consider two stages to an
encounter with a patient. The first stage is concerned with
information gathering. The aim is to answer the question:
‘What is the problem or what are the problems?’ The
second stage is concerned with developing a management
plan, aiming to answer the question: ‘How do I solve this
problem or these problems?’ Management plans should
be developed not just for patients, but also with patients.
A plan is seldom a case of saying:
You have an overactive thyroid; you will need to take a tablet
called carbimazole,
but more a case of:
Let’s look at how we could treat your overactive thyroid.
It is a two-way process of information sharing. The
doctor does not so much know the solution to the problem
(although may know what is clinically best), but reach a
solution through communicating with the patient. This
method of problem solving is more patient centred.
Doctor- and patient-centred
communication
At first sight, allowing patients to be involved in manage-
ment decisions might seem to be relinquishing medical
expertise and merely facilitating what patients want. This
would be unprofessional, and we could deservedly ques-
tion how patients can know what they want without
medical knowledge and training. Were you to say to the
thyrotoxic patient:
616
4.43 Fitness to practise – health problems
in a colleague 722
4.44 Recruitment to a randomised
controlled trial 723
Other communication, ethical and
legal scenarios 727
4.45 Genetic testing 727
4.46 HIV testing 729
4.47 Needlestick injury 730
4.48 Medical opinion on fitness for anaesthesia 732
4.49 Fitness to drive 734
4.50 Industrial injury benefits 735
We could treat your overactive thyroid with tablets called
carbimazole or we could use radiotherapy or we could
arrange for you to have an operation. Now which will it be?
she would probably respond:
Well, I don’t know what’s best. You’re the doctor.
Patient-centred communication does not mean abdicat-
ing decision making to patients. It is the process of provid-
ing patients with the appropriate knowledge and
understanding to enable them to make informed deci-
sions and take appropriate responsibility for their care.
Such an approach combines the professional knowledge
and opinions of the doctor with respect for the autonomy
of the patient. A better way to approach the thyrotoxic
patient would be:
There are a number of ways to treat an overactive thyroid. One
would be to take tablets for a few months to see if they settle
it down. They are often very effective, although some patients
do eventually need to have an operation. Another choice
would be to consider surgery at the outset, but in my
experience most surgeons prefer to operate if tablets don’t
work. A third option would be something called radiotherapy,
but this may not be a good idea if you were planning to
become pregnant in the near future. I usually prefer patients
to take advice from a doctor who specialises in thyroid
problems before deciding, but wonder if you have any
immediate thoughts about these treatments.
The degree to which we engage in open discussion
depends upon the patient. At one end of the spectrum are
patients with seemingly very little interest in decision 
participation – I’ll go with whatever you think is best, doctor.
At the other extreme are patients who ruminate over every-
thing that happens to them, and want to know everything
– How many stitches would the surgeon need to use, doctor?
Patients differ. Yet when we look for evidence-based
management of disease, we find management plans that
focus on disease and not the permutations of our patients.

Traditionally, doctors have been disease centred, but dis-
eases are wrapped in packages that are patients and a
fundamental clinical skill is applying evidence-based med-
icine to the spectrum of different patients. Guidelines
might advise against radioactive iodine in pregnancy and
the patient might say:
I was thinking about having a family soon.
But she might also say:
My mother had a thyroidectomy 30 years ago and had terrible
swallowing problems afterwards until the day she died.
Those swallowing problems may not have been associ-
ated with the thyroidectomy. One could also say that
surgery has moved forward in 30 years. But the patient
may nevertheless have decided she does not want to con-
template surgery. The point is that the optimal management
of a disease is not automatically the optimal management for
a patient with that disease.
Taking into account how a patient feels about their
disease and its management is what is meant by patient
centredness. Pure doctor centredness is doctor controlled and
tends to be inflexible from patient to patient. Management
decisions are made by the doctor and the patient is
expected to comply. The key to patient centredness is not
to abandon the strengths of disease and doctor-centred
practice, but to share information so that decisions about
management are shared with and acceptable to the patient.
Patient centredness and doctor centredness should work
together, the former relating to clinical knowledge of
disease and how it should be managed, the latter a means
of harnessing the patient’s perspective to convert that
knowledge into an acceptable management plan. Because
patients have a fundamental ethical right to be involved
in decisions about managing their disease, doctors have a
duty to be patient centred.
Patient centredness is central to helping patients decide
what is best for them. Consider that the surgeon of the
thyrotoxic patient felt thyroidectomy to be the best course
of action. It would certainly be right to explore her under-
standable concerns about the operation. Negotiating the
best course of action for her should address these con-
cerns. A balanced explanation by the surgeon may empha-
sise the low incidence of serious complications, despite
her fears, and include an expectation of what may happen
if she does not proceed to surgery now. Despite this
process of shared understanding, if the patient, competent
to decide and aware of the risks, declines surgery, she is
exercising her autonomy. More likely, she will be reassured
and begin to find surgery an acceptable option.
Patients have a right to be involved in decisions that
affect them. Practising modern medicine is not just about
knowledge, but also about the skills to share that knowl-
edge in ways that encourage patients to make sound
informed choices. Patients, in general, value our ability to
guide. When they are guided, rather than pushed, they are
far more likely to keep going along the treatment path we
suggest.
Ethics
ETHICS
The importance of ethical
decision making
Every day in medicine we make ethical decisions. Some of
these decisions are based on documented professional or
legal frameworks. Most are less clearly defined. How much
information about the side effects of a drug should we tell
a patient, for example?
Ethical decision making involves the application of
ethical principles. Often, the decisions we reach seem
intuitively right. But intuition, whilst valuable, may alone
be inadequate and even detrimental to a patient’s care. For
one thing, a purely intuitive approach alone may lead to
inconsistent behaviour in the way we care for patients,
especially those with complex issues. If we aspire to
provide the best care, we need to be more analytical.
Ethical principles
Four broad ethical principles underlie ethical decision
making (Box 4.1).
Applying ethical principles
Specific cases have a vital role in ethical argument. Ethics is
not a science where we agree upon a set of principles and then
deduce what is right or wrong from these. Rather, the implica-
tions of the principles in specific cases must be explored.
Ethical reasoning is an interactive process that involves
consideration of individual situations and application of
ethical principles. One logical requirement to this process
is consistency. If what you believe to be right in one situ-
ation seems inconsistent with what you believe to be right
in another, you must either identify a morally relevant
difference between the two situations or change your view.
When considering individual patients and applying ethical
principles, foremost in our minds in decision making
should be what is deemed in the patient’s best interests. It
helps, when making a decision, to ask why you have made
it and to be able to justify it.
A word on dignity
In recent years the notion of dignity, while emerging pri-
marily from palliative care, has been more formally
applied across the spectrum of medicine. The core values
of kindness, respect and dignity are indispensable and
invariably, although not automatically, allow ethical prac-
tice to flourish. Awareness of the A, B, C, D of dignity in
health care is of value to some: attitudes (largely about
appreciating the patient’s situation and your own impact
on it), behaviours (professional and respectful disposition
and clinical examination, and facilitation of communica-
tion), compassion and dialogue. The Royal College of
Physicians rightly emphasises the importance of dignity in
both clinical practice and professional examinations.
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Box 4.1  Ethical principles
1.  Respect for persons
We have a duty to respect the rights, autonomy and dignity of the
person. This duty incorporates concepts such as honesty,
truthfulness, sincerity and trust. In medicine, respecting a patient’s
autonomy is a fundamental ethical principle.
Autonomy is the capacity to think and decide, and act on the
basis of such thought and decision, freely and independently. This
requires health professionals to provide the necessary information
to help patients reach decisions for themselves and respect such
decisions even if these do not appear to be the best course of
action.
2.  Justice
Justice refers to our duty of universal fairness or equity. It
incorporates our duty to avoid discrimination, abuse or exploitation
of people.
3.  Beneficence
The duty to do good (in the medical context, to our patients) is a
fundamental guiding ethical principle. It entails doing what is best
Cases
Discussing clinical management
CASE 4.1  EXPLAINING A
DIAGNOSIS
Candidate information
Role
You are a doctor in the medical outpatient clinic.
Please read this summary.
Scenario
Re: Mrs Elizabeth Wright, aged 45 years
Mrs Wright has systemic lupus erythematosus (SLE). She has had
a malar rash and pain in her hands for 12 months. Her clinical
presentation, together with results of extensive investigations
including autoimmune serology and radiology, supports the
diagnosis of SLE confined to skin and joints without other
multi-systemic involvement. She is here today for results. She is a
hospital secretary and very concerned she may need to stop working.
Your task is to explain the diagnosis, addressing her concerns.
Your examiners will warn you when 12 minutes  ethics and law
have elapsed. You have 14 minutes to communicate 
with the patient / subject followed by 1 minute of reflec-
tion. There will then follow 5 minutes of discussion with
618
for patients, but raises the question as to who is the judge of what
is best.
Beneficence is often seen as being applied in practice when a
health professional determines, by objective assessment, what is in
a patient’s best interests. The patient’s views are encapsulated in
the principle of autonomy. Usually, that which the health
professional determines and the patient’s views lead to the same
conclusion, because most patients choose what is objectively in
their best interests.
In a sense, beneficence is the first duty of a doctor – to alleviate
symptoms and suffering, usually, but not always, through diagnosis
and treatment.
4.  Non-maleficence
The duty to avoid doing harm runs, in most situations, parallel to
the duty to do good. Most treatments carry some risk of doing
more harm than good but it does not follow that such treatments
should be avoided on the grounds that avoiding harm takes priority
over doing good. This said, the first rule of medicine traditionally is,
and firmly remains, do no harm.
the examiners. Do not take the history again except for
details that will help in your discussion with the
patient / subject. You are not required to examine the
patient / subject.
Patient / subject information
Mrs Elizabeth Wright is a 45-year-old hospital secretary
with two sons. For the last year she has had intermittent
but slowly worsening pain in the joints of her hands and
a facial rash that is sensitive to sunlight. She is previously
very well, takes no medications and is a non-smoker. She
has been investigated recently in the outpatient clinic and
informed that systemic lupus erythematosus (SLE) is a
possibility. She is here today for the results of tests. She is
very concerned that she may need to stop working, which
she can ill afford as a single mother. She is also concerned
because she is aware of a patient in her workplace needing
dialysis, and an internet search advised that SLE was not
a curable disease and could cause kidney failure. Other-
wise she knows very little about SLE.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
1.  Introduction
Introduce yourself and confirm her identity.

2.  Clarify the task
Be clear in your own mind what problem or diagnosis
needs to be discussed.
The tests confirm that SLE has very likely been the cause of your
problems.
3.  Establish previous experience
Stronger candidates are guided by patients when giving
explanations. They operate within a patient-centred frame-
work. Weaker candidates think ‘Oh no! What do I know
about SLE?’ and proceed to tell their patients very little or
far too much, often in a disorganised fashion. Try to estab-
lish what your patient knows about their diagnosis before
launching into your explanation. Rather than saying:
SLE is a condition which …
a better approach would be one of:
Have you heard of this condition before?
I wonder if you know anything about this condition before we start?
Have you any ideas about this condition?
What have you been told so far about this condition?
A specific, uncommon condition like SLE may mean
very little to a patient. Other diagnoses such as multiple
sclerosis, cancer and rheumatoid arthritis are well known
but often poorly understood. Establishing prior knowl-
edge or preconceptions helps determine at what level to
start your explanation. She might not know that SLE can
be a multisystem disease affecting more than skin and
joints. Alternatively, she might say:
I was reading that it can affect the kidneys and that some
patients end up on dialysis. Is that likely to happen to me?
4.  Be alert to ideas, concerns and expectations
Establishing prior experience can help you understand any
specific fears that may relate to it. Throughout your expla-
nation, try to take account of any ideas, concerns and
expectations you elicit. Examples of concerns that a patient
with SLE might have include no longer being able to go
out in the sun, an unsightly rash, arthritis, needing to take
drugs or serious complications such as renal failure. Effects
of a diagnosis on work, finances and home life are often
central concerns.
5.  Frame the explanation
Try to provide a framework or order to your explanation.
You might talk about why SLE occurs (‘misdirected’
immune system), possible clinical problems and the likely
natural history, with and without treatment.
6.  Keep it clear
Keep your explanation as clear as possible. Use language
she will understand (without being patronising), avoiding
complex medical terminology. Sometimes it helps to use
similar phrases to the patient:
Case 4.2  Explaining an investigation
How does it look on the whole, doctor?
It looks all right, on the whole. Most patients with your
condition live a very normal life.
7.  Repeat important information
This can be an effective way of emphasising ‘take home’
messages’:
I should emphasise again that most people do not end up with
kidney problems or need dialysis. Most patients have skin and
joint problems similar to yourself, and these tend to get better
with treatment.
8.  Confirm understanding
It can sometimes be useful to ask the patient to recount
what they feel to be the important points of the
discussion.
9.  Encourage feedback and invite questions
I appreciate we’ve covered rather a lot there. Is there anything
you would like me to go over again or are there any
questions you would like to ask me?
Be honest in your explanations and prepared to admit
uncertainty (with assurance you will seek the answer) if
she asks something you cannot answer.
10.  Agree a way forward
Ensure that there are arrangements for treatment and
follow up.
Discussion
Would you tell her that her condition
is incurable, if she asked?
The approach to explaining any diagnosis depends upon
the diagnosis itself and should be tailored to the patient.
Many conditions are potentially serious but treatable, and
in this case potentially ‘incurable’ in that it may return
without treatment but nonetheless it is likely to be fully
treatable. Other conditions are more palpably ‘incurable’
such as disseminated malignancy. But few if any condi-
tions are untreatable as palliation is always possible.
Words such as incurable are unhelpful, and it is more
helpful to tell her that her condition can usually be fully
suppressed with treatment.
CASE 4.2  EXPLAINING
AN INVESTIGATION
Candidate information
Role
You are a doctor on the medical ward.
Please read this summary.
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Scenario
Re: Mr Roger Thornhill, aged 74 years
Mr Thornhill has been losing weight for 5 months, and feeling
slightly breathless on exertion. He has hitherto been a well man,
playing golf every day until admission to hospital last week with
cough and possible pneumonia. He feels the antibiotics have
helped. However, his chest X-ray showed mediastinal widening and
a computed tomography (CT) scan confirmed a mass arising from
the left hilum, which is likely to be primary lung cancer but possibly
lymphoma. He was aware that the chest X-ray showed an
abnormal shadow but does not know the results of his CT scan. He
has not smoked for 20 years.
Your tasks are to explain the results of the CT scan and discuss
bronchoscopy as the best next step.
Your examiners will warn you when 12 minutes  What do you think the X-ray means, doctor? The other doctor
have elapsed. You have 14 minutes to communicate  said it could be a growth in the lung. I’ve smoked all my life
with the patient / subject followed by 1 minute of  so I wouldn’t be surprised, to be honest with you. Is it bad?
reflection. There will then follow 5 minutes of discussion
with the examiners. Do not take the history again except
for details that will help in your discussion with the
patient / subject. You are not required to examine the
patient / subject.
Patient / subject information
Mr Roger Thornhill is a 74-year-old man admitted to hos-
pital last week with cough and pneumonia. He has been
losing weight for 5 months. Although he feels a little better
after antibiotics, he has been told that his chest X-ray
shows an abnormal shadow that may not be purely attrib-
utable to infection. A chest CT scan has been performed
and he is awaiting the results. He has been worried that
the scan might show something sinister, like cancer. He
has been an active man, playing golf daily. He was widowed
6 years ago. He gave up smoking 20 years ago.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself and confirm his identity.
2.  Clarify the task
Be clear in your own mind what investigation needs to be
discussed, and the purpose for which it is being
performed.
3.  Establish previous experience
Try to establish what he knows about the problem before
explaining the investigation. Rather than saying:
You need to have a test called a bronchoscopy,
620
a better approach might be:
The chest specialist feels that we should look more closely into
this problem of coughing up blood. He suggests some further
tests. May I ask you what you’ve been told about the results
of your tests so far?
I know the X-ray wasn’t completely normal. What tests does he
suggest?
He suggests a test called a bronchoscopy. Have you heard of a
bronchoscopy before?
4.  Be alert to ideas, concerns and expectations
Establishing prior experience can help you understand 
any specific fears relating to the potential diagnosis or 
to the test itself. These should be addressed before
proceeding:
The X-ray does suggest the possibility of a growth in the lung. A
bronchoscopy is the best way of knowing this for certain. It’s
very hard to say what it means for you until we know for sure
what it is. Once we know, we are in a much better position to
know the best way forward.
5.  Frame the explanation
Try to provide a framework for your explanation of the
investigation (Box 4.2).
The bronchoscopy involves passing a flexible telescope with a
light on the end into the airways, usually under sedation. If
there is anything seen, such as a growth, then the specialist
would take a biopsy, a small piece of tissue, from it for closer
examination. It is a very common test these days, and
generally very safe.
6.  Keep it clear
Keep your explanation as clear as possible. Use language
he will understand.
7.  Repeat important information
This can be an effective way of emphasising ‘take home
messages’
8.  Confirm understanding
It can sometimes be useful to ask the patient to recount
what they feel to be the important points of the
discussion.
Box 4.2  Explaining an investigation
• The purpose of the investigation (usually to further a diagnosis,
assess the severity or extent of a disease, or monitor response
to treatment)
• The nature of the proposed investigation
• Any risks that may be involved

9.  Encourage feedback and invite questions
I appreciate we’ve covered rather a lot there. Is there anything
you would like me to go over again or are there any
questions you would like to ask me?
10.  Seek consent
Remember that you are explaining the reason for an inves-
tigation and not telling a patient they must have it. Fol-
lowing explanation, you should seek informed consent to
proceed.
Discussion
An 86-year-old woman with moderately
severe dementia has a suspicious lesion on
chest X-ray. Would you recommend
bronchoscopy?
Guidelines for investigating and treating suspected lung
cancer suggest bronchoscopy or percutaneous biopsy to
guide appropriate treatment – surgery, chemotherapy,
radiotherapy or palliation. But guidelines often fail to
address significant comorbidity. Here, assessment of cog-
nition, functional and social support and symptom
control are likely to supersede attempts to confirm a diag-
nosis, but investigation may be warranted if likely tumour-
related symptoms develop to allow more secure planning
of palliative measures. Her capacity to understand the
issues should be explored, ideally in the presence of next
of kin, and empirical treatment considered if she does not
accept investigation. If she accepts investigation, the least
likely to cause distress should be arranged, for example a
computed tomography scan rather than bronchoscopy.
What do you understand by the
terms sensitivity, specificity, positive
predictive value (PPV) and negative
predictive value (NPV)?
Sensitivity and specificity are to do with finding or not
finding disease. Sensitivity is concerned with finding disease,
and specificity with not detecting disease in those without
the disease. Disease positives and negatives are based  Explain the terms pre-test probability and
on ‘gold standard tests’ (ultimate diagnostic tests as 
the profession sees them). Predictive values are to do  post-test probability
with diagnostic / screening tests. If a test is positive, the ques-
tion is whether or not it is good at detecting disease; if a test
Table 4.1  Sensitivity, specificity and predictive values
Disease positive
Test positive (abnormal) a b
Test negative (normal) c d
Sensitivity = a / (a + c)
NPV, negative predictive value; PPV, positive predictive value.
Case 4.2  Explaining an investigation
is negative, the question is whether or not it is good at 
not missing disease. Sensitivity and specificity are not
affected by the prevalence of a disease; predictive values are
(Table 4.1).
Sensitivity
Sensitivity refers to the ability of a test to detect disease. It
considers all with disease (disease positives) and is the
proportion of true disease positives (a + c) that the test
detects (a). A highly sensitive test is able to detect disease
or target substance in trace amounts and so misses few
that have the disease, i.e. a low false-negative rate. For
example, bone marrow aspiration and soluble transferrin
receptor assay are highly sensitive tests for confirming iron
deficiency, whereas ferritin may be misleading.
Specificity
Specificity refers to the ability of a test to exclude disease.
It considers all without disease (disease negatives) and is
the proportion of true disease negatives (b + d) that the
test correctly identifies as negative (d). A highly specific
test is able to detect a single disease or target substance
and no other and seldom misdiagnoses disease, i.e. a low
false-positive rate. For example, mammography screens a
defined age population with higher specificity for detect-
ing breast cancer. Lowering the age threshold for screening
may lower specificity and increase false-positive results, as
younger women tend to have lumpier breasts.
Positive predictive value (PPV)
PPV considers all who test positive and is the proportion
of people with a positive test (a + b) who have the disease
in question (a). A high PPV is desirable for diagnostic tests,
i.e. a low false-positive rate.
Negative predictive value (NPV)
NPV considers all who test negative and is the proportion
of people with a negative test (c + d) who do not have the
disease in question (d). A high NPV is desirable for diag-
nostic tests, i.e. a low false-negative rate.
Pre-test probability refers to the proportion of people with
a target disorder in the population at risk and is simply
Disease negative
PPV = a / (a + b)
NPV  =  d /  (c + d)
Specificity  =  d /  (b + d)
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another term for prevalence. Pre-test probability may be
calculated using the formula (a + c) / (a + b + c + d). Post-
test probability refers to the proportion of patients with a
particular test result who have the target disorder.
What criteria are important in determining
whether or not to implement a screening
test for a disease?
Ideally, the disease should be common, important and
diagnosable by an accepted method. There must be a
latent interval between disease onset and important 
manifestations during which effective intervention is pos-
sible. The screening test should be simple, cheap (cost
effective) and performed on a group deemed by policy to
be at high risk. It should have a high sensitivity and a
specificity.
What is meant by a valid and reliable test?
A valid test is one that measures what it sets out to measure.
A reliable test is one that produces repeatable results.
Which factors may influence a decision to
investigate older people?
Guidelines for investigating conditions can fail to address
individual factors that should be considered when assess-
ing the potential benefits and risks of investigation; such
factors become more common with advancing age. Comor-
bidity and multiple pathologies become more likely in
older patients, with an increase in chronic diseases, and it
can be more appropriate to identify problems and use
problem solving than seek single unifying diagnoses,  are not required to examine the patient / subject.
and more appropriate to make judgements as to which
problems are most probably affecting quality of life.  Patient / subject information
Cognitive impairment, either mild or dementia, may pre-
clude informed consent for an investigation. Physical dis-
ability such as osteoarthritis can, for example, thwart
exercise stress testing. Patients’ views and wishes are of
course most valuable in deciding the best way forward. A
common example is the extent to investigate anaemia in  He feels he has had a good life. He does not want to be
an older person once a basic ‘blood screen’ has been
completed.
A pragmatic way of decision making for investigating
older people is to select investigations most likely to
change management or yield prognostic information. If a
patient is competent to give informed consent to an inves-
tigation then it is possible to proceed; if not then it may
be discussed with those close to the patient, and a decision
made in the patient’s best interests as judged by the doctor.
If either a competent patient or those close to a patient
not competent refuse investigation then empirical treat-
ment might be offered.
Automatic investigations that will not benefit patients
are inappropriate but discrimination against older patients
by restricting access to investigations is equally unaccept-
able. Decisions should be made by balancing potential
benefits and risks, and not determined by age.
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CASE 4.3  DISCUSSING TREATMENT
Candidate information
Role
You are a doctor on the cardiology ward.
Please read this summary.
Scenario
Re: Mr James Bonde, aged 80 years
Mr Bonde is recovering well from a non-ST elevation
myocardial infarction. Although well before admission, coronary
angiography is not being considered and he is keen to go home.
He is currently taking aspirin. Beta blockade is deemed risky on
account of sinus bradycardia. His blood pressure is 160 / 90. You
think he might benefit from clopidogrel, a statin and an
angiotensin-converting enzyme inhibitor to further modify risk.
Your task is to explain these treatments to him, and allow
him to make an informed choice about whether or not to take
them.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
Mr James Bonde is an 80-year-old man who has never
before been in hospital. He was admitted to hospital 4
days ago with a heart attack. His wife died of heart disease
6 years ago, having taken many medications for her heart.
kept in hospital for further tests or treatments if he can be
allowed home more quickly without these, and fully
accepts he might be declining potentially optimal, ‘cutting
edge’ approaches. He feels simply that he has done all that
he wants to in life and ‘will accept the end when it comes,
with or without treatment’. He will consider treatment that
keeps further chest pains at bay, but does not want ‘any-
thing too complicated’.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself and confirm his identity.

2.  Explain the reasons for considering treatment
I’m glad to see that you are recovering from your recent heart
attack. Your test results are largely encouraging but your blood
cholesterol level and blood pressure are still a little high. When
the cholesterol is high and we don’t treat it, this can increase
the risk of future heart attack, as can high blood pressure.
Fortunately, the risk can be reduced with medication and I
think we should discuss starting this medication in your case.
3.  Give the patient a chance to react to the   Discussion
need for treatment
Remember that a lot has happened to him recently. His
world has been changed by the heart attack. He probably
had an enormous fright when admitted, and is still coming
to terms with the repercussions of his diagnosis. He will
have received a great deal of advice from doctors, nurses
and members of the cardiac rehabilitation team. He will
be on a range of tablets indefinitely. It is important to
recognise that his hopes and yours may not immediately
be the same. There may be a mismatch of agendas. You
want him to start more tablets and then see your next
patient but he desperately wants some good news. Yet
more tablets may not be what he had in mind. Going
home may be. Give him a chance to react to what you see
as the most important next step, and appreciate his.
4.  Be alert to ideas, concerns and expectations
Establishing prior experience (e.g. of his wife) can help
you understand any specific beliefs. Throughout your
explanation, try to take account of any ideas, concerns and
expectations you elicit.
5.  Explain the likely benefits of treatment
Explain these as accurately as possible, without over-
whelming him with outcomes of studies. It often helps to
reassure patients that others are taking the same drug and
that your advice is commensurate with the larger body of
current medical opinion.
6.  Explain what the treatment involves
Explain the frequency of dosing of tablets, the duration of
therapy and any special instructions (e.g. when tablets
should be taken). Any requirements for blood monitoring,
if relevant, should be discussed.
7.  Explain likely side effects of treatment
Mention side effects that are common or serious. Try to
explain the balance of risk (benefits versus side effects).
Explain what should be done if a side effect occurs. Many
patients know that aspirin can cause ulcers, but carry on
taking it if they have bleeding symptoms. Patients have not
worked in medical units. Do not assume that what is
obvious to you is obvious to your patient.
8.  Encourage feedback and invite questions
I appreciate we’ve covered rather a lot there. Is there anything
you would like me to go over again or are there any
questions you would like to ask me?
Case 4.3  Discussing treatment
9.  Seek consent
Remember that you are explaining the reasons for tablets
and not telling him he must have them.
10.  Respect autonomy
Ultimately, the decision to accept treatment or stay in hos-
pital is his, and his informed decision should be respected.
Are you more reluctant to prescribe
medications for older people?
Treating older people must aim for maximum benefit (it
is older people who often derive most benefit from a
particular drug) and minimal adverse effects by avoiding
excessive or inappropriate medications. To achieve this
balance, individualised prescribing that considers comor-
bidity, co-prescription and social aspects of care, and
careful judgement of overall frailty and likelihood of
benefit, are crucial. Older people are often inappropriately
under-represented in therapeutic trials, and so the size of
benefit might be underappreciated in an older person, but
so might the absolute risk increase. Six rules in prescribing
for older people are shown in Box 4.3.
Is drug treatment for coronary syndromes
the same for older as younger patients?
Thrombolytic agents provide a greater absolute benefit in
older people and should only be withheld if there are
contraindications, although these are more likely in older
people. Meta-analyses of aspirin trials show around 25%
reduction over 2 years in secondary prevention of major
vascular occlusive events, relative risk reduction being
similar in younger and older people but absolute benefit
greatest for high-risk patients over 65 years (but the risk–
benefit ratio tips aspirin out of favour for low-risk older
people in primary prevention). Beta blockers after myocar-
dial infarction reduce mortality from ischaemia and
arrhythmias with evidence up to 75 years, but beyond this
age benefit can only be extrapolated and older people are
more likely to have relative or absolute contraindications,
such as sinus pauses or postural hypotension. Angiotensin-
converting enzyme inhibitors reduce mortality and mor-
bidity in cardiovascular disease but again older patients
are more likely to have contraindications such as hypo­
tension, moderate aortic stenosis or vulnerable renova­
scular disease.
Is treatment for hypertension the same for
older as younger patients?
Absolute benefit from antihypertensive treatment is much
greater in older people.
Is treatment for hyperlipidaemia the same
for older as younger patients?
The benefits of statin therapy are deduced from overall risk
rather than lipid concentration. The Heart Protection
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 Station |4| Communication skills and ethics
Box 4.3  Prescribing for older people
1.  Consider the indication
This includes stopping drugs when investigations do not support a
diagnosis. It is not uncommon for patients whose results do not
support ischaemic heart or other vascular disease to be continued
on antiplatelet, antihypertensive or lipid-lowering treatment and to
be re-admitted with anaemia or hyponatraemia.
2.  Be alert to possible side effects   these drugs are commonly prescribed. Over-the-counter
and limit prescribing
Almost any drug can provoke confusion. Extrapyramidal side effects
are not uncommon with antipsychotics, anti-emetics and
anti-histamines; depression can be triggered by beta blockers and
calcium channel blockers; constipation can be the result of opiates,
diuretics and anticholinergics. Broad-spectrum antibiotics,
antipsychotics, benzodiazepines, beta blockers and phenytoin are
just some drugs that may be better avoided in older people.
3.  Do not withhold treatments that work
Warfarin, for example, is often inappropriately withheld.
Osteoporosis treatment is underprescribed.
4.  Stop inappropriate medications
The aim should be symptom relief, for example in patients who are
dying, who should not be given a diet of drugs to prevent vascular
disease.
5.  Be imaginative with routes of administration
Use intramuscular gentamicin, for example, in an agitated,
confused patient with a urinary infection.
6.  Consider concordance
Ideally patients should be discharged with a list of their treatments
and the reasons for each.
Study showed significant reductions in first event rates
(around 25%, P < 0.0001) for myocardial infarction and
stroke each year after the first year and these rates were
similar in those under or over 70 years. Statins should be
considered for patients with occlusive arterial disease or
diabetes where life expectancy is greater than 1 year and
quality of life is positive.
Is warfarin justified in patients aged over
75 years with atrial fibrillation?
Warfarin in atrial fibrillation reduces stroke risk by 68%,
compared with 21% with aspirin. The high rate of intra­
cranial haemorrhage with warfarin in patients aged over
75 years does not negate its benefit, but comorbidities
limiting life expectancy may limit its potential benefit.
What do you know about
drug-induced disease?
Any drug may cause disease, and drugs should always be
included in the differential diagnosis of symptoms. For
624
example, a glance at the drug chart might reveal the con-
comitant use of a selective serotonin reuptake inhibitor
(SSRI), a tricyclic antidepressant and tramadol; SSRIs are
enzyme inhibitors that enhance the action of the other
drugs and the combination of a SSRI and tramadol can
produce a serotonergic syndrome. Common drugs causing
disease include non-steroidal anti-inflammatory drugs
(NSAIDs), aspirin, clopidogrel, warfarin, diuretics,
angiotensin-modifying agents and corticosteroids, but
drug use should also be explored, as around 25% of hos-
pitalised patients may be taking these yet in only around
1% of patients do they appear in their case records.
What do you know about adverse drug
reactions (ADRs)?
ADRs are a challenge for both primary and secondary care,
and reflect the value of a strong pharmacist presence in the
health-care team. Year on year drugs are withdrawn
because of safety concerns, examples in recent years
including cerivastatin, rofecoxib and co-proxamol; 6.5%
of hospital admissions are due to ADRs, and 14.7% of
patients experience an ADR in hospital, a major propor-
tion of these thought to be potentially preventable. Drugs
should thus always be considered in the differential diag-
noses of presentations. To assess cause and effect may
require any of a temporal relationship, re-challenge, exclu-
sion of other causes, novelty or de-challenge (dose reduc-
tion or withdrawal). Errors in omission appear to be more
common than commission. Alternative medicines are a
large problem, and for example ginseng, feverfew and
garlic reduce platelet function and St John’s wort induces
drug metabolism of protein pump inhibitors and this
combination may result in gastric bleeding. The Medical
Research Council for Drug Safety Science Hospital Admis-
sion Study revealed the top 10 causative drugs for ADRs 
as NSAIDs, diuretics, warfarin, angiotensin-converting
enzyme inhibitors, antidepressants, beta blockers, opiates,
digoxin, prednisolone and clopidogrel. NSAID-induced
peptic ulceration is the most frequent ADR cause of admis-
sion. Antiplatelet agents are a common example of the
benefit–harm balance consideration, as they benefit vas-
cular disease but may cause gastrointestinal bleeding, the
latter risk increased with NSAIDs and former benefit
reduced by some gastroprotective agents.
Are pharmaceutical companies and
pharmaceutical representatives to be
considered favourably by doctors?
Absolutely, and yet doctors are often naive as to how 
drugs must be developed, licensed and marketed. The 
pharmaceutical industry is an essential one of scientists,
health-care professionals and business people without
which we would have no drug development, no drug trials
and no drug information with and upon which to treat our
patients.
 Case 4.4  Discussing management, prognosis and possible complications in a patient
What do you know about drug licensing?
Drug licensing is not able to influence the vigilance all
doctors must have to licensed drugs, but is a vital line of
defence against drug-induced disease. The British Medical
Journal in 1909 published a report on ‘Beechams Reme-
dies’, a popular product at the time which falsely claimed
a dazzling range of benefits, but which contained little else
than soap and ginger. Licensing became formalised in
1958 in the thalidomide era, and now to gain a licence a
drug must pass the hurdles of quality of manufacture,
efficacy in the proposed indication and reasonable safety.
The Medicines and Healthcare products Regulatory Agency
(MHRA) in the UK, through its Commission on Human
Medicines and Licensing Authority, has a pivotal role. On
introduction, most drugs go through the phases of initial
high expectation then subsequent disappointment before
finding their balanced place. Drugs then generally have a
period of patency protection before coming ‘off-patent’
and becoming generic, whereupon ‘me-too’ products at
competitive rates may consume 90% of sales. Pharmaco-
vigilance is vital, and MHRA pharmaco-vigilance groups
receive yellow cards from reporting doctors, and these
provide vital cumulative clues of danger; not enough
doctors submit these.
CASE 4.4  DISCUSSING
MANAGEMENT, PROGNOSIS AND
POSSIBLE COMPLICATIONS IN A
PATIENT WITH MULTIPLE PROBLEMS
Candidate information
Role
You are a doctor in the medical outpatient clinic.
Please read this summary.
Scenario
Re: Mr John Rowe, aged 76 years
Mr Rowe had a partial gastrectomy for gastric cancer 2 years
ago. It was diagnosed very early, by oesophagogastroduodenoscopy
for dyspepsia. After surgery and a course of Helicobacter pylori
eradication he had no further symptoms and his surgeon told him
all appeared to be clear. He now has recurrence of dyspepsia and
is seeing you urgently in clinic and wants to know if the cancer
might have returned. He has recently seen the cardiologists
because of suspected angina and awaits angiography. He has been
started on aspirin, a statin and an angiotensin-converting enzyme
inhibitor but not a beta blocker on account of mild chronic
obstructive pulmonary disease for which he takes inhalers. He also
wishes to talk to you about his angina and breathing because he
feels the cardiologists did not tell him very much. And he has
recently had two episodes of fresh rectal bleeding, but he is not
too troubled by this. You may assume systematic enquiry otherwise
unremarkable.
Your task is to address his concerns and discuss a way forward.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
Mr John Rowe is a 74-year-old man who had an operation
for gastric cancer 2 years ago. It was diagnosed very early,
by investigation for ingestion. After surgery he had no
further symptoms and his surgeon told him ‘all was clear.’
He now has recurrence of indigestion. He has also recently
seen the cardiologists because of suspected angina and
had a positive exercise tolerance test and awaits angiogra-
phy. He has been started on aspirin, simvastatin and rami-
pril. He has mild emphysema for which he takes inhalers,
and gave up smoking 20 years ago. He also wishes to talk
about his angina and breathing because he feels the car-
diologists did not tell him very much. He is worried about 
the risks of an angiogram but also worried that without
further tests he could have a heart attack. He wonders what
his risk of a heart attack might be. He recently had two
episodes of fresh rectal bleeding, but is not too troubled
by this.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself and confirm his identity.
2.  Know how to deal with multiple problems
It is increasingly common in general internal medicine to
face numerous problems in a single consultation. Patients
with multiple problems are often uncertain about what is
really wrong. They might not know why certain tests are
being arranged. They might not know exactly why they are
taking medications. And in the era of increasing specialisa-
tion they might be attending multiple specialist clinics,
sometimes punctuated by acute admissions to hospital
after which they are discharged on different tablets, and
they might have difficulty organising and retaining some-
times seemingly conflicting advice from the different
health professionals they have seen.
3.  Take one step at a time
Your task is to arrange the puzzle into a series of boxes,
and address each of these on the basis of which you see
as priorities. In this case an appropriate way forward is to
address the dyspepsia first and consider further endoscopy
(which he has had before), and reassure him that you will
move on to discuss his angina and breathing problems
afterwards, and not forget his rectal bleeding.
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 Station |4| Communication skills and ethics
4.  Obtain the facts
Dyspepsia is often hard to differentiate from cardiac chest
pain. He has cardiac problems but equally a history of
gastric malignancy and recently starting aspirin and so has
two compelling reasons to proceed to oesophagogastrodu-
odenoscopy (balanced against minor procedural risks
posed by stable angina).
5.  Explore concerns
Make sure you explore any specific concerns he may have,
for example about proceeding to the angiogram.
6.  Discuss management options with   Reassure him of follow-up arrangements, and that you
a clear framework
I think we should strongly consider looking into the stomach
again with the endoscopy you had before. This will tell us
quickly whether or not there is anything we need to be worried
about. I’d hope it would simply show some ulceration that we
can treat with tablets, and this would not be uncommon in
people taking aspirin. But I think you should continue the
aspirin for the time being, as it gives some protection to the
heart. In the unlikely event that the endoscopy showed
anything more untoward then we would be in a better position
to know what to do sooner rather than later.
7.  Discuss potential prognoses and possible
complications of any diagnoses (with and
without treatment) or treatments
It can be easy to be drawn into discussion of possible
outcomes but as far as possible try to avoid hypothetical
discussion of what has not been diagnosed. With respect
to his angina, it would be best to leave management in the
hands of the cardiologists, but appropriate to comment
on the reasons for angiography (to consider if a procedure
such as stenting would help his angina) and the impor-
tance of medications in reducing the risk of a heart attack.
8.  Prioritise … but do not forget   You are a doctor in the medical outpatient clinic.
unturned stones
It is important at this stage not to ignore his rectal bleeding,
which he considers less important. But unturned small
stones can sometimes turn out to be very significant.
I do not think we should ignore the bleeding you have had
from the tail end, and it may be preferable for us to consider
examining the tail end with a flexible telescope with a light
on the end – similar to the endoscopy you have had before
– to be certain we are not missing something.
Assuming rectal examination normal, colonoscopy
might be a crucial test, and the decision is where to place
it in the overall sequence. One way forward would be to
request it provisionally (waiting lists will preclude rapid
access!).
9.  Encourage feedback and invite questions
I appreciate we’ve covered rather a lot there. Is there anything
you would like me to go over again or are there any
questions you would like to ask me?
626
Box 4.4  Issues to be aware of in managing
older people
• Reduced body reserve
• Atypical presentations
• Multiple problems / pathologies
• Polypharmacy
• Social adversities
10.  Agree a way forward and ensure follow-up
arrangements are in place
would happily review sooner at any time at his or his
general practitioner’s request if there are questions or
concerns.
Discussion
What issues should you be generally aware
of when managing older people?
Many of the scenarios in this book deal with older patients,
and appropriately so since general internal medicine is
managing an increasingly older population. A mnemonic
for issues you should be particularly aware of is given in
Box 4.4.
CASE 4.5  DISCUSSING DIAGNOSTIC
UNCERTAINTY
Candidate information
Role
Please read this summary.
Scenario
Re: Miss Melissa Hamilton, aged 24 years
You have been seeing Miss Hamilton in clinic for follow-up of
Crohn’s disease. She has been asymptomatic for 6 months. At the
end of the consultation she mentions that she has had pain in her
right calf for the past week. She hoped you might take a quick
look at it. Examination is unremarkable.
Your task is to discuss management options with her.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.

Patient / subject information
Miss Melissa Hamilton is a 24-year-old woman with
Crohn’s disease that has been well controlled on treatment
for 6 months. At the end of her outpatient consultation
she mentions that she has had pain in her right calf for
the past week. She didn’t want ‘to bother her GP’ and
hoped you might take a look at it. She is not particularly
concerned about it but wonders what it might be due to.
She is otherwise well. She started the combined oral con-
traceptive pill (COCP) 2 months ago whilst touring in
Australia with her boyfriend. They returned home 10 days
ago. She has no family history of thromboembolic disease.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself and confirm her identity.
2.  Clarify the task
Confirm that the problem is calf pain, and nothing else.
3.  Obtain the necessary facts
Gather information that is necessary to discuss manage-
ment. Crucially, this includes additional symptoms and
risk factors for venous thromboembolism – personal or
family history, long-haul travel, COCP.
4.  Be alert to ideas, concerns and expectations
She probably has no concerns about a deep venous throm-
bosis (DVT).
5.  Outline the possibilities
She appears to lead an active lifestyle, has no signs of a
DVT, and the absolute risk of thromboembolic disease on
the COCP is very low. Conversely, she has two possible
risk factors, the COCP and a long-haul flight, and throm-
boembolic disease, although unlikely, can be life-
threatening and is treatable.
6.  Share the probability and potential
seriousness of a diagnosis
Probability is discussed in Box 4.5.
This is most likely harmless muscle pain. There is a small
possibility the pain is due to a clot of blood in one of the
deeper veins of the leg. It is difficult to exclude this without
further tests. Although I think a blood clot very unlikely, there is
a risk that an untreated blood clot could travel to the lungs and
cause serious harm. We could arrange a blood test and then
possibly a scan of the leg to be more sure, if you wanted us to.
This sounds straightforward, but in practice there can be
a problem with sharing information in this way. Patients
frequently do not warm to the idea of being asked to make
Case 4.5  Discussing diagnostic uncertainty
Box 4.5  Probability and potential seriousness of
diagnosis
A symptom may have a low probability of representing serious
pathology but a high probability of serious consequences if ignored.
Such information should always be shared with a patient. The
management of disease in theory is often clear cut: investigation A
for suspected disease B; treatment Y for disease Z. In practice,
whether or not to embark on an investigation in the face of limited
evidence is a complex decision that should involve sharing your
knowledge, concerns and expectations with the patient.
a decision and ‘if you wanted us to’ may be too open
ended to actually help her decide. She might respond:
Well, you’re the doctor, I’ll take your advice. Do you think it’s
really necessary?
Sharing information is more than showing patients the
menu!
7.  Give an honest professional opinion
If these decisions are difficult for us, with medical training,
then they can be enormously difficult for patients, given
only small quantities of distilled information. Since there
is no clear history of muscle strain, the potential serious-
ness of a DVT may persuade you to say:
I’d advise a blood test called a D-dimer. If this is negative we can
be reassured that a blood clot is highly unlikely. If it is positive,
we should go on to arrange a scan of the leg to be sure.
8.  Confirm understanding
It can sometimes be useful to ask the patient to recount
what they feel to be the important points of the discussion.
9.  Encourage feedback and invite questions
I appreciate we’ve covered rather a lot there. Is there anything
you would like me to go over again or are there any
questions you would like to ask me?
10.  Cast a ‘safety net’
If a patient decides not to pursue tests, always have a safety
net, such as follow-up by the general practitioner or to seek
medical advice if symptoms develop further. Any decision
that involves waiting for something else to happen before
acting should be ‘safety netted’ and patients should be clear
about which symptoms should prompt reassessment.
Discussion
An 85-year-old man has had a large cortical
stroke causing dysphasia and dense
hemiplegia. Routine tests reveal a
haemoglobin of 9 g / dl with a low ferritin.
Would you investigate this further or accept
diagnostic uncertainty?
Oesophagogastroduodenoscopy (OGD) and colonoscopy
are the standard investigations to look for a source of
627
 Station |4| Communication skills and ethics
chronic blood loss in iron deficiency anaemia. However,
the balance of risk of proceeding with these might not be
in the patient’s best interests immediately. OGD might
increase the risk of hypoxia, colonoscopy impractical and
depending upon the type of dysphasia informed consent
could be an issue. Investigations should probably be
delayed until the outcome of the stroke is clearer, and as
an interim measure exclusion of other haematic deficien-
cies, supplemental iron and possible withholding of
antiplatelet treatment is appropriate. If recovery is satisfac-
tory investigations could be instituted a few weeks later,
and even if colorectal cancer is diagnosed and inoperable
or declined because of operative risk, then such informa-
tion may influence placement or the type of future care
provision. If there is severe residual disability from the
stroke, then investigations should probably not be pursued
and perhaps only considered if severe blood loss demands
repeated transfusion. Myelodysplasia is common in older
people and anaemia is not usually a contraindication to
antiplatelet therapy if monitored closely, or even anti­
coagulation if there is an embolic source and high risk of
further stroke in a recovering patient.
A 70-year-old woman has new onset
exertional chest pain. She has severe
osteoarthritis, walking only a limited
distance, and Parkinson’s disease. Would
you attempt to further the diagnosis of
angina with a stress test?
A stress test could define risk more precisely and identify
whether coronary angiography and potential revasculari-
sation is likely to be of benefit. Pharmacological testing
with dipyridamole, dobutamine or adenosine would be
needed. The likely net befits of investigation and possible
treatments should be explained and her views sought as
to whether to proceed to testing or a more conservative
strategy.
A 48-year-old non-smoker is being
discharged from your ward today following
investigation for chronic diarrhoea. No
cause has been found. He tells you that a
few weeks ago he had a single episode of
‘coughing up a teaspoonful of blood’ that
he’d forgotten to mention until now. His
chest X-ray was normal. What are the
important issues?
There is probably no sinister cause. It has not recurred and
he is a non-smoker with a normal chest X-ray. Neverthe-
less, the haemoptysis remains unexplained. There are
numerous potential approaches to the problem. At one
extreme he might be reassured and told that no further
tests are needed; at the other extreme he could be advised
to have a bronchoscopy to exclude a tumour. Each doctor
has his or her own ‘risk threshold’ for undertaking
628
investigations, but the problem with each is that they do
not involve the patient. It would be important to share
with him that a small lesion may not show up on chest
X-ray and that the only way to be certain of excluding this
would be with further tests. Teamwork is integral to good
clinical care and when you feel out of your depth in
making a decision then you should seek advice.
CASE 4.6  DISCUSSING RISK AND
TREATMENT EFFECT
Candidate information
Role
You are a doctor on the acute medical unit.
Please read this summary.
Scenario
Re: Mr Christopher Roberts, aged 47 years
Mr Roberts was admitted with atypical chest pain and is about to
be discharged on a statin because of a cholesterol level of
6.5 mmol / l. He is obese with a body mass index of 32, and has
numerous other risk factors for cardiovascular disease (CVD)
including smoking, alcohol consumption on the edge of safety and
borderline hypertension. You are aware of evidence that stopping
smoking, statin therapy, targeting his hypertension (alcohol
reduction playing a part), exercise and a ‘Mediterranean’ diet will
significantly reduce his relative risk of CVD and developing type 2
diabetes.
Your task is to discuss his perceived risks and the benefits of
these treatments and lifestyle modifications with him.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
Mr Christopher Roberts is a 47-year-old travel agent admit-
ted with chest pain initially thought to be angina. He is
very relieved to be told that investigations have not shown
evidence of a heart attack or angina and that his pain is
now thought to be muscular resulting from poor posture
and a sedentary lifestyle coupled with a lot of driving and
a recent minor whiplash accident. He is about to be dis-
charged on a statin because of a cholesterol level of
6.5 mmol / l. He is obese, with a body mass index of 32,
and has numerous other risk factors for coronary heart
disease including smoking, 42 units of alcohol per week

and high blood pressure. His father died of a heart attack
at the age of 55.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself and confirm his identity.
2.  Review the history
Recap to him that the tests did not show that he had had
a heart attack but that it was very clear on assessing him
that he had significant risk factors for heart disease.
3.  Clarify the task
Make it clear that reducing his risk of future heart attacks
is the aim of the discussion, and that this is a very achiev-
able goal.
4.  Be alert to ideas, concerns and expectations
That his father died relatively young from a heart attack
may be very much on his mind, but he may not know that
it puts him at increased risk or that overall risk relates to
the interplay with other, modifiable risk factors. Risk per-
ception is discussed in Box 4.6.
5.  Clarify risk
Having established his risk perception, clarify exactly what
his risk factors are – smoking, alcohol, deficient exercise,
high cholesterol and blood pressure – and potential health
consequences of these.
Box 4.6  Risk perception
• Risk perception can determine risk-reducing behaviour. People
who perceive themselves at increased risk of coronary heart
disease are more likely to adopt risk-reducing behaviours such
as smoking cessation, eating a Mediterranean diet, increased
exercise and taking medication. Risk perception consists of two
judgements, the perceived likelihood of an event and the
perceived severity of that event.
• Risks can be discussed in verbal categories, such as likely,
probable and possible, and in absolute probabilities, such as a
10% chance of having the event. Verbal categories mean
different things to different people. People tend to downplay
risk and make overly optimistic judgements of risk in
comparison with others of the same age and sex.
• The perception of being at increased risk is unlikely to motivate
people to adopt risk-reducing behaviours. It is also necessary to
perceive that one has control over the risk of an event and this
has two components – response efficacy is the perception that
risk-reducing behaviour will be effective and self-efficacy is
having confidence in one’s ability to adopt it.
Case 4.6  Discussing risk and treatment effect
6.  Risk communication
Frame advice around the benefits of risk modification
(Box 4.7).
7.  Optimise the likelihood of concordance
Concordance is more likely when risk perception is real-
ised, and he realises risk can be modified and that he can
do it. The message can be reinforced through gentle repeti-
tion and a plan of action and support.
8.  Confirm understanding
Confirm his understanding not just that he is at risk but
that his risk can be substantially reduced.
9.  Encourage feedback and invite questions
I appreciate we’ve covered rather a lot there. Is there anything
you would like me to go over again or are there any
questions you would like to ask me?
10.  Agree a way forward and ensure follow-up
arrangements are in place
This might include writing to his general practitioner 
and suggesting follow-up with the practice nurse, seeing 
a dietitian and attending a smoking cessation advice
service.
Box 4.7  Risk communication
Risk communication involves sharing information about risk, how
to reduce it and ensuring that patients have the confidence to
change their behaviour.
Response efficacy
It is helpful to outline not just the benefits in terms of coronary
heart disease, but also the more widespread benefits of
disease-modifying behaviours.
• Stopping smoking will of course also reduce respiratory disease
and exercise intolerance and be financially advantageous.
• Statin therapy has well-established primary and secondary
preventive outcome benefits.
• Targeting hypertension reduces stroke, coronary heart disease,
renovascular disease and peripheral vascular disease.
• Exercise not only reduces the risk of vascular disease but also
improves physical dexterity and overall well-being.
• A Mediterranean diet produces similar benefits.
Self-efficacy
Habits are hard to break. Patients must not only be aware of the
benefits of trying to improve their situation, but also should be
instilled with the belief that they can. Motivation can be assisted
by trying to identify which consequences of failing to modify
behaviour resonate most with a patient (e.g. not being able to
walk into the garden without feeling breathless by the age of 55,
erectile dysfunction) and support networks and agencies to assist,
such as specialist cardiac and respiratory nurses, smoking advice
services and so forth.
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 Station |4| Communication skills and ethics
Discussion
What is meant by the term prevalence?
This refers to the proportion of individuals in a population
with the condition of interest at a point in time.
Prevalence = number with the condition /
number in the population
What is meant by the term incidence?
Incidence is concerned with the rate of new occurrences.
There are three principal measures of incidence – risk, odds
and rate.
What is meant by the term risk?
Risk is simply the proportion (a 1 in 2 or 50% chance of a
coin landing heads or tails) of disease-free individuals
who develop the condition during the study period.
Risk = number of new cases in the period /
number of disease-free individuals at the start
It is the probability that a disease-free individual will
develop the disease over the period.
What is meant by the term odds?
This is the ratio (a 1 to 1 odds of the coin landing heads
or tails) of the probability of getting the disease to the
probability of not.
Odds = number of new cases in the period /
number who remain disease-free during the period
Odds against disease simply inverts the formula.
If 20 people have a stroke out of 100 in a population
studied (i.e. 80 do not), the risk of stroke is 20 / 100 = 0.2
or 20% and the odds of a stroke is 20 / 80 = 0.25 or 25%.
We could also think of odds as ‘this versus this’ and risk
as ‘this versus the whole population’.
What is meant by the term rate?
Risk and odds assume that all individuals are present
throughout the period. In practice, some enter after the
start and some leave before the end.
Incidence rate = number of cases /
total person time at risk
What is meant by the term risk ratio?
Risk ratio is also referred to as relative risk.
Relative risk = risk in exposed group /
risk in unexposed group
The risk of an event in an exposed or intervention group
is sometimes called the experimental event rate (EER). The
630
risk of an event in the unexposed or control group is
sometimes called the control event rate (CER). Assume the
risk of myocardial infarction in those treated with lipid-
lowering therapy is 1 in 100 (EER) and the risk in the
control group is 2 in 100 (CER). The relative risk of myo-
cardial infarction with treatment is (1 / 100) / (2 / 100) or
0.5. Equally, the risk without treatment is doubled or 2.
What is meant by the term odds ratio?
Odds ratio = odds in exposed group /
odds in unexposed group
What is meant by the term rate ratio?
Rate ratio = rate in exposed group /
rate in unexposed group
If these ratios are 1 there is no difference between
exposed and unexposed groups. If <1, the exposed group
is at lower risk, and if >1 at higher risk.
How does relative risk (RR) differ from
absolute risk (AR)?
Absolute risk refers to the risk difference between exposed
(e.g. treated) and unexposed.
Risk difference = risk in exposed group
− risk in unexposed group
similarly:
Rate difference = rate in exposed group
− rate in unexposed group
These absolute measures are generally referred to as
measures of attributable risk.
Relative risk should be interpreted in the context of the
prevalence of the condition in question. If, for example, a
study showed that the risk of a disease x were doubled by
a particular drug y (e.g. the risk of venous thromboembo-
lism is increased by hormone replacement therapy), then
it is important to place that increased risk in the context
of the likelihood of an event (absolute risk). If the natural
prevalence or absolute risk of disease x is 1 in 1 million,
then the absolute risk in the presence of treatment y is still
only 1 in 500 000. A decision to treat will depend upon
the risk–benefit ratio of treatment y.
Conversely, relative risk may not, at first sight, seem
high, but 10 extra strokes per 1000 people, for example,
would be clinically substantial.
What is meant by the term relative risk
reduction (RRR)?
RRR is an illustration of how the risk of an event has been
reduced by intervention.
RRR = 1 − RR
 Case 4.7  Negotiating a management plan for a chronic disease / long-term condition
If, for example, RR = 0.2, then RRR = 1 − 0.2 = 0.8 or
80%.
What is meant by the term absolute risk
reduction (ARR)?
ARR refers to the number of additional people who benefit
from an intervention out of 100 and is the absolute arith-
metic difference in rates of bad outcomes between control
and experimental groups in a trial. ARR is therefore useful
in determining whether the RRR is important. If CER = 2%
and EER = 1%, ARR is therefore 1% and so 1 in 100 people
benefit from treatment. If the CER is much smaller, say
0.001%, the ARR achieved by the same RRR of 50% is
0.0005%. This ARR would warrant a much higher ‘number
needed to treat’.
What is meant by the term number needed
to treat (NNT)?
NNT refers to the number of patients who need to be
treated to prevent one bad outcome (or achieve one addi-
tional favourable outcome and benefit one additional
patient). NNT is the reciprocal of ARR, i.e. 1 / ARR.
What is meant by the term number needed
to harm (NNH)?
NNH refers to the number of patients who need to be
treated to cause one bad outcome. The lower the NNH,
the more harmful is the treatment.
CASE 4.7  NEGOTIATING A
MANAGEMENT PLAN FOR A
CHRONIC DISEASE / LONG-TERM
CONDITION
Candidate information
Role
You are a doctor on the medical ward.
Please read this summary.
Scenario
Re: Mr Henry Jackson, aged 45 years
Mr Jackson was admitted with a large anterior myocardial
infarction and subsequent heart failure, requiring initial ionotropic
support. His echocardiogram showed moderate systolic dysfunction
and angiography a critical lesion in his left anterior descending
artery for which he received percutaneous coronary intervention.
He has been established on numerous secondary preventive drugs
(aspirin, clopidogrel, a statin, an angiotensin-converting enzyme
inhibitor, a beta blocker and eplerenone). He is being discharged
and has some concerns about going home.
Your task is to discuss his concerns and negotiate a
management plan for him following discharge from hospital.
Your examiners will warn you when 12 minutes 
have elapsed. You have 14 minutes to communicate 
with the patient / subject followed by 1 minute of reflec-
tion. There will then follow 5 minutes of discussion with
the examiners. Do not take the history again except for
details that will help in your discussion with the
patient / subject. You are not required to examine the
patient / subject.
Patient / subject information
Mr Henry Jackson is a 45-year-old man admitted 14 days
ago with a large anterior myocardial infarction. He was
very unwell for the first few days, and developed subse-
quent heart failure. He has had a stent inserted in one of
his coronary arteries. His echocardiogram shows that he
has significant damage to the left ventricle. He is now
taking six different medications. He is very concerned that
he still cannot walk far around the hospital without feeling
a little short of breath. He wonders if he will get back to
a normal life. He is very concerned that he was a previ-
ously very well man working as a manager for an IT
company. He has a wife and two children and could not
afford to give up work. He is a little overweight. He used
to smoke 30 cigarettes per day.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself and confirm his identity.
2.  Clarify the task
Reassure him that your task and expectation is to guide
him back to as normal a life as possible.
3.  Establish the facts
In practice you would establish as much history as possi-
ble but since your communication skills are being assessed
you should explore the concerns as soon as possible.
4.  Explore concerns
The key word is concerns. It is very easy to assume what a
patient’s concerns are likely to be and then address
assumptions. It is not uncommon to overlook a patient’s
concerns when giving advice after, for example, a coronary
syndrome, as there are standard areas that are usually
discussed relating to medications. Patients do not always
voice their concerns, thinking the doctor ‘too busy’ or
because they are afraid or simply do not know how to. It
is important to ask.
There are a number of things to explain before you go home,
but before we start is there anything worrying you in
particular?
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 Station |4| Communication skills and ethics
Concerns will include return to a normal life, return to
work, impact on family life, likelihood of taking tablets
indefinitely, whether it could happen again and the way
forward from here.
5.  Share management options
Patients vary in the extent to which they wish to be
involved in management decisions, but most want to be
informed of possible options. It is worth stating your posi-
tion if there appears to be a strongly ‘right’ option clini-
cally and a patient is not keen to concord (e.g. in taking
secondary preventive drugs). Where there is a range of
clinically acceptable options you could deploy ‘thinking
aloud’ skills, observing the patient’s reactions or asking,
encouraging good ideas and gently countering bad ones:
I wonder…
It might help if…
I expect that if we…(never say what will happen, only what
seems likely)
Explicit categorisation can help, telling your patient that
there are three things, for example, you want him or her
to know, and that they are as follows.
6.  Frame your suggested management plan
Being patient centred is shepherding rather than abdicat-
ing all responsibility for decisions to the patient. As well
as exploring concerns, you will have a framework of things
you need to discuss that might include reasons for each
medication (offering to write these down), need for
follow-up (hospital and cardiac rehabilitation nurse) and
secondary preventive modifications to lifestyle. Most
patients prefer doctors who are open, informative and
consider their concerns, but with one proviso – that their
doctor appears to be actively in control of the problem. A
good analogy is with active and passive listening. A doctor
who sits forward, makes good eye contact and seems atten-
tive is more likely to inspire confidence than one who sits
back and appears uninterested. Equally, a doctor who is
actively trying to negotiate the best management strategy
through considered, informed discussion is more likely to
achieve a better outcome.
7.  Respond to patient cues
Throughout, be alert to his reactions or ask what he thinks,
encouraging good ideas whilst gently countering bad ones.
8.  Confirm understanding
It can sometimes be useful to ask the patient to recount
what they feel to be the important points of the
discussion.
9.  Encourage feedback and invite questions
I appreciate we’ve covered rather a lot there. Is there anything
you would like me to go over again or are there any
questions you would like to ask me?
632
10.  Agree a way forward and ensure follow-up
arrangements are in place
Reassure him of follow-up arrangements with your team,
including the cardiac rehabilitation team, that you will
contact his general practitioner (GP) about his condition
and that you would happily review sooner at any time at
his or his GP’s request if there were any questions or
concerns.
Discussion
What do you understand by the term
chronic disease or long-term condition
(LTC)?
LTCs generally last longer than a year, are incurable,
require ongoing care and often progress. They include
diabetes, arthritis, asthma, coronary heart disease and
chronic heart failure.
Should LTCs be managed by primary or
secondary care?
Integration is crucial! Multiple areas of care have evolved
separately in the NHS (primary care, secondary care, out-
patient clinics, social care, mental health, intermediate
care), but the assumption in the past was that general
practitioners would coordinate all care. But an ageing
population and proliferation of LTCs make this an increas-
ingly difficult task. Ideally, secondary care admissions
should fit as acute episodes within a continuum of care
for a chronic process that is integrated between multiple
services in close liaison. The three broad contexts of man-
aging LTCs are acute care, disease management (monitor-
ing, treatment adjustments, secondary prevention) and
frailty management (recognising when patients, often
with multiple LTCs, and often in the last year or two of
life, can no longer adapt to their environment).
Is there a role for community geriatricians?
The proportion of elderly people with LTCs and frail
elderly is expanding with a predicted doubling of people
aged over 80 in the next 20 years.
The increasing cohort of older people and greater sur-
vival in older people brings with it a greater morbidity in
LTCs often with acute crises prompting admission to hos-
pital. Elderly care expertise in the community clearly helps
to prevent hospital admissions to acute hospitals, to
provide more treatment in community hospitals, and to
maintain people at home with regular review in their
locality. It allows advance decisions to be made about the
appropriateness or otherwise of admission to hospital in
the event of acute illness. It also allows comprehensive
assessment of people entering long-term care. Publications
such as the Department of Health’s Supporting People with
Long Term Conditions, endorsed by the British Geriatrics
Society, make a strong case for the role of geriatricians in
intermediate and community care.
 Case 4.8  Encouraging concordance with treatment and prevention
Most people with dementia and other advancing  Scenario
LTCs have not given any advanced indication of their
wishes in the event of life-threatening illness and whether
or not they would wish to be transferred to an acute 
hospital should they develop pneumonia or other poten-
tially terminal illness. The government’s initiative Pre-
ferred Priorities for Care (formerly Preferred Place of  and urinalysis revealed isolated proteinuria. The renal team
Care) addresses this, and geriatricians, in consultation
with GPs and other health professionals, must ensure
these issues are addressed at a stage when a patient’s cogni-
tive skills are still intact – at least sufficiently so to discuss
with them, their family members and carers potentially
predictable problems. This is not to deny at all that 
many care-home residents may benefit from appropriate
interventions, but where capacity is dwindling extreme
care is needed by people attuned to the person’s needs that
their common-law rights are respected, and take priority
over defensive actions by care-home managers or deputis-
ing services that default to acute hospital admission. If
appropriate and timely sensitive discussions and decisions
are implemented, and community support is available
with geriatrician support, inappropriate admissions to
hospital and undue distress to patients and relatives  are not required to examine the patient / subject.
could be avoided; and instead of aiming to achieve 
admission in less than 4 hours through the emergency
department many patients will be better served by 
advance decisions and community care in a familiar and
more comfortable environment rather than the acute
hospital.
A major role of day hospitals, where patients could
receive low-intensity investigation, treatment and care,  He was started on perindopril and amlodipine to control
was to preserve frail people in the community, but this,
sadly, was largely eroded by the advent of private nursing
home care.
Are domiciliary visits still important?
Domiciliary visits generally serve one of three purposes –
to assess patients too unwell or frail to visit outpatient
clinics, to assess patients in their own environment and
understand the medical and social context and, rarely
these days, to provide the human face of the hospital –
seen by many as a place of no return to fear – and reas-
surance that the aim is to enable rather than be the thin
end of the wedge that culminates in nursing home
placement.
CASE 4.8  ENCOURAGING
CONCORDANCE WITH TREATMENT
AND PREVENTION
Candidate information
Role
You are a doctor in the medical outpatient clinic.
Please read this summary.
Re: Mr Marc Davey, aged 46 years
Mr Davey was in hospital 2 months ago with severe
hypertension (240 / 120 on admission) and renal impairment.
Investigations did not reveal a secondary cause for hypertension
decided against renal biopsy and thought it very likely he had
nephrosclerosis from hypertension. He was established on an
angiotensin-converting enzyme inhibitor and calcium channel
blocker. His electrocardiogram showed left ventricular hypertrophy.
His blood pressure on discharge was 140 / 85 but today in clinic is
180 / 100. He told the nurse that he has not been taking his
medications because he has felt well.
Your task is to discuss ways to improve his blood pressure
control.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
Patient / subject information
Mr Marc Davey is a 46-year-old man being reviewed in
clinic. He was in hospital 2 months ago with headaches,
severe hypertension and resulting kidney damage. Investi-
gations did not reveal a secondary cause for hypertension.
his blood pressure but stopped taking these soon after dis-
charge because he developed an irritating cough. He has felt
well since and did not see a need to continue medications.
The hospital team had told him it was important to con-
tinue taking tablets but he does not remember the reason.
He has a wife and two children and enjoys life. He is not
overweight, but has successfully given up smoking. He
manages a vineyard, but does not consume excess alcohol.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself and confirm his identity.
2.  Clarify the task
Make it clear that achieving better control of his blood
pressure is the aim of the discussion. Do not assume at
the start that you are dealing with poor concordance.
3.  Explore whether poor concordance could be
a problem
The term concordance is often preferred to compliance
since the former suggests agreement between patient 
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 Station |4| Communication skills and ethics
and doctor. Concordance should always be checked  7.  Repeat important information
before evaluating the effectiveness of a treatment. Non-
concordance with antihypertensives is common, and it is
important not to apportion blame. Patients do not take
medications for many reasons and the discussion should
begin with this premise and not by highlighting this
patient’s ‘failure’. Before you attempt to influence him in
taking his medications, consider the three questions in
Box 4.8.
4.  Be alert to ideas, concerns and expectations
His cough is probably the result of the angiotensin- 
converting enzyme (ACE) inhibitor but he may think it a
side effect of all antihypertensives. He may, at the time,
have appreciated the severity of his illness but may not
understand that despite feeling well hypertension could
lead to worsening chronic kidney disease and an ultimate
need for renal replacement therapy. He may also not
understand the other effects of uncontrolled hypertension,
notably stroke.
5.  Counter misunderstandings
Explain that ACE inhibitors can cause cough, but not
amlodipine, and that there are alternatives (e.g. angi-
otensin receptor blockers). Explain the risks of uncon-
trolled hypertension.
6.  Discuss management options within a clear
framework
Frame the discussion around advantages that are likely to
be important to him – retarding progressive chronic
kidney disease, reduction in stroke risk, need for future
hospital admissions and so on. Such gift wrapping of treat-
ments can be highly effective. Sometimes illustrating the
point with reference to a similar case can help. Explain
that all blood pressure tablets can have side effects but that
these are usually mild and if problematic a different tablet
can always be considered.
Box 4.8  Questions about concordance
Are you dealing with poor concordance?
Often the importance of taking medications has not been carefully
explained or sufficiently emphasised. Even when explained, patients
may still not fully understand or may forget the importance of
medication.
Is poor concordance due to iatrogenic
symptoms?
Always consider drug side effects or drug–drug interactions as a
reason for a patient not taking prescribed medication.
Is the poor concordance due to another reason
that needs to be explored?
Very often, poor concordance is due to discrepancy between what
the doctor sees as important and what the patient sees as
important.
634
This is especially important when poor concordance 
may be due to misunderstanding or previous poor
explanation.
8.  Confirm understanding
It can sometimes be useful to ask the patient to recount
what he or she feels to be the important points of the
discussion.
9.  Encourage feedback and invite questions
I appreciate we’ve covered rather a lot there. Is there anything
you would like me to go over again or are there any
questions you would like to ask me?
10.  Agree a way forward and ensure follow-up
arrangements are in place
Reassure him of follow-up arrangements and that you
would happily review sooner at any time at his or his
general practitioner’s (GP) request if there are questions
or concerns.
Discussion
A 34-year-old man being treated for a
high-grade non-Hodgkin’s lymphoma on
your haematology ward is 3 days into a
chemotherapy regimen involving high-dose
steroids. This morning, according to your
house officer, he was in a strange mood,
tearful but also declaring he believed
himself cured. He left the ward in pyjamas
and overcoat and has not returned. What
should be done?
Patients have the right to decide how they are going to be
treated and indeed whether they are going to be treated.
Such autonomy should be respected. But where declining
treatment is likely to have serious consequences it is
imperative to explore a patient’s reasoning. Here, iatro-
genic mood disturbance from high-dose steroids must be
considered, and his ‘autonomy’ questioned until further
assessment has been made. Informing ward staff, the con-
sultant, the patient’s GP, relatives, and, on discussion with
the consultant, involving hospital security and the police
(restraint under the Mental Health Act is generally a last
resort but may need to be instituted) are steps which may
be needed to ensure his safety.
How might you help persuade a patient
to stop smoking?
As well as the serious cardiac, respiratory and neoplastic
risks of smoking, it carries considerable social harms and
promotes premature ageing. Smoking cessation (Box 4.9)
carries immediate benefits, including mortality reduction,
and reduces the risk of many diseases including

Box 4.9  Discussing smoking cessation
Ask about current smoking status
This includes asking about whether other household members
smoke.
Advise about the benefits of smoking cessation
These include physical, social, financial and cosmetic. Emphasise the
health benefits of stopping rather than the risks of continuing
smoking. Reinforce the patient’s own motivation for wanting to stop.
Ask about reasons for wanting to stop and
assess motivation
Ask if the patient really wants to stop and if they would be
prepared to stop now or within the next few weeks. Find out about
previous attempts to stop and what measures helped or hindered.
Ask if other household members are willing to stop, too.
Discuss ways of assisting
These could include setting a date and stopping completely,
enlisting the help of family and friends, enlisting the help of health
promotion services and GP, nicotine replacement therapy (best
avoided in severe cardiovascular disorders) and bupropion
(amfebutamone). It helps many patients to consider themselves
‘non-smokers’ rather than ‘ex-smokers’.
cardiovascular disease, chronic obstructive pulmonary
disease, cancer of lung, mouth, throat, larynx, oesophagus,
pancreas, bladder and cervix, peptic ulcer disease and
complications of pregnancy. Nicotine addiction is now
acknowledged as a treatable condition and there is sub-
stantial evidence of the effectiveness and cost effectiveness
of behavioural and pharmacological interventions.
Communication in special
circumstances
CASE 4.9  CROSS-CULTURAL
COMMUNICATION
Candidate information
Role
You are a doctor in the medical outpatient clinic.
Please read this summary.
Scenario
Re: Mr Ash Khan, aged 38 years
Mr Khan is an asylum seeker. He has been in the UK for 1 year
with his family and was referred to your clinic with sweats, fevers
and painful joints, although language differences have thwarted
some elements of history taking on previous occasions. On one
occasion you had an interpreter in clinic but he is not here today.
However, Mr Khan’s English comprehension has improved steadily
over the last year. After extensive investigations he appears to have
Case 4.9  Cross-cultural communication
chronic osteomyelitis of his knee. Tuberculosis has not been
suggested by chest X-ray or other results so far.
Your task is to explain the likely diagnosis to him and
propose referral to your orthopaedic colleagues for further
treatment and possible bone biopsy and surgery.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient/subject.
Patient / subject information
Mr Ash Khan is a 38-year-old asylum seeker. He has been
in the UK for 1 year with his wife and two children and
has found work in a restaurant. He was referred to clinic
with sweats, fevers and painful joints, although language
differences have thwarted good history taking on previous
occasions. On one occasion there was an interpreter in
clinic but he is not here today. However, Mr Khan’s English
comprehension has improved steadily over the last year.
After extensive investigations he appears to have chronic
osteomyelitis affecting his knee. Tuberculosis is possible
but not likely on the basis of tests so far. Mr Khan simply
wants to be relieved of pain and has been taking a lot of
tablets from a local herbalist.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself and confirm his identity. Inevitably if
there are language differences a consultation has the
potential to take longer and ideally in practice (not in
PACES) you would allow more time for this.
2.  Remember to treat patients equally and do
not do very much differently!
When people communicate, there is a vast array of cultural
influences. Cultural background, health beliefs and expec-
tations affect all health-care encounters with patients. These
differences may seem stark when there is an additional
language difficulty, but perhaps most important is to
remember that we are usually more similar to each other
than we are different! The range of human beliefs, concerns
and expectations that we must be aware of with any patient
needs to be considered, and perhaps with heightened
awareness when treating people from different cultures.
Beware of the tendency to stereotype people – to assume
they have characteristics because they appear to belong to a
certain group. When stereotyped, people can become
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 Station |4| Communication skills and ethics
victims of prejudice – opinions, often unfavourable, formed
without good reason. This can jeopardise good care.
3.  Establish as far as possible the patient’s
concerns and give non-verbal reassurance
This patient might simply want to have his pain relieved,
and you should indicate that this too is a concern of yours,
but that you wish to treat the underlying cause.
4.  Frame your suggested management plan
The medical steps are fairly clear – continuing to relieve pain,
and urgent referral to orthopaedic colleagues. Sometimes
religious reasons mandate an approach to management.
During Ramadan, for example, Muslim patients may not eat
anything, including tablets, during daylight hours and often
eat a large meal after dark. Type 2 diabetes is common in
Asian people and if Muslim there may be important reper-
cussions on the style of management chosen.
5.  Keep explanations clear and simple,   education, socioeconomic background, language, family,
avoiding jargon
The same principles of good communication apply when
dealing with patients from different cultures. In other
words, you should try to do more of the same, rather than
treat such patients differently. In this case, as well as
explaining the way forward with respect to input by the
knee specialists, you might need to counter the herbal
remedy beliefs. You might also need to explore his work
further, particularly if tuberculosis is still in question!
6.  Repeat important information
This can be particularly important when communicating
with people whose first language is not English.
7.  Respond to patient cues
Throughout, be alert to his reactions or ask what he 
thinks, encouraging good ideas whilst gently countering
bad ones.
8.  Confirm understanding and acceptance
It would be important to ask him to recount what he
understands to be the main points of the discussion.
9.  Encourage feedback and invite questions
Is there anything you would like me to go over again or are
there any questions you would like to ask me?
10.  Agree a way forward and ensure follow-up
arrangements are in place
Ensure that there are arrangements for treatment and
follow-up.
Discussion
What do understand by the term culture?
It refers to the shared beliefs, values and attitudes that
guide the behaviour of a social group. It is applied most
636
Box 4.10  Potential problems when using
interpreters
• Assuming the patient cannot understand any of what is being
said – beware of assumptions and seek to find out what a
patient can and cannot understand
• Failure to address both the patient and the interpreter
• Failure to communicate simply and in small chunks
• Incorrect understanding or transmission of information
• Avoidance of delicate topics
• Domination of the patient by the interpreter
• Failure to allow enough time (at least a doubling of time is
often required)
commonly to describe people of a shared national, ethnic
or regional origin, but there is a dynamic social context
for every individual’s culture that embraces age, gender,
occupation, religion and so forth.
What potential problems may arise when
using interpreters?
These are outlined in Box 4.10.
CASE 4.10  COMMUNICATING
WITH ANGRY PATIENTS
OR RELATIVES
Candidate information
Role
You are a doctor on the medical ward.
Please read this summary.
Scenario
Re: Mr Charlie Buchanan, aged 69 years
Mr Buchanan has a left hilar mass on his chest X-ray,
discovered during the course of investigations for pneumonia.
The computed tomography scan suggests a potentially operable
bronchial carcinoma, with lymphoma the main differential
diagnosis. Although recovered from his pneumonia, and now
feeling well, he was kept as an inpatient because the respiratory
team had a slot for bronchoscopy at the end of the week.
However, you have now been informed it has been postponed
because of a full list of urgent bronchoscopy appointments. You are
also aware that the respiratory team is thin on the ground next
week because of a conference and have been informed by the
respiratory specialist registrar that it will be the week after next.
He advises you to send Mr Buchanan home in the meantime. Mr
Buchanan is angry.
Your tasks are to listen to his concerns and discuss possible
solutions.
 Case 4.10  Communicating with angry patients or relatives
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
Mr Buchanan is a 69-year-old man with possible lung
cancer discovered on chest X-ray during the course of
investigations for pneumonia. The computed tomography
scan suggests a potentially operable tumour. Although
recovered from pneumonia, and now feeling well, he was
kept in hospital because the respiratory team had arranged
his bronchoscopy at the end of the week. However, the
respiratory specialist nurse advised him that this has now
been postponed and that it might be best if he went home
as the respiratory team will not be around next week. Mr
Harris does not think he should be told ‘what is best for
him.’ Mr Buchanan lives alone and his son and daughter-
in-law are going on holiday next week. He has a history
of anxiety and depression and feels that going home
without all of this being resolved and without support will
be hard. His wife died from oesophageal cancer 2 years
ago and he recalls similar delays with her investigations.
He is worried that each day missed is a day when the
cancer could be spreading. He has always been an avid
supporter of the NHS but his support is now beginning to
waver and with this news he feels angry. He is particularly
upset that the respiratory team are going to be ‘sunning
themselves’ whilst he waits for vital tests.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduce yourself
Introduce yourself and confirm the name / identity of the
patient.
2.  Make it clear that you want to help
Show from the outset that you are here to try to help.
Remain polite. The nature of medical training equips most
doctors well with the skills of negotiation. Some patients
simply do not have these skills. People are capable of
acting out of character and appearing aggressive when
upset. His primary motivation is likely to be fear or dis-
tress and he is depending on you to help. Do not take any
criticisms of the system personally.
3.  Remember to deal with emotions before facts
and that anger is not usually anger
Always try to calm emotions before dealing with any facts
and remember that anger is usually secondary to another
emotion such as fear, guilt or uncertainty. Discovering the
underlying emotion is far more likely to achieve resolu-
tion than taking anger at face value. Since minor disagree-
ment can explode unpredictably into more serious
confrontation, dialogue should, from the start, work
towards de-escalation and resolution.
4.  Acknowledge the concerns
Legitimising rather than confronting his understandable
concerns will help bridge the gap between his initial anger
and your remit to help:
Obviously you are very upset by this. I understand.
I can understand fully why you are upset. I am very concerned,
too, that you are having to wait.
5.  Explore the emotions and concerns
In this case fear of cancer spreading and opening of the
old wounds of his wife’s experiences will doubtless be
forefront in his mind:
I agree that we must sort this out as quickly as possible. I will
do everything I can to help. It will help me if I understand
what you fear most if the investigations are delayed.
6.  Work towards resolution, weaving in the facts
Steer away from areas of conflict – comments from other
staff that may have upset him, for example. Good com-
munication and finding common ground are the keys to
successful resolution. Focus on constructive ways forward.
7.  Try to ameliorate concerns that can honestly
be ameliorated
Give clear advice and honest professional opinions about
the implications of delay. Delays in investigations are
unhappily part of everyday experience in the NHS, and 
not always with as devastating implications as patients
imagine.
8.  Never criticise colleagues
Avoid comments that might incriminate colleagues. It
would not help to focus on the fact that the respiratory
team is largely away next week, as educational events are
inevitable and essential components of medicine and you
are not responsible for how another team has organised
itself or at liberty to comment. Criticism of any colleague
or department or service is always counterproductive. Most
NHS employees are stretched and working together is
paramount.
9.  Encourage feedback and invite questions
I appreciate we’ve covered rather a lot there. Is there anything
you would like me to go over again or are there any
questions you would like to ask me?
10.  Agree a way forward
Assure him that you will find out exactly when his test is
going to be.
637
 Station |4| Communication skills and ethics
Box 4.11  Handling threatening, abusive and
violent behaviour
• Unhappily abuse by patients to staff is increasingly
common, often threatening words but sometimes physical or
even sexual.
• Doctors must avoid the temptation to take the law into their
own hands, and first and foremost appreciate that there are
often medical reasons for this (confusion due to infection or
metabolic disturbance, for example) and such patients cannot
be left without treatment.
• If threats are towards a particular staff member they should no
longer be involved in that patient’s care.
• Sedation may be considered if violence is a symptom
of illness and it is necessary to prevent injury to patient
or staff.
• Restraining measures are occasionally necessary, but may
inflame or worsen a situation and cot-sides are frankly
dangerous.
• Advice from a psychiatrist may be sought, especially if
anti-psychotic medication is needed.
• Security should be called immediately if a patient is physically
violent. But removal by the police is not acceptable if there are
medical reasons underlying the behaviour.
• Empathy and practical support might need to be given to
nursing and other staff.
Discussion
Would you encourage him to make a formal
complaint?
He is perfectly at liberty to complain, but more imperative
is to find a mutual way forward than potentially drive the
divide further by encouraging a complaint. However, if he
requests help in making a complaint you should direct
him to the local complaints procedure. If you feel that
there may be a system failure a Clinical Incident report
could be forwarded to Trust Risk Management.
What do you do if a patient is threatening,
abusive or violent?
Strategies are outlined in Box 4.11.
CASE 4.11  COMMUNICATING
WITH UPSET OR DISTRESSED
RELATIVES
Candidate information
Role
You are a doctor on the acute medical unit.
Please read this summary.
638
Scenario
Re: Mr George Tilner, aged 63 years
Ms Tilner is the sister of a 63-year-old man, Mr George Tilner,
who has just died in the emergency department. He had advanced
non-Hodgkin’s lymphoma that was no longer responsive to
chemotherapy, and had recently received palliative radiotherapy. He
was admitted 2 hours earlier from a peripheral hospital with sepsis
and peri-arrest but your rapid perusal of his case notes showed
that he had spinal and renal metastases and you judge that a
decision to resuscitate would not be appropriate if he had a
cardiac or respiratory arrest despite fluids and antibiotics. He was
an accountant and his last wish was that he completed his clients’
work and that his briefcase be brought with him in the ambulance.
You know that his sister is in the relative’s room, and is very upset.
Your personal feeling is that an advance decision should have been
made to manage any deterioration at the peripheral hospital.
Your tasks are to explain to her that he has died, and manage
the emotional situation.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
You are the sister of Mr George Tilner, a 63-year-old man
admitted to the emergency department 2 hours ago from
a peripheral hospital. He has advanced non-Hodgkin’s
lymphoma that was no longer responsive to chemother-
apy, and had recently received palliative radiotherapy. You
have just arrived at the hospital, having received a call
from nursing staff at the peripheral hospital to say your
brother was very unwell with infection and was being
transferred to the emergency department. He was an
accountant and his last wish was that he completed his
clients’ work. Although you knew he was very unwell, you
are still awaiting news from the doctor about his condi-
tion. You hope the doctors will do all that they can to save
his life, but your sister-in-law is a district nurse and has
gradually persuaded your over recent weeks that in the
event of a deterioration from which recovery seems remote
it might be best to ‘let him go’ peacefully. You are about
to speak to the doctor.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Preparation and scene setting
Introduce yourself and confirm the identity of the relative.
Ideally, you would ensure that a member of the nursing
staff is there, and talk in a setting where interruptions are

very unlikely to occur. Sit at the same level as the relative,
and use a calm tone.
2.  Give vital information early
Do not give a detailed account of events up to his death,
other than making it clear that he was very unwell.
Ms Tilner, your brother was very unwell – comatose – when he
arrived, and I am very sorry to tell you that he has passed away.
While bad news communicated to patients should be
delivered gently with attention to cues from the patient,
communicating the death of a patient to a relative should
be equally gentle but not delayed, with attention to cues
guiding subsequent discussion.
3.  Deal with emotions before facts
She is unlikely to take in much more, if any, information
immediately. Allow her time to exhibit emotions.
4.  Acknowledge distress and support ventilation
of feelings
Above all, people need to know that you understand, and
you can do so non-verbally, practically (e.g. by offering
tissues) or by acknowledging that emotions are under-
standable (legitimising). Remember that at this point
patients are too preoccupied to assimilate further
information.
5.  Respond to patient cues
Throughout, be alert to any cues.
6.  Gently explain what happened
Usually, distressed relatives say what they need to say, and
you are there to support, acknowledge and provide what-
ever additional comfort seems intuitive.
I know that he was very ill. And I know he wouldn’t have
wanted to suffer. His wife, my sister-in-law, knew that he
didn’t have very long. It’s just such a shock. But he wouldn’t
have wanted things to drag on and be in pain, I know that.
It might be right to say, at this point:
I know it may not be of any great comfort now, but I think it is
important you know that I do not believe that he was in any
pain … or even aware of things.
Keep all explanation clear and straightforward.
7.  Do not raise personal concerns
Your feeling that acute admission might have been avoided
with advance planning is not helpful at this time. Focus
on supporting her through what has happened.
8.  Identify patient support systems
Try to establish who, if anyone, is going to be available to
be with her.
Case 4.12  Discharge against medical advice
9.  Check present information needs
While it is generally good practice to encourage feedback
and invite questions, this is one situation where asking 
a relative if she has further questions can sound a little
pressurising if handled as a direct question. It might 
be preferable to give an assurance that you can answer
questions now but are available to talk further at any time
later.
10.  Make clear what support is available
I’ll leave you with sister / staff nurse for now, but I am here, and
my team are here, at any time.
Discussion
How might you detach yourself from
distressed relatives?
It can sometimes be difficult to detach yourself from rela-
tives who are very distressed or upset, although largely
there is a discernible point when all that is to be said has
been said and relatives are not ready or able to ask more
questions. You should always leave relatives with a point
of contact, usually a nurse, and express your willingness
to come back at any time if there is anything you might
help with or answer.
CASE 4.12  DISCHARGE AGAINST
MEDICAL ADVICE
Candidate information
Role
You are a doctor on the medical ward.
Please read this summary.
Scenario
Re: Miss Sarah Walker, aged 23 years
Miss Walker was admitted 12 days ago with high fevers,
subsequently confirmed as acute bacterial endocarditis. She has
been on intravenous antibiotics four times daily with advice from
microbiology. She was taking intravenous heroin until the date of
admission and with assistance from the drug and alcohol advisory
service is now on an appropriate methadone replacement regimen.
She now wishes to discharge herself from hospital. She says that
she feels better. She spends considerable time off the ward
smoking, and the nursing staff have expressed concerns about
possible ongoing drug misuse, as her partner meets her outside the
hospital. Your medical plan is to keep her in hospital until her
inflammatory markers are much improved, with repeat
echocardiography. There remains the possibility of cardiothoracic
surgery being needed if her valve decompensates.
Your tasks are to explore her reasons for wanting to
self-discharge, discuss the medical reasons for her staying and find
alternative solutions if she cannot be persuaded to stay.
639
 Station |4| Communication skills and ethics

Your examiners will warn you when 12 minutes  4.  Explain the medical reasons for wanting the
have elapsed. You have 14 minutes to communicate  patient to stay
with the patient / subject followed by 1 minute of reflec-
tion. There will then follow 5 minutes of discussion with This is essential for her to reach an informed decision
the examiners. Do not take the history again except for because she might be unaware that the micro-organisms
details that will help in your discussion with the must be fully eradicated (and that this usually requires a
patient / subject. You are not required to examine the few weeks of intravenous antibiotics) otherwise the
patient / subject. problem will recur, with worsening damage to the valve.
Explain also that the diseased valve must be reassessed
after treatment. Confirm her knowledge that intravenous
Patient / subject information drug use is a high-risk practice for developing
Miss Sarah Walker is a 23-year-old woman admitted 12 endocarditis.
days ago with high fevers, subsequently confirmed as acute
bacterial endocarditis. She has been on intravenous anti- 5.  Aim to address the patient’s concerns
biotics four times daily. She was taking intravenous heroin
It would be wise to ask the social worker to review the
until the date of admission and with assistance from the
welfare of the children. This could be presented in a non-
drug and alcohol advisory service is now on a methadone
judgemental way to her partner. He would have a right to
replacement regimen but does not feel the dose adequate
look after his children if he is the father and he is fit to do
because she still feels psychological withdrawal. She is very
so but if he is not the father, or if there are concerns as 
keen to try to stop heroin altogether. She has two young
to his fitness to do so, then social workers could 
children at home, both currently being looked after by 
become involved on the presumption of assistance but in
her partner. She has little confidence in him doing so
parallel explore the children’s safety. It might also be 
because he was the person who introduced her to drugs
possible for the children to visit hospital more or for 
and continues to keep unreliable hours at home. She 
her to be allowed home for periods of time between 
is meeting him regularly outside the hospital to try to
antibiotic treatment, although not wise to send her into
negotiate his agreeing to her sister, whom she trusts, 
the community with an intravenous cannula. Addressing
caring for the children. She now wishes to discharge
her other concerns could also lessen the impact of
herself from hospital because of her concerns. She spends
hospitalisation.
considerable time off the ward smoking, but feels the
attitudes of the nursing staff are prejudiced against this,
while she feels it is currently her only enjoyment. Venous 6.  Accept that the patient may self-discharge
access is poor and although she has ‘had enough’ of treat- It is, ultimately, a competent, informed patient’s accepta-
ment she might be persuaded to continue if she knows her ble choice to self-discharge if she or he wishes.
children are safe.

7.  If self-discharge seems inevitable, try to reach

How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself and confirm her identity.
2.  Make it clear you want to help
It is crucial to start with the premise that she may have
fully understandable reasons for wanting to leave hospital,
and show that you are prepared to listen to these.
3.  Explore concerns and reasons for wanting to
self-discharge
Patients’ stated reasons for wanting to self-discharge may
mask deeper or more personal reasons. Fears for family
members are often high on the list. Frequently a list of
factors conspires to make the hospital unpalatable –
uncomfortable investigations and treatments, poor com-
munication, noisy wards, other patients, disturbed sleep,
unpalatable food ….
the best compromise
This might include discussing with the microbiologist the
possibility of less frequent intravenous antibiotics deliv-
ered by a district nurse and / or oral antibiotics and early
follow-up in clinic.
8.  Confirm understanding and acceptance
Confirm that she is fully informed to make her 
decision.
9.  Encourage feedback and invite questions
I appreciate we’ve covered rather a lot there. Is there anything
you would like me to go over again or are there any
questions you would like to ask me?
10.  Agree a way forward and ensure follow-up
arrangements are in place
Ensure that she signs a self-discharge form taking legal
responsibility for her own care, document all discussions
clearly and inform your consultant and her general prac-
titioner of arrangements.

640

Discussion
Is a discharge against medical advice form a
legal necessity?
It is not legally necessary, although it may enhance future
evidence to obtain signed declaration by the patient that
discharge is against advice. It is important to document
that the patient had capacity and was fully informed and
understood the medical reasons for staying.
CASE 4.13  DELAYED DISCHARGE
Candidate information
Role
You are a doctor on an elderly care ward.
Please read this summary.
Scenario
Re: Mrs Anna Clare, aged 93 years
Mrs Clare was admitted to your ward 1 month ago with
numerous medical problems – inoperable peripheral arterial
occlusive disease, anaemia due to aspirin-induced gastritis,
dizziness induced by antihypertensives and back pain due to
osteoporosis. She has a past history of recurrent strokes and may
have had a further one whilst in hospital. She is now very unsteady
even with a walking frame and assistance and unsafe to go home.
She has poor memory. She accepts she may need nursing home
care. Her daughter, Mrs Kenton, is keen on this but wants her to
stay in hospital until the ‘right one comes up.’ An interim place is
available in a home that is not the daughter’s favoured choice.
Your task is to discuss potential discharge solutions with the
daughter.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
You are Mrs Kenton, daughter of Mrs Anna Clare who is
aged 93. Mrs Clare was admitted to hospital 2 weeks ago
with numerous medical problems (previous strokes, poor
memory, poor circulation, anaemia to aspirin, dizziness
due to anti­hypertensives and osteoporosis). The major
issue is that she is no longer safe from the point of view
of either her mobility or her ability to be at home and has
accepted long-term residential care. You have inspected
numerous nursing homes on the advice of the social work
department and have a very definite favourite where a bed
will not be available for an indeterminate time, possibly
Case 4.13  Delayed discharge
many weeks. An interim bed is available and has been
suggested by the discharge team in an alternative nursing
home, but your father died in that nursing home and you
do not want her to go there. You feel she would receive
better care in hospital until the favoured placement
becomes avail­able, but would be amenable to considering
alternatives that did not carry sad and emotive memories.
You hope the doctor will agree to this and feel your mother
deserves such care.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself and confirm the name / identity of the
relative.
2.  Make it clear that you want to help
Establish from the outset that you want to work with her
to find the best possible solution that caters for the
optimum care her mother deserves. The fastest way to dis-
solve rapport and thwart a way forward is to give the
impression that you are there to tell her what to do.
3.  Start by listening and agreeing
Ask her if she understands exactly what has happened to
her mother during her lengthy hospital admission, and
offer to summarise it. Then state ground where you are
likely to both agree:
That’s right. We are, of course, very pleased that she has
recovered somewhat from the problems that brought her into
hospital. But there have been significant problems, as I know
you are very much aware, some of which are unlikely to go
away and some of which could even get worse over time. So
it is the opinion of our nursing staff, our therapists, ourselves,
and most importantly of course, herself and yourself, that she
would be safer in the longer term in a place where full-time
care could be provided.
4.  Explore ideas, concerns and expectations
Explore any specific fears she has about particular nursing
homes. There is a clear reason she does not want to
proceed with one nursing home and that is very reason-
able to accept.
I understand. I am sorry that that one was suggested to you.
5.  State a suggested management plan
I understand that you have a favoured nursing home. We would
of course support her getting a place there. What may be less
easy is to get it quickly, and if that is the case then we need
to think very carefully about finding a way forward that is
acceptable to her and which provides for her needs.
She may say that hospital is surely the best place for her
mother until such time.
641
 Station |4| Communication skills and ethics
Hospital has certainly been the best place for her, whilst she has
been so unwell. But an acute hospital setting is not
necessarily the best place at this stage. Because our nursing
staff and therapists are so necessarily occupied with their
acutely unwell patients, they do not always have that much
time with less acutely unwell patients, who by their very
nature may be more stimulated to do things in a more
streamlined setting. There are also risks to being in hospital
that we often take for granted, but which should not be
ignored – the fact that a hospital bed in a ward of acutely
unwell patients carries by its very nature an increased risk of
developing hospital-acquired infections.
6.  Be alert to cues
She is likely to show acceptance or disappointment in your
suggestions. Look out for cues, and respond if necessary.
7.  Do not criticise hospital managers
Managers generally want to help and must give patients
choice until the multidisciplinary team confirms the need
for a specific transfer. Never tell patients or relatives you
would like patients to stay in but managers will not allow
it. We all have a duty to discharge or transfer as soon as
appropriate. Managers are often prepared to come and talk
with patients, explaining the number of acute coronary
syndromes waiting in emergency departments (there has
been an appreciable increase in medical admissions since
the mid-1990s but an unparalleled and relentless sharp
upstroke, especially in the elderly, since autumn 2004 –
with complex reasons but perhaps in part related to a
decrease in out-of-hours primary care) and assuring
patients that they will get the bed they want but that they
cannot wait for it in an acute hospital bed. What they
cannot do is put a patient in an exiting ambulance against
their will (assault) or evict (not legally tested and brave
the Trust that tries!). There will always be the difficult or
resistant 1% of patients or relatives (but with the best of
intentions and at an emotional time).
8.  Encourage feedback and invite questions
I appreciate we’ve covered rather a lot there. Is there anything
you would like me to go over again or are there any
questions you would like to ask me?
9.  Confirm understanding and acceptance
Make sure that she is generally accepting of your sugges-
tions so far.
10.  Agree a way forward
Agree, for example, to speak to the hospital discharge team
and discuss appropriate interim alternatives.
Discussion
What is an integrated care pathway (ICP)?
ICPs aim to map a patient’s journey from admission to
discharge or beyond and have been used for many condi-
tions including stroke but have not been shown to improve
642
outcome measures where a unit already functions well.
ICPs are more useful in setting up a new unit from scratch.
Clerking proformas for particular diseases such as stroke,
however, may be useful.
Hospital trust managers are very keen on
discharge planning. Do you think you
should be as concerned as your hospital
managers?
Discharge planning is a crucial part of modern hospital
practice, and often badly managed. Depending upon the
patient, it might include information to patients and
carers, training of carers, pre-discharge home visits by the
multidisciplinary team (initially to assess the home and
subsequently to assess the patient in their home), pre-
discharge case conferences for patients with complex care
packages, clear instructions of who to contact should there
be problems, further community rehabilitation at home
or in a day hospital and follow-up arrangements.
What is early supported discharge?
Early discharge of selected patients is cost effective and safe
(shown by Langhorne and colleagues in a metaanalysis
published in the Lancet in 2005). It might include
three to seven daily visits per week for up to a month by
the multidisciplinary team (e.g. occupational therapy
assistant, physiotherapy assistant, health-care assistant).
Is there a role for discharge teams?
Increasing pressure on ward staff with acute admissions
within a target-driven health service, and in the context of
changing community resources and a thrust towards
patient choice, has led to difficulties in finding time for
optimum discharge planning. Discharge teams assist when
complex discharge is likely. Such patients might be elderly,
need rehabilitation, have social problems including home-
lessness, or have palliative care needs. Concerns might also
be raised by the family. Discharge teams help patients
through the system by ensuring maximum utilisation of
community hospital beds, identifying rehabilitation needs,
ensuring timely paperwork, working with, for example,
social work and palliative care, and generally acting as a
resource for discharge-related dilemmas. Patients will gen-
erally be discharged to one of three settings, as follows.
Home
A good social history is vital, and discharge teams may
work to integrate this information, for example by using
a booklet at the end of the bed for the patient and family
to fill out, along with:
• Assessing the realism of the patient’s expectations
• Ensuring early referral to occupational therapy,
physiotherapy or social work
• Prompting multidisciplinary discussion
• Prompting specialist assessment of care needs
(SACN) and care packages

• Identifying community resources such as nurse
specialists, the voluntary sector, the housing
department and interim placement.
Rehabilitation or other interim settings
Discharge teams coordinate rehabilitation or other com-
munity beds for patients who might benefit from rehabili-
tation or for patients with chronic diseases, who have
palliative care needs or who are awaiting care packages or
assessment for entry into long-term care.
Care home (residential or nursing, but the term
care home has been adopted since 2003)
Ideally the patient, family and the multidisciplinary team
should agree on this. Once medically ready for discharge
and the SACN has been given to the social work depart-
ment, a patient’s discharge is officially delayed, and there
then arises:
• Pressure on the patient and family to find a care
home (or accept interim placement) based on advice
from social workers as to which may be appropriate
based on the SACN (if a nursing home is needed
then the nursing home staff also assess the patient)
• Pressure on the social work department, whose
reimbursement starts dwindling for each day lost,
and pressure on the hospital because an acute bed is
blocked.
What is meant by delayed transfer
of care (DTOC)?
DTOC occurs when a patient is ready for discharge from
an acute bed (clinical decision, multidisciplinary team
decision, safe to do so) and there is no medical reason for
the delay. There are various categories, depending on the
reason for DTOC, such as lack of availability of onward
placement, delayed funding, delay in arranging domicili-
ary packages or delay in community equipment. It incurs
bills immediately to social services. The conflicting
mantras imposed on the NHS of expanding patient choice
(which often drives unrealistic expectations) and targets
for acute care (with 4-hour movement through emergency
departments but prompt discharge if there is not an acute
problem) mean that doctors and managers must work
together towards the same goal.
What is meant by the term
intermediate care?
This refers to care outside the acute setting that occupies
a transition period to another setting. It includes rehabili-
tation after an acute event, responses to an overt crisis and
care whilst long-term care is being considered or assessed.
How is a patient assessed for entry into
long-term care?
Individual trusts have developed processes assessing  Mr James Oakley is a previously well 58-year-old man
not just the medical diagnosis and treatment but
Case 4.14  Cancer – potentially curable
multidisciplinary team assessment of breathing, feeding
and diet, gut function, bladder, toileting, dressing, mobil-
ity and transfer, stair assessment, skin, pain, sensation
(hearing, vision), communication, comprehension, sleep,
memory, depression and anxiety, initiative and involve-
ment, relationships, past roles and physical behaviours.
Also considered are requirements for equipment.
What is meant by the term continuing care?
This refers to a situation where, following a thorough
assessment of needs, a person’s overall health needs are
judged to be so great that the NHS will manage and pay for
all the care they need. An NHS professional supervises the
agreed care plan, which can be in any setting, for example
a person’s own home, a hospice, care home or hospital.
Breaking bad news
CASE 4.14  CANCER – POTENTIALLY
CURABLE
Candidate information
Role
You are a doctor on the medical ward.
Please read this summary.
Scenario
Re: Mr James Oakley, aged 58 years
Mr Oakley is a previously well man on your ward with recent
night sweats, weight loss and abdominal discomfort. He works as
an information technology consultant and has been under a lot of
work stress recently, travelling a lot and under pressure to meet
sales targets. He attributed his symptoms to this but his general
practitioner admitted him with high fever and marked
splenomegaly. He was initially treated for possible atypical
pneumonia but his full blood picture suggests possible chronic
myeloid leukaemia. The haematology team plan to perform a bone
marrow aspirate and trephine but he wants to know the diagnosis
you suspect.
Your task is to discuss the possible diagnosis, addressing his
concerns.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient/subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
 
with a history of recent night sweats and abdominal 
643
 Station |4| Communication skills and ethics
discomfort. He works as an information technology con-
sultant and has been under a lot of work stress recently,
travelling a lot and under pressure to meet sales targets.
He attributed his symptoms to this but his general practi-
tioner (GP) admitted him with high fever and marked
splenomegaly. He was initially treated for pneumonia but
his blood tests are apparently not so straightforward. The
haematology doctors plan to perform a bone marrow aspi-
ration but he wants to know why, and what diagnosis his
doctors suspect. He is married with two children and is
keen to get back to work soon.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Preparation and scene setting
‘Bad news’ is any information that drastically changes a
patient’s view of their future for the worse. The way in
which it is communicated affects their perception of the
situation and, crucially, their attitude to living with an
illness and the ability to adjust. Many candidates are natu-
rally adept at creating rapport and building a feeling of
trust with patients. Important components of preparing
include:
• Having the time and privacy to talk without
interruptions
• Being clear about the diagnosis, problem or test
results so far and suitable ways forward
• The presence (not in PACES) of a supportive
co-worker such as a named nurse or ward sister
• The presence (not in PACES) of a relative or close
person if a patient wishes
• Sitting close enough for good eye contact and
detection of non-verbal cues; sitting at the same level
as the patient rather than above (or worse, standing)
is less threatening to an already apprehensive patient
• Opening with a neutral statement:
How are you feeling today?
You and I know that you have had these pains in your tummy
for some time now.
• Active listening, being attentive to what you hear
and showing concern and empathy through eye
contact, head nodding and other natural body
language.
In short, your patient should feel that this discussion is
the most important thing on your agenda, and not that
you are distracted.
2.  Establish what the patient knows already
Establishing previous experience and knowledge is crucial.
The rule is to ask before telling with such questions as:
Can you tell me what you understand about your illness?
What have you been told about things so far?
644
I believe you put your symptoms down to stresses at work. Did
any other possibilities cross your mind?
Have you thought about any other possibilities for the cause of
your symptoms?
Such a question both explores ideas and concerns and
prepares for more serious news. He might elaborate his
concerns about the possibilities. Non-verbal skills such as
silence, active listening and simple words such as yes, and
then and hmm, and repeating and reflecting back informa-
tion you are told can be very effective.
So you had been worried about something like that?
He might indicate immediately that he has an idea of
what might be wrong:
I’m worried it might be cancer.
If he already suspects a diagnosis then it is possible to
gently confirm rather than break bad news at this stage.
3.  Establish what the patient wants to know
A very useful step if handled well. Possible questions are:
You said you wanted me to be honest and open with you. Are
you the sort of person who likes to know everything about his
condition?
Would you like me to explain the problem as we understand it
so far?
We can’t be certain of what is wrong from the tests so far. But
are you the sort of person who likes to know all the
possibilities?
How much information would you like me to give you about
your diagnosis and treatment?
Patients tend to declare outright or indicate that they 
do not want to talk about their disease (in which case it
may be appropriate to ask if they would like you to 
explain things in more detail to a relative) or they want to
know more.
4.  Give a warning shot
When a patient is apparently unaware of potential bad
news, the skill is in conveying information without pro-
voking overwhelming distress or pushing them into
denial:
I’m afraid that things look a little more complicated than we
had thought / hoped.
I’m afraid it doesn’t look like a straightforward infection.
The next thing to do is wait! Allow time for the warning
shot to sink in. He can signal that no further information
is wanted:
Just tell me what we have to do next.
or that more information is wanted:
What do you mean not straightforward?

5.  Break bad news gently
When the pathologist looked at the blood samples he found
some abnormal cells.
Again, he can signal ‘enough’:
What do you need to do next?
or ‘go on’:
What do you mean by abnormal? I need to know if you mean
what I think you do?
At this point be as honest and informative as possible:
There is a possibility that they might be cancerous, a form of
blood cancer or leukaemia.
Bad news should always be broken gently but not be
unduly delayed. It should be given in clear, simple, small
pieces and patients should be given plenty of opportunity
to respond or question at any stage. Important informa-
tion should be repeated and patient understanding might
need to be checked, remembering that patients are likely
to experience a heavy impact and that repeating the word
‘cancer’ is not necessary unless it is very clear that it has
not been understood. Such fear words are best used only
when a diagnosis is established beyond doubt or is a
strong possibility.
6.  Acknowledge distress and support   guide or framework for breaking bad news is to use the
ventilation of feelings
Above all, people need to know that you understand, not
that you feel sorry for them. You can do this non-verbally,
practically (e.g. by offering tissues) or by acknowledging
that emotions are understandable (legitimising):
It’s normal to be upset. I understand that this is very hard.
Never rush in with immediate optimism or reassurance
(I’m sorry to tell you it’s cancer but the good news is / let me
tell you what we can do . . .). Always remember that at this
point patients are too preoccupied to assimilate further
information. Research shows that subduing or not allow-
ing ventilation of feelings and concerns thwarts recall of
what you tell patients next.
7.  Identify and prioritise concerns
It may be appropriate, after a while, to ask:
What are the particular things you are thinking about?
How does this news make you feel?
It is always important to elicit all concerns before giving
advice or information. When concerns are not explored or
patient needs not established patients are more likely to
remain preoccupied with their concerns, fail to assimilate
what is said, perceive information as inadequate and
develop anxiety or depression that will hinder the control
of future symptoms such as pain.
Case 4.14  Cancer – potentially curable
8.  Check present information needs
Is there anything else you want to ask me about?
Do you want to tell me anything more?
Research shows that too much information can cause as
big a problem as too little.
9.  Identify patient support systems
Who is at home with you?
What about family / friends / others?
10.  Make clear what support is available and
what is going to happen
Never remove all hope, however bad a diagnosis, giving
absolute assurance of what can be done and what should
be done next – further investigations or treatments,
support of hospital staff, GP, nursing staff, support groups
and so forth and follow-up arrangements (making it clear
that the patient can be seen at any time before this if there
are questions or concerns).
Discussion
How should bad news be broken?
There are many suggested approaches on how best to
break bad news. The truth is that there are many accept-
able ways to do it, and many unacceptable ways. One
SPIKES acronym:
• Setting: Point 1 above
• Perception: Point 2 above
• Invitation: Point 3 above
• Knowledge: Points 4 and 5 above
• Empathy: Points 6–8 above
• Strategy and summary: Points 7–10 above.
Box 4.12  Mistakes when breaking bad news
• Avoiding it in the first place and expecting that someone else
will do it
• Not scene setting appropriately, e.g. not enough time or not in
privacy
• Not establishing background knowledge
• Not establishing how much the patient wants to know
• Giving the bad news too quickly, rather than gently
• Hesitating too long before getting to the bad news, e.g. a
junior emergency department doctor goes to speak to anxious
parents about the accident their child has had; the doctor
explains what happened in detail, what was done in the
resuscitation area and only after considerable time tells them
that the outcome of their efforts to resuscitate was
unsuccessful
• Not acknowledging the patient’s distress
• Not exploring the patient’s concerns
• Not exploring the patient’s information needs
• Being dishonest, e.g. ‘We think you’ll be all right.’
645
 Station |4| Communication skills and ethics
Of course no single formula guarantees effective and
sensitive delivery of bad news, but appreciation that it is a
conversation in which each exchange directs the next step
– based on evolving knowledge and feedback and your own
intuition – is key. This is why the more experienced, senior
members of the team should ideally break bad news.
Can you think of some common mistakes
when breaking bad news?
These are listed in Box 4.12.
CASE 4.15  CANCER – PROBABLY
INCURABLE
Candidate information
Role
You are a doctor in the medical outpatient clinic.
Please read this summary.
Scenario
Re: Mrs Jean Paget, aged 86 years
Mrs Paget is a previously well woman with mild hearing
difficulty, in clinic for the results of recent investigations for iron
deficiency anaemia. She was discharged from hospital 3 weeks ago
following a transfusion to correct her anaemia. Subsequent urgent
outpatient investigations comprised an oesophagogastroduodeno­
scopy (OGD) and an abdominal computed tomography (CT) scan.
Colonoscopy was not performed, jointly agreed by patient and
doctor on account of her being physically frail and it being against
her wishes. The OGD showed an isolated, large gastric ulcer for
which she has started a proton pump inhibitor and preliminary
histology confirms malignancy but not the type. The CT scan shows
two large cystic masses in the pelvis, probably arising from an
ovary. The radiology report suggests that these may be malignant,
but you have not had an opportunity to discuss the scan in any
more detail with the radiologist. Mrs Paget’s daughter and
son-in-law are present, supportive family members with whom Mrs
Paget lives.
Your task is to break the news to Mrs Paget.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient/subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
Mrs Jean Paget is an 86-year-old woman who lives with
her daughter and son-in-law, supportive family members
accompanying her in clinic today. She has come for results
of outpatient tests. She was discharged from hospital 3
646
weeks ago following a transfusion to correct anaemia. The
urgent outpatient tests were performed to look for a reason
for anaemia and were upper gastrointestinal endoscopy
and an abdominal computed tomography (CT) scan.
Colonoscopy was not performed, jointly agreed by her and
the doctor when in hospital on account of her frailty and
it being against her wishes. Mrs Paget has mild hearing
difficulty but has previously been well and is not taking
any regular medications. Cognition is normal but she is
functionally limited by arthritis and dependent on her
family to assist her with dressing and meals. She has not
really considered possible diagnoses but feels that ‘at her
time of life’ she can accept any bad news.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Preparation and scene setting
Introduce yourself, ensuring that she can hear all that is
said. You may need to speak up. Ensure that she and her
family do not sense that you are pressured for time. Sit
forward, remembering that your first duty is to her, aiming
for good eye contact and active listening. Ask if she agrees
to your speaking openly with her and her family:
May I take it that you are happy for us to speak openly in front
of your family?
2.  Establish what the patient knows already
At this point, it is appropriate to seek her knowledge of
the reasons for investigation so far:
Could I ask, first of all, what you understand about the reasons
for your recent tests?
It may be helpful to summarise:
You will recall that we recently found you to be anaemic – your
blood count to be low – and that one of our concerns was
that there might be a reason for this in the tummy, giving rise
to a slow leakage of blood internally. That is why we agreed
we have a look into the tummy with the endoscopy, together
with a scan.
3.  Establish what the patient wants to know
The rule is to ask before telling, but not to delay breaking
bad news. In this situation it may be appropriate to say:
We have the preliminary results of those tests, and I take it you
would want me to be frank with you about everything that
we know.
4.  Give a warning shot
There was an ulcer in the stomach … and, in addition, two
lumps in the pelvis were seen on the scan … and the early
signs are that these findings may not be nice.
Wait for a few seconds for this to register!

5.  Break bad news gently
The key here is to continue explaining results clearly and
slowly, taking account of her reaction as each piece of
information is related:
The biopsy – when they took a small piece of tissue from the
stomach – suggests that the problem may be a growth.
6.  Acknowledge distress and support ventilation
of feelings
At this point there may be little value and further distress
in giving more details unless she asks for more informa-
tion. Now respond to reactions with appropriate gestures
(it may be reasonable to touch on the forearm, for example,
during the above explanation).
7.  Identify and prioritise concerns
Be open to any questions that she or her family might have.
8.  Check present information needs
At the end of this, she might ask what needs to be done.
You do not have enough information to suggest a definite
course of action, but you can hypothesise:
We are still waiting for the final pieces of information from the
biopsy. And I would also like to see the pictures of the scan
myself and discuss these in more detail with the radiologist.
But if this is what we suspect, then you and I will need to
discuss the way forward. It seems likely that the lumps in the
pelvis are connected to what we have found in the stomach,
but even if they are not, then I do not think it likely that an
operation on the stomach would be the answer. An operation
is, I think, unlikely to be possible and even if it were, it would
not be without considerable risk. There is a possibility that
we might hold things at bay for a period of time with some
other form of treatment – drug treatment. But the other
consideration that would be for you and your family to think
about is that, if you are having no symptoms, it may be
reasonable to leave things alone.
She might then ask:
And what would happen then, doctor?
You would need to make it very clear that you would
have a plan to support her:
We would talk with your doctor (general practitioner) and let
him / her know of the situation in full, so that treatment can
be given for any symptoms that arise. But in the first place, I
think it would be sensible for us to meet again in a week or
so, by which time we should have the final results of the
biopsy and I should have had an opportunity to review your
scan in more detail with the radiologist.
In other words, it is often desirable to discuss the diag-
nosis of cancer at the first appointment, but defer any
definite decisions about the way forward (especially if
results are still pending) until a second appointment (or
subsequent ward round for inpatients), by which time
patient and family will have had time to discuss the impli-
cations amongst themselves.
Case 4.15  Cancer – probably incurable
9.  Identify patient support systems
Find out a little about how things are at home.
10.  Make clear what support is available and
what is going to happen
Agree to meet again in the very near future to consider the
best way forward.
Discussion
What information would you need before
seeing her again?
A review of the CT scan with the radiologist, the final
histology report and possibly a CA125 blood test.
The radiologist, at a second view, thinks
the pelvic masses could be simple cysts
and are likely to be unrelated to the gastric
malignancy. The histopathology of the
latter, surprisingly, reports a high-grade
non-Hodgkin’s B-cell lymphoma rather than
carcinoma. When you see her again, will
you attempt to persuade her to have
treatment?
You would, of course, discuss the results and reach a
shared management plan. You might suggest that the only
way to be sure about the pelvic lumps would be to obtain
a biopsy, and this would require further hospital interven-
tion. But that this does not escape the fact that there is,
involving the stomach, a form of growth called lymphoma
that is not treatable by operation. There may be a possibil-
ity of treatment involving chemotherapy or radiotherapy,
but to know the absolute answer to this one would need
to obtain more information and seek advice from a spe-
cialist who treats lymphoma.
She asks if she will die without treatment.
How might you respond?
It is sometimes worth exploring why patients ask this
question. It might seem obvious, but it is important to
know what patients are thinking and saying:
I can answer that. But could I firstly ask you why you’ve asked
me that?
might help you understand her main concerns or fears.
She might tell you that her husband had chemotherapy
and that she does not want any treatment if it is not going
to make her better or cure her and ask:
Could we do anything else, doctor?
to which you could tell her:
We could make sure you were as comfortable as possible and
try to let you spend as much time as possible at home.
647
 Station |4| Communication skills and ethics
She says that she does not wish more
hospital tests or treatments. She says ‘When
my time has come, my time has come; I’d
rather take my chances than have any more
tests or treatment.’ Would you accept this?
If this is her informed choice, yes.
CASE 4.16  CANCER – PATIENT NOT
FIT FOR ACTIVE TREATMENT
Candidate information
Role
You are a doctor on the medical ward.
Please read this summary.
Scenario
Re: Mrs Rose Broadley, aged 79 years
Mrs Broadley has been under your team’s care for almost a
week, and is receiving anticoagulation for two large pulmonary
emboli diagnosed on admission. She has been non-specifically
unwell for the past 2 months, feeling tired and losing a little
weight and admission to hospital was arranged when she
developed worsening breathlessness. Unfortunately, she also has a
swollen left thigh and groin with an ulcerated patch from which
meticillin-resistant Staphylococcus aureus has been cultured and is
receiving intravenous antimicrobials. Inflammatory markers have
been high, perhaps not surprisingly, but because of the systemic
symptoms and the absence of any clear precipitating cause for her
pulmonary emboli, a computed tomography scan of thorax,
abdomen and pelvis was arranged that revealed a large caecal
mass and para-aortic lymphadenopathy. The diagnosis is almost
certainly cancer. Mrs Broadley asked earlier in the week if the
reason for the scan was to look for cancer, which you confirmed.
Your task is to explain results, and discuss possible ways
forward.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
Mrs Rose Broadley is a 79-year-old woman who has been  3.  Establish what the patient wants to know
in hospital for almost a week, and is receiving anticoagula-
tion for two large pulmonary emboli diagnosed on  everything.
admission. She has been tired and losing weight for 2
months and was admitted to hospital when she developed
worsening breathlessness. Unfortunately, she also has a
swollen left thigh and groin with ulceration from which
648
meticillin-resistant Staphylococcus aureus has been cultured
and is receiving intravenous antibiotics. Her doctors were
concerned as to why she developed pulmonary emboli
and a computed tomography scan of her thorax, abdomen
and pelvis was arranged. Mrs Broadley is a pragmatic
woman who likes to know the facts, is aware that there is
a suspicious lump that can be felt in her abdomen and
that the scan was to look for evidence of cancer. She is
about to speak to the doctor who has the results.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Preparation and scene setting
This case combines confirming bad news to a patient who
already knows it is a possibility with making a manage-
ment plan. The problems are complex, and the discussion
should focus on possibilities rather than making absolute
decisions now. In real life discussion might be with her
alone or with relatives if that is her wish, and ideally in
the presence of her nurse. It seems very likely she has
colorectal cancer with lymph node spread and that this
explains her thromboembolic tendency. The challenge is
that you do not have a tissue diagnosis, and the need for
anticoagulation and the sepsis make further investigation
(colonoscopy, biopsy) and potential treatments (curative
surgery or surgery to debulk tumour and reduce the likeli-
hood of obstruction and / or chemotherapy) difficult.
These facts need to be included in your discussion.
2.  Establish what the patient knows already
You know that she understands what has been happening,
but it is still helpful to summarise:
As you know, it has been a difficult sequence of events. You have
been feeling unwell for some time, and when you first came
into hospital we suspected, and confirmed, a blood clot on the
lung. This was compounded, as I know you are all too well
aware, by the infection in the upper part of the leg. And you
know, as we have discussed, that we were rather worried that
there might be some underlying reason for all of this
happening to you … hence, the scan.
She will probably acknowledge all of this. Whilst vital
not to delay giving the results of the scan, a preamble like
this not only leads seamlessly into breaking the bad news
but also shows that you are fully aware of her case and this
is crucial to maintaining her confidence.
Here you may assume that she wants to know
4.  Give a warning shot
The scan does give us a reason for all of this. It does show an
abnormality, and one that may not be nice.
 Case 4.16  Cancer – patient not fit for active treatment
5.  Break bad news gently
It shows a lump, within the bowel – within the lower part of
the bowel – that is of considerable size.
She will probably register understanding. It may be
appropriate to confirm, as patients cannot start to ventilate
feelings until you do:
It is very likely to be a growth.
Occasionally, if you choose to use the word growth
rather than cancer, patients will rephrase this by asking
Cancer? – to which it is appropriate to confirm that single
word. It may then be appropriate to say that there are also
lumps in glands adjacent to the bowel.
6.  Acknowledge distress and support   She may want to know what would happen without
ventilation of feelings
Now give her time to come to terms with this news.
7.  Identify and prioritise concerns
As a pragmatic woman who has already suspected serious
possibilities, she will probably want to know what needs
to be done. The following is an outline of areas your dis-
cussion should explore. Speak clearly and not too quickly
and be ready to address questions or clarify information
throughout.
There are a number of things to consider. The first is that,
although it seems very likely that this is what we suspect it is,
the way to be certain would be too look directly into the
bowel with a flexible telescope with a light on the end – a
test called colonoscopy – and that would enable us to take a
needle sample from it.
The problem is that the blood-thinning medication you
are taking makes it a little tricky, though by no means
impossible.
We strongly suspect that the colonoscopy would show a
growth, and a nasty one. The reason that we would do it
would be to consider what to do about it, including surgery or
other forms of treatment.
I would suggest that we do not make any decisions now
but simply say that ultimately we have to decide – and in
the last analysis you have to decide – what is the right thing
to do.
8.  Check present information needs
She might want to know more about possible
treatments:
We might be in a position to consider an operation. And what
we would like to do, if you agree, is to ask one of our
specialist surgical doctors to see you and talk though what
they think possible. An operation would not be without
considerable risk, because of the blood clots and because of
the infection, and because of the infection it is not something
we could consider immediately.
An operation, depending upon what was found, might carry a
possibility of getting rid of it, but also the possibility of not
getting rid of it completely. On the other hand, you might
decide that, even if surgery were possible, you would not wish
it. And simply accept that things are likely to progress.
We would fully understand if you were to say ‘if you’re not
sure it’s going to make it go away, I don’t want to go
through the pain of an operation’. On the other hand, if you
were to say ‘I know it’s risky but if it’s the only way to
possibly make things go away…’ we would do our best to
bring everything, and everyone, together to make that
happen.
One thing that you should be aware of is that, if surgery cannot
remove it completely, it might be possible to remove some of
it and that without surgery there is a possibility that things
could, at some stage, become obstructed.
We will respect whatever you decide / We will do our best
whatever you decide. It’s not an easy decision to make, I
know.
further treatment.
We would simply keep a very close eye on things, and do
whatever we can to ease / alleviate the situation.
9.  Identify patient support systems
Find out a little more, if you do not already know, about
her home circumstances.
10.  Make clear what support is available and
what is going to happen
What I would suggest, if I may, is that we think about this a
little more and talk again. Meantime, if you agree, we will ask
the surgeon to give an opinion on surgery. And we are here
at any time, before we next meet, if there is anything you
want to discuss, or if you would wish us to sit down with you
and your family … I am here, other members of my team are
here, and ward sister is here.
Discussion
An elderly woman has liver metastases from
an unknown primary site. She is frail,
deemed medically unfit to undergo
more than palliative treatment, and
wishes to know ‘just what I need to
know, doctor, but no more’. You judge her
mental capacity to be borderline. What
might you tell her?
She could be told that the news is not good; that there is
trouble in the liver that is not nice (to use the word growth
or cancer would very much depend upon feedback from
her); that a lot of tests could be done to try to find out
where it came from, but that there would not seem to be
any ground gained by subjecting her to uncomfortable
tests; that the fact is the growth is here, and that it seems
best now to try to get her home, perhaps with a period of
convalescence, with the support of family, and keep a close
eye on things, treating any symptoms such as pain if and
when they arise.
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 Station |4| Communication skills and ethics
An 88-year-old man has been losing weight.
He smokes and has a recent Horner’s
syndrome and a Pancoast’s tumour clinically.
He was informed that this is worrying. The
chest X-ray now confirms it. What would
you tell him?
Using the 10-step framework for breaking bad news, he
might be told:
Remember how we discussed that we were very worried about
things. The X-ray confirms our worries. What we are seeing
may not be nice.
If he does not indicate that he has heard enough:
We must wait until we know exactly what we are dealing with,
but there is a high possibility of a growth.
When he is ready, he will want direction, but may  How to approach the case
not know what to say. He may say something as open
ended as:
Not good, is it?
You must not leave him without support and clear sense
of your ownership in helping him:
No, but it is here. And what we must now do is decide how we
are going to deal with what is here.
CASE 4.17  CHRONIC DISEASE
Candidate information
Role
You are a doctor in the neurology clinic.
Please read this summary.
Scenario
Re: Mrs Amy March, aged 28 years
Mrs March was referred to the neurology clinic 2 months ago
with blurred vision in her right eye, subsequently diagnosed as a
second episode of optic neuritis; she had had a similar episode 6
months previously and attended the eye clinic. During her last visit,
it was suggested by the neurologist, when she asked, that her
symptoms could be due to multiple sclerosis. Magnetic resonance
imaging arranged after that appointment and performed last week
has been reported as showing multiple demyelinating plaques in
the brainstem and periventricular areas consistent with multiple
sclerosis.
Your task is to explain the diagnosis.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the
650
examiners. Do not take the history again except for details
that will help in your discussion with the patient / subject.
You are not required to examine the patient / subject.
Patient / subject information
Mrs Amy March is a 28-year-old teacher who presented to
the eye clinic 6 months ago with blurred vision in her 
right eye, diagnosed as optic neuritis. A second episode
occurred 2 months ago and she was referred to the neurol-
ogy clinic where it was suggested to her, when she asked,
that multiple sclerosis was a possibility. She is at the clinic
today for results of a magnetic resonance (MR) scan to
look for evidence of multiple sclerosis. She is very con-
cerned about what a diagnosis of multiple sclerosis might
mean if she wished to become pregnant, and the future
implications of this disease.
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Preparation and scene setting
Introduce yourself, and ask how she has been since the
last appointment.
2.  Establish what the patient knows already
Establishing previous experience and knowledge is crucial,
not least exactly what she was told about the possibility
of multiple sclerosis and whether she had still been think-
ing about it.
3.  Establish what the patient wants  
to know
Establish what has gone through her mind about multiple
sclerosis, and if it engendered any particular worries. Here
you may assume that she wants to know everything.
4.  Give a warning shot
Tell her that the scan does confirm the thoughts that the
neurologist had last time.
5.  Break bad news gently
Explain the results of the MR scan, that it does suggest
multiple sclerosis and allow her time to take this on 
board.
6.  Acknowledge distress and support  
ventilation of feelings
Watch for her reactions.
7.  Identify and prioritise concerns
When she appears ready, explore particular concerns. Tell
her that people with multiple sclerosis can have very
healthy pregnancies, indeed that sometimes multiple
 Case 4.18  Discussing an acutely terminal situation with relatives
sclerosis tends to improve during pregnancy, although
symptoms can flare up after delivery and so close monitor-
ing is needed from the obstetrician and neurologist. Reas-
sure her that not all patients develop disabling disease,
and that it can vary very much from one patient to another
but that most patients continue to lead normal lives.
Explain that it tends to relapse and remit, but that some
patients go for many years between relapses. Explain that
her specialist will discuss what, if any, treatments might
be desirable at this stage.
8.  Check present information needs
Do no overwhelm her with information; at this stage,
largely respond to her concerns:
Is there anything else you want to ask me about?
Do you want to tell me anything more?
9.  Identify patient support systems
Establish who is at home with her and if her symptoms
have interfered with her work at all.
10.  Make clear what support is available and
what is going to happen
Explain that you will speak with the neurology consultant
about any treatment and ensure that things are kept under
review.
Discussion
Would you allow a patient in denial
of their illness to continue in such denial,
or attempt to change this?
Occasionally, it is necessary to challenge denial because it
hinders their ability to deal with important unfinished
business or their treatment. It is sometimes possible  father is clearly critically unwell and barely conscious.
to confront patients gently by highlighting the inconsist-
encies, such as a declared belief they are getting better in
the face of increasing disability. But where a patient is in
persistent denial, it may be because they are unable to
tolerate the pain of reality and leaving them in that defence
mode until further opportunities during the illness may
be best.
CASE 4.18  DISCUSSING AN
ACUTELY TERMINAL SITUATION
WITH RELATIVES
Candidate information
Role
You are a doctor on the acute medical unit.
Please read this summary.
Scenario
Re: Mr Frank Wentworth, aged 88 years
Mr Wentworth is an 88-year-old man admitted to hospital 2
hours ago with a thoracic aneurysm rupture (‘mediastinal
catastrophe’) diagnosed clinically and with a radiologically wide
mediastinum on chest X-ray. You wondered about a computed
tomography scan but your consultant feels that the diagnosis is
beyond significant doubt, that there is no alternative, reversible
explanation for his presentation and that a scan would not alter
management. A team decision has been reached to keep him
comfortable. You have just come back to review him, and his
daughter is now with him. You have not spoken with her before
but it is clear to her that her father is very unwell and it appears to
you that he is deteriorating quickly because he is less alert than 2
hours ago, with gradually falling blood pressure. You offer to go to
the ward sister’s office to discuss her father’s case.
Your task is to discuss with her what has happened and what
the outcome is likely to be, responding to her distress.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
You are the daughter of Mr Frank Wentworth, an 88-year-
old man admitted to hospital 2 hours ago with a ruptured
thoracic aneurysm. You are a schoolteacher, phoned at
work by a nurse at the hospital to say that your father was
very unwell and that you should come in. You have just
arrived. You do not know anything else, but have been 
at the bedside for a few minutes and can see that your
 
You are not really sure what an aneurysm is but fear the
worst, although you do not think this means imminent
decline. Your husband is also on the way to hospital. 
Your father has previously been very healthy, playing 
golf until last year. He has been widowed for 2 years 
but has remained independent on his own. You have 
been invited to the ward sister’s office to talk to the doctor.
You are extremely worried and will be very distressed to
hear the worst but need to know exactly what the doctor
thinks.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Preparation and scene setting
Introduce yourself, and sit close enough to allow good eye
contact and at her level.
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 Station |4| Communication skills and ethics
2.  Establish what the relative knows already
Ask what she knows so far but do not labour it; she will
want to know what is going on straight away.
3.  Establish what the relative wants to know
This step in the breaking bad news 10-step sequence
should be bypassed if it is clear that she is waiting in dis-
tressed anticipation of what she needs to know.
4.  Give a warning shot
Simply saying:
(I’m afraid) the news is not good
may be enough to start.
5.  Break bad news gently
Explain what has happened, clearly and calmly. So that
there is little doubt of the critical position, one way to
conclude the explanation would be to say:
There may not be an easy way out of this … there may not be
a way out of this.
pausing between both statements, the first telling her
gently that he may not recover, the second building on the
first to inform her that you may have run out of options
to save his life.
6.  Acknowledge distress and support ventilation
of feelings
She will be very distressed and now is the time to let your
comments sink in, and not the time to give more
information.
7.  Identify and prioritise concerns
Every case must be treated on its own merit. Sometimes  to say something such as ‘Well, the way things have been
it is appropriate to ask how a patient feels about bad  going it might be just months’, but while it is important
news that has been broken. Here, it would be inappropriate
to question her thoughts, which are obvious, and you
should simply continue to acknowledge her distress,
respond to questions and speak honestly, clearly and with
understanding.
She may ask:
What can you do?
A suitable reply would be:
We can only watch and wait and see if the bleeding stops. It is
all that we can do. There is simply no way of getting to where
the bleeding is. He may be dying.
Right now?
Yes.
It can be difficult for relatives to accept such abrupt news
like this. But it is vital to be straightforward and honest.
Things are absolutely critical.
652
8.  Check present information needs
How long do you think he has got?
These hours are critical.
One concern that it is always helpful to anticipate and
mention is about pain and distress.
What we can do is make certain that, whatever else, he
is not in any pain or distress. As he becomes less
conscious it is very unlikely he will feel any pain, not
at this stage. But if we had any reason to suspect
discomfort at any stage we could treat that with
medication, with morphia.
9.  Identify support systems
You may wish to check that her husband is on his way,
and whether or not she has other relatives who should be
aware of the situation.
10.  Make clear what support is available and
what is going to happen
Assure her that the doctors and nursing staff are available
at any time to speak to her again.
Discussion
Patients with incurable but more
chronic conditions often ask about
how much time is left. How might
you respond?
Clearly it depends upon the situation. It is important to
acknowledge that you cannot be certain but patients then
often ask you to guess. It may be appropriate, if realistic,
to be as honest as possible about prognosis it is important
not to give specific time frames. Patients sometimes ask
about specific dates like whether they will be here for
Christmas. You might say ‘I would hope so’, but ask if
there is any reason they mention Christmas in particular.
It might be, for example, that a relative died at Christmas
and the patient is worried that it will be particularly hard
on other family members.
Why is it important to respond
to questions about prognosis?
Patients might otherwise be misled about their outlook
and might not use their remaining time to deal with
important practical and emotional unfinished business
with loved ones. This will also make the bereavement
process more difficult for loved ones and increase psychi-
atric morbidity from, for example, major depressive
disorder.

Confidentiality, consent and capacity
CASE 4.19  LEGAL POINTS IN
CONFIDENTIALITY
Candidate information
Role
You are a doctor on the medical ward.
Please read this summary.
Scenario
Re: Mrs Marcia Smith, aged 30 years
Mrs Smith, a Thai woman who speaks good English, was admitted
to the ward with abdominal discomfort and fatigue, now confirmed to
be due to hepatitis B infection. She also has inguinal lymphadenopathy
and you have sought her consent for a human immunodeficiency virus
test. She has lived in the UK for 6 months with her English husband
whom she met and married a year ago. She refuses the test. She also
tells you not to tell her husband her diagnosis.
Your tasks are to explore her reasoning, and discuss the
importance of the test and possible consequences of refusal.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
Mrs Marcia Smith, a 30-year-old Thai woman who speaks
good English, was recently admitted to hospital with
abdominal discomfort and fatigue, now confirmed to be
due to hepatitis B infection. She also has lymph node
enlargement in her groin and her doctors have asked if she
might consent to a test for human immunodeficiency virus
(HIV). She has lived in the UK for 6 months with her
English husband, whom she met and married a year ago.
She is very afraid. A friend of hers died 2 years ago from
HIV in Thailand, although sustained treatment had not
been available. She is also very afraid for her 2-month-old
baby, and her husband. She does not want the doctors 
to perform the test, nor tell her husband of her current
diagnosis.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself and confirm her identity.
Case 4.19  Legal points in confidentiality
2.  Establish rapport
There is potential conflict between her right to confiden-
tiality and the rights of her husband (and baby) to infor-
mation and possible treatment in the event that he (they)
was (were) infected. From the outset, you may be balanc-
ing her confidentiality against potential risks to others. But
avoid giving her ‘ultimatums’ at this stage. It is vital not to
‘rush in’. Your first duty is to her, analysing her perspective
and how you may best help. Explain this to her, and assure
her you are there to help.
3.  Explore patient understanding  
and concerns
Ensure she is aware of the problem and try to explore her
beliefs, concerns and expectations about the problem.
4.  Attempt to discover the patient’s reasons  
for not wanting to disclose
Is she scared about being diagnosed with HIV? If so, why?
Is she scared for herself, or for the effect it will have on
her family or marriage? Perhaps she knows that she 
has been exposed to HIV in the past and has always feared
this sort of predicament. Is it possible that she has been
diagnosed with HIV in the past but has been living in
denial?
5.  Share your concerns and desired
management plan
Your first concern is that she may be infected with HIV in
addition to hepatitis B. Try to let her see the importance
of excluding or confirming the diagnosis. A supportive
approach is essential, letting her see the potential advan-
tages – the HIV test may be negative; were the test positive,
it would allow earlier institution of treatment and testing
of contacts (who could well be negative). Much better
treatments are available for HIV than her friend would
have received. Denial will not make the problem go away.
She will know this, and her decision to avoid testing and
telling is almost certainly motivated by fear.
6.  Respond to patient cues
Continuously look for non-verbal as well as verbal 
cues.
7.  Discuss possible consequences of refusal
In a non-threatening way, explain that you have a dilemma
of interests. Whilst your first concern is for her, you are
very concerned that in the event that she does have a posi-
tive test there are wider implications.
8.  Confirm understanding
Ensure that she fully understands that your first duty is to
her and not her husband, that you will not tell her
husband, but that for the best steps to be taken for her
health and the potential health of her family she needs to
tell him.
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 Station |4| Communication skills and ethics
9.  Allow time to think about what has been
discussed and invite questions
Allow her time to think about what has been discussed
and to ask questions. She may have initially decided that
the worst outcome would be for her husband to know that
she has hepatitis or HIV. Your task has been to identify
other outcomes for her to consider.
10.  Agree a way forward
If she does not immediately agree, it is likely that she
needs more time to contemplate what you have discussed
and you should at least attempt to end the discussion with
a plan to talk again.
Discussion
Why is confidentiality important?
Confidentiality is central to the trust that exists in the
relationship between doctor and patient. This has been
enshrined in doctors’ codes of professional conduct
including the Hippocratic Oath, the Declaration of Geneva
and General Medical Council (GMC) Guidelines. Infor-
mation that a doctor learns from a patient ‘belongs’ to that
patient. From a legal point of view a patient’s case records
do not belong to that patient, but from an ethical point
of view patients should have the right to determine in
general who has access to information they provide.
Respect for patient autonomy supports confidentiality and
opposes paternalistic attitudes, common in the past, in
which doctors ‘knew what was in a patient’s best
interests’.
What is your legal commitment
to respect confidentiality?
The general obligation is to keep patient information con-
fidential. This obligation is not absolute; the law may
allow or obligate breach of confidentiality, but any breach
should only be to the relevant person or authority. The
question of whether or not breach of confidentiality is
legal is often a matter of balancing harm to the patient if
confidentiality is breached against harm to others if it is
not. The equation is seldom simple and the law sees a
strong public interest in individual doctor–patient confi-
dentiality being maintained.
GMC guidelines do not have the force of law but are
taken seriously by the Courts.
Breach of confidentiality does not occur if a patient is
not identifiable or if a patient has consented to disclosure
of information.
Doctors have a duty to take reasonable precautions to
prevent confidential information from falling into the
wrong hands.
Under what circumstances might
confidential information be disclosed?
These are outlined in Box 4.13.
654
Box 4.13  Circumstances in which confidential
information might be disclosed
Circumstances in which confidential information
must be disclosed
• When legally required by a Court Order
• When a statutory duty to statutory regulatory bodies, as in
communicable disease notification and the reporting of births,
deaths, abortions and work-related accidents
• In cases of national security such as terrorism or major crime
prevention or in assisting in the solving of a major crime
(although you may not disclose detailed information to police
officers about any matter).
Circumstances in which confidential information
may, at a doctor’s discretion, be disclosed
• When a third party is deemed to be at risk of harm, e.g. at risk
of contracting a serious infectious disease
• In the public interest, e.g. informing the Driver and Vehicle
Licensing Agency in the case of a patient with seizures known
to continue to drive illegally
• Through sharing information with the health-care team.
When disclosure of relevant information between health-care
team members is clearly required for investigation or treatment to
which a patient has agreed, the patient’s explicit consent may not
be required. Such sharing of information is not generally viewed by
the law as breaching confidentiality. Examples include passing
information to medical secretaries for typing and writing
information on request forms for investigations.
Timing of disclosure
Breaching confidentiality should usually be the ‘last resort’. The patient
should be given an explanation as to why disclosure is intended, and
the doctor must be able to justify the decision. Before disclosing, a
doctor might sensibly seek advice from colleagues, professional bodies
such as the British Medical Association, and their medical defence
organisation.
What are the possible consequences
of breach of confidentiality?
These include loss of trust and breakdown in doctor–
patient relationship, disciplinary action by the GMC,
investigation of serious professional misconduct by the
GMC and civil legal action.
Does information remain confidential
after death?
Yes, and information cannot be released without consent
of the patient’s executor or a close relative fully informed
of the consequences of disclosure.
CASE 4.20  BREACHING
CONFIDENTIALITY WHEN A THIRD
PARTY MAY BE AT RISK
Candidate information
Role
You are a doctor on the renal ward.
Please read this summary.
 Case 4.20  Breaching confidentiality when a third party may be at risk
Scenario
Re: Mr Joe Green, aged 25 years
Mr Green is a builder about to undergo a renal biopsy for
suspected immunoglobulin A nephropathy. He tells you that he is
hepatitis C positive but instructs you not to share this information
with anyone else.
Your task is to discuss this with him and decide whether or not
the biopsy should proceed.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
Mr Joe Green is a 25-year-old builder who has been diag-
nosed with probable glomerulonephritis following an
episode of macroscopic haematuria. He has been admitted
to hospital for further tests including a renal biopsy. He has
previously been well but has sporadically taken intrave-
nous drugs and has had multiple sexually transmitted
diseases. He was tested for hepatitis C at the genitourinary
medicine clinic 2 years ago and the test was positive
(human immunodeficiency virus (HIV) being negative)
but has not required any specific treatment. He was due for
follow-up blood tests last year but did not attend. He was
afraid of possible progression. His girlfriend works as a
nurse at your hospital. She does not know he is hepatitis C
positive and he is afraid that if this information is recorded
she could conceivably have access to it. He will tell her
about his hepatitis but now is ‘not the right time.’ He felt
he should tell the doctor in case it affects his biopsy but
does not want anyone else to know.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself and confirm his identity.
2.  Establish rapport
There is potential conflict between his right to confidenti-
ality and the potential risk to colleagues, especially the
doctor performing the biopsy and those performing phle-
botomy. Start by reassuring him that you will try to help.
3.  Explore patient understanding and concerns
It is always best to gather information before reaching
conclusions and deciding on a course of action. Ask more
about his hepatitis C. How does he know that he has
hepatitis C? How did he contract it? What investigations
and treatments has he had so far? Who has been supervis-
ing his care? He may feel that these are irrelevant questions
and that you do not need this information. Explain that
it may be important in building a better understanding of
his kidney problem and that a renal biopsy can be danger-
ous if liver function is impaired.
4.  Attempt to discover the patient’s reasons for
not wanting to disclose
Is he scared about his girlfriend finding out because of the
impact on their relationship or are there other reasons?
You might explore why he has told you of his diagnosis
but instructed that others not be informed. Exploring his
fears may give you the answer.
5.  Share your concerns and desired
management plan
Your first concern is that he has a condition that could put
colleagues at risk. Although all patients should be deemed
potential sources of risk when performing invasive proce-
dures knowledge of the condition is important both for
taking extra vigilance with procedures and in his overall
assessment. Certain forms of glomerulonephritis are more
common in hepatitis C infection or with HIV (his last test
was 2 years ago). A further concern is for his girlfriend.
Explain that it would be important for the medical team
involved in the procedure and in his management to know
that he has hepatitis C, but that the information would go
no further than those involved in his immediate care.
Explain that it would be sensible to obtain up-to-date
serology for hepatitis B and C and HIV to build up a better
picture of his condition, institute early treatment if there
is evidence of active disease, and reassure if results are
unchanged. Explain why his girlfriend should know.
6.  Respond to patient cues
Continuously look for non-verbal as well as verbal cues.
7.  Discuss possible consequences of refusal
If he still refuses disclosure, explain that you may need to
talk to colleagues on astrictly ‘need to know’ basis. Discus-
sion with your medical defence organisation may be
appropriate.
8.  Confirm understanding
Ensure that he understands the reasons for his hepatitis
being known, not least that he may be offered best
treatment.
9.  Allow time to think about what has been
discussed and invite questions
Allow him time to think about what has been discussed
and to ask questions.
10.  Agree a way forward
The examiners are aware that such a discussion is difficult.
They are not looking for a ‘model answer’ but checking
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 Station |4| Communication skills and ethics
your awareness of the range of issues provoked and ability
to handle these sensitively and professionally. They would
be more concerned if you found such a case clear cut and
chose one of two extremes – agreeing to the patient’s
instructions or informing him that you intended to breach
confidentiality without having had careful discussion
around it. If he remains firm in his decision and refuses
to allow disclosure, you may conclude that failure to
inform some of your colleagues will place them at serious
risk. It is then possible to breach confidentiality on the
grounds of risk to others and on a strictly ‘need to know’
basis. You should inform him of what you propose to do.
Discussion
Does his girlfriend have a right to know?
A patient who has decided not to tell contacts at risk must
recognise that this decision may have serious outcomes for
these contacts and that breach of confidentiality would be
a potential ultimate step. Persuading him to share that
knowledge is preferable, and other possible routes could
be to involve his general practitioner or his genitourinary
medicine specialist, ideally with his consent.
A 32-year-old man has presented
to your general medical clinic with weight
loss and admits to a history of intravenous
drug misuse and having multiple sexual
partners. He is now living with his
girlfriend, who is pregnant. You mention
the possibility of HIV infection and he
admits to having suspected this but adds
‘if I had AIDS I would want to kill myself,
doctor’. He also says that he feels angry.
How might you respond?
It takes time to come to terms with the possibility of a
serious diagnosis such as cancer or HIV infection, and very
often anger is a secondary emotion, the primary one fear.
At this stage you are not talking to him about having HIV
infection, but about the importance of testing for it. Again,
you should attempt to explore his fears, and find out why
he would want to kill himself. It may be that to him HIV
is a ‘death penalty’ and that he does not fully understand
its natural history and current treatments. It may be appro-
priate to offer him a referral to trained HIV counsellors for
further discussion of the implications of the test and its
possible result. His partner and the fetus would be at risk
and would warrant screening for HIV and the hepatitis B
and C viruses if this patient were positive. There are also
implications for the obstetric team. The difficulty is that
this patient has not yet been tested. Although he has not
refused to be tested, he has threatened self-harm should
the test be positive. Hopefully, exploring his views and
reaching a shared understanding of the problem may per-
suade him of the value of being tested and sharing the
problem with his partner.
656
CASE 4.21  BREACHING
CONFIDENTIALITY IN THE
PUBLIC INTEREST
Candidate information
Role
You are a doctor in the neurology clinic.
Please read this summary.
Scenario
Re: Ms Holly Long, aged 22 years
Ms Long is a previously well student brought into hospital 6
weeks ago after a road traffic accident. She lost consciousness at
the wheel and drove into a wall. She has had a normal ambulatory
electrocardiogram and echocardiogram. She says she lost
consciousness only transiently after she took a fizzy drink giving
rise to severe heartburn. To build in evidence that this was likely to
be situational syncope rather than seizure activity with an aura you
feel she also warrants magnetic resonance brain imaging and an
electroencephalogram. She is here for the results of her heart tests
and is keen to drive again.
Your task is to talk with her.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
Ms Holly Long is a previously well 22-year-old student
brought into hospital 6 weeks ago after a road traffic acci-
dent. She lost consciousness at the wheel after a gulp of a
fizzy drink with immediate heartburn and drove into a
wall and has had subsequent tests to exclude a heart
problem. She was told she could not drive until after the
results. She is here for the results. She has a partner at a
different university 100 miles away and desperately wants
to be able to drive to visit him at weekends. She feels well
and has decided to drive ‘whatever the doctor says’ and
will tell him so.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself and confirm her identity.
 Case 4.21  Breaching confidentiality in the public interest
2.  Establish rapport
Your first duty is to her, analysing her perspective and how
you may best help. Show this from the start.
3.  Explain the results
Explain that the test results were reassuring. Explain that,
whilst this is so, the tests do not exclude a seizure. Whilst
physicians might not treat a first seizure, driving regula-
tions do not permit driving within 12 months of unex-
plained loss of consciousness.
4.  Explore patient understanding and concerns
Ensure she understands this and explore any difficulties it
might pose.
5.  Attempt to discover the patient’s reasons for
not wanting to adhere to advice
Show that you appreciate her concerns about not being
able to drive to visit her partner.
6.  Explain the risks and consider alternatives
Reiterate the dangerous accident she had, threatening both
her own life and that of others. Are there alternatives to
her, such as public transport? Ensure that she is aware it
is only for a period of time.
7.  Respond to patient cues
Continuously look for non-verbal as well as verbal cues.
8.  Discuss possible consequences of refusal
In a non-threatening way, explain that you have a dilemma
of interests. Whilst your first concern is for her, you are very
concerned that, were she to continue driving, she might be
at risk personally and legally, and be a risk to others.
9.  Allow time to think about what has been
discussed and invite questions
Allow her time to think about what has been discussed
and to ask questions. She may have initially decided that
the worst outcome would be for her not to be able to drive
for 6 months. She may now see that taking your advice is,
on balance, best.
10.  Agree a way forward
Remember that patients have a right to a second opinion,
although it may be appropriate to advise patients that some
decisions are likely to be uniform amongst doctors, particu-
larly where bound by a professional or legal framework.
Discussion
When may disclosure of confidential
information be made in the public interest?
Personal information may be disclosed in the public inter-
est without a patient’s consent where the benefits to an
individual or society outweigh the patient’s interests in
keeping that information confidential. Where there is a
serious risk to patients or others, disclosures may be justi-
fied even where patients have been asked to agree to dis-
closure but have withheld consent. You should inform
patients that disclosure will be made, where practical to
do so. Ultimately, the public interest can be determined
only by the Courts, and the General Medical Council may
also require you to justify your actions.
What is the driving advice
in medical conditions?
A person who drives with a medical condition has auton-
omy and a right to confidentiality. Yet breach of this con-
fidentiality may be more important in the greater interests
of benefit to society. The Driver and Vehicle Licensing
Agency (DVLA) publishes a booklet on driving rules in
medical conditions. A summary of rules for more common
conditions is given below.
Seizures
Drivers with class 1 licences (non-heavy goods or public
vehicles) must inform the DVLA after a first seizure. They
must be seizure free for 12 months before they may drive,
on or off medication. The DVLA may apply discretion and
allow resumption of driving after a clearly provoked
seizure (e.g. head injury); alcohol withdrawal does not
qualify as provoked. The same 12-month restriction is
invoked after any subsequent seizure. The restriction is for
3 years if seizures continue but are purely nocturnal.
Patients should not drive for 6 months following any anti-
epileptic drug (AED) dose reduction, since there is a 40%
risk of seizures occurring with drug withdrawal. This
should be borne in mind with inpatients receiving AEDs;
if a seizure occurs through inadequate prescribing then
DVLA restrictions are fully imposed.
People with non-class-1 licences may not drive until
seizure free for 10 years.
Syncope
The rules following syncope are outlined in Case 2.41
(Syncope).
Cardiac conditions
The rules depend on the condition. An acute coronary
syndrome imposes a 4-week restriction (reduced to 1 week
if successful percutaneous coronary intervention), and
patients need not inform the DVLA.
Stroke / transient ischaemic attacks
A 4-week restriction applies if there are not considerable
problems with weakness, vision or cognition. Visual fields
should be at least 120° in the horizontal plane with no
greater than 20° loss in up or down gaze. Formal field
testing is needed if recovery is in doubt, unless the field is
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 Station |4| Communication skills and ethics
Box 4.14  Disclosure of confidential information
to the Driver and Vehicle Licensing
Agency (DVLA)
• The DVLA is legally responsible for deciding if a person is
medically unfit to drive and should know of a condition likely,
now or in future, to affect safety.
• Patients should understand that their condition may affect the
safety of themselves and others.
• Patients have a legal duty to inform the DVLA about their
condition.
• If a patient refuses to accept the diagnosis or its safety
implications, you should suggest a second opinion, assist the
patient in obtaining it and advise them to refrain from driving
until it has been sought.
• If a patient continues to drive when medically unfit, you should
make every reasonable effort to dissuade them, which may
include informing a next of kin.
• If this fails, you may disclose relevant medical information, in
confidence, to the DVLA’s medical adviser, informing the patient
that you intend to do this.
clearly too compromised for driving, as in the case of a
hemianopia or quadrantanopia.
Dementia
The rules in dementia are outlined in Case 2.44 (Mild
cognitive impairment and dementia). Where a patient is
deemed unsafe to drive by a doctor and may not have
insight, memory or capacity to inform the DVLA, nor 
next of kin to do so, a doctor may inform the DVLA
immediately.
Other
People with a variety of other medical conditions (e.g.
diabetes on insulin, Parkinson’s disease) must inform the
DVLA of their condition.
When should you disclose confidential
information to the DVLA?
This is outlined in Box 4.14.
CASE 4.22  CONFIDENTIALITY WHEN
TALKING WITH RELATIVES AND
OTHER THIRD PARTIES
Candidate information
Role
You are a doctor on the medical ward.
Please read this summary.
658
Scenario
Re: Mr Peter Price, aged 34 years
Mr Price has muscular dystrophy and has been admitted to
your ward with lobar pneumonia. He is stable but has a number of
signs associated with a high risk (reduced consciousness,
hypotension and leucopenia). His carer, who is not a relative, asks
how he is. You also would value some background information
about his home circumstances, quality of life and any prior
expressed wishes in the event of this sort of situation.
Your task is to speak to the carer.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
You are a carer of Mr Peter Price, a 34-year-old man with
muscular dystrophy. He has just been admitted to hospital
with lobar pneumonia. His condition is unstable. You
have cared for Mr Price for 4 years in his own home, but
despite physical disabilities, notably his being unable to
move his limbs, his general health has been very good.
You are very anxious that he is now so unwell.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself and establish the carer’s identity.
I’m sure you will understand that out of respect for (patient’s
name), I need to be sure to whom I’m speaking.
2.  Acknowledge a valued contribution
Your primary responsibility is to the patient, whose
medical details remain confidential. It is very easy to forget
this when a patient is unable to speak. It is equally impor-
tant, however, to respect the concerns of a third party and
the valued information they can often provide. Show
respect for the carer’s expertise (and experience with this
particular patient), and acknowledge the interdependence
between patient and carer. The case records may be a valu-
able source of information and even demonstrate the
patient’s willingness for information to be shared with the
carer.
3.  Explain a little
State, in broad terms, that the situation is not good. Listen
to responses and look for cues. It is remarkable how
 Case 4.22  Confidentiality when talking with relatives and other third parties
worried relatives and carers end up doing much of the
talking and by disclosing very little you can often open  purposes and have not objected.
the door to a lot of information from them. Frequently
the relative or carer knows, or has suspected, a lot more
than you may think.
4.  Ask a little
Additional questions may open the door much wider!
5.  Explain in more depth, directed by responses
You may then be in a position to speak more freely about
the condition, again respecting your first duty to the
patient and making sure anything you say is strictly infor-
mation that will be of use to the carer in his or her role,
and ultimately beneficial to the patient.
6.  Involve the carer in the desired   giving information to relatives, but written consent should
management plan
Involve the carer as far as you can in making decisions,
without compromising the autonomy of the patient.
Asking ‘What do you feel he would want us to do?’ is not
asking the carer to make a decision but inviting his or her
valued insights to help guide your own decision making.
7.  Respond to cues
Continually look for non-verbal as well as verbal cues.
8.  Consider other issues
It may or may not be appropriate, depending upon how
well you feel the carer knows him, to establish whether
the carer is aware of any prior wishes regarding resuscita-
tion in the event of a cardiopulmonary arrest.
9.  Allow time to think about what has been
discussed and invite questions
Allow the carer time to think about what has been dis-
cussed and to ask questions.
10.  Agree a way forward
Assure him or her that you will do all that you can to get
the patient better, and that now you have established the
carer’s involvement you would be happy to update him or
her at any time on the patient’s progress.
Discussion
Under which circumstances may implied
consent be sufficient for disclosure of
confidential information to third parties?
Implied consent (Case 4.23) is appropriate for sharing
information in the health-care team, provided that wishes
are respected if a patient objects to a particular person or
agency being made aware and this would not put others
at risk, or when disclosing information for clinical audit,
including identifiable information if patients have been
informed that their information may be used for such
Under what circumstances must express
consent be sought to disclose information
to third parties?
Express consent (Case 4.23), verbal or written, is needed
for disclosure of information to a third party under most
other circumstances, including to a nearest relative.
What type of consent is needed when
disclosing information to third parties such
as employers, police, lawyers and insurance
companies?
Verbal consent from patients is usually sufficient when
be obtained when communicating with employers and in
any legal matters. Patients must be aware of the purpose
of disclosure, the obligation a doctor has to the third 
party and that this may include disclosure of personal
information.
Can information about a patient be
disclosed for education and research
without consent?
Information about patients can be useful for such pur-
poses as education, research, audit, administration, moni-
toring, epidemiology and public-health surveillance.
Express consent is generally preferable for disclosure,
whether or not it is judged that patients can be identified
from the disclosure and even though disclosure is 
unlikely to confer personal consequences. Anonymised
data without patient consent may be acceptable for educa-
tion and audit, and in research where it is not practicable
to contact patients a research ethics committee should
decide whether the likely benefits of research outweigh the
loss of confidentiality. Express consent should be sought
when publishing material such as case histories or photo-
graphs of a patient, whether or not that patient is clearly
identifiable.
An 80-year-old man has just recovered
from a stroke. He lives independently
and is to be discharged from your ward
later this week. One of the nurses on your
ward asks if you will speak to his daughter.
You are asked by a woman over the phone,
‘What has happened to my father?’ Would
you tell her?
You would establish the caller’s identity. Clearly, if you
have met her on the ward, recognise her voice, and know
that her father has always been happy to share his medical
problems with her, you would be less guarded. If you had
no prior knowledge that he consents to divulging of
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 Station |4| Communication skills and ethics
information, you should explain why you could not
without his permission.
The daughter now requests that
you not tell him anything more
about his condition without her
prior permission – ‘he is a worrier’. Would
you agree to this?
You should not be willing to withhold information from
him based solely on his daughter’s wishes. You should
explain that he has a right to know what has happened
(respecting his autonomy) and to make his own decisions
based on that information. You could reassure her that
you would not force information on him, explaining only
as much as he appeared to want to know. You might also
suggest that discussion by phone is not ideal and offer to
speak to her if she comes in to hospital to visit her father.
You should avoid stating legal rights in these sorts of situ-
ations. Relatives never warm to being told ‘I’m within my
rights not to tell you’. Phrases like ‘I share your concerns’,
‘I understand how concerned you must be’, or ‘I appreciate
how you must feel’ offer empathy and show that you are
listening.
What are Caldicott Guardians?
Caldicott Guardians are senior people in NHS, local
authority social care, and partner organisations, responsi-
ble for protecting the confidentiality of patient informa-
tion and enabling appropriate information sharing.
CASE 4.23  CONSENT FOR
INVESTIGATION OR TREATMENT
Candidate information
Role
You are a doctor on the acute medical unit.
Please read this summary.
Scenario
Re: Ms Kate Morland, aged 23 years
Ms Morland was admitted last night with a severe occipital
headache of sudden onset. She is a normally fit and well young
woman, who works at your hospital as a nurse. She sustained a
minor whiplash injury 3 days previously in a minor road traffic
accident. Her headache came on suddenly at a party. It was the
worst headache she has ever experienced and reduced her to tears.
Her computed tomography brain scan is normal.
Your tasks are to explain the reasons for performing a lumbar
puncture (to exclude subarachnoid haemorrhage) and obtain her
consent.
660
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
Ms Kate Morland, a 23-year-old nurse, was admitted to the
emergency medical admissions unit last night with the
worst headache she has ever experienced. She is a normally
fit and well young woman, who works at this hospital. She
sustained a minor whiplash injury 3 days ago in a minor
road traffic accident. She is very scared. She has never felt
this unwell. She is afraid that colleagues have witnessed her
tears and distress. She has been told that a lumbar puncture
is necessary but is afraid of further investigations involving
needles and does not understand why she needs to stay in
hospital because her brain scan was normal.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
She is very apprehensive, probably a cumulative effect of
recent personal stresses, being admitted to her own work-
place and fear of needles. Patients’ fears are multiplied
significantly if they feel, as they often do, uncertain about
what is happening to them, what is planned and why.
Establish an aura of calm. Explain that, before you do
anything else, you would like to recap on the reasons for
the scan, the desirability of doing one further test – the
lumbar puncture – and to talk this through with her so
that she can decide whether or not to go ahead. Make it
very clear that in the last analysis it is her decision.
2.  Explain the situation so far
Reassure her that the test results so far are good and that
nothing bad, such as a brain tumour, has been seen.
Explain the main unresolved concern.
The main concern in this situation is the possibility of a small
bleed, known as a subarachnoid haemorrhage. This is usually
detected by the scan, but a small number of cases, perhaps
around 10%, may not be picked up. Although it is generally
small bleeds that are not picked up, the concern is that
subarachnoid bleeds arise from a weakness in the wall of a
blood vessel, and if not detected can recur with much more
serious consequences. If detected, there are possible
treatments to correct the underlying cause.
3.  Explain the best way forward
The only way to detect a smaller bleed is with a test called a
lumbar puncture, these days a relatively straightforward test
without too much discomfort.

4.  Establish previous experience and be alert to
ideas and concerns
Before explaining the test in more detail, establish any
specific ideas or concerns. Many patients have heard exag-
gerated stories about lumbar punctures and big needles.
Alternatively, she might have personal knowledge of
someone close to her who had a difficult lumbar puncture
for a serious disease.
5.  Explain the nature of the investigation   for battery. Generally, if a person touches another without
or treatment
Explain that a lumbar puncture involves, with local anaes-
thetic, a small needle inserted in to the lower part of the
back to draw off spinal fluid. In the case of a subarachnoid
bleed, this should be blood stained. She will need to lie
curled up on her side during the procedure and remain in
bed for around 4 hours afterwards.
6.  Explain the risks and benefits of the
investigation or treatment
Complications include headache (common) and much
more rarely serious complications such as infection.
7.  Explain any possible alternatives
In this case the alternative is to do nothing, because sub-
arachnoid haemorrhage may be unlikely. Less optimal
tests in patients at higher suspicion of subarachnoid
haemorrhage who abjectly decline lumbar puncture might
include magnetic resonance cerebral angiography,
although this might only detect larger aneurysms.
8.  Show respect for autonomy
In respecting her right to decide, you must be sure that  procedure
she has been informed and understands that the test  • The risks and benefits, and alternative options or treatments;
is ordinarily safe and straightforward and that the 
possible diagnosis, albeit unlikely, is potentially  practice accepted as proper by a responsible body of doctors
life threatening. Without telling a patient what must  skilled in that art (i.e. what a responsible body of medical
be done, it is crucial to explain that in your opinion a
particular course of action seems to be in that patient’s
best interests.
9.  Confirm understanding and invite questions
Allow her time to assimilate all of this information,
confirm that she understands what you have explained
and invite any questions.
10.  Seek permission to proceed
Use an open question:
How does this sound?
Discussion
What is consent?
Agreement to an action based on knowledge of what that
action involves and its likely consequences.
Case 4.23  Consent for investigation or treatment
What are the necessary requirements for
valid consent?
Consent rests on the principle of respect for patient auton-
omy. For it to be legally valid three conditions must be
met (Box 4.15).
What is battery?
A procedure performed without consent may be grounds
consent, this constitutes battery, for which damages may
be awarded. Unlike negligence (Case 4.40), proof of harm
is not necessary.
What is meant by implied
and express consent?
Types of consent are discussed in Box 4.16.
Box 4.15  Valid consent
Requirements for valid consent
1. The patient should be properly informed.
2. The patient should understand that information and be
competent (legally, have capacity) to give consent.
3. Consent must be given voluntarily, without coercion.
A written record of the conversation is necessary.
‘Informed consent’
A patient needs a certain amount of information for consent to be
legally valid. He or she must be aware of:
• The nature of the intervention; avoidance of battery requires
that the doctor explains, in broad terms, the nature of the
this relates to the avoidance of negligence. In general, a doctor
is not negligent if he or she has acted in accordance with the
opinion would disclose in the same or similar circumstances).
This is termed the Bolam test after the relevant legal case.
However, the standard of information provision by doctors is
evolving in English law, mainly as a result of General Medical
Council guidelines, and is drawing nearer to the prudent-
patient test widely used in North America. According to this
test, doctors should provide the amount of information that a
‘prudent patient’ would want.
What most patients would want to know
For an investigation or treatment most patients would want to
know:
• The possible or likely diagnosis, and its prognosis with or
without treatment
• The purpose of the proposed investigation or treatment
(furthering diagnosis, excluding serious diagnoses, improving
prognosis)
• Any common or serious complications or side effects of the
proposed investigation or treatment, and of the possibility of
proposed treatment failing to produce the desired aim.
661
 Station |4| Communication skills and ethics
Box 4.16  Types of consent
Implied consent
Because touching a patient without consent can constitute battery,
consent is needed even when, for example, taking a pulse or
examining the chest. Yet doctors seldom obtain consent, either
expressed orally or in writing, for such routine tasks, and in law
patients could not successfully sue doctors most of the time
because the Courts accept the concept of implied consent. If a
patient offers their wrist while the doctor takes the pulse, consent
is implied by their behaviour. However, the fact that a patient is in
hospital for examination does not constitute consent to
examination, investigation or treatment.
Express consent
Express consent, explicitly given (usually verbal but sometimes
written), for investigation or treatment is preferable when:
• The investigation or treatment is complex or involves significant
risks or side effects
• Clinical care is not the primary purpose of the investigation
• The investigation or treatment forms part of research
• There may be significant personal consequences for the patient.
Express consent may be oral or written, the latter a legal
requirement in some circumstances, e.g. organ donation, and
desirable where interventions are complex, there may be significant
consequences on employment, social or personal life, clinical care is
not the primary purpose of the intervention, or in research.
What information should be shared with a
patient in order to obtain consent?
The exchange of information between doctor and patient
is central to good decision making. How much informa-
tion is shared with patients will vary, depending on their
individual circumstances. The approach to discussion
should be tailored according to:
• Their needs, wishes and priorities
• Their level of knowledge about, and understanding
of, their condition, prognosis and the treatment
options
• The nature of their condition
• The complexity of the treatment
• The nature and level of risk associated with the
investigation or treatment.
Assumptions should not be made about:
• The information a patient might want or need
• The clinical or other factors a patient might consider
significant
• A patient’s level of knowledge or understanding of
what is proposed.
Patients must be given the information they want or
need about:
• The diagnosis and prognosis
• Any uncertainties about the diagnosis or prognosis,
including options for further investigations
• Options for treating or managing the condition,
including the option not to treat
662
• The purpose of any proposed investigation or
treatment and what it will involve
• The potential benefits, risks and burdens, and the
likelihood of success, for each option; this should
include information, if available, about whether the
benefits or risks are affected by which organisation
or doctor is chosen to provide care
• Whether a proposed investigation or treatment is
part of a research programme or is an innovative
treatment designed specifically for their benefit
• The people who will be mainly responsible for and
involved in their care, what their roles are, and to
what extent students may be involved
• Their right to refuse to take part in teaching or
research
• Their right to seek a second opinion
• Any bills they will have to pay
• Any conflicts of interest that the doctor or
organisation may have
• Any treatments believed to have greater potential
benefit for the patient than those the doctor or
organisation can offer.
These matters should be explored with patients, with
concerns listened to, views sought and respected, and that
information is understood checked. Questions should be
answered honestly and, as far as practical, as fully as
wished.
How should information be shared?
The way information is communicated is as important as
the information itself. It should be easy to understand and
given with due consideration.
What would you do if a patient asks for
decisions to be made on their behalf?
If a patient asks you to make decisions on their behalf or
wants to leave decisions to a relative, partner or friend, you
should explain that it is important that they understand
the options open to them, and what the treatment will
involve. If they do not want this information, you should
try to find out why. If the patient still does not want to
know in detail about their condition or the treatment, you
should respect their wishes as far as possible. But you must
explain the importance of providing at least the basic
information they need in order to give valid consent to a
proposed investigation or treatment. If the patient insists
that they do not want even this basic information, you
must explain the potential consequences of carrying out
an investigation or treatment if their consent may be open
to subsequent legal challenge. You must record the fact
that the patient has declined relevant information and
who they asked to make the decision about treatment. You
must also make it clear that they can change their mind
and have more information at any time. Apart from cir-
cumstances in which a patient refuses information, you
should not withhold information necessary for making

decisions, unless you believe that giving it would cause the
patient serious harm.
Can a patient demand a treatment?
A patient with capacity may refuse a particular treatment
but cannot demand a particular treatment that the doctor
does not consider to be in that patient’s best interests.
What exceptions are there to informed
consent?
Exceptions are where a patient is judged not to have the
capacity to give informed consent.
How might doctors be at risk of committing
battery when obtaining consent from a
competent patient?
By failing to give sufficient information about the nature
of the procedure.
How might doctors be at risk of negligence
when obtaining consent from a competent
patient?
By failing to give sufficient information about common
and rare serious side effects, benefits and possible
alternatives.
A 65-year-old man has diabetic nephropathy
as evidenced by microalbuminuria. You wish
to start an angiotensin-converting enzyme
(ACE) inhibitor. What type of consent would
you obtain?
Rights are so basic yet so easily ignored. This is especially
true of the right to consent to treatment or refuse it. In
theory, consent should always be obtained for any treat-
ment. In practice, there is often an implicit understanding
that consent for examination, investigation or treatment
is implied. Although such assumptions seldom result in
problems, legal justification for them is not inevitable. You
should obtain express consent, explaining why you feel
the ACE inhibitor would be beneficial (knowledge of
disease and its treatment), important side effects (knowl-
edge of drug), any alternatives, and the risks or benefits
and likely outcomes of these.
CASE 4.24  CONSENT AND
CAPACITY
Candidate information
Role
You are a doctor on the stroke unit.
Please read this summary.
Case 4.24  Consent and capacity
Scenario
Re: Mr Ashley Wills, aged 77 years
Mr Wills has been on your ward for 4 weeks following a left
total anterior circulation infarct with dense right-sided hemiparesis,
expressive dysphasia and a degree of receptive dysphasia. Over the
past 4 weeks recovery has been minimal and his swallow, as
assessed by the speech and language therapists, remains unsafe. At
least one confirmed episode of aspiration has occurred. He has
pulled out his nasogastric tube on numerous occasions and feeding
has been erratic because it is difficult to replace. His serum albumin
(although not reliably related to nutritional status) has fallen to
26 g / l. Your team feel that a percutaneous endoscopic gastrostomy
(PEG) tube is in his best interests to support adequate nutrition
and optimise potential recovery. It is increasingly likely that he will
require long-term nursing care. You cannot be certain that Mr Wills
understands or retains information.
Your tasks are to discuss with Mrs Wills, your patient’s wife,
why a PEG tube is being considered and obtain her consent.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
Your husband, Mr Ashley Wills, is a 77-year-old man who
has been on the stroke unit for 4 weeks following a large
stroke with dense right-sided weakness and loss of speech.
His comprehension of anything he is told is variable, and
you cannot always be sure of what he understands. Over
the past 4 weeks recovery has been minimal and his
swallow remains unsafe. He is sometimes agitated, pulling
out his nasogastric feeding tube on numerous occasions
and his feeding has been erratic. You can see that his
nutritional state is not optimal and the doctors have told
you that this is confirmed on blood tests. The doctors feel
that a percutaneous endoscopic gastrostomy (PEG), a
feeding tube passed directly into the stomach, would
support adequate nutrition and optimise potential recov-
ery, but you have also been told that he is unlikely to get
home again. Your husband has always feared ‘ending up
in a nursing home’ and you are not sure that he would
want further intervention.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduce yourself and establish the  
relative’s identity
Introduce yourself and confirm that she is Mr Wills’ wife.
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 Station |4| Communication skills and ethics
2.  Establish background knowledge
Find out what she understands about her husband’s con-
dition and the problems faced (rehabilitation challenges,
nutrition compromised) to get an idea of where to start
your explanation.
3.  Explain the problem
Explain that the stroke has led to swallowing problems,
preventing adequate nutrition and putting him at risk  you should consider two possibilities. If you can be con-
of further episodes of aspiration. Explain that he has
pulled out the nasogastric tube on numerous occasions
and that it has proved challenging to replace and that  be respected. If you cannot be convinced of this, and feel
in any event this is not an ideal long-term solution to
meeting his nutritional needs. Explain that with time  resolve to seek further advice from senior colleagues and,
and without adequate nutrition her husband will inevita-
bly decline.
4.  Explain possible solutions
Explain that one option is a PEG tube, and explain that
this involves insertion of a small feeding tube directly into
the stomach through the abdominal wall. This can be
performed in various ways but the most common method
is via endoscopic guidance, under local anaesthetic and
with a degree of sedation. Explain the potentially serious
complications (infection, perforation, death). PEG tubes
carry a modest but significant mortality as well as signifi-
cant morbidity.
5.  Be alert to cues
You may perceive how she feels about your proposed strat-
egies from non-verbal cues.
6.  Ask how the relative feels, and how she
thinks the patient would feel about this
Sometimes patients’ relatives are reluctant to give a view
because they feel it is too much responsibility for a loved
one to take. More often, relatives have concerns. They
simply want what is best for their loved one but find it
hard to make decisions because there seem to be risks with
every choice. Reassure her that you will always try to do
what is in the patient’s best interests, but that it is impor-
tant to know if to her knowledge her husband might have
had any strong wishes one way or the other.
7.  Attempt to address concerns
Relatives struggle, understandably, to come to terms with
major changes such as the likelihood of nursing home
dependency. However, in coming to terms with this there
are many smaller hurdles or decisions to be negotiated
along the way. Apart from the general wishes of most
people not to be ill or to face nursing care or mental inca-
pacity, most will not have thought in detail and discussed
specific wishes like PEGs and even with valid advance
directives the devil is often in the detail. When faced with
a choice between nutrition to optimise whatever recovery
is possible and certain decline, most relatives will agree to
664
a PEG tube unless decline seems inevitable even with
nutrition, in which case doctors would not consider it.
8.  Relative agrees or relative disagrees with
what you see as in patient’s best interests
Most relatives agree to PEG feeding if it is clinically indi-
cated. In those uncommon circumstances where there is a
major differing view between relatives and medical staff
vinced that information provided by his wife confirms his
advance refusal of consent to a feeding tube, this should
that these are exclusively his wife’s wishes then you should
ultimately, you may need to contemplate a course of
action that is at odds with a relative’s wishes but that is
seen as in that patient’s best interests by the medical team;
such a course of action should generally be followed
gently, allowing relatives time to question the issue them-
selves and see things from your perspective.
9.  Confirm understanding and invite questions
Be clear that she understands the issues raised, and invite
questions.
10.  Agree a way forward
A likely way forward will be to request PEG insertion, with
the understanding that this decision might be revised if he
were to deteriorate in the next few days but proceed if he
remains stable.
Discussion
What are the key aspects, based on case
law, of capacity to give or withhold
consent?
For a patient to give valid consent to a procedure or treat-
ment, she or he must be competent or, in legal terms, have
the capacity to do so. The key aspects of capacity are listed
in Box 4.17.
Box 4.17  The key aspects of capacity (the ‘test’
of capacity)
Each of the following must apply for a person to have capacity:
1. The ability to understand information relevant to the decision
(proposed interventions such as investigations or treatments,
alternative options, the intervention’s possible benefits and
risks, and the consequences of non-treatment); the person
should also of course believe that information to be true
2. The ability to retain that information (for how long depends
upon what the information is)
3. The ability to weigh up the information to reach a decision
4. The ability to communicate a decision.

Incapacity must be proven. All adults are assumed by
law to have capacity unless proven otherwise. Further, a
person may not be globally competent or incompetent. It
is ‘function or decision specific’. For example, a patient
may be capable of declining surgery but incapable of
judging their safety at home. Capacity may also fluctuate
over time. Even where capacity may be limited, a doctor
has a duty to give an account in simple terms to a patient
of what is being proposed. According to the Mental  medical, emotional and all other factors relevant to the
Capacity Act (below) a person lacks capacity if because of
‘an impairment of, or a disturbance in the functioning of,
the brain and mind’ (which can be permanent or tempo-
rary) he or she is unable to fulfil any of the four criteria
in Box 4.17.
Can any doctor (or health-care professional)
judge a patient’s capacity?
It is the personal responsibility of any doctor or health-
care professional proposing an investigation or treatment
to establish whether a patient has the capacity to give valid
consent. Where incapacity is being judged it is wise to seek
agreement from colleagues and other members of the
team involved in the patient’s care, and where there is any
doubt to seek the opinion of a psychiatrist.
What do you know of the legal necessity to
treat incapacitated patients?
The concept of necessity is that not only is a doctor able
to give treatment to an incapacitated patient when it is
clearly in that patient’s best interests, but it is also common
law to do so. This still only applies to treatment aimed to
improve or prevent deterioration in health. If the patient
is known to have prior objections to all or some parts  proxy decision making in Scotland). A solicitor, for
of a treatment, doctors are not justified in proceeding,
even in emergency situations. If incapacity is temporary
(e.g. anaesthesia, intoxication, unconsciousness), doctors
should not proceed beyond what is essential to preserve
life or prevent deterioration in health.
How may doctors be guided when making
decisions for a patient without capacity?
Doctors, not relatives, are responsible for making medical
decisions about incapacitated patients. Any procedures
requiring a consent form should be consented to by
doctors, not a next of kin. Guidance when making deci-
sions for patients without capacity is given in Box 4.18.
What are the key principles and innovations
of the English Mental Capacity Act 2005?
The Mental Capacity Act provides a statutory framework
to empower and protect vulnerable people who are not
able to make their own decisions. It makes it clear who
can take decisions, in which situations, and how they
should go about this. It is underpinned by five key princi-
ples (Box 4.19).
Key innovations of the Mental Capacity Act are outlined
in Table 4.2.
Case 4.24  Consent and capacity
Does the Mental Capacity Act aid
determination of best interests?
It provides a best interests checklist (Box 4.20).
‘Best interests’ can be particularly emotive in end of life
care. Case law suggests that the ‘intolerability’ of treatment
is not the sole test of whether treatment is in a patient’s
best interests. The term ‘best interests’ encompasses
patient’s welfare. A patient’s best interests may be inter-
preted as meaning that a patient should not be subjected
to more treatment than is necessary to allow them to die
peacefully and with dignity.
Can incapacity be inferred from a particular
medical illness or diagnosis?
No. Alzheimer’s disease or any other dementia, for
example, does not necessarily imply incapacity.
What do you know about legal
representation for incapacitated adults?
Social services can provide agency or appointeeship for han-
dling the financial affairs of an incapacitated adult.
Doctors may sign letters confirming mental incapacity;
psychiatrists may become involved where mental state
assessment is challenging.
Power of attorney (PA)
PA gives someone the legal right to act on behalf of
another. PA is only applicable for people who can under-
stand and not for people with incapacity (compare with
example, may act as PA to sell your house while you are
on holiday. PA formerly lapsed if a person became inca-
pacitated but in 1985 a special type of PA known as endur-
ing power of attorney (EPA) changed this. PA can be revoked.
Sometimes PA representatives can try to take PA too far.
PA does not give the right to make medical decisions,
which remain up to the patient, or, if the patient is inca-
pacitated, the doctor acting in the patient’s best interests,
except in those circumstances where lasting power of attor-
ney (LPA), which replaced EPA, has been invoked allowing
for proxy decision making under the Mental Capacity Act.
Court of Protection / Court Appointed Deputies
Court of Protection (CoP) (now a system of Court
Appointed Deputies) applies to circumstances in which
EPA (now LPA) has not been given and a patient has
become incapacitated. It is concerned mostly with prop-
erty, and requires medical evidence. CoP applications can
be made by a solicitor (usual) or the state (Director of
Social Services). Solicitors then request details as to why a
doctor feels that a patient is incapacitated. Many doctors
(e.g. care of the elderly physicians) complete the forms
where incapacity is clear (brief, layperson’s language is
acceptable, e.g. poor memory, deluded); psychiatrists are
often involved where incapacity is not so clear. The Court
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 Station |4| Communication skills and ethics

Box 4.18  Guidance when making decisions for a patient without capacity

Best interests
Doctors may act in what they see as a patient’s best interests. The
doctrine of necessity underpinning the treatment of people who
lack capacity requires that there must be a necessity to act and that
such action must be in the best interests of the person concerned.
This is a grey area; traditionally it has been felt that best interests
will be served when a doctor acts in accordance with accepted
medical opinion (Bolam test). When more than one option seems
reasonably in a patient’s best interests (including non-treatment)
that which least restricts that patient’s future choices should be
chosen. However, the Mental Capacity Act now more clearly
stipulates how best interests should be determined.
Advance decisions
Doctors may be guided by any expressed wishes or advance
decisions made at a time when the patient had capacity. Losing
capacity, such as losing consciousness, does not negate previous
wishes and a valid and applicable advance directive (Case 4.28)
overrides best interests if these are discrepant.
Legal proxy
If a patient has a legal proxy – a welfare attorney or guardian
– this person must be consulted about cardiopulmonary
resuscitation decisions. In England and Wales* the Mental Capacity
Act allows people over 18 years of age who have capacity to make
a lasting power of attorney (LPA), appointing a welfare attorney to
make health and personal welfare decisions on their behalf once
such capacity is lost. Before relying on the authority of this person,
the health-care team must be satisfied that the patient lacks
capacity to make the decision, a statement has been included in
the LPA specifically authorising the welfare attorney to make
decisions relating to life-prolonging treatment, the LPA has been
registered with the Office of the Public Guardian and the decision
being made by the attorney is in the patent’s best interests. In
England and Wales neither welfare attorneys nor deputies can
demand treatment that is clinically inappropriate.
Those close to a patient
Where a patient has not made an advance decision or has a legal
proxy, treatment decisions rest with the most senior clinician in
charge of the patient’s care. Decisions must be made on the basis
of the patient’s best interests. In order to assess best interests, the
views of those close to the patient should be sought, unless this is
impossible, to determine any previously expressed wishes and what
the patient would be likely to consider of benefit. In reaching a
decision, in England and Wales**, the Mental Capacity Act requires
that best-interests decisions must include seeking the views of
anyone named by the patient as someone to be consulted, anyone
engaged in caring for the person or anyone interested in the
patient’s welfare. Under the Act, all health-care personnel must act
in the best interests of a patient who lacks capacity. In these
circumstances, it should be made clear to those close to the patient
that their role is not to take decisions on behalf of the patient, but
to help the health-care team to make an appropriate decision in the
patient’s best interests.
Independent mental capacity advocate
In England and Wales the Mental Capacity Act requires an
independent mental capacity advocate (IMCA) to be consulted
about all decisions about ‘serious medical treatment’ where patients
lack capacity and have nobody to speak on their behalf. The
definition of serious medical treatment includes circumstances
where ‘what is proposed would be likely to involve serious
consequence for the patient’. An IMCA does not have the power to
make decisions but must be consulted as part of the determination
of the patient’s best interests. The rights of an incapacitated patient
to such principles as non-discrimination, confidentiality, liberty and
dignity are of course identical to those of a patient with capacity.

*In Scotland the Adults with Incapacity (Scotland) Act 2000 allows people over 16 years of age, who have capacity, to appoint a welfare
attorney to make decisions about medical treatment once that capacity is lost. The Sheriff may, on application, appoint a welfare guardian
with similar powers. Before relying on the authority of a welfare attorney or guardian, the health-care team must be satisfied that the
patient lacks capacity to make the decision (the terms of a power of attorney may state how incapacity is to be determined), the welfare
attorney or guardian has the specific power to consent to treatment (a register of valid proxy decision makers is held by the Public
Guardian), the decision being made by the attorney would benefit the patient and the attorney has taken account of the patient’s past and
present wishes as far as they can be ascertained. In Scotland, welfare attorneys and guardians cannot demand treatment that is clinically
inappropriate. In Northern Ireland there is currently no provision for anybody to make decisions on behalf of patients who lack capacity,
although those close to patients should be consulted where a best-interests decision is being made by the clinician in charge of the patient’s
care.
**In Scotland the Adults with Incapacity (Scotland) Act requires doctors to take account, so far as is reasonable and practicable, of the views
of patients’ nearest relatives and carers. In Northern Ireland, where there is no statutory provision for decision making for patients who lack
capacity, it is nonetheless good practice to discuss decision making with those close to the patient in order to determine what would be in
the best interests of the patient.

appoints a receiver (e.g. relative, accountant) who acts for
the incapacitated person. CoP is not necessarily perma-
nent because it depends more on behaviour than
prognosis.
It is common to look after patients in hospital who are
vulnerable and lack insight and capacity, for example the
elderly woman who lives alone in her own house, has no
close relatives and who wanders at night around the house
putting on the gas, or outside on to the road. If she lacks
insight, she may ask to go home and simply reject all of
your concerns. Your responsibility is for her safety. It may
be impossible to put in care at home at night and if she
has progressive dementia without acute psychosis or
depression transferring her to psychiatric care is only shift-
ing the problem. She will probably need gentle ushering
to a community hospital bed unless direct care-home

666
 Case 4.24  Consent and capacity

Box 4.19  The five key principles of the mental
capacity act
1. People are assumed to have capacity unless proven
otherwise.
2. Before deciding that someone lacks capacity, all steps
should be taken to enhance his or her decision-making
abilities.
3. Someone cannot be said to lack capacity simply because he or
she is making what might be seen as an eccentric or unwise
decision.
4. A person’s best interests should always be taken into account
in making a decision on his or her behalf.
5. The least restrictive option (of basic rights and freedoms)
should always be used.
Box 4.20  Determining best interests
The person making a decision must:
• Consider when / if the person is likely to regain capacity
• Encourage patient participation (e.g. repeatedly pulling out a
nasogastric tube may be indicative of wishes)
• Consider past and present feelings, previous beliefs and values
and other relevant factors
• Consult others (account should be taken, where practicable and
appropriate, of the views of at least one of: anyone named by
the person to be consulted on matters of the kind; anyone
engaged in caring for the person or interested in their welfare;
any donee with lasting power of attorney (LPA) granted by the
person; any Court-appointed deputy). For people who lack
capacity and who lack a spokesperson (no relative, friend, carer,
LPA or deputee) an independent consultee arrangement is
possible.

Table 4.2  Key innovations of the Mental Capacity Act

Key innovation What it means

Definition of incapacity
Designated ‘proxy’ decision makers
may act on behalf of someone who
lacks capacity under two
mechanisms
Development of two public bodies
to support the statutory framework
designed around the needs of
those who lack capacity
A clear test of incapacity (see Box 4.17)
Lasting power of A person who still has capacity may donate an LPA to one or more people.
attorney (LPA) This is similar to enduring power of attorney (EPA) which preceded it, but
allows for the donor’s (that person giving power of attorney) care, including
medical care, to be decided by the donee (that person given power of
attorney) although an LPA cannot refuse life-sustaining treatment unless
expressively given this power and is bound by advance directives (whilst
these forms of proxy may become increasingly common, it is likely that most
patients will continue to have no such provision)
Court-appointed The Court can appoint a deputy or deputies who can make welfare, health
deputies and financial decisions on behalf of a person who lacks capacity but are not
able to refuse consent to life-sustaining treatment. They can only be
appointed if the Court cannot make a one-off decision to resolve issues
A new Court of Has jurisdiction relating to the whole Act and final arbiter for capacity
Protection matters
A new Public Guardian Registering authority for LPAs and deputies

Greater emphasis on decisions
being made in the patient’s best
interests
Three further provisions to protect
vulnerable people
Clear parameters for research
Applies both to doctors and to any proxy decision makers
Independent mental Someone appointed to support a person who lacks capacity but has no one
capacity advocate to speak for them
Makes representations about feelings, beliefs and values and brings to
attention of decision maker relevant facts
Can challenge decision maker
Advance decisions to Statutory support of advance directives and decision making (does not apply
refuse treatment to any treatment a doctor considers necessary to sustain life unless strict
formalities have been complied with that include a decision in writing that is
signed and witnessed and that includes an express statement that the
decision stands ‘even if life is at risk’)
Criminal offence For ill treatment or neglect of a person who lacks capacity
Research may be lawful if approved by relevant bodies (e.g. ethics committees) and cannot be performed
as effectively on those with capacity
Carers or nominated third parties must be consulted and agree that patient would approve

667
 Station |4| Communication skills and ethics

placement is available, with her general practitioner on

board. Although not urgent, ultimately her house may
need to be sold and other affairs attended to. Therefore,
concurrently, assuming she has no LPA in a distant relative
or in her solicitor, social services should be contacted to
start CoP proceedings.
Does the Mental Capacity Act allow
detention of patients?
It is only permitted if it is reasonably believed to prevent
harm and measures must be proportionate to the likeli-
hood of serious harm. ‘Deprivation of liberty’ paperwork
needs to be completed as part of the justification for  Ms Dashwood was admitted to hospital recently with
the decision, which may be a holding measure if specific
sectioning under the Mental Health Act becomes
appropriate.
What do you know about safeguarding
vulnerable adults in hospital?
Vulnerable adults include those who lack mental capacity,
those with cognitive impairment, those disabled mentally
or physically, those with sensory impairment, those in
institutions, those with no fixed abode and those socially
isolated.
Vulnerable adult risk management involves case-specific
management, often a multi-agency approach, and involv-
ing the patient as far as possible in decision making; where
this is not possible and there are no relatives or carers, or
if there are concerns about the motives of relatives or
carers, an independent mental capacity advocate (IMCA)
may aid decision making in best interests, making more
robust the traditional doctor ‘best interests’ decisions.
IMCAs may be helpful if there are major medical decisions
or if care placement is being planned, and they have the
right to use the CoP if they have concerns about decisions
being proposed.
Sadly, vulnerable adults are often subject to abuse, most
commonly by those ‘caring’ for them, often in institutions,
sometimes in their own home; carers may not be aware of
the abuse, and abuse is not always intended; sometimes it
has become ‘the norm’ over many years, and sometimes
the patient’s needs outgrow well-intentioned carers or
institutions.
Signs of abuse may be physical (e.g. bruises, pressure
areas), behavioural (e.g. fear, avoidance), loss of financial
assets or neglect (e.g. malnutrition, weight loss, dehydra-
tion, unkempt appearance).
The clinician’s role is an index of suspicion, accurate
record keeping, arranging any appropriate medical pho-
tography, multidisciplinary team liaison and referral to the
hospital social services team (HSST). The HSST coordi-
nates all subsequent investigation and referral to the adult
protection (AP) team or the AP police who may determine
whether or not an offence has been committed; the AP
police take over investigation of any offence, and it is
important for clinicians to share information on a need-
to-know basis.
CASE 4.25  REFUSAL OF CONSENT
Candidate information
Role
You are a doctor on the medical ward.
Please read this summary.
Scenario
Re: Ms Eleanor Dashwood, aged 75 years
pneumonia. During the course of investigations she was found to
have iron deficiency anaemia and subsequently a hard rectal mass
was discovered, most probably a carcinoma. She is asymptomatic.
She is otherwise well and has no past medical history of note. She
has now made a good recovery from her pneumonia and is keen to
go home. She refuses any further investigations or treatments for
the likely tumour.
Your task is to establish that this is her informed decision.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
Ms Eleanor Dashwood is a previously well 75-year-old,
independent woman admitted to hospital with pneumonia.
She is recovering from this but during the course of her stay
she was found to be anaemic and subsequently a rectal lump
was discovered, most probably a cancer. She told the doctors
she had no symptoms but in fact has had constipation and
episodes of fresh rectal bleeding over the last 2 months. She
has not told anyone because her husband developed similar
symptoms a few months before his bowel cancer was diag-
nosed. His cancer had spread to the liver at diagnosis and
was incurable. He died despite a complex array of investiga-
tions and treatments. She does not wish to ‘go down the
same route of hospitals and tests’ and would prefer to let
nature take its course, even if that means rapidly deteriorat-
ing like her husband. She will refuse any further investiga-
tions or treatments for the likely tumour.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself and make it clear you are here to help.

668

2.  Explain the situation so far
As I think you know, you had a rather nasty pneumonia
when you came in to hospital that has responded very
well to antibiotics. But I think you also know that during
the course of our tests we found that you were anaemic
– that your blood count was low. We also discovered a lump,
in the tail end, and this is very likely to be the reason for the
anaemia, very possibly a lump that may not be nice … a form
of growth.
She will be likely to acknowledge all of this and may  immediate problems that can sometimes arise is a blockage in
either tell you she has thought about this and decided she
does not want anything done or she may be a little more
open to your thoughts and ask what you feel ought to be
done.
3.  Explain the best way forward
The best way forward for her can only be established in
conjunction with her.
That is for us to decide together. First of all, we would need to
consider some further tests to try to establish accurately
what it is.
4.  Establish previous experience and be alert to
beliefs and concerns
Her husband’s experience is clearly pivotal in her decision.
Acknowledge this.
I understand. I do understand.
It may be that she imagines painful tests. It may be that
she imagines only chemotherapy, about which she has
heard so many dreadful things, but would consider an
operation. There are many ‘maybes’. The point is that,
before respecting her wishes (autonomy) for no further
tests, you must try to understand precisely what her posi-
tion is and help to inform her. Her decision may already
have been made. But you should try to discover the reasons
she made it and whether or not she has sufficient informa-
tion at her disposal to make an informed decision. She
may choose not to receive any more information, but
ideally informed consent to no treatment should be
obtained and based upon discussion of the acceptability
and effectiveness of the various options.
5.  Explain the nature of the investigation   8.  Show respect for autonomy
or treatment
I understand fully how you must feel. And I’ll say immediately
that we will respect any decision you make. I should also tell
you that at this stage we are by no means certain of the
diagnosis and that tests would help us to be more certain
– and to more certainly know whether this is a very different
situation from that of your husband. It may well be.
Were we to investigate, I would recommend a scan of the
tummy, and then very likely a biopsy of the lump – by asking
one of our surgical colleagues to take a sample of tissue from
the lump via a flexible telescope with a light on the end. We
would then be in a much better position to know the best
way forward.
Case 4.25  Refusal of consent
6.  Explain the risks and benefits of  
the investigation or treatment and the
consequences of not pursuing matters
The tests would be likely to tell us one of two things. Firstly,
they might show that this problem is very well localised, and
if that is the case then very possibly curable. Secondly if, and
there is always the possibility, things were not as confined as
we hoped, then we might well be able to predict future
problems and take action to lessen these. One of the more
the bowel, which can be difficult, and far more difficult to
treat if it happens without our prior knowledge. There is, of
course, a possibility that the lump is not as worrying as we
had thought, and that the anaemia is due to something very
simple. It would be nice to know this.
7.  Explain any possible alternatives
She may ask what would happen next if she chose not to
pursue tests.
The alternative is simply to let you go home, perhaps asking
your doctor to keep a close eye on things, and arranging for
you to see us again at any stage if you were to change your
mind. Or we could see you here in clinic in a few weeks to
have another talk about things. I would just say, however, that
you are a healthy lady in all other respects, and that makes it
much more likely that you would find the tests, and perhaps
treatment, more straightforward.
Ask if she has any relatives or people close to her 
with whom she might wish to discuss options, or with
whom she might wish you to talk. A common problem,
however, is that relatives may take a different view and
exert pressure on the physician to act. The primary emotion
is almost always desire for the best management of the
patient. The physician may explain (if the patient is happy
for such a discussion) that the issue has been fully dis-
cussed in terms of likely benefits and risks and outcomes,
and that as a result of this information an informed deci-
sion has been made by the patient. Occasionally, relatives
may feel that the patient is unable to make the best 
decision (‘she is old and does not know what is best’) to
which the physician must explain that there is no evidence
she or he does not have the capacity to make informed
decisions.
We will do our best, whatever you decide.
9.  Confirm understanding and  
invite questions
Allow her time to assimilate all of this information,
confirm that she understands what you have explained
and invite any questions.
10.  Keep the door open
If she still refuses ongoing investigation, make it very clear
that you are happy to see her again. In this situation, where
she will have a lot to assimilate, it might be sensible to
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 Station |4| Communication skills and ethics
arrange follow-up in clinic anyway, if she agrees. She might
be more likely to miss out on potential treatments unless
you set up possible avenues towards these.
Discussion
If a young woman with Graves’
thyrotoxicosis wanted to pursue
homeopathic treatment, even when the
endocrinologist has recommended
carbimazole, would you agree?
You may not have the facts in front of you, but feel she
‘needs’ more than homeopathic treatment. But it is vital
to understand why she feels the way she does and explore
her reasons for choosing homeopathy. She may have expe-
rience of homeopathy for other conditions, she may have
been ready to consider carbimazole before learning of a
dangerous side effect (leucopenia), and she may have con-
sidered other forms of treatment. You should talk to her
about Graves’ disease, its complications, the benefits and
risks of treatment and the likely natural history without
treatment. You might tell her you are unaware of any 
effective homeopathic treatments. Is it possible, if she is
adamant that homeopathic treatment will help her, 
that she would consider conventional treatment as  CASE 4.26  DELIBERATE SELF-HARM
well? Failing this, might she accept switching to 
conventional treatment within a certain time limit if  Candidate information
her approach fails. You would of course inform your con-
sultant of any conversation and document your advice
carefully.
You have been seeing a 50-year-old
man with tuberculosis in the respiratory
clinic. He wishes to pursue homeopathic
treatment rather than continue with
antibiotics. Would you agree?
There comes a point where collusion with a patient is
wrong, clinically, ethically and legally. Here, you have not
just to consider this man’s autonomy, but risks to other
members of the public from his active tuberculosis. Rather
than approaching this dilemma in a dogmatic way, listen-
ing to the patient’s reasons, beliefs and concerns may
avoid confrontation. Perhaps the importance of antibiotic
therapy has never been fully explained. Perhaps he has
heard that homeopathy can help a wide range of respira-
tory conditions. Listening and simple explanation may be
enough to persuade him of his misconception. Perhaps he
feels that the antibiotics should have worked by now and
is concerned that he is still coughing. Perhaps he is frus-
trated that he cannot return to work and needs to vent his
feelings.
Can a patient refuse treatment, even to the
point of death?
Refusal of consent is discussed in Box 4.21.
670
Box 4.21  Refusal to give consent
• Any adult with capacity, because of their right of autonomy or
self-determination, may refuse investigation or treatment for
reasons that are rational, irrational or for no reason.
• Legally, such refusal of treatment supersedes the sanctity of
life.
• To treat in these circumstances would constitute trespass or
battery.
• Existing consent may be withdrawn at any time and new
refusal overrides prior consent.
An example of refusal of treatment with a potentially
life-threatening outcome would be that of a patient who is a
Jehovah’s Witness refusing blood products for whom a blood
transfusion might be lifesaving. Respect for autonomy (self-
determination) means that this refusal must be respected.
Notwithstanding this, if an individual chooses an option that not
only contradicts what appears to be in his or her best interests and
that most people would choose, but also appears to contradict that
individual’s previously expressed attitudes, then you would be
justified in questioning the individual’s capacity to make a valid
refusal in order to exclude a possible depressed or deluded state.
Role
You are a doctor on the acute medical unit.
Please read this summary.
Scenario
Re: Miss Jane Hughes, aged 22 years
Miss Hughes was admitted to the emergency medical
admissions unit earlier today after taking an overdose of
paracetamol. She reported taking 16 50 mg tablets 12 hours
before admission, with the intention of committing suicide. Her
paracetamol level was below the treatment line and liver function
tests are normal including the international normalised ratio. She
is now keen to go home. The ward nurse is concerned that she
may be at risk of further suicide attempts, and although a
psychiatry opinion has been requested this might not happen until
tomorrow.
Your tasks are to explore the reasons for her suicide attempt,
assess her current suicide risk and suggest a way forward.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.

Patient / subject information
Miss Jane Hughes is a 22-year-old primary school teacher
with no medical history of note. She was admitted to
hospital this morning following an overdose of 16 para-
cetamol tablets. She has recently moved to the area, having
finished her teacher training last year, and although she
has no history of psychiatric disease or suicide attempts
herself in the past she has suffered recently ‘in silence’
from the death of her father and taken to getting exces-
sively drunk with new friends in the area on week nights,
and, increasingly, drinking alone. Last month one of her
class children died in a road traffic accident and she has
found herself ruminating over this a lot. She is ‘a bright
young thing’ according to friends, and ‘has everything
going for her’ but suffers from low self-esteem, which she
knows is irrational. She has never had any delusions or
hallucinations. She does not know why she took the over-
dose now, only that she told a friend who brought her to
hospital. She just wants to go home and forget it hap-
pened. She is about to see the doctor.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself and make it clear you are here to help.
2.  Show empathy
Deliberate self-harm, unhappily, is an increasing problem
for emergency services and it is all too easy to assume that
‘just another overdose’ has arrived, ‘probably with no
intention of significant self-harm’. Suicide is an escalating
problem and no patient’s intentions should be underesti-
mated and every patient’s case should be considered on
its own unique merit. These cases are complex, and
warrant psychiatric appraisal. All doctors should be able
to make an initial assessment of the situation and the risk.
Firstly, tell her that you are sorry she is in hospital and that
you understand things must have been very difficult to
have reached this stage.
3.  Establish ideas and concerns
There are clearly background issues, which she may or may
not allude to.
4.  Assess patient following a suicide attempt
All doctors should be able to perform an initial psycho­
social assessment following attempted suicide (Box 4.22).
5.  Explain what should be done next
Reassure her that you are satisfied medically but that you
are concerned for her overall welfare.
Case 4.26  Deliberate self-harm
Box 4.22  Assessment following
attempted suicide
Questions about the episode
• Events preceding the act
• Reasons for the act
• Suicide intent
• Any psychiatric disorders including previous suicide attempts
• Family history
• Coping resources and support network
• Whether ready to accept help
Factors suggesting suicide intent
• Act undertaken alone
• Act timed that intervention unlikely
• Precautions to avoid discovery
• Active preparation for attempt
• Preparations made anticipating death
• Leaving a note
• Failure to inform potential rescuers afterwards
• Admission of suicidal intent
Factors associated with an increased risk  
of further suicide attempts
• Male
• Under 19 or over 45 years of age
• Unemployment
• Separated, divorced, widowed or living alone
• Previous suicide attempts with admission to hospital
• Alcohol or drug problems
• Psychiatric disorder
• Chronic disease
6.  Reassure that information given  
is confidential
Give absolute reassurance of this.
7.  Reassure that the psychiatrist will help  
to identify problems
Explain that the reasons for seeking a psychiatrist’s help
are that it is not your area of expertise and that you wish
to protect her from future self-harm by dealing with issues
that hold her back so that she can get on with life.
8.  Explain possible alternatives
She may ask what would happen if she chose not to wait
to see a psychiatrist. This depends on your assessment of
her risk. Options include trying to arrange for more imme-
diate psychiatric assessment by a liaison psychiatrist or
member of the liaison psychiatric team or to seek tele-
phone advice from a psychiatrist as to whether it is felt
that she could be allowed home with early review. If risk
is sufficiently worrying, you should be honest with her and
explain that you have a duty of care to ensure that she does
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 Station |4| Communication skills and ethics
not leave until she has seen a psychiatrist. Application of
the Mental Health Act should be a last resort.
9.  Invite further questions
Is there anything you would like me to go over again or are there
any questions you would like to ask me?
10.  Agree a way forward
The examiners are aware that such a discussion is difficult.
They are not looking for a ‘model answer’ but checking
your awareness of the range of issues provoked and ability
to handle these sensitively and professionally.
Discussion
What would you do if a patient wants to
leave hospital before being assessed by a
mental health professional?
Doctors have a duty of care that includes protecting
patients as best as possible from ongoing risk. If a patient
refuses to stay for mental health assessment following an
episode of deliberate self-harm, you should if possible
make your own assessment of risk (see Box 4.22). If you
are still concerned, you should try to persuade the patient
to stay and if they still refuse you may detain them under
common law pending formal psychiatric assessment. If
you are satisfied that risk is low, you may allow the patient
to be discharged with appropriate information to the
general practitioner (ideally after telephone approval from
and perhaps follow-up with a psychiatrist).
What does common law allow in the matter
of detention or treatment of patients?
It allows doctors to act in a patient’s best interests in emer-
gency situations where consent cannot be given (patient
unconscious or lacks capacity). It allows detention pending
assessment or treatment against a patient’s will if in that
patient’s best interests (by saving life or to ensure improve-
ment or prevent deterioration of physical or mental
health). It should be documented that you are treating in
best interests under common law.
Can you detain or treat against a patient’s
will if they have capacity?
Detention or treatment against a patient’s will under
common law or under the Mental Health Act is not pos-
sible if a patient has capacity. To do so may constitute a
criminal offence. Where there are doubts about capacity
(which may be function specific rather than global and
may change over time) and a patient is at risk it is usually
better to detain and treat than not do so. In the case of
deliberate self-harm, patients frequently do have capacity
but you may equally be concerned that capacity is tempo-
rarily lost by a psychiatric illness such as depression and
if your assessment deems a patient to be at serious risk
then you are unlikely to be criticised. Detention and treat-
ment may be given under common law.
672
Which aspects of the Mental Health Act are
relevant to general medicine?
The Mental Health Act 1983 permits compulsory deten-
tion and / or treatment of patients with a mental illness
and / or mental impairment of a nature and / or degree that
requires inpatient treatment against their wishes. If a
patient needs to be in hospital because of a risk to self or
others he or she may be detained or brought into hospital
if appropriate people agree. But the Act does not allow
treatment of mentally impaired patients for physical prob-
lems against their will, even if the physical problem is a
result of deliberate self-harm such as self-poisoning.
Therefore psychiatrists, often asked to ‘section’ such a
patient for compulsory treatment, cannot do so, although
treatment may be given under common law. The Act does,
however, allow treatment where a physical condition
causes the mental condition, as in an organic psychosis.
Relevant sections of the Mental Health Act are listed in
Table 4.3. Although there is a different legal system in
Scotland, the principles are the same.
The Mental Health Act was revised in 2008, and a key
change is a wider definition of mental disorder, encom-
passing any disorder or disability of the mind.
Table 4.3  Sections of the Mental Health Act
Section Provision
2 Allows assessment and / or treatment for up to
28 days
Requires two appropriately qualified doctors and
a social worker
3 Allows extension for up to 6 months (may follow
2)
4 Allows patient to be brought to hospital in an
emergency
Requires a doctor and social worker
5 (2) Allows any registered (i.e. not Foundation Year 1)
hospital doctor to detain an inpatient under the
nominated hospital consultant if psychiatric
assessment likely to be delayed
Patient may be detained for 72 hours pending
full Mental Health Act assessment
Initiated by a form H1 that is submitted to the
local Mental Health Act administration team
Does not allow treatment of any kind, which
must be under common law if a patient does not
consent (herewith a ‘best interests’ decision
based on presumed current incapacity allows
attempted treatment)
5 (4) Allows a nurse to detain for 6 hours pending the
arrival of a doctor to detain under 5 (2)
136 Allows police to bring a patient to an accident
and emergency department, where doctors may
decide to informally assess or arrange for a
Section 2 or 3

An elderly woman takes a lethal ingestion
with the intention of suicide. She declines
intervention. She is assessed by the
psychiatric team who feel that she has
capacity to make this decision. Would you
accept this?
At first sight it may seem that any patient attempting
suicide must lack capacity because of depressed mood but
this is by no means necessarily so. Some patients do feel
that life is so miserable for intractable reasons and see no
hope, such that, notwithstanding possible depression,
they have the capacity to decide they no longer wish to
live. While every opportunity must be given to allow the
patient to change their mind, and it must be clear that the
patient fully understands the implications of the decision,
if a psychiatrist has confirmed capacity and declared that
the decision should be respected, the patient’s autonomy
should be respected.
End-of-life issues
CASE 4.27  END OF LIFE AND
PALLIATIVE CARE
Candidate information
Role
You are a doctor on the medical ward.
Please read this summary.
Scenario
Re: Mrs Sylvia Earnshaw, aged 85 years
Mrs Earnshaw was admitted to the ward 3 days ago following
an attempt to pass an oesophageal stent. A decision that curative
surgery would not be possible for her oesophageal cancer was
reached on a previous admission. She was admitted because of
drowsiness following the procedure (an intended day case) and the
procedure was not wholly successful, unable to negotiate the distal
end of the tumour, and a repeat attempt was not ruled out.
However, since admission she has deteriorated with aspiration
pneumonia, thus far not responding to antibiotics and is
progressively drowsy.
Your task is to discuss the care now appropriate for Mrs
Earnshaw with her son.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient/subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Case 4.27  End of life and palliative care
Patient / subject information
You are the son of Mrs Earnshaw, an 85-year-old woman
admitted 3 days ago following an attempt to pass a stent
into her oesophagus. You are aware that the procedure was
to relieve symptoms, but not really sure if that means an
operation to cure things will be possible at a later date.
She was admitted because of drowsiness following the
stent procedure (an intended day case) and since then she
has become more breathless. You are very concerned that
she is much worse than before she was admitted, and
wonder what is happening to her.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself and establish that he is Mrs Earnshaw’s
son.
2.  Establish what the relative knows
Firstly, establish a rapport with a relative you have not met
before, establishing what he knows, appreciating that rela-
tives may either have been told little or have been afraid
to ask for more information and may still have false expec-
tations about the future.
What have you been told so far about her condition?
3.  Give a warning shot
This is largely a breaking bad news scenario, and before
explaining her condition you should say that she is very
unwell. A simple statement, followed by a pause, is enough.
Your mother’s condition is not good.
4.  Explain the situation
Relatives sometimes then volunteer that they are aware of
the overall prognosis, but that things have deteriorated
more quickly than anticipated, but are sometimes very
surprised. Be prepared for any scenario.
Your mother has developed a rather nasty chest infection,
almost certainly because of the growth in the oesophagus
– the gullet – that means that she has been at very high risk
of aspirating or regurgitating food and fluids and saliva down
into her lungs. The procedure, as I know you know, was tricky
and the gastroenterologist found it impossible to pass the
tube beyond the growth.
5.  Acknowledge distress and allow ventilation  
of feelings
Wait for his response before explaining more.
6.  Identify and prioritise concerns
He will probably want to know what that means in terms
of overall prognosis now.
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 Station |4| Communication skills and ethics
The fact that the growth was difficult to bypass is of course a
real concern. I know the gastroenterologists had hoped that
if they could alleviate the obstruction it might enable her to
eat and drink for a time. And I know that they have not
discounted the prospect of having a further attempt. But
clearly, as more complications arise, it becomes harder to see
a good way forward. The growth, as you can appreciate,
has not been one amenable to removal, or cure, and any
treatments have therefore been directed to keeping symptoms
at bay for as long as possible.
7.  Explain what is likely to happen
Explain that you will continue to treat the infection
actively, but there are inevitably limits. Explain that if it
becomes inevitable that she is not going to get better, it
might be appropriate to switch treatment entirely to con-
trolling pain and breathlessness. You might feel that that
stage has already been reached, but at least allow him
some time to come to terms with the sudden change in
his mother’s condition. It may be appropriate to discuss
continuation of intravenous fluids for the time being.
8.  Identify support networks
It is human to want to discover a little more about the
practical implications to him such as what other family
members may be nearby, how far it is for him and other
family to visit and so forth.
9.  Invite questions
Always do this.
10.  Conclude with assurances
Always conclude with an assurance that you will do all
that you can to keep her comfortable and always be happy
to discuss the situation with him or any member of the
family.
Discussion
What is meant by end of life (EoL)?
Patients approaching the end of their life need high-
quality treatment and care that supports them to live as
well as possible until they die, and to die with dignity.
Providing treatment and care towards the EoL will often
involve decisions that are clinically complex and emotion-
ally distressing, and may involve ethical dilemmas and
uncertainties about the law. Patients, according to General
Medical Council (GMC) guidance on EoL care, are
‘approaching the end of life’ when they are likely to die
within the next 12 months but this includes patients
whose death is imminent (expected within a few hours or
days) and those with:
• Advanced, progressive, incurable conditions
• General frailty and coexisting conditions that mean
they are expected to die within 12 months
• Existing conditions if they are at risk of dying from a
sudden acute crisis in their condition
• Life-threatening acute conditions caused by sudden
catastrophic events.
674
What is meant by EoL care?
How people die will remain in the lasting
memory of relatives, carers, and the health and
social care staff who have cared for the dying
person and so it is important that all staff
recognise their responsibility to provide the best
possible care at the end of life.
(DOH 2008)
EoL care helps all those with advanced, progressive, incur-
able illness, including dementia, to live as well as possible,
until they die. It enables the supportive and palliative care
needs of both patient and family to be identified and met
throughout the last phase of life, including the last days
of life and care after death. This includes management of
pain and other symptoms and provision of psychological,
social, spiritual and practical support.
EoL care generally applies to all patients who have a
prognosis of less than 1 year. Patients with dementia are an
exception as the time scale to reach EoL can be much
longer. Therefore it is important to involve patients with
dementia in decisions regarding EoL care whilst they still
have the cognitive ability to make choices.
The National End of Life Strategy recognises that quality
and choice in EoL care are far from equitable and sets 
out an ambitious, far-reaching agenda to address this,
including:
• Promotion of public awareness and reducing taboos
about death and dying
• High-quality, integrated care across all settings
• Identification of people approaching the EoL to be
strengthened
• All people approaching the EoL and their carers to
have their needs assessed and a care plan which
records their preferences, including where they
would wish to die
• Ensuring that care is well coordinated and can be
accessed rapidly 24/7, aiming to avoid unnecessary
emergency admissions to hospital
• Ensuring that health and social care staff provide
sensitive and culturally and spiritually responsive
care during the last days of life and after death
• Ensuring health and social care organisations provide
readily available information on all local services
• Recognising the needs of carers and families
• EoL care training.
What do you understand by the term
‘palliative care’?
This is the holistic care of patients with advanced, progres-
sive, incurable illness, focused on the management of a
patient’s pain and other distressing symptoms and the
provision of psychological, social and spiritual support to
patients and their families. Palliative care is not dependent
on diagnosis or prognosis, and can be provided at any
stage of a patient’s illness, not only in the last few days of

life. The objective is to support patients to live as well as
possible until they die and to die with dignity.
What principles govern EoL care?
The choices and priorities of the individual are central to
all EoL care planning and delivery. Care planning must
meet the wishes, beliefs and priorities of the individual
patient. The patient is central to the care plan, and they
and / or their carers should be involved from the outset.
The care plan should be regularly reviewed as the patient
has the right to change their plan at any time.
Important principles, outlined in GMC guidance on EoL
care, are as follows.
Equalities and human rights
Patients who are approaching the end of their life  restrictive of the patient’s future choices. Those close to the
must have equal quality of care, and they and those close
to them receive dignity, respect and compassion. The
Human Rights Act 1998 incorporates into domestic law
the bulk of the rights set out in the European Convention
on Human Rights (ECHR). Health professionals must be
able to demonstrate that decisions are compatible with
human rights set out in the Articles of the Convention.
The rights in the ECHR that are most relevant to decisions
about treatment and care towards the end of a patient’s
life are:
• Article 2: The right to life and positive duty on
public authorities to protect life
• Article 3: The right to be free from inhuman and
degrading treatment
• Article 5: The right to security of the person
• Article 8: The right to respect for private and family
life
• Article 9: The right to freedom of thought,
conscience and religion
• Article 10: The right to freedom of expression, which
includes the right to hold opinions and receive
information
• Article 14: The right to be free from discrimination
in the enjoyment of these other rights.
Presumption in favour of prolonging life
Decisions concerning potentially life-prolonging treat-
ment must not be motivated by a desire to bring about
the patient’s death, and must start from a presumption in
favour of prolonging life. This presumption will normally
require all reasonable steps to be taken to prolong a
patient’s life. However, there is no absolute obligation to
prolong life irrespective of the consequences for the
patient, and irrespective of the patient’s views, if they are
known or can be found out.
Presumption of capacity
The presumption is that every adult patient has the capac-
ity to make decisions about their care and treatment. Lack
of capacity must not be assumed.
Case 4.27  End of life and palliative care
Maximising capacity to make decisions
If a patient’s capacity to make a decision may be impaired,
they must be provided with all appropriate help and
support to maximise their ability to understand, retain,
use or weigh up the information needed to make that
decision or communicate their wishes. Detailed guidance
about maximising and assessing a patient’s capacity may
be found elsewhere in this book in the sections on consent
and capacity.
Overall benefit
If an adult patient lacks capacity to decide, decisions made
on that patient’s behalf must be based on whether treat-
ment would be of overall benefit to the patient and which
option (including the option not to treat) would be least
patient who lacks capacity should be consulted to help
reach a view. The term ‘overall benefit’ describes the ethical
basis on which decisions are made about treatment and
care for adult patients who lack capacity. It involves an
assessment of the appropriateness of treatment and care
options that encompasses not only the potential clinical
benefits, burdens and risks of those options, but also non-
clinical factors such as the patient’s personal circum-
stances, wishes, beliefs and values. GMC guidance on
overall benefit is consistent with the legal requirement to
consider whether treatment ‘benefits’ a patient (Scotland)
or is in the patient’s ‘best interests’ (England, Wales and
Northern Ireland), and applies principles set out in the
Mental Capacity Act 2005 and the Adults with Incapacity
(Scotland) Act 2000.
What sorts of ethical and legal issues arise
in EoL decision making?
The most challenging decisions in this area are generally
about withdrawing or not starting a treatment when it 
has the potential to prolong the patient’s life. This may
involve treatments such as antibiotics for life-threatening
infection or renal dialysis, cardiopulmonary resuscita-
tion, or ‘clinically assisted nutrition and hydration’ and
mechanical ventilation. There are many ethical and legal
considerations, which is why a multidisciplinary approach
with emphasis on communication and individually 
tailored management is so important. Here are some
examples:
• Advance decision making (Case 4.28)
• Cardiopulmonary resuscitation (Cases 4.29 and
4.30)
• Withholding and withdrawing treatment (Cases 4.32
and 4.33)
• Clinically assisted nutrition and hydration (Case
4.34)
• Respect for autonomy and choice
• The Mental Capacity Act 2005 and lasting power of
attorney (LPA) (Case 4.24).
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 Station |4| Communication skills and ethics
Do you know of any decision-making
models in relation to EoL care?
GMC guidance on EoL care incorporates decision-  the opportunity to decide what arrangements should
making models for patients with or lacking capacity  be made to manage the final stages of their illness. This
(Box 4.23).
What measures in the acute hospital setting
help ensure good EoL care?
• Recognising and diagnosing EoL
• Advance care planning (ACP)
• Information, explanation and discussion with
patient and family
• Treatment escalation plan (TEP) and Do not attempt
resuscitation (DNAR) documentation
• Preferred priorities of care (PPC) documentation
• Advance decisions to refuse treatment (ADRT)
and LPA
• The hospital e-discharge summary
• The End of Life Electronic register (Electronic
Palliative Care Co-ordination System e.g. ADASTRA),
a list of all EoL patients including their TEP/DNAR
status and their PPC
• Assessment and reassessment of the situation and
changing needs
• Liverpool Care Pathway or equivalent
Recognising and diagnosing EoL
Commonly used tools include:
• The surprise question: ‘Would you be surprised
if this patient were to die in the next 6–12   and do they have particular care preferences, now and in
months?’
• Performance status
• The patient’s choice to not have further treatment
• Symptoms and clinical observations: weight loss of
10% or more in 6 months; serum albumin < 25 g / l;
rapid decline
• Would my patient now benefit from supportive and
palliative care?
• More than three admissions in the last year for
exacerbations of chronic illness.
Some EoL prognostic indicators in certain conditions
are given in Box 4.24.
Advance care planning (ACP)
ACP is the process of discussing the type of treatment and
care that a patient would or would not wish to receive in
the event that they lose capacity to decide or are unable
to express a preference. It seeks to create a record of a
patient’s wishes and values, preferences and decisions, to
ensure that care is planned and delivered in a way that
meets their needs and involves and meets the needs of
those close to the patient.
As treatment and care towards the EoL are delivered by
multidisciplinary teams often working across local health,
social care and voluntary sector services, planning ahead
as much as possible helps ensure timely access to safe,
676
effective care and continuity in its delivery to meet the
patient’s needs. Patients whose death from their current
condition is a foreseeable possibility are likely to want 
 
could include having access to palliative care, and attend-
ing to any personal and other matters they consider
important. If a patient has a condition that will impair
their capacity as it progresses, they should be encouraged
to think about what they might want should this happen.
Advance care plans should be fully recorded and need 
to be reviewed and updated as the patient’s situation or
views change.
TEP and resuscitation decision  
patient-held record
These should be discussed and documented. Resuscitation
decision-making is covered elsewhere. Degrees or limits of
proposed treatment escalation should be discussed with
patients or relatives, and creating TEP forms without doing
so is a leading cause of complaint to hospital trusts. Whilst
consent is not legally needed for withholding or limiting
a treatment, this is a hugely contentious area and best
practice calls for discussion with patients or those close to
patients.
Preferred priorities of care (PPC) document
What are the patient’s feelings on their disease, what 
concerns do they have, what goals are they looking to
reach, do they understand their illness and its prognosis,
the future?
PPC is a document that individuals hold and take with
them. It enables them to write down their thoughts and
choices. It facilitates continuity of care. It is not legally
binding. You must consider the Mental Capacity Act
(2005), and any person making a decision regarding
care / treatment of a patient lacking capacity has to take
into account any statement of wishes and preferences
made previously.
Advance decision to refuse treatment (ADRT)
This is legally binding and comes into effect when an
individual loses mental capacity. It can only be used to
refuse treatment and applies to refusal of specific treat-
ments such as intravenous antibiotics and assisted feeding.
It cannot be used to refuse basic comfort care.
Lasting power of attorney (LPA) – health
This is a strong legal document held by the patient. An
appointed person has power of attorney to deal with the
ill person’s health and welfare decisions.
The EoL register
This gives rapid information on the patient’s illness, 
needs and wishes when critical intervention is being

Box 4.23  Decision-making models for patients with or lacking capacity
Patients with capacity to make a decision
• The doctor and patient make an assessment of the patient’s
condition, taking into account the patient’s medical history,
views, experience and knowledge.
• The doctor uses specialist knowledge and experience and
clinical judgement, and the patient’s views and understanding
of their condition, to identify which investigations or treatments
are clinically appropriate and likely to result in overall benefit.
The doctor explains the options, setting out potential benefits,
burdens and risks of each. The doctor may recommend a
particular option, but must not put pressure on the patient to
accept advice.
• The patient weighs up the potential benefits, burdens and risks
of the various options as well as any non-clinical issues relevant
to them, and decides whether to accept any of the options.
They have the right to accept or refuse an option for a reason
that may seem irrational to the doctor or for no reason at all.
• If the patient asks for a treatment that the doctor considers
clinically inappropriate, the doctor should discuss the issues
with the patient and explore the reasons for their request. If,
after discussion, the doctor still considers that the treatment is
inappropriate, they do not have to provide it. They should
explain their reasons and any other options available, including
the option to seek a second opinion or legal representation.
Patients lacking capacity to make a decision
• The doctor, with the patient (if able to contribute) and the
patient’s carer, makes an assessment of the patient’s condition
taking into account the patient’s medical history and the
patient’s and carer’s knowledge and experience of the condition.
• The doctor uses specialist knowledge, experience and clinical
judgement, together with any evidence about the patient’s
views (including advance statements, decisions or directives), to
identify which investigations or treatments are clinically
appropriate and are likely to result in overall benefit for the
patient.
• If the patient has made an advance decision or directive
refusing a particular treatment, the doctor must make a
judgement about its validity and its applicability to the current
circumstances. If the doctor concludes that the decision or
directive is legally binding, it must be followed in relation to
that treatment. Otherwise it should be taken into account as
information about the patient’s previous wishes.
• If a legal proxy has been appointed to make health-care
decisions for the patient, the doctor explains the options to the
legal proxy (as they would do for a patient with capacity),
setting out the benefits, burdens and risks of each option. The
doctor may recommend a particular option that they believe
would provide overall benefit. The legal proxy weighs up these
considerations and any non-clinical issues relevant to the
patient’s treatment and care, and, considering which option
would be least restrictive of the patient’s future choices, makes
the decision about which option will be of overall benefit. The
doctor should offer support to the legal proxy in making the
decision, but must not pressurise them to accept a particular
recommendation.
• As well as advising the legal proxy, the doctor must involve
members of the health-care team and those close to the patient
as far as it is practical and appropriate. If the legal proxy does
not have the power to make a particular decision, the doctor
Case 4.27  End of life and palliative care
must take account of the proxy’s views (as someone close to
the patient) in the process of reaching a decision.
• Where there is no legal proxy with authority, and the doctor is
responsible for making the decision, the doctor must consult
with members of the health-care team and those close to the
patient (as far as it is practical and appropriate) before reaching
a decision. The doctor will explain the issues, seek information
about the patient’s circumstances and seek views about the
patient’s wishes, preferences, feelings, beliefs and values. The
doctor may explore which options those consulted might see as
providing overall benefit for the patient, but the role of those
consulted is to advise about the patient’s known or likely
wishes, views and beliefs and they must not be given the
impression that they are being asked to make the decision. The
doctor must take the views of those consulted into account in
considering which option would be least restrictive of the
patient’s future choices and in making the final decision about
which option is of overall benefit to the patient.
• In England and Wales, if there is no legal proxy, close relative or
other person who is willing or able to support or represent the
patient and the decision involves serious medical treatment, the
doctor must approach their employing or contracting organisation
about appointing an independent mental capacity advocate
(IMCA), as required by the Mental Capacity Act 2005. The IMCA
will have authority to make enquiries about the patient and
contribute to the decision by representing the patient’s interests,
but cannot make a decision on behalf of the patient.
• If a legal proxy or other person involved in the decision making
asks for a treatment to be provided which the doctor considers
would not be clinically appropriate and of overall benefit to the
patient, the doctor should explain the basis for this view and
explore the reasons for the request. If after discussion the
doctor still considers that the treatment would not be clinically
appropriate and of overall benefit, they are not obliged to
provide it. However, as well as explaining the reasons for their
decision, the doctor should explain to the person asking for the
treatment the options available to them, including the option of
seeking a second opinion and applying to the appropriate Court
for an independent ruling.
Legal proxy refers to a person with legal authority to make
certain decisions on behalf of another adult. Legal proxies include: a
person holding a lasting power of attorney (England and Wales) or
welfare power of attorney (Scotland), a Court-appointed deputy
(England and Wales) or a Court-appointed guardian or intervener
(Scotland). Northern Ireland currently has no provision for
appointing legal proxies with power to make health-care decisions.
Powers of attorney must be registered with the Office of the Public
Guardian in England, Wales and Scotland. ‘Carer’ refers to the
person supporting the patient and representing their interests in the
consultation about their health and what might be needed in terms
of any investigations, treatment or care. The term ‘those close to the
patient’ means anyone nominated by the patient, close relatives,
partners and close friends, paid or unpaid carers outside the
health-care team and independent advocates. It may include
attorneys for property and financial affairs and other legal proxies,
in some circumstances.
Who it is appropriate and practical to consult will depend on,
for example: a patient’s previous request; what reasonable steps
can be taken to consult within the time available before a decision
must be made; and any duty to consult or prioritise specific people
set out in relevant capacity laws or codes.
677
 Station |4| Communication skills and ethics
Box 4.24  End-of-life (EoL) indicators
Cancer
• Disease progression not amenable to treatment
• Involvement of major organs
• Worsening performance status
• Worsening functional ability
Neurology
• Motor neurone disease an EoL prognosis from diagnosis
• Parkinson’s disease when drug treatment no longer effective
• Multiple sclerosis very difficult but dyspnoea, worsening pain,
medical complications
Chronic obstructive pulmonary disease
• Forced expiratory volume < 30% predicted
• Long-term oxygen
• Right-heart failure
• > 6 weeks of systemic steroids in the last year
• Heart failure
• Dyspnoea at rest
• Failure to respond to drug therapy
• Renal function declining
Renal disease
• Conservative treatment, not dialysis
• Chronic kidney disease stage 5
• Symptomatic of renal failure
Dementia
• An inability to perform activities of daily living
• You would not be surprised if the patient died within the next
6–12 months
• 10% weight loss in the previous 6 months without other
causes
• Recurrent infections and pneumonia
• Double incontinence
• No consistently meaningful verbal communications
considered. It is an easily accessible electronic Web-based
register with information for out-of-hours services. 
Most patients are put on the system by their general prac-
titioner. It allows existing choices to be implemented. It
can prevent unwanted hospital admission. It is accessible
on edit or view basis by staff involved in the patient’s care.
TEP / DNAR status and any PPC, ADRT and LPA may be
entered. It is voluntary for the patient and needs the
patient’s consent.
Liverpool Care Pathway (LCP)   not intend to have that result – is justified provided that
for the dying person
The LCP (one of numerous for the dying) ensures equita-
ble management and care of patients who are dying irre-
spective of diagnosis, situation (designed to be used in any
678
setting and across settings if patients are transferred) and
place of death. It is used in the last days of life when death
is the expected outcome of this episode of care. It docu-
ments the process accurately and consistently (using a
single record that replaces all notes / care plans and is used
by all staff). It is endorsed in the End of Life Strategy.
The LCP comprises three sections – initial assessment
and diagnosing dying, ongoing assessment, and care after
death. The multiprofessional team must agree that the
patient is dying and that two of the following apply: bed-
bound; semi-comatose; only able to take sips of fluids; no
longer able to take tablets.
The LCP is not incompatible with treatment of condi-
tions that may relieve suffering such as pneumonia, or
delivery of parenteral fluids, particularly where withdrawal
of the latter at LCP induction may produce emotive con-
cerns. It may of course be discontinued if a patient
improves (around 10% of patients will live despite being
on the LCP). The LCP is not a tool to hasten or stall death,
but to provide comfort and dignity in situations where
death is likely within a week. Goals of care with the LCP
include:
• Communication with patient and family
• Current medication assessed and non-essentials
discontinued
• As required subcutaneous drugs written up according
to protocol
• Comfort measures
• Psychological insight / religious needs
• Ongoing care and support over the days needed
• Care after death.
Typical subcutaneous drugs include diamorphine 2.5–
5 mg for pain, hyoscine 400–1200 μg for noisy secretions,
midazolam 2.5–5 mg for agitation or restlessness and 
levomepromazine 6.25 mg for nausea and vomiting; 
these may be extended in doses over 24 hours in a syringe
driver, if, for example, two or more boluses of medica-
tion are required. Discussing resuscitation and LCP deci-
sions with the patient, or, where incapable, relatives, is
imperative.
Which drugs may be used to alleviate pain
in modern palliative care?
Some are listed in Table 4.4.
What is the doctrine of double effect (DDE)?
The DDE attempts to distinguish between harms intended
and harms foreseen but not intended. The DDE raises
concern that it may protect dangerous practice. The DDE
states that an action (such as an increase in opioid dose)
that the professional foresees may shorten life – but does
the intention is to benefit the patient and not shorten their
life. In the classic interpretation, a patient is in pain, a
higher dose of opioid is given to relieve that pain, but at
the same time in the belief that this may shorten life. The
 Case 4.27  End of life and palliative care

Table 4.4  Drugs to alleviate pain in palliative care

Routine use Opioids such as morphine or diamorphine are commonly used as long-acting regularly prescribed preparations (e.g.
Zomorph) and short-acting preparations for breakthrough pain (e.g. Oramorph)
Renal disease Oral
If the eGFR is < 30, renally excreted opioids such as codeine, morphine and diamorphine should be avoided except in
very small doses. Oxycodone is 90% excreted by the liver. Buprenorphine, fentanyl and alfentanil are 100% excreted by
the liver. An analgesic step-ladder in renal impairment is:
1. Paracetamol (50% normal dose)
2. Tramadol (50% normal dose) or buprenorphine patch
3. Oxycodone (normal dose if eGFR > 30, 50% normal dose if eGFR 10–30) – immediate release Oxynorm and
modified release Oxycontin
If the eGFR is < 10, a fentanyl patch may be suitable, with immediate release buccal fentanyl for breakthrough pain.
The latter is immediate, rather than older breakthrough drugs which could take 30 minutes to act, and available as a
sublingual lozenge (e.g. Effentura) rather than the outmoded lollipop. Fentanyl may be fatal in opioid-naive patients in
whom it is better to judge opioid requirements first of all with shorter acting drugs
Subcutaneous
Alfentanil may be used for immediate release (0.5–1 mg), or in a subcutaneous syringe driver
Syringe driver
A 24-hour syringe driver to alleviate symptoms in dying patients could include:
• Alfentanil 250 µg (instead of morphine)
• Glycopyrronium 200 µg (instead of hyoscine)
• Midazolam 2.5 mg (not adjusted for renal impairment)
• Haloperidol 0.5–1 mg (instead of levomepromazine)
Buprenorphine This is generally used for those with renal disease or those with compliance or swallowing problems. It is available as 5,
10 or 15 µg/h Butrans patches over a week or as 35 µg Transtec patches; greater requirements than this may warrant
switching to fentanyl
Pregabalin Pregabalin is now first line for neuropathic pain, as is amitriptyline, but the latter has many side effects. Pregabalin is
best started in low dose (25–50 mg). Serotonergic syndrome is a potential complication
Lidocaine 5% lidocaine patches are licensed for post-herpetic neuralgia and said not to provide deep skin penetration but, in
practice, seem to help some patients with localised pain from, for example, bone metastases, and are relatively harmless
Non-steroidal anti- These have fallen from favour somewhat because of thrombotic risk but remain very useful in palliative care
inflammatory drugs and
cyclo-oxygenase-2 inhibitors
Tapentadol This is a novel synthetic opioid with some morphine agonistic action and substantial norepinephrine (noradrenaline)
reuptake inhibition. It acts on spinal cord pain pathways; 50 mg is equivalent to 10 mg oxycodone, 20 mg morphine
and 200 mg tramadol
Opioid-induced constipation Methylnaltrexone blocks opioid receptors peripherally in the gut but not centrally and is highly effective in opioid-
induced constipation
eGFR, estimated glomerular filtration rate.

Association for Palliative Medicine (APM) has provided
position statements on the DDE and use of sedation at  believes that the DDE is unnecessary to justify the use of
the EoL:
The DDE states that the risk of a potential,
known (foreseen), unintended consequence or
side effect of treatment is justified only if all the
following criteria are met: the intended effect is
good in itself; the clinician’s intention is solely
to produce the good effect; the intervention is
proportionate to the situation; the good effect is
not achieved through the bad effect.
There is a misconception that morphine-related and
sedative drugs bring about death more quickly, and that
doctors both know this and in some way condone their
use with the double effect. The APM refutes this claim. It
knows of no credible evidence to suggest that a patient’s
life is shortened either by opioids or by sedatives when
used in line with accepted palliative care practice. The APM
dosing regimens necessary to manage pain or distress in
all but the most exceptional circumstances.
All medication used in palliative care, including sedative
medication, is aimed at the relief of specific symptoms.
Medication that is sedating in its effect should be used
only if the symptom cannot be relieved with more specific
interventions. Rarely, patients may experience distress
when symptoms cannot be controlled even after exhaus-
tive attempts with specific interventions. In these circum-
stances, some patients may require sedating medication to
diminish awareness of their suffering. If medication is
sedating in its effect, the dose should be monitored to
ensure that it is the minimum required to relieve the
patient’s distress. Medication used in this way does not
shorten life. Sedation in palliative care is thus sedation
while the patient dies and is not sedating the patient to
death. Morphine and related drugs are vital painkillers but
are wholly unsuitable for use as sedation.

679
 Station |4| Communication skills and ethics
Consider a patient dying from a
malignant brain tumour who develops
pneumonia and respiratory failure. A
ventilator may prolong life but may also
delay an inevitable death. What courses of
action are there?
Broadly, there are five options at the EoL (Box 4.25).
Is allowing a person to die different from
killing that person?
Many people believe that there is a moral difference
between killing someone and allowing that person to die
but Rachels (1986) showed that the distinction is not
necessarily clear, describing two cases. In the first, person
A stands to gain a large inheritance if his 6-year-old cousin
dies and sneaks into the child’s bathroom and drowns the
child in a way that will look like an accident. In the
second, person B also stands to gain and plans to drown
the child but, on approaching the cousin, the child slips
and hits his head, falling face down in the bath; person B
watches the child die. A kills; B allows to die; but there
seems no moral difference here. The question of a moral
difference becomes more relevant when applied to with-
holding or withdrawing life-prolonging treatments. The
central idea is that if a doctor kills a patient the doctor
causes the patient’s death, but if a doctor allows a patient
to die the patient’s death is the result of disease or ‘nature
taking its course’. Thus, options 4 and 5 in Box 4.25 seem
worse than 2 and 3, which are accepted medical practices.
Option 1 is now uncommon. Options 4 and 5 are illegal,
and arguments against euthanasia include palliative care
obviating its need, concerns about manipulation or
exploitation, and ‘slippery slope’ effects. Although emo-
tionally it may be easier to withhold than to withdraw
life-prolonging treatment, the British Medical Association
and GMC have indicated that there are no legal, or neces-
sarily moral, differences between the two.
Box 4.25  End-of-life options
1. The sanctity of life view – to ventilate and therefore prolong
life whatever else may apply. He would probably die from
progression of his tumour.
2. To withhold life-prolonging treatment – to withhold ventilation,
for example. He would probably die from respiratory failure.
This has sometimes in the past, but very contentiously, been
considered ‘passive euthanasia’.
3. To withdraw life-prolonging treatment – to ventilate then
withdraw from ventilation. He would probably die rapidly on
withdrawal of ventilation. This has sometimes in the past, but
very contentiously, been considered ‘passive euthanasia’.
4. Assisted suicide – this is illegal.
5. Active euthanasia (performing an action that results in a
patient’s death) – killing a patient for any reason is normally
murder.
680
Have you heard of the Assisted Dying for
the Terminally Ill Bill and, if so, what ethical
issues does it raise?
This concerns deliberate acts to end life, not assisting in
the natural dying process. The Bill was the subject of a
House of Lords Select Committee Report. The idea of
deliberately ending life brings intense ethical questions,
notably concerning morality, the integrity of the medical
profession and social implications of the effects of society
permitting direct killing, and so weakening the prohibi-
tion against killing, which currently protects us all. Pallia-
tive care is concerned with enabling patients with advanced
life-threatening conditions to live with the best possible
quality of life until death. Clinical experience and research
suggest that most requests for euthanasia or physician-
assisted suicide arise because of poor symptom control,
depression, poor social and family support and loss of
autonomy. Palliative care focuses on improving these
aspects of a patient’s life and many of us believe that the
Assisted Dying Bill and attempts to legalise physician-
assisted suicide are ethically unsound, fail to appreciate
the nature and scope of palliative care and undermine the
progress made in the care of the dying in recent years.
One of your patients, a dying man with
end-stage renal failure, diabetes and
peripheral gangrene, has a hypoglycaemic
attack. Would you treat him?
This would depend upon any prior wishes he may have
made. He may have told his doctors to ‘let him go’ if he
takes any turn for the worse. He may, alternatively, have
declined treatment for his renal failure and requested a
comfortable death. A scenario such as hypoglycaemia may
not have been anticipated or explicitly discussed. A
common response to a potentially fatal change in condi-
tion that has not been previously discussed is to treat the
current episode and later discuss with the patient what they
would wish were it to recur. This said, because hypoglycae-
mia, unlike other potentially fatal changes in his condi-
tion, is caused by the medication and easily reversed, there
may be legal risks in not treating, whatever the patient says.
A woman has breast cancer with cerebral
metastases. She asks you how many of her
anticonvulsant pills she would need to take
to end her life. How might you respond?
We sometimes hasten death in clinical practice. The crucial
distinction is intention, which may be to hasten death or
relieve suffering. Doctors may set out to relieve pain and
suffering but see that life may be shortened. Foreseeing is
not necessarily the same as intending. This has been tested
in law and held to be permissible and in keeping with the
duties of a doctor. It is one aspect of the DDE, which
makes a distinction between harms that are intended and
harms that are foreseen but not intended. Telling the
patient how many pills she would require to kill herself

could be seen as assisting suicide and a criminal act. Your
communication skills should endeavour to elicit key
aspects of her suffering as she sees them and explore alter-
native ways of relieving them.
CASE 4.28  ADVANCE DECISION
MAKING
Candidate information
Role
You are a doctor on the medical ward.
Please read this summary.
Scenario
Re: Dr Max Winter, aged 79 years
Dr Winter is a retired microbiologist with chronic obstructive
pulmonary disease (COPD). Four months ago he prepared an
advance directive in conjunction with his family. This stated that in
the event of worsening respiratory problems requiring admission to
hospital he would not wish cardiopulmonary resuscitation or any
form of ventilation including non-invasive ventilation. He was
admitted to hospital a few minutes ago with an acute exacerbation
of COPD and marked hypoxia. He is confused, probably a result of
his hypoxia, and now says that he will accept any treatment to
make him better, although this is at odds with his advance
directive. The emergency team have ignored his advance directive
and just instituted non-invasive ventilation, with apparently good
effect. His wife wishes to discuss the advance directive with you.
Your task is to discuss his management with his wife, taking
into account the issue of the advance directive.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
You are a retired general practitioner. Your husband, Dr
Max Winter, is a 79-year-old retired microbiologist with
chronic obstructive pulmonary disease (COPD). Four
months ago he prepared an advance directive in conjunc-
tion with his family. This stated that in the event of worsen-
ing respiratory problems requiring admission to hospital
he would not wish cardiopulmonary resuscitation or any
form of ventilation including non-invasive ventilation. He
was admitted to hospital a few minutes ago with an acute
exacerbation of COPD and marked hypoxia. He is con-
fused, probably a result of his hypoxia, and now says that
he will accept any treatment to make him better, although
this is at odds with his advance directive. The emergency
team have ignored his advance directive and just instituted
Case 4.28  Advance decision making
non-invasive ventilation, with apparently good effect. You
have mixed feelings. On the one hand you are pleased to
see your husband less distressed but on the other are con-
cerned about his prior wishes being ignored. You wonder
if the advance directive has any validity.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself and establish that she is Dr Winter’s
wife.
2.  Establish rapport and be alert to cues
Firstly, establish a rapport with a relative you have not met
before, establishing what she knows, and if she does not
volunteer the fact it may become clear that she is a profes-
sional colleague.
3.  Seek further information about the patient
Relatives are highly valuable resources of information. She
will know intimately the nature of his condition and his
wishes in the event of a precipitous acute episode of illness.
4.  Be sure that you understand the legal
principles of advance decision making
Advance decision-making legal principles are discussed
below.
5.  Explain the situation
Be honest about what has happened. In this case there 
is a possibility that he is temporarily incapacitated by
hypoxia and the previous advance directive, made when
he had capacity, means there is a risk that the doctors
applying non-invasive ventilation are committing battery.
However, it seems very reasonable to have erred on the
side of the possibility of his having changed his mind.
Where there is uncertainty it is always preferable to make
the choice that preserves future choice as much as possible.
His wife will probably fully accept this, provided you are
open with her and any Court (it would be very unlikely
to go that far) would almost certainly see it that way, too!
6.  Have a plan
The best way forward is likely to be to continue to treat
non-invasively, stopping short of invasive ventilation,
until her husband is able to competently confirm his
wishes about any subsequent institution of non-invasive
ventilation.
7.  Ensure that your suggestions do not conflict
with any ideas, concerns and expectations
Most importantly, ensure that she understands that where
there was doubt the emergency team had little choice but
681
 Station |4| Communication skills and ethics
to act in what they saw as being his current wishes or in
his best interests but that you will be very sure to ascertain
his wishes as soon as he is able to communicate these.
8.  Seek acceptance of this plan
Highlight that the decision was ultimately that of the
medical team, but that in future you will ensure that any
unequivocal wishes will be confirmed and respected.
9.  Invite questions
Make it clear that you are happy to answer questions now
or later.
10.  Conclude with assurances
Always conclude with an assurance that you will do your
best to keep her husband comfortable and accord with his
wishes as soon as these can be confirmed.
Discussion
What is an advance statement?
This is a statement of a patient’s views about how they
would or would not wish to be treated if they became
unable to make or communicate decisions for themselves.
It can be a general statement about, for example, wishes
regarding place of residence, religious and cultural beliefs,
and other personal values and preferences, as well as about
medical treatment and care. Whilst not legally binding,
such statements must inform best interests decisions.
What is an advance decision or
advance directive?
This is a statement of a patient’s wish to refuse a particular
type of medical treatment or care if they become unable
to make or communicate decisions for themselves. They
are called advance decisions in England and Wales, and
advance directives in Scotland. In England and Wales,
advance decisions are covered by the Mental Capacity Act
2005. In Scotland and Northern Ireland, advance direc-
tives are not covered by statute but it is likely that they are
binding under common law.
How might you act on advance requests
for treatment?
When planning ahead, some patients worry that they 
will be unreasonably denied certain treatments towards
the end of their life, and so may wish to make an advance
request for those treatments. They may want a treatment
that has some prospects of prolonging their life, even if  (AMTS) of 4 / 10. Her son says she would
it has significant burdens and risks. When responding  not wish any treatment. Would you agree
to a request for future treatment the reasons for the
request, and the degree of importance the patient attaches
to it, should be explored. It should be explained how  Regarding her autonomy, the patient is probably not com-
decisions about the overall benefit of the treatment would
be influenced by the patient’s current wishes if they  background cognitive impairment, pain and possible
682
lose capacity, and made clear that, although future deci-
sions cannot be bound by request for a treatment, the
request will be given weight by those making the decision.
A patient’s previous request, when benefits, burdens and
risks are finely balanced, will usually be the deciding
factor.
How might you act on advance refusals
of treatment?
Some patients worry that towards the end of their life they
may be given medical treatments that they do not want.
They may want to make their wishes clear about particular
treatments in circumstances that might arise in their future
care. When discussing any proposed advance refusal it
should be explained how such refusals would be taken
into account if capacity is lost.
Binding advance refusals
An advance decision to refuse treatment (ADRT) states
what a patient does not want to happen to them and must
relate to a specific treatment and a specific circumstance.
It comes into force when the patient loses capacity to
consent to or refuse treatment. It is legally binding in
England and Wales (and potentially binding in Scotland
and Northern Ireland) if constituted according to the con-
ditions in the Mental Capacity Act and if it meets the
specific clinical circumstances. An ADRT for life-sustaining/
life-prolonging treatment requires more rigorous legal cri-
teria, and must be in writing, signed and witnessed and
state that it should be enforced even if life is at risk. There
are restrictions on an ADRT, for example that basic nursing
care cannot be refused.
Non-binding advance refusals
Written and verbal advance refusals of treatment that are
not legally binding should be taken into account as evi-
dence of the person’s wishes when assessing whether a
particular treatment would be of overall benefit.
How might you assess the validity and
applicability of advance refusals?
Assessment of validity and applicability is outlined in 
Box 4.26.
An elderly woman with dementia, living
alone but with carers, fractures the neck
of her femur. She is admitted to hospital
with an abbreviated mental test score
to his request?
petent and her AMTS is likely to represent a pot pourri of
 Case 4.29  Resuscitation status decision making – discussion with patient
Box 4.26  Assessing the validity and applicability of advance refusals
Validity
The main considerations are that:
• The patient was an adult when the decision was made (16
years old or over in Scotland, 18 years old or over in England,
Wales and Northern Ireland)
• The patient had capacity to make the decision at the time it
was made (UK wide)
• The patient was not subject to undue influence in making the
decision (UK wide)
• The patient made the decision on the basis of adequate
information about the implications of their choice (UK wide)
• If the decision relates to treatment that may prolong life it must
be in writing, signed and witnessed, and include a statement
that it is to apply even if the patient’s life is at stake (England
and Wales only)
• The decision has not been withdrawn by the patient (UK wide)
• The patient has not appointed an attorney, since the decision
was made to make such decisions on their behalf (England,
Wales and Scotland)
• More recent actions or decisions of the patient are clearly
inconsistent with the terms of their earlier decision, or in some
way indicate they may have changed their mind.
analgesia. On the principle of justice, most patients are
more likely to do well with repair of their fractured neck
of femurs and the benefits of surgery may outweigh the
risks. It may be desirable to go ahead with treatment, with
efforts to explain the rationale and get her family ‘on
board’.
A young woman with a history of asthma,
necessitating multiple admissions to ITU,
and depression is admitted with a further
exacerbation of asthma requiring immediate
ITU support. A handwritten letter in her
notes addressed to her chest physician
states that she wishes no treatment in the
event of future collapse. Should she be
admitted to ITU?
The answer is almost certainly yes. The validity of the
advance decision may be in question for numerous
reasons. It might have been written while she was depressed
and her capacity might have been in question. The details
may be sparse rather than specific. There may not be evi-
dence that it was written by her. In case law there is a
potential risk of battery if she receives treatment against
the instructions of a valid advance directive but not treat-
ing puts her doctors at risk of manslaughter and because
of the uncertainty the correct course of action is almost
certainly to treat because of the uncertainty.
Applicability
The following considerations apply across the UK:
• Whether the decision is clearly applicable to the patient’s
current circumstances, clinical situation and the particular
treatment or treatments about which a decision is needed
• Whether the decision specifies particular circumstances in which
the refusal of treatment should not apply
• How long ago the decision was made and whether it has been
reviewed or updated (this may also be a factor in assessing
validity)
• Whether there are reasonable grounds for believing that
circumstances exist which the patient did not anticipate and
which would have affected their decision if anticipated; for
example, any relevant clinical developments or changes in the
patient’s personal circumstances since the decision was made.
If there is doubt or disagreement about the validity or
applicability of an advance refusal of treatment, further enquiries (if
time permits) and a ruling from the Court may be sought. In an
emergency, if there is no time to investigate further, the
presumption should be in favour of providing treatment, if it has a
realistic chance of prolonging life, improving the patient’s condition,
or managing their symptoms.
CASE 4.29  RESUSCITATION STATUS
DECISION MAKING – DISCUSSION
WITH PATIENT
Candidate information
Role
You are a doctor on the respiratory ward.
Please read this summary.
Scenario
Re: Mr Robert Churchill, aged 75 years
Mr Churchill has severe chronic obstructive pulmonary disease.
He has a home oxygen cylinder. For the last 3 years he has been
confined to his house, with twice-daily carers to assist with
bathing, meals and housework. Breathlessness is his main
limitation. Over the last year he has been admitted to hospital five
times with increasing frequency and with exacerbations of
breathlessness, sometimes precipitated by infection. Investigations
for pulmonary emboli have been negative. He was readmitted
yesterday with breathlessness and responded to initial non-invasive
ventilation from which he has been successfully weaned. However,
his resuscitation status has not been documented.
Your task is to discuss his resuscitation status with him. You
may assume that you were involved in his care yesterday and on
previous admissions and that he knows who you are.
683
 Station |4| Communication skills and ethics
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
Mr Robert Churchill is a 75-year-old man who has severe
chronic obstructive pulmonary disease. He has a home
oxygen cylinder. For the last 3 years he has been confined
to his house, where he lives alone, having been widowed
for 5 years. He has twice-daily carers to assist with bathing,
meals and housework. Breathlessness is his main limita-
tion. Over the last year he has been admitted to hospital
five times with increasing frequency and with exacerba-
tions of his breathlessness. He was readmitted yesterday
with breathlessness and required a tight breathing mask
to improve respiratory distress. He is better today but
knows things are not going to get any better in the long
run. He has two children, but they live a long distance
away. He has considered the future and ‘doesn’t want to
go on indefinitely like this’ but the issue of whether or not
he should be resuscitated in the event of a cardiac or res-
piratory arrest has never been discussed.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction, setting and rapport
A discussion about resuscitation should be between a
patient and ideally a doctor who has already created a
rapport with that patient, even if brief. The setting should
ideally be quiet, and without distractions.
2.  Ensure the patient has enough information
about their condition
A resuscitation discussion should only come once he has
a full grasp of his condition and its likely prognosis even
with treatment.
3.  Then come directly to the reason   death rather than sustaining life, or increasing the likeli-
for the discussion
Mr Churchill, there is one thing I should discuss with you that
relates to what we might do in the event – not that I’m
expecting it – but in the event of things going very wrong
(with your health) on this admission to hospital.
4.  Pace the explanation slowly and carefully, and
in words the patient will understand, allowing
him to assimilate what you are saying
You have been in hospital rather a lot over the last year, and
now you’re back in hospital sooner than you and your doctors
684
had hoped. Someone with a lung condition as bad as yours
may suddenly take a turn for the worse. I know you know
this, having used the breathing apparatus last night and on
other occasions in the past. We will of course do all that we
can to improve the situation for you this time. But there is
always the possibility, as with any unwell patient, that things
could go very wrong: that the heart could stop, or the
breathing stop, altogether. Have you ever thought about what
your wishes might be in that situation?
5.  Many patients immediately understand  
all of this, and pre-empt further discussion  
by declaring clearly pre-considered wishes.  
Some patients wish to go further and may  
ask about resuscitation
If things were to go horribly wrong, and your heart or
breathing were to stop, would you wish us to try to re-start
things with heart-starting machines or breathing tubes and
so forth?
6.  Be prepared to deal with emotions  
before facts if you sense the discussion  
is causing distress
I can see that you find this difficult. We could talk about it later,
if you prefer, or, if you wish, with members of your family here
(if you know there are family members) or some patients
simply prefer that we do what we think is the very best for
them.
7.  Many patients prefer to leave the decision to
their doctors
I would leave it in your hands, doctor. Do as you think best.
8.  Some patients might ask what you think
Well, we would have great concerns that in the event of things
getting to that stage, trying to rescue the situation would be
in vain. It simply would not work.
It is not inappropriate to tell patients or relatives that
you think resuscitation extremely unlikely to be successful
or to be futile or that invasive ventilation would be very
unlikely to bring recovery. Many patients do not appreci-
ate, until it is explained, that resuscitation and the poten-
tial consequences of temporary revival without meaningful
recovery or longer term survival might simply be increas-
ing the distress of an inevitable natural death, prolonging
hood of ‘two deaths’.
9.  Confirm patient understanding and explore
any other concerns
Ensure that he is clear about the course of action, be pre-
pared to explore any other concerns and ask if he would
like anything clarified.
10.  Conclude with assurances
Always conclude with an assurance that, if a decision is
made not to resuscitate, you and your team will continue
 Case 4.29  Resuscitation status decision making – discussion with patient
to do all that you can to actively treat his condition and
to relieve symptoms. Make it clear, where appropriate, that
a decision can be reviewed and altered at any time.
Meanwhile, we will do all that we can to get you better (up to
the brink).
Discussion
Why is it important to consider
cardiopulmonary resuscitation (CPR) decision
making in advance care planning?
The primary goal of health care is to benefit patients, by
restoring or maintaining their health as far as possible,
thereby maximising benefit and minimising harm. If treat-
ment fails, or ceases to benefit, or if an adult with capacity
has refused treatment, that treatment is no longer justified.
Prolonging a patient’s life usually provides a health benefit
to that patient. Nevertheless, it is not appropriate to
prolong life at all costs with no regard to quality or to the
potential burdens of treatment. The decision to use any
treatment should be based on the balance of burdens,
risks and benefits, and that principle applies as much CPR
as to any other treatment.
CPR has a reasonable success rate in some circum-
stances but the survival rate after cardiorespiratory arrest
and CPR is generally relatively low. After CPR for cardiores-
piratory arrest that occurs in hospital, the chances of  will rarely be time to make a proper assessment of the
surviving to hospital discharge are at best about 15–20%.
Where cardiac arrest occurs out of hospital, the survival  attempting CPR will usually be appropriate.
rate is lower, at best 5–10%. The probability of success
depends on factors including cause, how soon CPR is
started, and equipment and staff available to deliver it.
Attempting CPR carries a risk of significant adverse effects
such as rib or sternal fractures, hepatic or splenic rupture,
or prolonged treatment in an intensive care unit, possibly
including prolonged artificial ventilation. There is also a
risk that the patient will be left with hypoxic brain damage
and resulting disability. And if CPR is unsuccessful, it may
mean that the patient dies in an undignified and traumatic
manner.
It is not uncommon for difficult decisions about CPR
to arise in respect of patients for whom it may be possible
to re-start the heart after cardiac arrest but for whom
admission to an intensive care unit for continued organ
support would be clinically inappropriate because they
would be unlikely to survive that admission.
Do not attempt CPR (DNACPR) decisions
If cardiac or respiratory arrest is an expected part of the
dying process and CPR will not be successful, an advance
decision not to attempt CPR will help to ensure that the
patient dies in a dignified manner. These management
plans are called Do not attempt CPR (DNACPR) orders,
or Do not attempt resuscitation (DNAR) or Allow natural
death (AND) decisions. The overall clinical responsibility
for decisions about CPR, including DNAR decisions, rests
with the most senior clinician in charge of the patient’s
care. Any decision about whether or not to attempt CPR
must be readily accessible to all health professionals who
may need to know it. The person who makes a CPR deci-
sion is responsible for ensuring that the decision is com-
municated effectively to other relevant health professionals.
Decisions about CPR must be reviewed regularly and espe-
cially whenever changes occur in the patient’s condition
or in the patient’s expressed wishes.
Do you know of any CPR decision-making
frameworks?
A CPR decision-making framework is shown in Table.4.5.
What is the ‘presumption in favour of CPR’
when there is no DNACPR decision?
There is always a presumption for protecting life and
attempting CPR in unknown situations.
Emergencies
Emergencies can arise when there is no time to make a
proper assessment of the patient’s condition and the likely
outcome of CPR, when no previous DNACPR decision is
in place. If no explicit decision has been made in advance
about CPR and the express wishes of the patient are
unknown and cannot be ascertained, there should be a
presumption in favour of CPR. In such emergencies there
patient’s condition and the likely outcome of CPR and so
If further information comes to light
There may be situations in which CPR is commenced on
this basis, but during CPR further information comes to
light that makes continued CPR inappropriate. That infor-
mation may consist of a DNACPR order or a valid and
applicable advance decision refusing CPR in the current
circumstances, or may consist of clinical information indi-
cating that CPR will not be successful. In such circum-
stances, continued attempted resuscitation would be
inappropriate.
Certainty of sufficient information to judge that
CPR will not be successful
There will also be some patients for whom attempting
CPR is clearly inappropriate, for example a patient in 
the final stages of a terminal illness where death is immi-
nent and unavoidable and CPR would not be successful,
but for whom no formal DNACPR decision has been
made.
What is the approach to decision making
when CPR will not be successful?
There are circumstances in which CPR will not to be suc-
cessful or will be unlikely to be successful and, if success-
ful, likely to prolong or increase suffering.
685
 Station |4| Communication skills and ethics

Table 4.5  Cardiopulmonary resuscitation (CPR) decision-making framework

Is cardiac or respiratory arrest a clear
possibility in the circumstances of the
patient?
Yes ↓ 
Is there a realistic chance that CPR
could be successful?
Yes ↓ 
Does the patient lack capacity and have
an advance decision refusing CPR or a
legal proxy with relevant authority?
No ↓
Are the potential risks and burdens of
CPR considered to be greater than the
likely benefits of CPR?
No ↓
CPR should be attempted unless the
patient has capacity and states that
they would not want CPR attempted.
No If there is no reason to believe that the patient is likely to have a cardiac or respiratory
→ arrest it is not necessary to initiate discussion with the patient (or those close to a
patient who lack capacity) about CPR. If, however, the patient wishes to discuss CPR
this should be respected.
No When a decision not to attempt CPR is made on these clear clinical grounds, it is not
→ appropriate to ask the patient’s wishes about CPR, but careful consideration should be
given as to whether to inform the patient of the Do not attempt resuscitation (DNAR)
decision.
Where the patient lacks capacity and has a legal proxy, this person should be informed
of the decision not to attempt CPR and the reasons for it.
If a second opinion is requested, this should be respected wherever possible.
Yes If a patient has made an advance decision refusing CPR, and the criteria for
→ applicability and validity are met, this must be respected. If legal proxy has been
appointed they should be consulted.
Yes When there is only a very small chance of success, and there are questions about
→ whether the burdens outweigh the benefits of attempting CPR, the involvement of the
patient (or, if the patient lacks mental capacity, those close to the patient) in making
the decision is crucial. When adult patients have mental capacity their own view should
guide decision making.

CPR will not be successful template of appropriate evidence-based multidisciplinary

In some cases, the decision not to attempt CPR is a
straightforward clinical decision. If it is believed that CPR
will not re-start the heart and maintain breathing, it
should not be offered or attempted. However, the patient’s
individual circumstances and the most up-to-date guid-
ance must be considered carefully before such a decision
is made. The responsibility for making the decision rests
with the most senior clinician, although they may delegate
the task to another person who is competent. Wherever
possible, a decision should be agreed with the whole
health-care team. If there is genuine doubt or disagree-
ment a further senior clinical opinion should be sought.
CPR unlikely to be successful and likely to
prolong or increase suffering
When a patient is in the final stages of an incurable illness
and death is expected within a few days, CPR is very
unlikely to be clinically successful. In some cases it may
prolong or increase suffering and subject the patient to a
traumatic and undignified death. In these circumstances,
most patients want a natural death without unnecessary
interventions that most consider to be undignified. Earlier
discussions with patients about their general care and treat-
ment aims may have addressed this issue. The Liverpool
Care of the Dying Pathway provides a comprehensive
care for the last days of life and prompts clinicians to con-
sider and document the patient’s CPR status.
Communication
When the clinical decision is that CPR should not be
attempted because it will not be successful, and the patient
has not expressed a wish to discuss CPR, it is not necessary
or appropriate to initiate discussion with the patient.
Careful consideration should be given as to whether or not
to inform the patient of the decision. Although patients
should be helped to understand the severity of their condi-
tion, whether they should be informed explicitly of a
DNACPR decision will depend on the individual circum-
stances. In most cases a patient should be informed, but for
some, for example those who know that they are approach-
ing the end of their life, information about interventions
that would not be clinically successful will be unnecessarily
burdensome. Others indicate by their actions and involve-
ment in decision making that they want detailed informa-
tion. Therefore an assessment should be made of how
much information the individual patient (or, if the patient
lacks capacity, those close to them) wants to know. If con-
cluded that the patient does not wish to know about or
discuss a DNACPR decision, their agreement should be
sought to share with those close to them, with carers and
with others, information they may need in order to support

686
 Case 4.29  Resuscitation status decision making – discussion with patient
the patient’s treatment and care. If a patient lacks capacity,
any legal proxy and others close to the patient should be
informed of the DNACPR decision and the reasons for it.
A decision not to attempt CPR applies only to CPR. It must
be made clear to patients, people close to patients and
members of the health-care team that it does not apply to
any other aspect of treatment.
What is the way forward if a patient
requests CPR in situations where it will not
be successful?
Neither patients nor those close to them can demand
treatment that is clinically inappropriate. If the health-care
team believes that CPR will not re-start the heart and
breathing, sensitive efforts should be made to provide a
realistic view of the procedure without causing undue
alarm. If, ultimately, the patient or those close to the
patient do not accept a DNAR decision in these circum-
stances a second opinion should be offered. Although a
patient does not have a legal right to demand any treat-
ment, including resuscitation, and the general require-
ment is for discussion rather than agreement, and although
it might seem medico-legally more attractive to concord
with such a patient’s wishes, the ethical dilemma is that it
may not seem in their best interests and resources could
be put to the test in the unfortunate scenario of a concur-
rent cardiac arrest elsewhere for the team. In practice, for-
tunately, patients and doctors reach the same view the vast
majority of the time, but if a patient explicitly requests
resuscitation and the medical view is that it would not be
of benefit then many doctors would choose to accord with
that patient’s wishes and make a sensible judgement about
how far to take that resuscitation attempt at the time it
happens, limiting any burdens and harms that may arise
from resuscitation.
What is the approach to decision making
when CPR may be successful?
These decisions are made by weighing up the potential
benefits and burdens resulting from CPR.
Patients who have capacity
If CPR may be successful, the benefits of prolonging life
must be weighed against the potential burdens and risks.
This is not solely a clinical decision. Discussion must be
sensitive and, if the patient is prepared to engage, informa-
tive of the burdens and risks, including likely clinical and
other outcomes if CPR is successful. This should include
sensitive explanation of the extent to which other inten-
sive treatments and procedures may not be seen as clini-
cally appropriate after successful CPR. For example, in
some cases, prolonged support for multi-organ failure in
an intensive care unit may not be clinically appropriate
even though the patient’s heart has been re-started. Any
doubts the health-care team may have about whether the
burdens and risks of CPR would outweigh the benefits,
including whether the level of recovery expected after
successful CPR would be acceptable to the patient, should
be discussed.
A decision that CPR will not be attempted because the
burdens outweigh the benefits should be made only after
careful consideration of all relevant factors, discussion
with the patient, or those close to patients who lack capac-
ity, and these include the factors in Box 4.27.
Some patients may wish CPR when there is only a small
chance of success, in spite of the risk of distressing clinical
and other outcomes. If it is the considered judgement that
CPR would not be clinically appropriate for the patient,
the patient should have accurate information about the
nature of possible CPR interventions, and the length of
survival and level of recovery realistically expected if suc-
cessfully resuscitated. The reasons for their request should
be explored, with an attempt to reach agreement; for
example, limited CPR interventions could be agreed in
some cases. When the benefits, burdens and risks are finely
balanced, the patient’s request will usually be the deciding
factor. If, after discussion, CPR is still considered not clini-
cally appropriate, provision for it is not obliged. The
reasons and any other options should be explained,
including seeking a second opinion.
Some patients may, despite potentially distressing
adverse effects, have specific reasons for wanting to try to
delay death, even if this is only for a very short period of
time. If such a wish is expressed, accurate information
must be provided about the likelihood and length of sur-
vival that might realistically be expected, and about the
potential risks and effects of attempted CPR.
Restriction of CPR to treatment of ‘shockable’ rhythms
only is advocated by some clinicians in some specific clini-
cal settings. Any such decision must be thought through
clearly on the basis of the balance of risks, burdens and
benefits to the individual patient and should be discussed
with the patient (or those close to patients who lack
capacity).
Box 4.27  Factors to consider in weighing up the
benefits and burdens of cardiopulmonary
resuscitation (CPR) where CPR may be successful
• The likely clinical outcome, including the likelihood of
successfully re-starting the patient’s heart and breathing for a
sustained period, and the level of recovery that can realistically
be expected after successful CPR
• The patient’s known or ascertainable wishes, including
information about previously expressed views, feelings, beliefs
and values
• The patient’s human rights, including the right to life and the
right to be free from degrading treatment
• The likelihood of the patient experiencing severe unmanageable
pain or suffering
• The level of awareness the patient may have of their existence
and surroundings
687
 Station |4| Communication skills and ethics
Patients who lack capacity
The approaches are discussed in Case 4.30 (Resuscitation
status decision making – discussion with relative).
What is the ethical and legal stance on
refusal of CPR by adults with capacity?
Adults with capacity have the right to refuse any medical
treatment, even if that refusal results in their death. Where
health-care teams believe that CPR may be successful in
re-starting a patient’s heart and breathing for a sustained
period, discussion should take place with the patient to
determine their views and wishes regarding CPR. If a
patient decides that they do not wish to have CPR
attempted, this should be documented carefully and steps
should be taken to ensure that this is communicated to
those who need to know. Patients are not obliged to justify
their decisions, but health professionals usually wish to
discuss the implications of a refusal of treatment with
patients in order to ensure that the decision is based on
accurate information and not on any misunderstanding.
Advance decisions refusing CPR
CPR must not be attempted if it is contrary to valid and
applicable advance decisions made when patients had
capacity (Case 4.28 Advance decision making).
When might it be appropriate to
temporarily suspend a DNACPR decision?
Uncommonly, some patients for whom a DNACPR deci-
sion has been established may develop cardiac or respira-
tory arrest from a readily reversible cause such as choking,
induction of anaesthesia, anaphylaxis or blocked trache-
ostomy tube. In such situations CPR would be appropri-
ate, while the reversible cause is treated, unless the patient
has specifically refused intervention in these circum-
stances. It may also be appropriate to temporarily suspend
a DNACPR decision during some procedures if the proce-
dure itself could precipitate a cardiopulmonary arrest – for
example, cardiac catheterisation, pacemaker insertion, or
surgical operations. If a patient wishes an advance decision
refusing CPR to remain valid during a procedure or treat-
ment that significantly increases the risks of the procedure
it would be reasonable not to proceed.
CASE 4.30  RESUSCITATION STATUS
DECISION MAKING – DISCUSSION
WITH RELATIVE
Candidate information
Role
You are a doctor in the acute medical unit.
Please read this summary.
688
Scenario
Mr Chris Ryder, aged 55 years
Mr Ryder has advanced Huntington’s disease. For the last year
he has required full-time care in a nursing unit with specialised
psychiatric skills because of behavioural disturbance. He is not
competent to make decisions for himself. He has been admitted
with aspiration pneumonia and has worsening acute renal failure
due to sepsis. Haemodialysis may be the only way to manage his
renal failure in the short term, but in the context of his comorbidity
you have to decide if this is appropriate. His sister is here to talk
with you. She is not genetically affected.
Your task is to discuss the appropriateness of haemodialysis
and intensive care, along with resuscitation status, with his sister.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
You are the sister of Mr Chris Ryder, a 55-year-old man with
advanced Huntington’s disease. For the last year he has
required full-time care in a nursing unit with specialised
psychiatric skills on account of behavioural disturbance.
He is not competent to make decisions for himself. You
have lived with the knowledge of his inevitable decline for
many years and anticipated situations from which he may
not recover. You do not carry any risk of developing the
disease yourself. He has now been admitted with aspira-
tion pneumonia and has severe renal failure caused by his
infection. Your brother did not make a written advance
directive about his future wishes, but your feeling is that he
would not wish to be kept alive if there were no possibility
of long-term cure of the underlying cause. You are a trained
nurse and feel that intensive-care transfer, if it came to that,
would not be in his best interests.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself and establish that she is Mr Ryder’s
sister.
2.  Establish what the relative knows
Firstly, establish a rapport with a relative you have not met
before, establishing what she knows, and what she thinks,
before moving to a gentle explanation of where you are in
terms of her brother’s medical condition and possible
ways forward:
What have you been told so far about his condition since
admission to hospital?
 Case 4.30  Resuscitation status decision making – discussion with relative
3.  Seek further information about the patient
Relatives are highly valuable sources of information. She
may know intimately the duration and nature of his
decline, his care needs and, in a chronic condition such as
this, may well have anticipated what his wishes might be
in the event of a precipitous acute episode of illness, and
established her own views.
4.  Do not forget empathy
No matter how pragmatic she may seem about his illness,
remember that even expected declines often still strike
harshly. Remain empathetic and pace your explanations
slowly and carefully, and in words relatives will
understand.
5.  Explain the situation
Explain that his pneumonia is in itself treatable, but that it
has provoked kidney failure that may or may not be recov-
erable. Explain that pneumonia is a more likely event in
patients with advancing chronic conditions like Hunting-
ton’s disease but that the kidney problem is now the most
threatening. Explain that it is being managed with careful
fluid replacement and monitoring of blood chemistry.
6.  Approach the issue of more invasive
interventions
The next, very difficult question that I know you know I’m
coming to is, if things were to deteriorate sharply, what we
might do. We are treating as energetically, as vigorously, as
we can, with fluids and antibiotics and by correcting the
abnormalities in the blood which arise from the kidney failure.
And we hope that things may improve. But he is at serious
risk, and there is no getting away from that.
7.  Ensure that your explanation does not conflict
with any ideas, concerns and expectations
Most importantly, ensure that she understands that his life
is threatened and if she makes it clear that she does and that
she does not think that he would wish for more complex
interventions it is appropriate to reinforce her views:
I would have to agree. And my strong feeling and advice to you
is that if there were further deterioration / a disaster, I would
not be inclined to go down the route of dialysis or ventilators
and intensive care … because I just do not think he would
come through it. And the trouble is that even if he were to
come through it all, without a clear way forward beyond all of
this, without seeing him getting better, I think it would be
putting him through unnecessary distress.
8.  Many relatives worry that the decision is
theirs and theirs alone
It may be important to highlight that the decision is ulti-
mately yours, but that her views of what his wishes might
be are highly valuable.
9.  Confirm understanding and invite questions
Make it clear that you are happy to answer questions now
or later.
Box 4.28  Cardiopulmonary resuscitation
(CPR) decision making in adults who
lack capacity
Advance decision or directive
A valid and applicable advance decision or directive should be
respected (Case 4.28).
Legal proxy
If a patient has a legal proxy, this person must be consulted about
CPR decisions. The rules governing the role and validity of the legal
proxy are exactly the same for CPR decision making as any other
treatment decision and are detailed in Case 4.24 (Consent and
capacity).
Those close to the patient
Where a patient has not made an advance decision or appointed
a legal proxy, the treatment decision rests with the most senior
clinician in charge of the patient’s care. Where CPR may re-start
the patient’s heart and breathing for a sustained period, the
decision as to whether CPR is appropriate must be made on the
basis of the patient’s best interests. In order to assess best
interests, the views of those close to the patient should be
sought, unless this is impossible, to determine any previously
expressed wishes and what level or chance of recovery the patient
would be likely to consider of benefit. In reaching a decision
in England and Wales the Mental Capacity Act requires that
best-interests decisions must include seeking the views of anyone
named by the patient as someone to be consulted, or anyone
engaged in caring for the person or interested in the patient’s
welfare. Under the Act, all health-care personnel must act in
the best interests of a patient who lacks capacity. In these
circumstances, it should be made clear to those close to the patient
that their role is not to take decisions on behalf of the patient, but
to help the health-care team to make an appropriate decision in
the patient’s best interests.
Independent mental capacity  
advocate (IMCA)
In England and Wales the Mental Capacity Act requires an IMCA
to be consulted about all decisions about ‘serious medical
treatment’ where patients lack capacity and have nobody to
speak on their behalf. The definition of serious medical treatment
includes circumstances where ‘what is proposed would be likely to
involve serious consequence for the patient’. It can be argued that
a decision not to attempt CPR because it will not work will not
have ‘serious consequences’ for the patient, because the patient
will die with or without attempting CPR. For this reason, an IMCA
does not need to be called when it is clear to the medical team
that CPR would not be successful. Where there is genuine doubt
about whether or not CPR would have a realistic chance of
success, or if a DNACPR decision is being considered on the
balance of benefits and burdens, in order to comply with the law
an IMCA must be involved. If a DNACPR decision is needed when
an IMCA is not available (for example at night or at a weekend),
the decision should be made, recorded in the health record and
discussed with an IMCA at the first opportunity. An IMCA does
not have the power to make a decision about CPR but must be
consulted as part of the determination of the patient’s best
interests.
689
 Station |4| Communication skills and ethics
10.  Conclude with assurances
Always conclude with an assurance that if a decision is
made not to resuscitate, you and your team will continue
to do all that you can to actively treat his condition and
to relieve symptoms. Make it clear, where appropriate, that
a decision can be reviewed and altered at any time.
But we will do all that we can, keeping a very close eye and
treating all that is treatable here on the ward. And we are
here, if there are any questions at any time.
Discussion
What do you know about cardiopulmonary
resuscitation decision making for adults
who lack capacity?
The possibilities are described in Box 4.28 and more detail
on treating adults who lack capacity is in Case 4.24
(Consent and capacity).
CASE 4.31  APPROPRIATENESS OF
INTENSIVE THERAPY UNIT TRANSFER
Candidate information
Role
You are a doctor on the medical ward.
Please read this summary.
Scenario
Re: Mrs Angela Elliot, aged 62 years
Mrs Elliot has advanced multiple sclerosis. She is immobile,
dependent upon carers for transfer from her wheelchair to bed,
and unable to feed herself. Bulbar function is significantly impaired
whenever she has intercurrent infection, its recovery following
episodes is incomplete and she can only just tolerate a strict diet.
Percutaneous gastrostomy feeding was being considered.
Unfortunately, she has been readmitted to hospital with her fourth
episode of pneumonia in 12 months. On this occasion admission to
the intensive therapy unit (ITU) was considered for the first time,
but because of a lack of ITU beds she was observed carefully by
the ITU outreach team and ‘made it through the night’ with
high-flow oxygen, suction and antibiotics. She is slowly improving,
and no longer breathless. The nursing team have questioned
whether she should be considered for ITU next time she has
pneumonia, as Mrs Elliot has apparently expressed concerns about
‘going on a ventilator’ and would like to speak to a doctor.
Your task is to address her concerns.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
690
Patient / subject information
Mrs Angela Elliot is a 62-year-old woman who has
advanced multiple sclerosis. She is fully dependent upon
carers for transfer from her wheelchair to her bed, and
unable to feed herself. She can swallow food, albeit very
carefully prepared and of the right consistency, but swal-
lowing is further impaired each time she is unwell. Percu-
taneous gastrostomy feeding has been considered and is
acceptable to her. Unfortunately, she has been readmitted
to hospital with her fourth episode of pneumonia in 
12 months. On this occasion admission to the intensive
therapy unit (ITU) was considered, but she ‘made it
through the night’ with oxygen, chest physiotherapy and
antibiotics. She is slowly improving, and no longer breath-
less. She has great concerns about a ventilator because she
does not want to be ‘kept alive indefinitely on an artificial
machine’. Her daughter died after spending 4 months in
an ITU following a road traffic accident. She has no other
children, and is widowed. She would like to discuss
whether ITU would really benefit her in future if this
happens again. She has a fear of being ventilated only to
die at the end of months of distress.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction, setting and rapport
Introduce yourself and state that you are glad to see her
feeling a little better. Make it clear that you will do every-
thing you can to continue to make her feel comfortable,
and treat the chest infection.
2.  Acknowledge how unwell the patient has been
Mention that you know how unwell she has been, and
that, while you feel she should continue to improve on
this occasion, she came very close to needing ventilatory
support.
3.  Explore the patient’s concerns
Mention that the nursing staff have told you she had some
concerns at being treated in intensive care. Explain that
while you are always happy to consider what seems the
best treatment at the time, it would be important to know
if she has any strong feelings one way or the other about
any specific measures, including intensive care.
4.  Address the patient’s concerns
Patients with long-term conditions have often given
thought to what their wishes might be in the event of hypo-
thetical clinical circumstances. While some patients would
‘want everything done’, many are very clear about circum-
stances they would not wish to occur, and this is very likely
to include being artificially ventilated when there is no
prospect of recovery (doctors would be unlikely to offer
such a treatment in any event). The difficulty is that
 Case 4.31  Appropriateness of intensive therapy unit transfer
medicine is seldom clear-cut, and the prospect of recovery
is often a case of best judgement rather than absolute cer-
tainty one way or the other. It is reasonable, provided the
patient wishes it, to consider ventilation when there is a
reversible acute cause for respiratory failure such as infec-
tion, but the balance of favouring to ventilate is progres-
sively tempered as worsening of the underlying condition
thwarts the likelihood of successful weaning from ventila-
tion, and ultimately ventilation is tilted out of favour.
Patients may choose not to be ventilated even when the
balance seems to be in their favour, provided this is an
informed choice. Occasionally, patients will feel guilty
about refusing an option that may prolong their life, espe-
cially if they have close relatives. Ventilation may carry the
prospect of recovery from future infective exacerbations,
but the patient will judge if the extent of that recovery is
something she wishes to be brought back to. ITU would, of
course, decline admission when recovery does not seem
likely. Increasingly, non-invasive ventilation has been an
alternative to invasive ventilation and can be applied
outside ITU, but its best evidence is in the setting of chronic
obstructive pulmonary disease (COPD) exacerbations.
5.  Discuss resuscitation status
It is often, but not inevitably, appropriate to discuss resus-
citation status. Such discussion is usually a logical and
natural extension if you have reached a decision about ITU
being inappropriate, but should be discussed sensitively.
6.  Ensure that the patient is fully informed
If a decision is to be made not to admit to ITU in future,
especially if there is still a prospect of ITU benefit out-
weighing risk, ensure that this is made with adequate
understanding of the alternatives and the consequences,
and formed without coercion or undue influence.
7.  Agree a plan
Agree to respect her informed choice.
8.  Confirm understanding
Ensure that she is clear about the course of action and be
prepared to explore any other concerns.
9.  Invite questions
Ask if there is anything she would like clarified.
10.  Conclude with assurances
Always conclude with an assurance that, if a decision is
made not to admit to ITU in future, you and your team
will continue to do all that you can to actively treat her
condition and to relieve symptoms.
Discussion
Which patients fare better in ITU,
and which worse?
The role of ITU is largely in support whilst primary therapy
works. There is often a sense of ITU being inaccessible or
unassailable to physicians outside it, but studies have
shown that the often ‘poor prognostic’ pessimism of ITU
physicians is not always thoroughly founded. For example,
being old, being immunosuppressed or having malig-
nancy have all been shown to have good outcomes with
ITU where appropriate patient selection occurs. It does,
however, seem clear that poor candidates for ITU generally
are those with a combination of severe illness, a poor level
of pre-morbid function (e.g. chair- or bed-bound) and
multi-organ failure. However, it can be difficult to make
physiological and ethical judgements at the same time and
early, collaborative decision making between physicians
and intensivists is to be encouraged.
Is invasive ventilation contraindicated
in COPD?
Invasive ventilation is more likely to be appropriate where
there is a reversible cause and an acceptable quality of life
or habitual level of activity. Each case must be assessed
individually. COPD is not a blanket reason not to ventilate
because of fears about weaning. You should get an idea,
for example, of how much oxygen is required at home or
what is meant exactly by ‘housebound’. Invasive ventila-
tion may be appropriate for a remediable acute cause, if
there is no significant other organ failure, for a first episode
of respiratory failure or if the patient has made an informed
wish for it to be attempted, whereas it would be inappro-
priate for a patient with end-stage COPD and a high pre-
morbid arterial pCO2.
How does age affect ITU outcome?
Around 25% of ITU admissions are of patients over 75
years of age, and this is likely to increase. Surgical patients
are more likely to need admission than medical, usually
related to sepsis and other postoperative complications.
Around 80% of patients over 80 years of age who are
ventilated with sepsis do not survive. Other adverse factors
include poor cognition, decreased consciousness, recent
stroke, limited activities of daily living, poor nutrition and
unplanned admission. Despite this, age is a risk factor for
poor outcome (7%) by only around one-tenth that of the
underlying physiology (73%) in the acute physiology and
chronic health evaluation (APACHE) III scoring system.
Physiological problems should be much bigger determi-
nants of admission to ITU than age; single-organ reversible
disease even in very old people who were previously
healthy (another important determinant of outcome) cer-
tainly deserves consideration of ITU involvement.
What complications can follow a spell
in ITU?
Post-critical illness morbidity is increasingly recognised,
particularly in centres operating post-ITU clinics, and this
includes neurocognitive dysfunction, neuromuscular dys-
function, disordered taste, a wide variety of neuropathies
including peripheral and entrapment neuropathy, trache-
ostomy site complications, and depression.
691
 Station |4| Communication skills and ethics
CASE 4.32  WITHHOLDING AND
WITHDRAWING LIFE-PROLONGING
TREATMENTS – ANTIBIOTICS AND
DRUGS
Candidate information
Role
You are a doctor on an elderly care ward.
Please read this summary.
Scenario
Re: Mrs Eliza Bennett, aged 83 years
Mrs Eliza Bennett has been on your ward for 3 weeks with
unresolving pneumonia. She has significant comorbidity. She has
had type 2 diabetes for many years, latterly requiring insulin, with
associated chronic kidney disease and advanced diabetic
maculopathy. She was admitted with right lower lobe pneumonia,
which has failed to respond to two courses of intravenous
antibiotics. The microbiologist has suggested a third regimen, but
the possibility of non-infective underlying causes, including cancer,
is there, although not established, and she has been too unwell for
complex investigations. She has steadily declined, with a falling
serum albumin and increasing peripheral oedema. She is now too
drowsy to engage in discussion. Intravenous access is now not
possible peripherally, and your house officer called you to consider
a central venous catheter. Mr Bennett is visiting his wife.
Your task is to discuss her treatment options with Mr Bennett,
her husband.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
Your wife, Mrs Eliza Bennett, is an 83-year-old woman
who has been on the ward for 3 weeks with pneumonia
that is steadily getting worse. She has been unwell, in your
view, for the last year. She has longstanding diabetes,
requiring insulin as well as tablets, with associated kidney
problems and visual impairment. She used to be very
active and has been very depressed for the last year, virtu-
ally housebound by weakness in her legs and poor vision.
To you, and you think to her, this is the last straw. She is
not getting better, her legs are swelling up and you have
seen her becoming more confused and drowsy since
admission. She has always said that she would not want
to go on if her diabetes had got the better of her and would
not want to be dependent upon carers or nurses. The
doctors are concerned that she has not responded to anti-
biotics and they appear to be running out of options.
692
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself, establish his identity and acknowledge
that it is a difficult time.
2.  Acknowledge the value of the relative
As his wife is not able to speak for herself, his presence is
highly valuable in determining what her wishes might have
been. Acknowledging him as her closest relative, it may be
helpful to ask if there are other family members nearby
who might also wish to be involved in discussions.
3.  Reassure the relative that any decisions  
will be carefully considered and that the ‘burden
of responsibility’ for difficult decisions will not
rest with him
Reassure him that decisions will consider what is best for
his wife, and that his views will be very helpful. Explain
that you are very concerned that treatments do not seem
to be working as you had hoped, and that you now must
contemplate what are reasonable interventions and what
may not be reasonable interventions and not in his wife’s
best interests. Explain that decisions will very much take
account of any views he has but that decisions will be
made together. Remember that your consultant is there to
help with difficult decisions such as this, and you should
make difficult decisions with more senior team members.
4.  Explain the problem
This should start with a summary of the background,
explaining that his wife’s pneumonia has not responded.
Acknowledge that there is uncertainty as to why this is so.
It is likely that her diabetes (hyperglycaemia, small-vessel
disease, renal failure) is impairing the fight against infec-
tion. It may be that there is an underlying reason (includ-
ing a growth) predisposing to infection, but his wife has
been too unwell for more complicated investigations.
Explain that, as time goes on, the prospects of recovery
from the pneumonia diminish, particularly as other 
things start to go wrong (drowsiness, hypoalbuminaemia,
oedema). Explain that all you have been able to do recently
is continue with antibiotics, attempt to correct any abnor-
malities in the blood chemistry and watch and wait, trying
to ensure that she is comfortable. Explain that the new
problem is that it is no longer possible to secure peripheral
intravenous access for delivery of antibiotics.
5.  Explain your view
Explain that the next step could be to consider intravenous
access via a catheter inserted into a larger vein in the neck,
but that this is more invasive. Acknowledge that this is not
without complications, and not always comfortable to
 Case 4.33  Withholding and withdrawing life-prolonging treatments
insert, but is an effective way of ensuring that treatment
continues, although you cannot say if treatment will work.
It is unlikely that she is able to take tablets at the moment,
but if she were to improve and show the ability to take
things orally, then oral antibiotics could be considered.
6.  Explore what the relative feels the patient
would have wanted
He may request, based on his knowledge of his wife’s
values and views, that this would be a step too far.
7.  Explore any concerns the relative may have
A common concern is that the patient may suffer or be in
pain. When a patient is not responding to treatment, it is
crucial to reassure relatives that one thing you can do is
ensure their comfort.
8.  Consider and justify, or plan to change, any
apparent discrepancies such as delivering some
medications but not others
If a decision is made to withdraw antibiotics, the issue  portionate to expected benefits.
of continuing insulin may need to be discussed. If she
cannot take tablets, and is already insulin dependent, then
withdrawal of insulin could lead to rapid spiralling of
hyperglycaemia and possible death from hyperglycaemic
coma. This could be avoided with subcutaneous insulin
and this may still be a reasonable intervention while
nature confirms its likely course without antibiotics. If and
when it becomes certain that she is dying then it may be
appropriate to withdraw insulin in favour of purely symp-
tomatic palliative measures.
9.  Confirm understanding and invite questions
Make it clear that you are happy to answer further ques-
tions now or at any time.
10.  Give strong reassurance about continuing
with care
Make it clear that the team will continue to care for his
wife with very close attention to what is reasonably treat-
able and to alleviation of symptoms. Tell him that you are
happy to answer questions at any time.
Discussion
Do you know of any guidance on
withholding and withdrawing life-
prolonging treatments?
The 2010 General Medical Council (GMC) guideline on
end-of-life care supersedes previous guidance on with-
holding and withdrawing life-prolonging treatment and
covers greater ground, providing decision-making models  Candidate information
(Case 4.27 End of life and palliative care) for patients 
with or without capacity in all areas of end-of-life care
including withholding and withdrawing life-prolonging
treatments.
Must you provide treatment to a patient
who demands it but which you do not think
is in that patient’s best interests?
If a patient asks for a treatment that the doctor considers not
clinically appropriate, the doctor is not obliged to provide
it, but should offer to arrange for a second opinion.
How might you be guided in making
decisions about limitation of treatment
for patients without capacity?
Any valid advance refusal of treatment must be respected.
Without this, assessment of the benefits, burdens and risks 
and overall acceptability of treatment must be made on a
patient’s behalf by the doctor, taking into account what is
known of the patient and information from those closest to the
patient. Best-interests decisions and the use of valid advance
decisions or legal proxy or information from third parties are
described in more detail in Case 4.24 (Consent and capacity).
Prolonging life will usually be in a patient’s best inter-
ests if treatment is not excessively burdensome or dispro-
But not continuing or starting treatment is in a patient’s
best interests when there is no net benefit. Life has a
natural end and doctors should not strive to prolong the
dying process. Case law suggests that life-prolonging treat-
ment can lawfully be withheld or withdrawn from a
patient who lacks capacity when starting or continuing
treatment is not in their best interests, and that there is no
obligation to give treatment that is futile or burdensome.
When reaching a view on whether a particular treatment
would be more burdensome than beneficial, assessments
of the likely quality of life for the patient with or without
that treatment may be one of the appropriate considera-
tions. Where it is decided that treatment is not in a patient’s
best interests, there is no ethical or legal reason to provide
it and thus no need to distinguish withdrawal of treatment
from not starting treatment.
Where a patient lacks capacity and there is uncertainty
about appropriateness of treatment, treatment that may be
of some benefit should be started until clearer assessment
is made. This is particularly important in emergencies
where there may be doubt about the severity of a condi-
tion or the benefit of a treatment.
CASE 4.33  WITHHOLDING AND
WITHDRAWING LIFE-PROLONGING
TREATMENTS – CLINICALLY
ASSISTED NUTRITION AND
HYDRATION
Role
You are a doctor on the stroke unit.
Please read this summary.
693
 Station |4| Communication skills and ethics
Scenario
Re: Mr Harold Hunt, aged 86 years
Mr Hunt was admitted to your ward 3 days ago following a left
total anterior circulation stroke. He remains unconscious and the
consensus opinion of all members of the health-care team is that
his prognosis is very poor. His daughter feels that he should be ‘left
in peace’. He is on ‘a drip’ but one of the nurses mentioned the
possibility of a ‘feeding tube’ to her. She is now not sure if he is
being starved.
Your task is to discuss the issue of clinically assisted nutrition
and hydration with his daughter.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
Mr Harold Hunt, your father, is an 86-year-old man who
was admitted to the ward 3 days ago following a very large
stroke. He remains unconscious and the consensus opinion
of all members of the health-care team is that his prognosis
is very poor. You feel that he should be ‘left in peace’. He had
a very active life in the army, but since being widowed 3
years ago became rather withdrawn and always said he
would want ‘to have all of his faculties’. He has been on ‘a
drip’ since admission but one of the nurses mentioned the
possibility of a ‘feeding tube’. You do not see the value of
feeding your father if he is going to die, but are worried that
if he is being starved it may be uncomfortable for him. You
wonder if the drip should continue, and if so whether it
might be delaying an inevitable death.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself, establish her identity and acknowledge
that it is a difficult time.
2.  Acknowledge the value of the relative
As her father is not able to speak for himself, her presence
is highly valuable in determining what his wishes might
have been. It is always useful to establish if there are other
people who might wish to be involved in discussions.
3.  Reassure the relative that any decisions   hydration but withholding nutrition
will be carefully considered and that the   The British Medical Association (BMA) and General
‘burden of responsibility’ for difficult decisions
will not rest with her
Reassure her that decisions will always consider her father’s
best interests first, aided by her better knowledge of her
694
father. Although relatives often wish strong account be
taken of their views, they may also need to be reassured
that ultimately the ‘burden of responsibility’ for decisions
rests with the medical team. She will wish to express the
perceived values and preferences of her father but may well
feel uncomfortable if she feels that a life and death deci-
sion about a family member is hers.
4.  Explain the reasons for and against clinically
assisted nutrition and hydration
Explain that where a patient cannot take fluids or food
orally, an assessment is always made of the requirements
for hydration and nutrition, and the appropriateness of
instituting these. Explain that in this situation intravenous
fluids were started initially because it could not be deter-
mined whether her father would recover and, if so, how
long this would take, but that supportive fluids are neces-
sary early on if there is to be some recovery. Explain that
artificial nutrition is less immediate, but should be started
via a tube passed through the nose directly into the
stomach (nasogastric tube) within the first few days in
patients showing signs of recovery. Acknowledge that it is
a very sensitive issue and not one with absolutely right or
wrong answers, but that the generally accepted view is not
to institute artificial nutrition unless a patient is showing
signs of recovery. Specifically, a patient should be con-
scious and able to sit up and ideally aware of the reasons
for the tube.
5.  Explain your view
It is often best, particularly where you feel relatives are
showing agreement, to suggest what you think might be
appropriate, provided this is not dogmatic and you dem-
onstrate willingness to be fluid in your decisions depend-
ing upon feedback. You might consider artificial nutrition
if there were a spontaneous change for the better, but now
it is entirely reasonable to watch and wait.
6.  Explore what the relative feels the patient
would have wanted
She will probably agree with withholding nutrition.
7.  Explore any concerns the relative may have
She may need to be reassured that there is no evidence
that withholding nutrition causes distress by ‘starvation’.
She may not see the logic of maintaining intravenous
fluids when nutrition is being withheld.
8.  Consider and justify or plan to change any
apparent discrepancies such as delivering
Medical Council (GMC) have stated that withdrawing 
a life-prolonging treatment may not be ethically 
distinguishable from withholding it, although the former
can seem more difficult. Whilst intravenous or subcutane-
ous fluids could be withdrawn, there are reasons
 Case 4.33  Withholding and withdrawing life-prolonging treatments
for continuing their provision, although these cannot be
evidence based. In this case 3 days may seem too soon to
withdraw a relatively non-invasive treatment, especially if
access for fluids is not causing distress. Unlike nutrition,
fluids pose little risk. Nasogastric feeding may provoke
aspiration and may be uncomfortable and is not suitable
for unconscious or agitated patients or for patients who
cannot sit up. Percutaneous endoscopic gastrostomy
(PEG) feeding is not suitable unless patients demonstrate
potential for longer term survival. Hydration may avert
distress, although there is no convincing evidence for this
and indeed the Liverpool Care Pathway for palliation spe-
cifically excludes hydration and nutrition.
9.  Confirm understanding and invite questions
Make it clear that you are happy to answer further ques-
tions now or at any time.
10.  Give strong reassurance about continuing
with care
Explain that needs and symptoms may change, and that
he will be carefully assessed regularly.
Discussion
When might the question of clinically
assisted nutrition or hydration be
considered?
The offer of food and drink by mouth is part of basic care
(as is the offer of washing and pain relief) and must always
be offered to patients able to swallow without serious risk
of choking or aspirating. Food and drink can be refused
by patients at the time it is offered, but an advance refusal
of food and drink has no force. If a patient is not receiving
adequate nutrition or hydration by mouth, even with
support, an assessment of their condition and their indi-
vidual requirements must be made. Their needs for nutri-
tion and hydration must be considered separately with
consideration of what forms of clinically assisted nutrition
or hydration may be required.
What is meant by clinically assisted
nutrition or hydration?
Clinically assisted nutrition includes intravenous feeding,
and feeding by nasogastric tube and by PEG and radio­
logically inserted gastrostomy feeding tubes through the
abdominal wall. All these means of providing nutrition
also provide fluids necessary to keep patients hydrated.
Clinically assisted hydration can also be provided by intra-
venous or subcutaneous infusion of fluids through a ‘drip’.
The terms ‘clinically assisted nutrition’ and ‘clinically
assisted hydration’ do not refer to help given to patients
to eat or drink, for example by spoon feeding – these are
generally considered part of nursing care. The terms are
replacing the term ‘artificial hydration’ and ‘artificial
nutrition’.
How might you decide if clinically assisted
nutrition or hydration should be provided?
Providing nutrition and hydration by tube or drip may
provide symptom relief, or prolong or improve quality of
life, but may also present problems, and decision-making
models should be used to help determine whether these
should be provided (Boxes 4.23 and 4.29).
Should clinically assisted nutrition
or hydration should be provided in
advanced dementia?
An increasingly common scenario is advanced dementia,
when poor oral intake is a result of irreversible brain failure
resulting in loss of motivation for intake with apathy, and
sometimes to an extent a weak swallow. Here it is usually
appropriate to exclude reversible factors, including depres-
sion, and encourage oral intake with all possible means,
which can be time intensive. If clear that the patient is
declining primarily because of the dementia and that the
poor oral intake is a consequence of this, the benefits of
clinically assisted hydration and nutrition become less and
less persuasive and are not without considerable burdens
and risks. Ultimately, the ethical distinction between
allowing a patient to decline or die primarily from dehy-
dration (usually unethical) or accepting decline and death
primarily from an underlying irreversible disease in which
dehydration is a secondary inevitable factor (which may be
ethical) is an important one. Furthermore, in advanced
dementia the risks of artificial feeding are higher than the
benefits, invariably, and the point is that food and fluid are
not withheld but always offered orally.
A 68-year-old man with advanced Lewy
body dementia is admitted with an unsafe
swallow and multiple failed nasogastric
feeding attempts because he pulls out the
tubes. He is receiving intravenous fluid. His
essential medical therapy is warfarin for a
metallic heart valve. What are the options?
Percutaneous gastrostomy feeding would probably not be
appropriate in this situation. Blood tests are appropriate to
guide a life-saving treatment (warfarin) until a definitive
decision for no further active management has been made.
The option to comfort feed may seem the most appropriate
to medical staff, but his family’s views on his perceived
wishes may help. Withdrawal of hydration before discus-
sion would not seem correct immediately, particularly
while his family are coming to terms with a difficult situa-
tion. His family are likely to be strongly in agreement that
no further attempts should be made to feed via a nasogas-
tric tube. It may be decided that if no future can be envis-
aged beyond this admission to hospital, no further
intravenous or subcutaneous access for hydration would be
appropriate once the current cannula ‘tissues’. A decision
should then also be made as to whether or not to give anti-
biotics in the event of aspiration. Assurance of preservation
695
 Station |4| Communication skills and ethics
Box 4.29  Deciding if clinically assisted nutrition or hydration should be provided
If clinically assisted nutrition or hydration is necessary to keep a
patient alive, the duty of care will normally require the doctor to
provide it, if a patient with capacity wishes to receive it. But the
evidence about the benefits, burdens and risks of these techniques
as patients approach the end of life is not straightforward and
clear. This can lead to concerns that patients who are unconscious
or semi-conscious may be experiencing distressing symptoms and
complications, or otherwise be suffering either because their needs
for nutrition or hydration are not being met or because attempts to
meet their perceived needs for nutrition or hydration may be
causing them avoidable suffering. Clinically assisted nutrition or
hydration may be withheld or withdrawn if the patient does not
wish to receive it, or if the patient is dying and the care goals
change to palliative care and relief of suffering, or if the patient
lacks capacity to decide and it is considered that providing clinically
assisted nutrition or hydration would not be in their best interests.
Nutrition and hydration provided by tube or drip are regarded
in law as medical treatment and should be treated in the same way
as other medical interventions. Nonetheless, some people see
nutrition and hydration, whether taken orally or by tube or drip, as
part of basic nurture for the patient that should almost always be
provided. For this reason it is especially important to listen to and
consider the views of the patient and of those close to them
(including their cultural and religious views) and explain the issues,
including the benefits, burdens and risks of providing clinically
assisted nutrition and hydration. All should understand that when
clinically assisted nutrition or hydration would be of overall benefit
it will always be offered, and that if a decision is taken not to
provide clinically assisted nutrition or hydration the patient will
continue to receive high-quality care, with any symptoms
addressed.
Patients who have capacity
If it is considered that a patient is not receiving adequate nutrition
or hydration by mouth, the decision model in Case 4.27 should be
followed. Nutrition and hydration should be considered separately
and considered clinically appropriate because, for example, they
would provide symptom relief or are likely to prolong life. Benefits,
burdens and risks should be explained. If clinically assisted nutrition
or hydration is not considered clinically appropriate the patient’s
condition should be monitored and the benefits, burdens and risks
reassessed as the condition changes. If a patient asks for nutrition
or hydration by tube or drip, the reasons for their request should be
explored, giving weight to the patient’s wishes and values. When
the benefits, burdens and risks are finely balanced, the patient’s
request will usually be the deciding factor. However, if after
discussion the treatment is still not considered clinically appropriate,
it does not have to be provided, but the reasons and other options
should be explained, including the option to seek a second opinion.
Adult patients who lack capacity
If a patient lacks capacity and cannot eat or drink enough to meet
their nutrition or hydration needs, assessment of whether providing
of his dignity should be given, with a shift in care to comfort
and suppression of distress. Warfarin should be withdrawn
as blood tests cannot be obtained, and the possibility of
sudden valve obstruction accepted as a potential mode of
death unless he is not likely to die from other causes quickly
in which case subcutaneous heparin could be administered
after discussion with his family.
696
clinically assisted nutrition or hydration would be of overall benefit
should be made using the decision model in Case 4.27 (End of life
and palliative care) with the same clinical considerations as for
patients who have capacity.
Adult patients who lack capacity and are not expected to
die within hours or days
Clinically assisted nutrition or hydration must be provided if it
would be of overall benefit, taking into account the patient’s beliefs
and values, any previous request for nutrition or hydration by tube
or drip and any other views he or she has previously expressed
about care. The patient’s request must be given weight and, when
the benefits, burdens and risks are finely balanced, will usually be
the deciding factor. If judged that the provision of clinically assisted
nutrition or hydration would not be of overall benefit to the patient,
it may be concluded that treatment should not be started or should
be withdrawn. This view should be explained to the patient, if
appropriate, and those close to the patient, and the patient’s
interests must have been thoroughly considered including where
appropriate steps to get a second opinion from a senior clinician
with experience of the condition but not directly involved in the
patient’s care. If consensus is reached that clinically assisted
nutrition or hydration would not be of overall benefit treatment is
withdrawn or not started, and the patient must be kept comfortable
and monitored for any change with preparedness to reassess the
benefits, burdens and risks of providing clinically assisted nutrition
or hydration in light of changes. If clinically assisted nutrition or
hydration is started or re-instated after a later assessment, and it is
subsequently concluded that it would not be of overall benefit to
continue a further second opinion should be sought.
Adult patients who lack capacity and are expected to die
within hours or days
If a patient is expected to die within hours or days, and it is
considered that the burdens of providing clinically assisted nutrition
or hydration outweigh the benefits they are likely to bring, it will not
usually be appropriate to start or continue treatment (it is important
to be aware that not eating and drinking is often a part of the dying
process and should be distinguished from dying as a result of not
receiving food or fluid). If a patient has previously requested that
nutrition or hydration be provided until death, or those close to the
patient are sure that this is what the patient wanted, the patient’s
wishes must be given weight and, when the benefits, burdens and
risks are finely balanced, will usually be the deciding factor.
Patients in a persistent vegetative state (PVS) or
similar condition
If considering withdrawing nutrition or hydration from a patient in a
PVS or a condition closely resembling PVS, the courts in England,
Wales and Northern Ireland currently require that they be
approached for a ruling. The courts in Scotland have not specified
such a requirement, but legal advice should be sought.
He shows signs of improvement
with comfort feeding but has
choking episodes with comfort feeding.
What would you do now?
There are two, at first glance conflicting, options but each
one depends upon the type of improvement. If he is
 Case 4.34  Percutaneous endoscopic gastrostomy feeding
showing signs of returning to his pre-admission self, then
it may well be appropriate to revise decisions, and this
could include stopping comfort feeding, administering
artificial hydration and considering percutaneous gastros-
tomy feeding, although there are enormous concerns
about the risk–benefit ratio of the latter in dementia. If,
however, he shows the day-to-day minor undulation that
is true of many hospital patients, then it is vital for his
family not to be given false hope or to burden the patient
or family with swinging decisions in the context of an
inevitable end.
CASE 4.34  PERCUTANEOUS
ENDOSCOPIC GASTROSTOMY
FEEDING
Candidate information
Role
You are a doctor on the medical ward.
Please read this summary.
Scenario
Re: Mr James Hawkins, aged 82 years
Mr Hawkins was admitted to your ward a week ago with
aspiration pneumonia. On admission the prognosis seemed poor
and resuscitation in the event of cardiac or respiratory arrest was
not considered appropriate. He has idiopathic epilepsy (since
childhood, and currently treated with phenytoin, carbamazepine
and sodium valproate) and Parkinson’s disease, on treatment for 8
years. A year ago he had a stroke after which he spent 6 weeks in
a rehabilitation hospital before returning to his wife at home. She
is his main carer, and he requires help with washing, dressing,
meals and mobility around the house. Following antibiotic
treatment he has recovered to the point of cardiorespiratory
stability, but cannot swallow. The speech and language therapist
assessing him believes he might never safely swallow because this
was significantly impaired before admission and the balance has
now been tipped. Unfortunately, Mr Hawkins has not tolerated
numerous attempts to pass a nasogastric feeding tube and the
speech and language therapist has suggested that a percutaneous
endoscopic gastrostomy (PEG) would enable him to receive
nutrition. Unfortunately, Mr Hawkins is unable to participate in
such a discussion because he has been too cognitively impaired for
the last year. His wife fears that he will starve without a PEG and
wishes to discuss the issues with you.
Your task is to discuss the options with her and help her reach
a decision.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
Mr James Hawkins, your husband, is an 82-year-old man
admitted to hospital a week ago with aspiration pneumo-
nia. On admission the prognosis seemed poor and 
resuscitation in the event of cardiac or respiratory arrest
was not considered appropriate. He has epilepsy (on 
treatment since childhood) and Parkinson’s disease (on
treatment for 8 years). A year ago he had a stroke after
which he spent 6 weeks in a rehabilitation hospital before
returning home. You are his main carer, and he requires
help with washing, dressing, meals and moving around
the house. He is confined to a wheelchair much of the
time, but sometimes can walk with a stick. Following anti-
biotic treatment he has recovered somewhat, but cannot
swallow. The speech and language therapist believes he
might never safely swallow again. Unfortunately, he has
not tolerated numerous attempts to pass a nasogastric
feeding tube and the speech and language therapist has
suggested that a percutaneous endoscopic gastrostomy
(PEG) feeding tube would enable him to receive nutrition.
Unfortunately, he is unable to participate in such a discus-
sion because he has been too cognitively impaired for the
last year. You fear that he will ultimately starve without a
tube and will not receive his usual medications, and wish
to discuss the issues with the doctor.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself, confirm her identity and say that you
would like to respond to her concerns about feeding and
discuss possible ways to tackle this.
2.  Explain the current situation as you see it
Explain that, despite some improvement, the position
remains very serious. Explain the reasons for considering
a PEG tube, in this case delivery of medications and
administration of feeding.
3.  Explain the main issues relating to  
PEG tubes
Discuss the issues relevant to PEG tube insertion in more
detail. Explain that it might not be a means of improving
or prolonging life. Explain there is no good evidence that
it would do so where there are problems with memory
and understanding. There would be a small but significant
risk of complications including peritonitis (around 2%)
and an increased risk of aspiration, which in this case is
particularly relevant.
4.  Try to establish the patient’s wishes
Ask if she and her husband have ever discussed what his
wishes might be if such a scenario ever arose.
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5.  Explain alternatives
Explain that the alternative is to administer medications
via alternative routes (phenytoin intravenously, diazepam
rectally), but that not all drugs can be delivered, and for
practical purposes there would be no feeding and so inevi-
tably there would be a starvation factor. Point out that
fluids can be given intravenously or subcutaneously (a
small needle under the skin of the abdomen).
6.  Be alert to cues
Do not simply deliver your spiel without being aware of
any reactions she may have.
7.  Explore her concerns
Understand that it is a heart-rending decision. Ask if she
has any particular feelings about things at this stage.
Explain that a decision does not have to be made now.
Patients’ and relatives’ expectations from PEG tube feeding
are often improved nutrition, prevention of aspiration,
extension of life, improvement of pressure sores, comfort,
strength and help in overcoming an acute illness. The
evidence is that rarely do patients achieve these expecta-
tions; in 70% there may be no improvement and there is
no prevention of aspiration; in the frail elderly there is a
30-day mortality of 22% and a 1-year mortality of 50%.
8.  Respond to questions
She might ask for your advice. You might say that putting
everything together, without seeing a clear way forward to
long-term improvement, it may not be in his best interests
to ‘go there’. If that is what she decides then assure her that
there is no evidence that he would suffer from things like
hunger pains, not at this stage.
9.  Confirm understanding and agree a way
forward
Make sure that she has enough information and either
agree a way forward or allow her more time to think things
over.
10.  Reassure that decisions are not irreversible
Make it clear that no decision that she or the medical team
makes is irreversible and of course if the situation were to
change then any decision could be reviewed.
Discussion
A 68-year-old man has a left total anterior
circulation stroke with right hemiparesis
and dysphagia. His swallow is deemed
unsafe by the speech and language therapy
(SLT) team. His family want to know if you
will be feeding him to keep his strength up.
When is enteral feeding recommended and
what methods are there?
Enteral feeding in adult hospital patients is indicated if
feeding is likely to be delayed more than 5–7 days. Earlier
698
instigation is favoured in malnourished patients. Methods
for enteral feeding are nasogastric tube (NGT) feeding,
PEG or less commonly percutaneous endoscopic jejunos-
tomy feeding.
At day 2 the SLT team feel his swallow
is still unsafe and NGT feeding is
suggested. What are the complications of
NGT insertion?
These include discomfort, epistaxis, oesophageal stenosis,
aspiration and complications from enteral feeds.
At day 10 the SLT team feel his swallow has
shown little sign of improvement. A
gastrostomy tube is recommended. What do
you know about gastrostomy feeding?
A gastrostomy tube is considered when nutritional 
intake is likely to be impaired for more than a few weeks
or when a NGT is not tolerated or is contraindicated. PEG
feeding is an effective way of providing enteral feeding 
to patients who have functionally normal gastrointestinal
tracts but who cannot meet their nutritional needs 
because of inadequate oral intake. The procedure places a
feeding tube directly into the stomach via a small incision
through the abdominal wall and utilises a powerful light
source from an endoscope and insufflation of air to allow
positioning.
What are the benefits
of gastrostomy feeding?
Malnutrition determines disease outcomes because it
affects every system in the body, leading to both physical
and psychological disability. PEG feeding aims to improve
nutritional status and reduces mortality, length of hospital
stay and complications in carefully selected patients who
are likely to be or later become nutritionally depleted for
longer than 4–6 weeks. Studies have shown clear benefits
of PEG feeding after stroke (in terms of improving nutri-
tional status and reducing mortality) and in patients with
oropharyngeal cancer (in terms of improving nutritional
status). When compared with other methods of enteral
nutrition, such as NGT feeding, gastrostomy feeding
caused less discomfort and had lower rates of complica-
tions such as bleeding, blockage and dislodgment of the
tube, and possibly lower rates of reflux and aspiration
although these may still occur.
Which patients may be considered for
gastrostomy feeding?
Although studies have shown benefits for PEG feeding in
stroke and oropharyngeal cancer, the appropriateness of
gastrostomy insertion in other patient subgroups is contro-
versial. Other conditions for which patients are commonly
referred for PEG tube insertion include motor neurone
disease, multiple sclerosis, Parkinson’s disease, dementia,
head injury, intensive care patients, oropharyngeal cancer
 Case 4.34  Percutaneous endoscopic gastrostomy feeding
and oesophageal cancer. The National Confidential Enquiry
into Patient Outcome and Death (NCEPOD) undertook
the largest study in the UK of mortality after PEG insertion
and found a 6% mortality in a cohort of 16 648 patients. Of
those who died, 43% died within 1 week of PEG insertion,
and in 19% of patients PEG insertion was thought to have
been futile. Each patient must be considered according to
his or her individual needs.
What are the contraindications
to gastrostomy?
Active coagulopathies and thrombocytopenia must be cor-
rected. Anything that precludes endoscopy, such as haemo-
dynamic compromise, sepsis or a perforated viscus, is an
absolute contraindication.
What are the complications
of gastrostomy feeding?
These may be immediate, early or late:
• Immediate (< 72 hours) – endoscopy related,
haemorrhage or perforation, aspiration, oversedation
• Early – ileus, pneumoperitoneum, wound infection,
wound bleeding, trauma
• Delayed – gastric outlet obstruction, buried bumper
syndrome, dislodged tube, peritonitis, peristomal
leakage or infection, skin or gastric ulceration,
blocked tube, tube degradation, gastric fistula after
removal of tube, granulation around site of insertion.
Overly granulated stoma sites are common. Treating the
cause, such as gastric leakage, infection or poor position,
may be more appropriate than the non-evidence-based
measures to treat. Blockage is usually secondary to drugs or
feed. It can sometimes be removed by massaging the tube,
or a push–pull method using a syringe on the end, or
enzyme preparations or fizzy drinks may be delivered into
the tube. Inadvertent removal occasionally occurs, and
delay in recognising may result in stoma closure; a urinary
catheter may be used as a holding measure to prevent
closure. Feed-related peritonitis is possible after reinsertion
of a gastrostomy tube. When uncertainty exists about the
position of a replacement tube, water-soluble contrast can
determine position before feeding is re-started. The ‘buried
bumper’ syndrome is rare but serious – the internal bumper
migrates from the gastric wall towards the skin, anywhere
along the PEG tract, as a consequence of excessive tension
between the internal and external bumper. Symptoms may
include pain on feeding, retrograde leakage of feed onto
skin, and rarely gastric perforation.
What is the role of gastrostomy feeding
in dementia?
There is insufficient evidence to support PEG feeding in
dementia and other neurodegenerative diseases. Patients
with advanced dementia develop feeding problems from
lack of motivation and sometimes impaired swallow.
Whether or not to use percutaneous gastrostomies to feed
patients with dementia is an emotive and controversial
question, compounded by the fact that patients often lack
capacity. A Cochrane review showed no evidence of
increased survival, reduced pressure ulcers or improved
quality of life, nutritional status, function, behaviour or
psychiatric symptoms of dementia in patients with
advanced dementia fed with gastrostomy tubes. No large
prospective studies have examined outcomes of PEG
feeding in patients with dementia. A retrospective study of
361 patients found that patients with dementia who had
a PEG inserted had higher mortality than other patient
subgroups (54% 30-day mortality and 90% at 1 year).
These findings have been reproduced by other investiga-
tors, who found that eating problems occurred in 85.8%
of patients with dementia before death, which suggests
that difficulties with feeding are an end-stage problem.
Guidelines on dementia highlight the importance of
quality of life in advanced dementia and support the role
of palliative care in these patients from diagnosis until
death. Best practice in these patients could be to encourage
eating and drinking by mouth for as long as tolerated, to
use good feeding techniques, to alter the consistencies of
food, and to promote good mouth care. When disease
progression is such that the patient no longer wants to eat
or drink, then rather than inserting a gastrostomy tube
end-of-life care pathways might be considered.
What is re-feeding syndrome?
Re-feeding syndrome refers to potentially fatal shifts in
fluids and electrolytes that may occur in malnourished
patients receiving rapid enteral or parenteral nutrition.
The syndrome is due to metabolic and hormonal changes.
The hallmark is hypophosphataemia, but the syndrome is
complex and may include hypokalaemia, hypomagnesae-
mia, thiamine deficiency and changes in sodium and fluid
balance, changes in calcium, and changes in glucose, fat
and protein metabolism.
Normal glucose metabolism
Glycolysis normally converts glucose to pyruvate via a
series of oxidation reactions and enzymes including pyru-
vate kinase to produce ATP / energy (Fig. 4.1). Excess
glucose is converted to glycogen for storage via glycogen-
esis. During strenuous exercise glycogenolysis and glycoly-
sis produce more energy, but if the rate of these processes
exceeds oxygen delivery then anaerobic glycolytic path-
ways are used, which generate lactate.
Starvation
In early starvation the body switches from carbohydrate to
protein and fat metabolism. The glucose needed to
produce energy from glycolysis is generated from two
mechanisms; both of these gluconeogenesis mechanisms
occur chiefly in the liver (Fig. 4.1):
• Lipolysis, which converts triglycerides in adipose
tissue to fatty acids and glycerol, the latter
convertible to glucose
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 Station |4| Communication skills and ethics

ATP/energy

Pyruvate

Glycolysis
Normal energy production Glucose

Excess glucose stored

Glycogenesis as glycogen

Utilises carbon
from AAs
Early starvation Protein (muscle) Amino acids (AAs) Glucose

Urea via Oxidation via Gluconeogenesis

urea cycle TCA cycle in liver

Glycerol

Triglycerides Acetyl CoA

Acetone
(adipose tissue) HMG-CoA
Ketotic in liver
pathway
Fatty acids Ketone bodies Acteoacetate

β-hydroxybutyrate

Prolonged Diabetic
starvation ketoacidosic
Ketotic pathway used Ketotic pathway used early because,
after gluconeogenesis despite hyperglycaemia, glucose
pathways exhausted cannot be incorporated intracellularly
because of insulin deficiency

Figure 4.1  Glucose metabolism, starvation and diabetic ketoacidosis. ATP, adenosine triphosphate; CoA, coenzyme A; HMG, 3-hydroxy-3-
methylglutaryl; TCA, tricarboxylic acid cycle..

• Protein catabolism, in which protein, largely from
muscle, is degraded to amino acids and the carbon
from amino acids is subsequently used in glucose
synthesis; starvation is a highly catabolic state, and
urea is produced reflecting this.
In prolonged starvation, metabolic and hormonal
changes aim to prevent muscle and protein breakdown,
and the liver reduces its rate of gluconeogenesis to preserve
muscle. Now, the ketotic pathway (Fig. 4.1) in which fatty
acids are used to produce ketone bodies, an alternative
source of fuel for most cells, is prominent. The brain,
generally unhappy to use ketones for energy, may be
forced to do so in more desperate starvation states. During
prolonged starvation, some electrolytes such as phosphate
are severely depleted, although serum levels may remain
normal since these electrolytes are mainly in the intracel-
lular compartment, which contracts in starvation, and
renal excretion is reduced.
Diabetic ketoacidosis (DKA) similarities  
to starvation
The ketotic pathway in DKA is the same as that used in
starvation (Fig. 4.1), but it occurs earlier and is more
severe. In starvation insulin levels fall in response to the
lack of food and glucose. In DKA insulin levels are low
owing to insufficient production leading to hyperglycae-
mia; however, intracellular glucose levels are very low
because without insulin glucose cannot be taken up by
cells, and alternatives to glycolysis for energy production
must be sought immediately.

700

Re-feeding
Glycaemia in re-feeding increases insulin and decreases
glucagon secretion, stimulating glycogen, fat and protein
synthesis, a process requiring phosphate, magnesium and
thiamine, and driving potassium and glucose into cells
through an ATPase sodium–potassium pump; phosphate
and magnesium are also taken up into cells. The clinical
manifestations of re-feeding syndrome result from these
depleted electrolytes and the sudden increase in metabolic
rate.
Clinical manifestations of re-feeding syndrome
These are outlined in Table 4.6.
How may re-feeding syndrome be
prevented and managed?
An individualised re-feeding regimen should be  Scenario
determined by a dietitian to prevent re-feeding syndrome
(Box 4.30).
Where phosphate is moderately (0.3–0.6 mmol / l) or
severely (< 0.3 mmol / l) depleted, an intravenous infusion
of 9 mmol or 18 mmol, respectively, should be delivered
Table 4.6  Clinical manifestations of re-feeding syndrome
Deficiency Clinical manifestations
Phosphate Widespread cellular dysfunction of most
physiological processes
Potassium Cardiac arrhythmias
Magnesium Cardiac and neuromuscular instability
Thiamine Wernicke’s encephalopathy (ocular abnormalities,
ataxia, confusion, hypothermia, coma)
Korsakoff’s syndrome
Sodium and Fluid overload (rapid introduction of glucose
water after starvation reduces urine output)
Box 4.30  Prevention of re-feeding sydrome
• Check potassium, calcium, phosphate and magnesium
• Prior to feeding administer thiamine 200–300 mg daily orally,
one or two high-potency vitamin B tablets thrice daily (or
intravenous vitamin B), and multivitamin or trace element
supplements daily
• Start feeding slowly (no more than 50% of energy
requirements to start with, 0.0418 MJ/kg / day, slowly
increasing over 4–7 days)
• Ensure adequate hydration
• Supplement and / or correct any levels of potassium
(2–4 mmol / kg / day), phosphate (0.3–0.6 mmol / kg / day),
calcium and magnesium (0.2 mmol / kg / day intravenously or
0.4 mmol / kg / day orally) and monitor and amend treatment
for these electrolytes for 2 weeks
Case 4.35  Vegetative state
over 12 hours. Where magnesium is moderately depleted
(0.5–0.7 mmol / l), intravenous replacement should be
0.5 mmol / kg / day over 24 hours then 0.25 mmol / kg / day
for 5 days; where magnesium is severely deplete
(< 0.5 mmol / l), intravenous replacement should be
24 mmol over 6 hours then as for moderately depleted.
CASE 4.35  VEGETATIVE STATE
Candidate information
Role
You are a doctor on the medical ward.
Please read this summary.
Re: Mr Roger Hunt, aged 19 years
Mr Hunt is a 19-year-old patient with type 1 diabetes who
sustained severe cortical brain damage from an episode of
prolonged hypoglycaemia while out drinking with friends at New
Year. He breathes spontaneously but has been on your ward for 4
months and not shown any signs of interacting with his
environment. He receives percutaneous gastrostomy feeding. He
has had two episodes of aspiration pneumonia. His father is
convinced he will get better one day, but is concerned that the
doctors will label his son as being in a persistent vegetative state
and seeks your reassurance that you will not stop actively treating
future infections or providing artificial hydration and nutrition.
Your task is to address his father’s concerns.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
Your son, Roger Hunt, is 19 years old and has type 1 dia-
betes. Four months ago he sustained severe brain damage
from an episode of prolonged hypoglycaemia while out
drinking with friends. He breathes spontaneously but,
according to the doctors, has not shown any signs of inter-
acting with his environment. However, you are certain that
he occasionally smiles and even seems to shed tears in
your and your wife’s company. He receives percutaneous
gastrostomy feeding. He has had two episodes of pneumo-
nia. You are convinced he will get better one day, but are
very concerned that the doctors will label him as being in
a persistent vegetative state. You want reassurance that the
doctors will not stop actively treating future infections or
providing artificial hydration and nutrition.
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 Station |4| Communication skills and ethics
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself and establish that he is Mr Hunt’s
father.
2.  Establish what the relative knows
Firstly, establish what he knows about his son’s condition,
so that you have a basis for addressing his concerns.
3.  Elicit ideas, concerns and expectations
Explore his ideas, concerns and expectations, actively
listening.
4.  Address ideas, concerns and expectations
Start with an immediate reassurance that there are no
plans to withdraw care for his son. Note his remark about
a persistent vegetative state. Explain that at this stage in his
son’s illness there would be every attempt to vigorously
treat any infection, manage his diabetes carefully and of
course provide full hydration and nutrition in conjunction
with appropriate colleagues. Explain that certain move-
ments and facial gestures are not uncommon in this situ-
ation, and that while you do not have the expertise to be
sure that they are not signs of awareness, your understand-
ing is that they could very well be involuntary reflex move-
ments. The point is that you do not want to unequivocally
remove hope and yet you want to truthfully reinforce what
seems likely.
5.  Be alert to cues
Throughout your explanation, be alert and ready to
address any cues suggesting concern or disagreement.
Above all, be empathetic and at no point challenge his
desire to see his son get better, even though you may be
less certain of its likelihood.
6.  Elaborate on the meaning of the term
persistent vegetative state
Offer to explain more about a persistent vegetative state.
In particular explain that a diagnosis cannot be made this
early on in the illness and can only be made later by
certain specialists.
7.  Be honest about the prognosis as it   2. Complete lack of awareness of the self or the environment
appears now
At the same time, do not reinforce what you feel to be
excessive hope. Explain that you and the medical and
nursing team would have hoped that more definite signs
of improvement would have started to develop by now,
and that as time goes on the prospects of the recovery that
you would all wish for become less easy to envisage.
702
8.  Concede uncertainty
Despite this, concede that at this stage there are no certain-
ties; that alone is often a heart-rending thing to wrestle
with.
9.  Invite questions
Make sure there are no areas that have not been discussed
and express that you are willing to address any issues at
any time with him.
10.  Conclude with assurances
Reiterate that at this stage a diagnosis of persistent vegeta-
tive state has not and cannot be made, and that you will
continue to actively treat his son’s condition and any
complications.
Discussion
What is the vegetative state?
The vegetative state is a complex neurological condition
in which patients appear awake but show no sign of aware-
ness of themselves or their environment. It may develop
suddenly (as a consequence of traumatic or non-traumatic
brain injury, such as hypoxia, infection or haemorrhage)
or gradually (in the course of a neurodegenerative disor-
der, such as Alzheimer’s disease). It is uncommon, and
appears perplexing because there is apparent dissociation
between the two cardinal elements of consciousness:
awareness and wakefulness. Guidance produced by the
Royal College of Physicians in 2003 defines it as ‘a clinical
condition of unawareness of self and environment in
which the patient breathes spontaneously, has a stable
circulation, and shows cycles of eye closure and opening
which may simulate sleep and waking.’ Thus three main
clinical features define the vegetative state (Box 4.31).
Since the brain damage is cortical and the brainstem is
preserved, awareness and consciousness are lost but breath-
ing and circulation are spontaneous and support in an
intensive care unit is not usually required. Patients may
experience sleep–wake cycles or be in a state of chronic
wakefulness. Wakefulness is determined by nuclei in the
Box 4.31  The three features of the
vegetative state
1. Cycles of eye opening and closing, giving the appearance of
sleep–wake cycles (whether this reflects the circadian rhythms
is unclear)
3. Complete or partial preservation of hypothalamic and brainstem
autonomic functions
Royal College of Physicians guidelines consider a vegetative
state persistent when longer than a month and permanent when
longer than 6 months for non-traumatic brain injuries (3 months in
US guidelines) and 1 year for traumatic brain injuries. Persistent
and permanent vegetative states are often abbreviated to ‘PVS’.
 Case 4.35  Vegetative state

hypothalamus that coordinate the circadian rhythm and is
a prerequisite for consciousness and awareness, but in the
event that higher centres (the cerebral cortex) are severely
damaged or destroyed the wakefulness is without con-
sciousness or awareness. Apparent awareness in this state
of wakefulness, including opening of eyes, movements,
swallowing and even emotional outbursts, are automatic
reflexes. Spontaneous eye opening indicates intact brain-
stem arousal mechanisms but not necessarily awareness.
How does the vegetative state differ
from other disorders of consciousness
such as coma?
Experts suggest that the vegetative state should be seen as
part of a continuous spectrum of disorders of conscious-
ness, in which someone’s wakefulness and / or awareness
are impaired after severe brain injury (Table 4.7).
What is coma?
Coma is a condition of unresponsiveness in which patients
lie with eyes closed, do not respond to attempts to arouse,
and show no evidence of awareness of self or surround-
ings. Patients lack not only signs of awareness (similar to
vegetative state) but also wakefulness (unlike vegetative
state) regardless of how intensely they are stimulated.
Patients typically either recover or progress to a vegetative
state (that is, they show signs of wakefulness) within 
4 weeks.
How is coma measured?
The depth of coma is measured by the Glasgow Coma
Score (Table 4.8).
What is the minimally conscious state?
The minimally conscious state is a condition in which
patients appear not only to be wakeful (like the vegetative
state) but also to exhibit inconsistent (fluctuating) but
reproducible signs of awareness (unlike the vegetative
state). It may be a transient state and precede recovery of
communicative function or it may last indefinitely.
What is locked-in syndrome?
Locked-in syndrome (or pseudocoma), although not a
disorder of consciousness, may be confused with vegeta-
tive state. Patients are both awake and aware, yet entirely
unable to produce any motor output or they have an
extremely limited repertoire of behaviours (usually vertical
eye movement or blinking). Numerous anatomical and
aetiological types are possible, but a classic locked-in syn-
drome occurs with basilar territory infarction sparing res-
piratory drive centres but damaging long tracts and cranial
nerve nuclei in the brainstem bilaterally. The cortex is

Table 4.7  Spectrum of disorders of consciousness

Condition Definition Main clinical characteristics Consciousness Purposeful

motor
behaviour

Awareness Sleep–wake
cycles
Coma Unarousable state Absence of eye opening (even with intense No No No
of unresponsiveness stimulation)
No evidence of awareness of self or environment
Condition protracted for more than 1 hour
Vegetative Wakefulness Presence of eye opening and closing No Yes No
state accompanied by the Absence of any reproducible purposeful behaviour
absence of any sign including: (a) response to sensory stimulation; (b)
of awareness awareness of self or environment; (c) language
comprehension or expression
Minimally Reproducible signs Presence of eye opening and closing Partial, Yes Inconsistent
conscious of awareness Presence of inconsistent but reproducible purposeful fluctuating
state behaviour including (any of): (a) non-reflexive response
to sensory stimulation; (b) awareness of the self or the
environment; (c) language comprehension or
expression
Lack of functional communication or object use
Locked-in Impairment in the Presence of eye-coded communication (limited to eye Yes Yes Yes
syndrome production of movements, depending on lesion)
voluntary motor Preserved awareness
behaviour Complete or partial inability to produce motor
behaviour

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 Station |4| Communication skills and ethics

(b) sustained, reproducible, purposeful, or voluntary

Table 4.8  Glasgow Coma Score
response to visual, olfactory, auditory, tactile or noxious
Eye opening stimuli; and (c) comprehension of language or expression.
• Spontaneously 4
If evidence of these exists, the patient is considered to be
(minimally) aware. Examinations should be conducted at
• To speech 3 different times of the day because patients who are mini-
• To pain 2 mally conscious as opposed to vegetative may have alter-
nating periods of awareness and unawareness as well as
• No response 1 circadian oscillations in levels of wakefulness.
Best verbal response
• Orientated 5
Why do we provide life-sustaining
treatments to patients in a
• Disorientated 4
vegetative state?
• Inappropriate words 3
There are well-documented cases of recovery from a veg-
• Incomprehensible sounds 2 etative state, which is why it has been referred to as a
• No response 1 persistent rather than permanent vegetative state. This
said, it usually is permanent because of the nature of the
Best motor response underlying damage. Important considerations in the
• Obeys verbal commands 6 future care of a patient in a vegetative state are summarised
in Box 4.32.
• Localises painful stimuli 5
• Withdrawal to pain 4 Does misdiagnosis of the vegetative
• Flexion to pain (decorticate posturing) 3 state occur?
• Extension to pain (decerebrate posturing) 2 Current clinical methods of diagnosis are limited, evi-
• No response 1
denced by a high rate (about 40%) of misdiagnosis (that
is, patients who are aware are considered to be uncon-
scious). The main causes of misdiagnosis are associated
with a patient’s disability (such as blindness), confusion
unimpaired but cannot deliver any of its actions. Patients in terminology, and lack of experience of a relatively rare
can breathe and think normally but can perform few if any condition. Furthermore, standard behavioural assess-
actions. ments cannot distinguish an aware (minimally conscious)
but completely immobile patient from a non-aware
Why are coma and the vegetative state not patient (vegetative state).
the same as brain death?
In brain death there is loss of brainstem activity. Brainstem Is there a place for brain imaging as a
reflexes are absent and spontaneous breathing and circula- diagnostic tool?
tion cannot occur and can only be maintained artificially. In such behaviourally non-responsive patients, functional
Only irreversible coma with absent brainstem reflexes neuroimaging methods (such as magnetic resonance
indicates brain death. imaging or electroencephalography) can detect residual
cognition and awareness and can even establish two-way
What affects prognosis in patients with a communication, without requiring any behavioural
vegetative state? output from patients. The Multi-Society Task Force on 
Three major factors affect the prognosis: time spent in the PVS suggests, however, that such tests, although recognised
vegetative state, age and type of brain injury; traumatic as providing useful information when used in conjunction
brain injuries are associated with better outcomes at 1 year
than non-traumatic injuries.

How is the vegetative state diagnosed?
No tool exists for quantifying the extent of consciousness.
Differentiating between awareness and non-awareness
ultimately relies on a principle that someone is conscious
if they can indicate so. The diagnosis of the vegetative state
is based on a detailed history and careful (but subjective)
observation of the patient’s spontaneous and elicited
behaviour. Clinical assessments involve repeated examina-
tions for evidence of: (a) awareness of self or environment;
Box 4.32  Considerations in the future care of a
patient in a persistent vegetative state
• Establishing the diagnosis
• Deciding on its permanence
• The presence of any valid advance decision
• Deciding whether or not to withdraw life-prolonging
treatments, which even in the presence of an advance decision
often has to be decided in the Courts

704

with clinical evaluation, are believed to be unable,  How to approach the case
alone, to either confirm the diagnosis of vegetative state
or predict the potential for recovery of awareness. Current
guidelines should be modified to embrace functional
neuroimaging.
CASE 4.36  BRAINSTEM DEATH
Candidate information
Role
You are a doctor on the medical ward.
Please read this summary.
Scenario
Re: Mrs Anne Daly, aged 58 years
Mrs Daly is a previously well 58-year-old woman admitted to
hospital 2 days ago with collapse. She was intubated on arrival to
hospital but subsequent brain imaging confirms that she has had a
spontaneous subarachnoid haemorrhage. She has not received
sedation since initial ventilation and shows no signs of recovery.
Two consultants have confirmed brainstem death. She was
previously well, and normotensive. Her daughter, Mrs Watts,
is in the waiting room, aware that brainstem testing is being
carried out although not completely aware of the implications
of this.
Your task is to discuss the results with her daughter.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
You are the daughter of Mrs Daly, a previously active
58-year-old woman. She was admitted to hospital 2 days
ago following a fall whilst walking her dogs on the moor.
She sustained a significant head injury. She was artifi-
cially ventilated on arrival to hospital and subsequent 
brain scans showed that she had sustained a large sub-
arachnoid haemorrhage. She has subsequently shown no
signs of recovery. She was previously well, and normoten-
sive. You are aware that brainstem testing is being carried
out, and although not completely aware of the implica-
tions of this sense that the news will be bad and that your
mother is not going to recover. You are surprised that she
is so desperately unwell, however, because her heart
appears good on the monitor and she looks well but
asleep. She carried a donor card, and you will tell the
doctor this.
Case 4.36  Brainstem death
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself and establish that she is Mrs Daly’s
daughter.
2.  Establish what the relative knows
Ask her what she knows about her mother’s condition.
3.  Explain the situation
Explain that there have been no signs of recovery of con-
sciousness and that this has been the major concern.
4.  Explain brainstem death
Explain sensitively and empathetically that, as a result of
the injury, she has sustained irreversible brain damage and
this has just been confirmed by the specialists. Explain that
she will not wake up and that this means that she has died
as a result of her injuries. Point out the ventilator is sus-
taining her breathing and that when turned off her heart
would stop soon afterwards.
5.  Acknowledge distress and allow ventilation  
of feelings
Wait for her response before giving any more details.
6.  Explain what will happen now
Explain that the medical team has to make the decision to
turn off the ventilator, that it will not cause her mother
any distress, and that she need not feel any responsibility
for this decision.
7.  Discuss organ donation
Thank her for being able to mention this at this time.
Assure her that as it is her mother’s wish you will arrange
for the transplant team to assess her mother for suitability,
and until such time as any organ retrieval were to take
place ventilation would be continued.
8.  Identify support networks
It is human to want to discover a little more about the
practical implications to her such as what other family
members may be nearby and need to know, and even a
little about the dogs.
9.  Invite questions
Ask if she has any immediate questions.
10.  Ensure that the relative has a point of contact
Ideally there would also be a nurse present to attend to
her now but be prepared to meet her again later in the day
or week if she has further questions.
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 Station |4| Communication skills and ethics
Discussion
How might brainstem function
be assessed?
Assessing brainstem function is vital to managing coma,
raised intracranial pressure, brainstem strokes and con-
firming brain death.
Pupils assess midbrain integrity. Pupil size and reactivity
assess third nerve function through the superior colliculus
and connections to the Edinger–Westphal nucleus (mid-
brain) and efferent parasympathetic outflow.
The corneal reflex assesses the fifth and seventh nerves,
connected in the pons.
Resting eye position might suggest asymmetric brain-
stem dysfunction, dysconjugate position a disorder of the
third, fourth or sixth nerves or their nuclei (third and
fourth in midbrain and sixth in pons). Spontaneous sac-
cadic (fast) horizontal and vertical eye movements suggest
that the brainstem mechanism for generating this is intact
and there is no need to test for oculocephalic or oculoves-
tibular responses. Horizontal saccades rely on an intact
paramedian pontine reticular formation (pons), third
nerve nucleus, sixth nerve nucleus and median longitudi-
nal fasciculus connecting these. Vertical saccades rely on
the dorsal midbrain.
Swallowing requires intact glossopharyngeal and vagus
nerves and connections including the swallowing centre
in the reticular formation of the medulla.
Respiratory pattern is sometimes useful in localisation.
Apneustic breathing (prolonged inspiration followed by a
period of apnoea) and cluster breathing (closely grouped
respirations followed by a period of apnoea) imply
pontine damage. Ataxic breathing (chaotic) and gasping
breathing (gasps followed by variable apnoea) occur when
the medullary respiratory centre is damaged and are pre-
cursors to respiratory arrest. Cheynes–Stokes breathing
(often used to describe a range of brainstem damage  may fall and blood pressure rise (Cushing response), breathing is
patterns of breathing) can be due to cortical damage, but
is mostly due to cardiovascular or respiratory disease.
Slow, shallow breathing may occur when drugs depress
medullary function. Central neurogenic hyperventilation
(rapid, deep continuous breathing at a rate of around  medial edge of the uncus and hippocampal gyrus over the free
25 cycles / min) is not localising but suggests deepening
coma and worsening prognosis.
Long-tract signs can occur and may be crossed with
cranial signs because of decussation.
What are oculocephalic and
oculovestibular responses?
Passive head rotation stimulates vestibular and neck recep-
tors which in comatose patients with intact brainstems
leads to reflexive slow conjugate eye movements mediated
by the vestibulo-ocular reflex (VOR) pathway in the brain-
stem in the direction opposite to head rotation. Ice water
irrigation of the ear switches off this pathway, leading to
the unopposed contribution of the contralateral vestibular
system, and the eyes deviate towards the ice. Both the
oculocephalic (doll’s head manoeuvre) response and 
706
the oculovestibular (caloric) response test the VOR, but
the latter is more sensitive.
Major brainstem pathology is unlikely with normal
VORs. An absent horizontal VOR with an intact vertical
VOR may indicate pontine damage. If both are absent
there may be wider brainstem pathology or a metabolic
disturbance, the latter more likely if pupils react. A very
small number of drugs depress brainstem function. VOR
testing may be difficult if there are dysconjugate eye move-
ments (when brainstem dysfunction is likely) or if there
are fast saccades (when brainstem dysfunction is unlikely).
Which brainstem syndromes arise from
brain shift?
There are four important syndromes (Box 4.33).
Box 4.33  Brainstem syndromes arising from
brain shift
Central herniation
A supratentorial mass displaces the diencephalons (cerebral
peduncles, thalamic areas, thalamus and related structures between
the cerebral hemispheres and upper brainstem) through the
tentorium to compress the upper midbrain, then the pons, then the
medulla. Signs such as unilateral hemiplegia, together with
paratonia (gegenhalten) and extensor plantars (diencephalic stage),
precede diminished alertness and Cheynes–Stokes breathing. The
pupils are small, perhaps because of hypothalamic sympathetic
dysfunction, but reactive. There is decorticate (flexor) posturing to
pain. Progression from midbrain to upper pontine dysfunction
causes temperature fluctuation, unreactive pupils in mid-position,
loss of vertical eye movements (doll’s head manoeuvre),
diminishing vestibulo-ocular reflexes (VORs) and apneustic or
cluster breathing or central hyperventilation. Decerebrate posturing
to pain develops. Progression to lower pontine and upper
medullary damage causes chaotic breathing and absent VORs. Tone
is flaccid. Progression to medullary damage is terminal. Heart rate
chaotic or gasping, and pupils become dilated and fixed.
Lateral (uncal) herniation
Lesions in the lateral middle fossa or temporal lobe push the
lateral edge of the tentorium. The first sign is a unilateral dilating
pupil as the third nerve is compressed, followed by a third-nerve
palsy. Midbrain compression with diminished alertness and coma
and the sequence as for central herniation can follow, without an
initial diencephalic stage and decorticate responses.
False localisation
Expanding supratentorial lesions may distort structures and
produce signs due to traction from afar, often affecting cranial
nerves V to VIIII.
Tonsillar herniation
Subtentorial lesions may cause herniation of the cerebellar tonsils
through the foramen magnum to compress the pons and midbrain
directly. There may also be upward compression, giving rise to
supratentorial effects, but the rostrocaudal sequence of damage
typical of central herniation is lacking.

Table 4.9  Brain death criteria
Preconditions Irreversible brain damage, e.g. head injury, brain
haemorrhage, anoxia
Apnoeic coma
Absence of reversible factors such as drugs or
metabolic or temperature disturbance
All brainstem Pupils fixed and unresponsive to bright light (not
reflexes necessarily dilated)
absent Absent corneal reflexes
Absent vestibulo-ocular reflexes
No motor responses within the cranial nerve
distribution to stimulation of any somatic area
No reflex response to touching the pharynx (gag
reflex) or a suction catheter in the trachea
(cough reflex)
Apnoea No respiratory movements without the ventilator
How is brain death determined?
There is irreversible loss of capacity for consciousness and
capacity to breathe. Both of these are lost without the
stem. Because it is possible to maintain circulation and
ventilation with ventilators in patients with irreversible
brain damage without brainstem function, criteria for
brain death were developed (Table 4.9). Testing should be
by two experienced clinicians, at least one a consultant.
Is there a legal definition of death?
There is no legal definition of death. Death is usually
defined by irreversible loss of capacity for consciousness
together with irreversible loss of capacity to breathe due
to cessation of brainstem function. Brainstem death there-
fore equates to death of an individual.
CASE 4.37  DISCUSSING LIVE
ORGAN DONATION
Candidate information
Role
You are a doctor in the renal clinic.
Please read this summary.
Scenario
Re: Mr Stephen Wells, aged 45 years
Mr Wells, a solicitor, has chronic kidney disease due to diabetes
mellitus on a background of poor renal reserve caused by damage
from sepsis as a child. He currently receives haemodialysis. He is on
the transplant list. His sister is with him today because they have
both discussed the idea of live organ transplantation, having read
of its success. Her concerns are the risks to her and her brother.
Your task is to discuss live organ transplantation.
Case 4.37  Discussing live organ donation
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
You are the sister of Stephen Wells, a 45-year-old solicitor
who has chronic kidney disease from diabetes mellitus
and kidney damage as a child. He currently receives
haemodialysis. He is on the transplant list. You are with
him today because you have both discussed the idea of
live organ transplantation, having read of its success. Your
concerns are the risks to yourself and your brother, but you
would prefer your brother to have your kidney than one
from an unknown source, and feel his body would not
reject an organ from a relative.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself. Both potential recipient and donor
should be present (in PACES only one subject but the
principles are the same).
2.  Establish background knowledge
Find out what they know about organ donation.
3.  Explore ideas, concerns and expectations
Explore their understanding of the advantages of live
organ donation. Explain that there are very clear advan-
tages but that the complications of transplantation,
including rejection, remain a risk.
4.  Explain the principles of live organ donation
Explain briefly there would be a dual hospital stay for the
operation but that the surgical procedure is not your area of
expertise and you would arrange a meeting with the trans-
plant surgeon were they to decide to go down this route.
5.  Respond to ideas, concerns and expectations
Explain that matching is a potential problem but that it
needs not be perfect nor, indeed, need it be a relative. Her
being a sibling does not remove the possibility of rejection
and he will still need to take immunosuppression with its
attendant risks.
6.  Explain potential benefits to recipient  
and donor
Explain that outcome is better with donation from a live
than a deceased person. While on the waiting list there is
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 Station |4| Communication skills and ethics
no guarantee of when a suitable organ will be available
and his health might deteriorate in the meantime; live
organ donation would remove this problem. There may
be significant psychological satisfaction in donating to a
relative.
7.  Explain potential risks to recipient and donor
Risks to the donor include operative and perioperative
risks (major surgery requiring around a week in hospital
and some weeks off work), and having a single kidney
(although compatible with a normal life). Risks to the
recipient are immediate surgical complications and
rejection.
8.  Other matters
There may be insurance issues for the donor.
9.  Invite questions
I appreciate we’ve covered rather a lot there. Is there anything
you would like me to go over again or are there any
questions you would like to ask me?
Be honest in your explanations and prepared to admit
uncertainty (with assurance you will seek the answer) if
there are questions you cannot answer.
10.  Explain what would happen next
Explain that, if they decide to take things further,  donation?
formal assessment by the transplant team would be
needed.
Discussion
How is organ transplantation governed
in the UK?
Following the retained organs controversy (Case 4.38), the
Human Tissue Act in 2004 introduced new legislation and
regulation for all human material, whether from living or
deceased people. It applies to England, Wales and North-
ern Ireland and the Scottish Assembly passed similar leg-
islation in 2006. The Human Tissue Authority (HTA) is
the body that ensures that human tissue is used safely and
ethically, and with proper consent. The HTA regulates the
removal, storage, use and disposal of human bodies,
organs and tissues for purposes such as research, trans-
plantation, and education and training, and gives approval
for organ and bone marrow donations from living people.
It was created by the Human Tissue Act 2004, which
replaced the Human Tissue Act 1961, the Anatomy Act
1984 and the Human Organ Transplants Act 1989. The
Unrelated Transplant Regulatory Authority (ULTRA) and
the post of HM Inspector of Anatomy were abolished and
their functions transferred to the HTA.
Is there a shortage of organ donors?
There is a worldwide shortage of cadaveric donor organs,
and a living related donor is more likely to provide the
best histocompatibility but more likely to feel pressure to
708
donate. Shortage of organs is doubtless in part the result
of the understandable reluctance of staff to approach rela-
tives for consent after a patient dies.
How might the supply of organ donors
be increased?
The situation could be improved by educating the public
to leave evidence of their wishes, reducing the need to
broach the subject with grieving relatives. The default posi-
tion of a population opting in to donate is mooted by
governments.
Does the Human Tissue Act improve the
number of organ donors?
Currently, even if the deceased carries a donor card, a rela-
tive’s objections can prevent transplantation. The Act
ensures that the patient’s recorded wishes, or the decision
of a representative nominated by the patient, must be fol-
lowed. Failing this, consent from a person in a ‘qualifying
relationship’ is necessary (there is a hierarchical list). The
Act unambiguously outlaws all commerce in human
bodies and body parts.
Can dying patients who are potential
donors be ‘kept alive’ in intensive care
while consent is being sought for organ
Donor ventilatory and circulatory support is essential
before heart transplantation and desirable for other organs.
Transplantation procedures can only occur when brain-
stem death has been determined, and this should be by a
team separate to that caring for the patient. ‘Elective venti-
lation’, the concept of sustaining the life of a dying patient
for the sole purpose of transplantation, appears to be
illegal, but the Act authorises methods to preserve organs
of deceased individuals while consent is being sought.
Are there advantages of live organ
donation?
Carefully selected living related donors are more immu-
nologically compatible and the chances of graft rejection
are reduced.
What ethical criteria should be met by live
organ donors?
These are listed in Box 4.34.
Is there a place for unrelated live
transplants?
A donation may be obtained from a non-genetically-
related person provided no payment is involved. Histori-
cally, live unrelated donors of kidneys were seldom
considered because there was no greater chance of graft
survival, but modern immunosuppression means that less
well-matched grafts can now survive.

Box 4.34  Criteria for live organ donors
• The risk to the donor must be low
• The donor must give full informed consent
• The consent must be given freely and without coercion or
pressure
• The donor must understand that he or she may withdraw
consent at any time before the procedure
• The offer of the organ must be without any inducements,
including financial
• There must be a good chance of a successful outcome for the
recipient
CASE 4.38  REQUESTING AN
AUTOPSY (POST MORTEM)
Candidate information
Role
You are a doctor on the medical ward.
Please read this summary.
Scenario
Re: Mrs Jane Ayre, aged 76 years
Mrs Ayre was a 76-year-old woman who died yesterday on
your ward. She had been admitted with weight loss, vomiting and
hypotension. She was awaiting further investigation after an
abdominal computed tomography scan showed bilateral adrenal
masses. The concern had been whether she might have adrenal
metastases and secondary hypoadrenalism. Her daughter is here,
and your consultant has asked you to seek permission for an
autopsy to clarify cause of death, but is happy for a death
certificate to be issued if she does not consent.
Your task is to request permission for an autopsy.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
Your mother, Mrs Ayre, died yesterday on the hospital
ward, aged 79. The cause of death was unclear but very
possibly cancer. She had been admitted from home follow-
ing 1 week of vomiting and dizziness. She had been losing
weight for a few months prior to this. She and you had
been told that cancer was a possibility although you had
Case 4.38  Requesting an autopsy (post mortem)
Box 4.35  Common reasons for requesting
an autopsy
• The cause of death was not clear
• Whilst the cause of death may have seemed clear, some
features of the disease remain unusual
• The disease was rare and an autopsy could shed new light on
it
• The information from the autopsy might help the management
of other patients (in some cases family members) who suffer
from the same condition
not expected her to die so suddenly. The doctor is about to
ask your permission for an autopsy. You are not happy for
an autopsy, feeling that if cancer was likely there is no
reason to further explore. You are also worried an autopsy
could delay funeral arrangements and cause disfigurement.
After consideration, you will agree to an autopsy.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself and confirm her identity.
2.  Acknowledge that it is a difficult time
Tell her how sorry you are that her mother has died and
that staff members were saddened by the news. Pause to
allow her to express her emotions. Asking for permission
to carry out an autopsy at a time when relatives may be
distressed is not always easy and not a task that should be
delegated to the most junior member of the team. Before
approaching relatives, it is important to establish if the
patient had made any prior wishes.
3.  Retrace the relevant background
Explain the medical team’s thoughts about what might
have been wrong with the patient and why.
4.  Explain the reasons for requesting an autopsy
Common reasons for requesting an autopsy are listed in
Box 4.35.
Additional benefits include education and training,
research and audit.
5.  Explain the autopsy consent form
Explain that she will need to sign a consent form. This
includes an option for relatives to request a limited
autopsy, with separate sections for permission for organ
retention, permission for education and training and per-
mission for the use of retained tissue in research.
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 Station |4| Communication skills and ethics
6.  Explore concerns
She may have concerns about further examination when
all she wants, and she feels her mother wants, is to be left
in peace.
7.  Be prepared to discuss arrangements  
about the body
Explain that an autopsy will not (usually) delay funeral
arrangements. Relatives sometimes ask if the body can be
viewed after autopsy and might need to be reassured that
in hospital autopsies standard incisions are used that are
not visible when the body is gowned and that the body
can be viewed after autopsy.
8.  Invite questions
I appreciate we’ve covered rather a lot there. Is
there anything you would like me to go over
again or are there any questions you would like to ask me?
9.  Explain what would happen next
Explain that nothing needs to be done by the daughter,  ogy department or returned to the funeral director at the
that the hospital would arrange everything and that  family’s request.
the funeral director would liaise with the hospital  There is concern that hospital autopsies will decline in
directly.
10.  Seek consent or accept refusal
And thank her for discussing this.
Discussion
What changes have occurred in recent
years in the law regarding retention
of human tissue and organs?
The public inquiries at Bristol Royal Infirmary and Alder
Hey Children’s Hospital found organ retention without
the knowledge or consent of relatives to be common prac-
tice. The Chief Medical Officer subsequently arranged a
consensus that revealed 105 000 retained organs, body
parts, stillbirths and fetuses within English hospital trusts
and the Retained Organs Commission was set up to
oversee the return, donation for research or disposal of
retained material according to the wishes of relatives who
enquired, and to advise on future legislation.
The Human Tissue Act makes it a criminal offence to
remove, retain or use tissue or organs without consent and
covers all material containing human cells removed  • Deaths not due, or entirely due, to natural causes, e.g. accidents,
from the living or dead (gametes or embryos are covered
by separate legislation). Thus no research or teaching is
now possible without consent. Use for clinical or  • Deaths involving septicaemia if originating from injury or
public health audit, education or research using ano-
nymised material does not require consent if the material
comes from the living, but will always be needed if from
deceased persons. The Act is not be retrospective, but the
Human Tissue Authority, the regulatory body for the Act,
issues codes of practice for dealing with material already
retained.
710
What is the role of the Human Tissue
Authority?
It is to regulate the removal, storage, use and disposal of
human bodies, organs and tissue from the living and
deceased.
What are the implications for hospital
autopsies?
Most hospital trusts have guidelines for autopsy requests.
Most autopsies in hospital are hospital requested and per-
formed by a hospital pathologist, and for these relatives
must grant permission.
Consent forms usually cover the option for relatives to
request a limited autopsy, and separate sections for per-
mission for organ retention (usually brain or lungs), per-
mission for education and training (often a clause stating
that information may be used for such purposes unless
relatives disagree) and permission for the use of retained
tissue in research.
Disposal of organs retained can either be by the pathol-
number, and training will suffer, although the legislation
acknowledges that people expect clear information and
partnership with the medical profession. Hospital trusts
must therefore produce clear procedures and consent
forms and adequate training in gaining consent from
relatives.
In which circumstances might the
coroner (in Scotland Procurator Fiscal)
wish to perform an autopsy?
While the statutory duty to report a death to the coroner
resides with the registrar of births and deaths, doctors
should be aware of the circumstances in which a registrar
is required to report a death and should report a death
themselves in those circumstances (Box 4.36).
Box 4.36  Deaths that should be reported
to the coroner
• Deaths that are sudden or unexplained
• Deaths where the deceased had not been attended by a
medical practitioner for their last illness and within 14 days
before death
deaths occurring after an operation, occupational disease, lack
of care, self-neglect, suicide and self-harm, violence
medical intervention
• Dead on arrival to hospital
• Deaths in police custody or prison or following admission from
these
• Deaths where the cause is natural but unknown and the doctor
cannot issue a death certificate

Does a coroner’s autopsy need consent?
No. Relatives do not have the right to either grant or refuse
permission for an autopsy requested by the coroner, nor
any organ retention, although the Act will make it neces-
sary for consent to be obtained for retention or use of
material after investigations are concluded.
Clinical governance
CASE 4.39  CRITICAL INCIDENT
Candidate information
Role
You are a doctor on the acute medical unit.
Please read this summary.
Scenario
Re: Mrs Jane Parker, aged 84 years
Mrs Parker was admitted 3 days ago with life-threatening
haematemesis. She had a history of a stroke from which she had
made a partial recovery. You resuscitated her with blood. The
gastroenterologist requested central access for monitoring purposes
while preparations were made for endoscopy. This was a difficult
procedure because her systolic blood pressure was 80 mmHg.
Eventually you obtained flashback of dark-red blood in the left
internal jugular region and gained access. At endoscopy a bleeding
gastric ulcer was injected and she was admitted to the high-
dependency unit (HDU).
The gastroenterologist met you yesterday to let you know of a
critical incident. The day after admission to the HDU Mrs Parker
suffered a further stroke with dense left-sided weakness and a
computed tomography scan showed a very large right parietal
infarction, probably from watershed ischaemia. It was also noticed
in the HDU that your central line was positioned in the left carotid
artery. It had not been used, although for reasons not yet
established had not been removed despite a chest X-ray showing
malposition. Unhappily, the HDU doctor told Mrs Parker’s daughter
that arterial catheterisation should never occur because it can
cause a stroke. You honestly cannot recall reviewing the chest
X-ray.
The gastroenterologist is convinced that the stroke was
caused by hypotension on a background of a cerebrovascular
disease, not least because the stroke occurred on the wrong
side to implicate the catheter. He is also very irritated by the
careless remarks of the HDU doctor. However, he feels that the
incident should be reported because although unlikely to be
causative, and a well-recognised complication of the procedure, a
system failure led to the potentially dangerous situation
of non-removal of the malpositioned line. He has spoken to
the daughter and given these views. However, the patient’s
daughter, with whom you spoke on admission, would also like to
talk to you.
Your task is to talk to the daughter and respond to her
concerns.
Case 4.39  Critical incident
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
Your mother, Mrs Jane Parker, is an 84-year-old woman
who was admitted to hospital 3 days ago with a bleeding
stomach ulcer. She had a stroke 2 years ago, leaving her
relatively immobile and she lives with you. She has con-
tinued to have ‘mini-strokes’ with effects on mobility and
memory and you have been concerned about her quality
of life. At endoscopy the bleeding ulcer, which you
accepted as life threatening, was treated and she was
admitted to the highdependency unit (HDU) because of
very low blood pressure. You were very happy with the
admitting doctor’s (the candidate’s) communication to
you of events. Subsequently, your mother has had a stroke
and is now very unwell. You were not surprised by this,
although you were upset when another doctor, in the
HDU, told you that the admitting doctor had placed a
catheter incorrectly into the artery of her neck and that this
probably caused the stroke. The consultant has subse-
quently made you feel easier, explaining that the line was
placed incorrectly, but that it does not seem to have been
the cause of the stroke but that the matter will be looked
into thoroughly. You believe the consultant, have no wish
to make a complaint because you have been very happy
with the care given to your mother over the years and
accept that she has been unwell for some time. However,
you would like to speak to the admitting doctor, both to
hear his view of events and to be further reassured that the
HDU doctor was ‘out of line’.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction and setting
Show that you are willing to listen, explain and help in
whatever way you can. Angry or upset patients and rela-
tives should never feel threatened.
2.  Listen to concerns
Allow her to say what she wants to, without interruption.
Find out the exact nature of her concerns. More often than
not, venting of emotions is what people want, in this case
concern and likely confusion created by the careless words
of a colleague.
3.  Acknowledge concerns
First and foremost, make her see that you understand her
concerns. Make it very clear that you and the consultant
711
 Station |4| Communication skills and ethics
are concerned about the incident. Tell her that she has a
right to know exactly what happened.
4.  Apologise, if appropriate
Where it is clear that a mistake has been made, say how
sorry you are that the incident occurred. In this case,
however, you should not admit to the allegation of the
HDU doctor but you do want to concede that a recognised
complication of the procedure occurred. You may also
need to say how sorry you are that she has been upset and
confused by apparently conflicting comments.
5.  Do not criticise colleagues but give your view
Colleagues have the same rights to be consulted and given
the opportunity to seek advice, and ill-considered remarks
could lead patients or relatives to misleading conclusions
and prejudice a colleague’s interests. Colleagues should
never be criticised openly, but this does not necessarily
mean dismissing or excusing a patient’s or relative’s
expressed concern or complaint. While you should not
criticise the HDU doctor (no matter how you may feel
about his careless remarks) it is appropriate to say you
agree with the comments made by the consultant, rein-
forcing what you see as correct information. Overall, you
need to let her see how sorry you are that her mother’s
condition has deteriorated, without focusing so much on
the HDU doctor’s view.
6.  Explain how the incident occurred
Explain, as clearly as possible, how the incident occurred.
Explain that your action was in good faith in the best
interests of her mother, who was very unwell, and that you
were deeply concerned to learn that you had placed the
catheter in the artery as soon as it became known to you.
7.  Work with facts – do not speculate!
Since you should work with facts, do not speculate as to
why the catheter was left incorrectly in situ until the facts
have been established.
8.  Give an assurance of further action
Explain that normally mechanisms should be in place to
recognise such a complication (chest X-ray +  / − blood
gases). Tell her that the incident will be reported as a ‘criti-
cal incident’ to the risk management team, who will inves-
tigate it further and decide what action might be taken to
avert such an incident in future (the use of Doppler-guided
central line placement is now considered best practice).
9.  Invite questions and provide further
information if needed
Ask if there are any other specific concerns she has not
mentioned. Hopefully she accepts your candid response
to the incident but if she wishes to make a formal written
complaint she should be informed of to whom to write.
In any event, you should offer to be of further assistance
should she have further questions or concerns.
712
10.  Document everything fully and carefully
The vast majority of critical incidents are errors not of one
person but of a system within which fallible people
operate. Discuss the incident with your consultant, docu-
ment everything clearly and depending upon the signifi-
cance of the incident discuss it confidentially with your
medical defence organisation.
Discussion
What do you understand by the term
clinical governance (CG)?
The full definition, originally from the government paper
‘A First Class Service 2000’, is ‘a framework through which
NHS organisations are accountable for continuously
improving the quality of their services and safeguarding
high standards of care by creating an environment in
which excellence in clinical care will flourish’. In short, it
means striving for the best quality, minimising harm and
maximising benefit within budget and resources.
CG was given impetus by health-care disasters like
Shipman and the Bristol Enquiry. Key areas of CG are out-
lined in Box 4.37. Ideally, CG should be proactive, but it
often needs to react to complaints, claims and incidents.
What is a critical incident?
A critical incident is an event that gives rise to, or has the
potential to produce, unexpected or unwanted effects
involving the safety of patients. It is a serious event that
harmed or could have harmed and as such would be likely
to give rise to public concern or criticism of the service
involved. Annually in the NHS there are known to be
around 850 000 adverse events and 28 850 000 com-
plaints. This may be the tip of the iceberg. Trusts have
clinical risk management teams to aid investigation of
clinical incidents and many have their own legal depart-
ment and solicitors.
Should you report all incidents?
All incidents should be reported, but, because of the enor-
mous number of them, grading systems or risk matrices
Box 4.37  Key areas of clinical governance
• Clinical risk management, e.g. incident reporting
• Education and training, e.g. standardised outcomes and
assessments
• Patient and public involvement, e.g. expert patients, copying
letters to patients
• Staffing, e.g. appropriate selection
• Effective communication and use of information, e.g. use of
computerised imaging and electronic patient records
• Audit, e.g. local, national
• Research, evidence-based practice and clinical effectiveness,
e.g. use of National Institute for Health and Clinical Excellence
guidelines

have been introduced that incorporate both their likeli-
hood and their consequence, to give priority to the more
serious.
What do you understand by the term
system error?
Seldom is one individual wholly responsible for a critical
incident. The role of risk management teams is to investi-
gate the system within which individuals operate to iden-
tify gaps that expose it to errors. The above case illustrates
such gaps (e.g. the use of Doppler imaging for inserting
central venous catheters, chest X-ray confirmation post-
procedure and the question of who is responsible for
checking it if a patient moves to a different team’s care).
Incidents happen because of failures in the organisation’s
management, local conditions (e.g. understaffing, tired-
ness, under-resourced), individual unsafe acts (e.g. missing
out a step in a procedure because short of time or multi-
tasking) and what has been called ‘the final defence barrier
breach’ (e.g. in an adequately staffed procedural room, a
doctor may have omitted to check the date and label on
the local anaesthetic but a nurse might have noted it). For
these reasons alone, it is never acceptable to rush to blame.
What is the National Patient Safety
Agency (NPSA)?
Everyone makes mistakes. The questions are why are they
made repeatedly, how can we learn from them and can we
eliminate some of them. The NSPA takes a seven-themed
approach to this (Box 4.38).
How is a hospital managed?
A Trust Board has overall responsibility for scrutinising
trust policy, implementing national / government policies
and advising the Trust Executive. The Trust Board com-
prises a chief executive together with executive and non-
executive directors. Board executives are usually ex-bankers
or lawyers or business people, and sometimes nurses.
The Trust Executive is the hospital’s functioning 
body. It comprises clinical directorates and corporate
directorates.
Clinical directorates typically include medicine (usually
enormous), general surgery, specialist surgery, trauma and
orthopaedics, child and women’s health, critical care /   trusts. Much work is ‘fire fighting’ – handling complaints,
emergency medical services, diagnostic services and  approving study leave and so forth.
professional services. Each clinical directorate provides  Each corporate directorate comprises a director and pro-
services, e.g. the disciplines of general medicine and  vides certain services. Corporate directorates might typi-
specialist medicine within the Medicine Directorate, and
physiotherapy, occupational therapy, speech and language
therapy and dietetics within the Professional Services
Directorate. Each clinical directorate comprises a Clinical
Director (CD), directorate manager, a lead nurse and a
directorate accountant. These are all responsible to the
Medical Director, who in turn is answerable to the Chief
Executive. These people meet regularly. The CD is usually
a doctor, who relies very much on the directorate manager
as he or she usually struggles to combine CD work with
Case 4.39  Critical incident
Box 4.38  National Patient Safety Agency
(NPSA) approach
Promoting a safety culture
This includes enhancing awareness and building safety into daily
work with such activities as induction, handovers and audit.
Leading and supporting staff
This includes clinical leadership and supporting staff ideas.
Integration of risk management activity
This includes working across teams, departments, trusts and the
NHS, e.g. the tracking of blood for transfusion from source to
patient. It embraces all information such as incidents, complaints,
litigation and audit, and balances costs with levels of risk. It is not
feasible, for example, for all surgical instruments to be single use.
Risk management at the directorate level includes risk and medical
management, critical incidents and audit, and at the governance
committee level are a health and safety committee, evidence-based
practice, infection control and so forth.
Promotion of reporting
This includes reporting of incidents, near misses and methods for
investigation and review (information, mapping of event, barriers to
safety). Barriers to safety include discontinuity of care,
communication failure and the different layouts of each ward, and
barriers to reporting include fear of blame, no clear benefit, ‘not my
job’, no feedback or ‘a waste of time’. A non-punitive atmosphere
is essential to promote reporting.
Communication with patients and public
Key principles are honesty, apology, explanation and thorough
investigation.
Learning and sharing lessons
Information needs to be disseminated by, for example, email,
written memos, policy documents and discussion.
Implementation of solutions
A National Confidential Enquiry into Patient Outcomes and Deaths
(NCEPOD), for example, under the NPSA, recommends more
consultant involvement in clinical care to recognise and manage
critical illness.
clinical work. Roles include ensuring clinical and opera-
tional performance, changing strategies within the trust in
line with national policies and working with primary care
cally include the Chief Executive, the Medical Director,
finance and information management and technology
(IM&T), human resources (staffing, occupational health),
operations (e.g. clinical directorate management, opera-
tional performance, business planning, emergency prepar-
edness), facilities (e.g. estates, catering, laundry, parking,
security, fire, bookshop), nursing and service improve-
ment (e.g. complaints handling) and planning.
The flow of NHS money is from the Department of
Health, which feeds it to primary care organisations,
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 Station |4| Communication skills and ethics
which feed via the Planning Directorate to NHS trusts
(linked to strategic health authorities), who set their own
budgets.
What do you know about the Access to
Health Records Act?
This gives patients the general right to see their medical
records, obtain copies thereof and have the records
explained to them. It applies only to records after 1
November 1991. A doctor may deny access (it is not that
the whole record should be withheld but only specific
information within it) on the grounds that it is ‘likely to
cause serious harm to the physical or mental health of the
patient or any other person, or could lead to the identifica-
tion of another individual (other than the health profes-
sional) who has been involved in the care of the subject’.
An application must be in writing and made by a patient,
person authorised by the patient, person appointed by the
Court or an executor. When application for access is made
by an individual on behalf of a patient who is incompe-
tent or deceased, no information can be given that the
patient had considered confidential and the holder is not
required to explain why any part of the record has been
withheld. Viewing of the records should be provided
within 21 days (40 days for records at least 40 days old).
A reasonable fee may be charged.
CASE 4.40  MANAGING A
COMPLAINT AND THE QUESTION OF
NEGLIGENCE
Candidate information
Role
You are a doctor on the medical ward.
Please read this summary.
Scenario
Re: Mr Jeremy Finch, aged 64 years
Mr Finch is a 64-year-old man on your ward who last week
had an endobronchial biopsy for a suspicious lung lesion. Yesterday
evening he was told by a member of staff (you are not yet sure
who), in the presence of his daughter, that the lesion might well be
benign, and yet this morning you received the formal report
suggesting it is an adenocarcinoma. You discussed this sensitively
and Mr Finch seemed to accept the diagnosis but his daughter
now wants to talk to you.
Your task is to address his daughter’s concerns.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
714
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
You are the daughter of Mr Jeremy Finch, a 64-year-old
man who has been told by his doctor this morning that
the result of his lung biopsy is that he has lung cancer. You
are understandably upset although you had been con-
cerned for some time that he had been coughing up blood
and it took you some months to persuade your father to
come to hospital. You are, however, very upset that yester-
day evening a junior doctor on night shift came to take
blood from your father with you present and commented
that very often these turn out to be benign. You are con-
cerned because this is not the first ‘disaster’. When your
father was first admitted he was told he had pneumonia
and given a dose of penicillin when it was documented
very clearly in his general practitioner’s referral that he was
allergic to penicillin. You feel that the hospital makes one
mistake after another and want to complain and may
consider suing the hospital for negligence.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction and setting
Introduce yourself and confirm her identity. Show that you
are willing to listen, explain and help in whatever way you
can. Angry or upset patients and relatives should never feel
threatened.
2.  Listen to concerns / complaint
Allow her to say what she wants to, without interruption.
Do not take any criticism personally. Find out the exact
nature of her complaint. More often than not, venting 
of feelings to a sincere and responsible listener is enough
for patients or relatives. Progression to a complaint is less
likely if you can facilitate this.
3.  Acknowledge concerns
Let her see that you understand her grievances, and are
dedicated to responding to these appropriately.
4.  Apologise, if appropriate
Where it is clear that a mistake has been made, say how
sorry you are that this incident occurred. Unless it is very
clear that a complaint is unreasonable, it is always best to
offer a sincere apology, and, if unreasonable, to say you
are sorry the person feels that way.
 Case 4.40  Managing a complaint and the question of negligence
5.  Do not criticise colleagues but give your view
Focus on any problem in the system, not on any
individual.
6.  Explain how the incident occurred
Explain, as clearly as possible (if you know), how the
incident occurred.
7.  Work with facts – do not speculate!
It is inappropriate to speculate (or worse, ascribe blame)
when you do not have all the facts; these should be estab-
lished, if need be, by proper inquiry. Emphasise the clini-
cal imperatives – to now seek advice from the respiratory
and cancer specialist about the best way to treat her father’s
condition.
8.  Give an assurance of further action about  
the complaint
Tell her that you will share the information with your
consultant and report the incident as a ‘critical incident’
to the risk management team, who will investigate things
further and decide what action might be taken to avert
such an incident in future.
9.  Invite questions and provide further
information if needed
Hopefully she accepts your candid response to the inci-
dent but if she wishes to make a formal written complaint
she should be told to whom to write. In any event, you
should offer to be of further assistance should she have
any further questions or concerns.
10.  Document everything fully and carefully
The vast majority of critical incidents are errors not of one
person but of a system within which fallible people
operate. Discuss the incident with your consultant, docu-
ment everything clearly and depending upon the signifi-
cance of the incident discuss it confidentially with your
medical defence organisation.
Discussion
Why do people make a complaint?
People complain to vent anger, seek changes, receive an
apology, feel better, blame someone else and stop the
same thing happening again. Sometimes they complain
seeking compensation. People complain about clinical
care, staff attitudes, outpatient delays, poor communica-
tion, discharge and aspects of non-clinical care.
How might complaints be avoided
or minimised?
Knowing why people complain can help minimise com-
plaints. Every effort should be made to avoid dispute or
altercation. The General Medical Council recommends
that patients and relatives have a right to expect prompt,
open, constructive and honest responses to their concerns.
This will include an explanation of what has happened
and, where appropriate, an apology. Communication is
the key to ‘damage limitation’, while withholding facts or
retreating behind a wall of silence can inflame concerns.
Clear documentation is the key to defending actions now
that may be questioned at any time in the future. Happily,
gratitude is overwhelmingly more common than
complaints.
Must you cooperate with a complaint,
even if you disagree with the person
making the complaint?
You must cooperate fully with a complaint or formal
inquiry, although any complaint made that demands
more than an initial verbal response should be handled
by the complaints procedure. You must provide informa-
tion as to whom to write – the complaints manager / com-
plaints department, through whom all complaints are
managed.
What are the purposes of NHS complaints
procedures?
These are to resolve a patient’s complaints (e.g. by explana-
tion or apology) and to improve NHS services. Where
compensation is sought, this is no longer a complaint to
be managed by the complaints department, but a claim,
and the patient must seek legal representation.
What are the general levels of complaints
procedures?
There are two levels to which a complaint might go (Box
4.39). Most are locally resolved, with a response within 
20 days.
Can an NHS complaints procedure be used to
discipline a doctor or award compensation?
No.
Box 4.39  Levels of complaint
Local procedures
• Attempt to resolve complaints by local staff and managers
NHS ombudsman
• Can investigate, if certain criteria are fulfilled, usually in matters
of maladministration
• Ombudsman decides whether to investigate, conducts
investigation and reports to the NHS body involved,
disseminating findings widely and implementing action
needed
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 Station |4| Communication skills and ethics
What sorts of medical error occur?
Common errors in order of frequency are:
• Failure or delay in diagnosis
• Medication error
• Unsatisfactory management
• Failure of supervision
• Complication of procedure
• Injury.
Common missed acute diagnoses (which may lead to a
negligence claim) are:
• Myocardial infarction in younger women
• Infective endocarditis (often because investigated
through a care pathway, e.g. anaemia investigation)
• Subarachnoid haemorrhage (with reliance on
computed tomography imaging, which misses   Doctors have a broad range of duties including making appropriate
10%)
• Meningitis with delayed antibiotics
• Diabetic ketoacidosis
• Hyponatraemia due to Addison’s disease
• Occult neoplasm
• Alcohol-related Wernicke’s encephalopathy or
subdural haematoma
• Asthma being diagnosed without a peak expiratory
flow rate
• Pneumonia without early antibiotics
• Pulmonary embolism and deep vein thrombosis
• Medication error.
What are the conditions for negligence?
People often use the term professional negligence loosely
to mean bad clinical practice. The legal definition is much
more precise. Legal action for negligence is the patient’s
claim for compensation for losses caused by the profes-
sional. For a successful claim, all of the conditions in Box
4.40 must be proved.
These four conditions may be summarised as ‘duty,
deviance, damage and due to’.
Is there a time limit for suing for an act
of alleged negligence?
A patient must sue within 3 years of the act of alleged
negligence. For a complaint the time limit is 6 months,
often extended to a year.
Are individual doctors or trusts sued?
Before 1990 a patient or relative who wished to make a
civil claim as a result of NHS care sued an individual,
named doctor or health-care professional and the defence
of the claim was handled by the relevant defence organisa-
tion. Since then ‘Crown indemnity’ has been introduced,
and it is the trust that is sued and the case is investigated
and defended by the hospital’s legal team, solicitors and
the NHS Litigation Authority. The NHS Litigation Author-
ity has developed as a powerful centralised legal body for
the NHS. It decides on the basis of the four ‘D’s if it thinks
the case if defendable, which in most cases it will be.
716
Box 4.40  Conditions for negligence
1.  The professional had a duty of care to the
patient
The law imposes an onus on a doctor only if a professional
relationship exists between the doctor and the patient. The doctor
has particular knowledge and skills and the patient consults them,
as when a patient consults their general practitioner or is cared for
by a doctor in hospital. A duty of care does not exist for strangers
(‘Good Samaritan’ acts), although a doctor may become liable if he
or she proceeds to treat improperly or causes harm. It is usually
easy to establish whether a duty of care exists.
2.  The professional was in breach of the
appropriate standard of care
A patient must show that the doctor did not fulfil his or her duty.
diagnoses, giving appropriate treatments and ensuring that
patients are fully informed so that consent is valid. However, it is
well known that equally knowledgeable, skilled and experienced
doctors may tackle a case differently. Therefore the Courts have
used the ‘Bolam test’ to decide whether a duty of care has been
breached – that duty is not breached if a ‘responsible body of
medical opinion would have acted in the same way in the same
situation’. It is also accepted that experts differ in opinion (e.g.
treating cough, sputum and fever with antibiotics or considering it
viral) and either may be acceptable. The test, however, must be that
other experts would have done the same, and not ‘that could have
happened to me, I could easily have found myself in that situation’;
the latter analogous to driving at 40 mph in a 30 mph zone.
3.  Harm resulted
Negligence cannot be considered if no damage was incurred, even
if there was a breach of duty.
4.  The breach of duty caused the patient’s harm
The patient must show that the doctor’s mistake or failure or
action caused the injury or other losses. This is the most difficult
condition to prove, as breach of duty and harm may both have
occurred, but that the former caused the latter does not necessarily
follow.
Where clearly indefensible (e.g. wrong finger amputated),
it will attempt to settle out of court rather than proceed to
civil court proceedings. Doctors are therefore witnesses in
proceedings and not personally liable for payment of legal
costs or damages, but their involvement in a claim may be
considered as a separate issue by the trust’s consultants or
directorates.
Are damages awarded in cases
of negligence punitive?
Any damages awarded aim to meet losses incurred, but not
to exceed them. In other words, punitive damages are not
awarded.
What are vicarious liabilities?
NHS employers may be covered for cases of negligence by
the Crown Indemnity Scheme. Patients may sue health
 Case 4.41  Fitness to practise – poor performance in a colleague
professionals personally but, provided certain conditions
are fulfilled, they may choose to seek compensation from
the employer. The advantages of vicarious liability to
patients is that more substantial claims for damages may
be affordable to employers and, if action is brought many
years after an event, the health professional may be harder
to trace.
What is an inquest?
This is a fact-finding enquiry about a reported death, con-
ducted by the coroner, who requests written and sometimes
verbal evidence from a variety of sources. It is not a trial.
There are no parties, and there is no indictment, prosecu-
tion or defence. Possible verdicts in order of decreasing
likelihood include natural causes, accidental death, indus-
trial disease and unlawful killing. The verdict for a patient
who has died from complications following an operation
may be accidental death because the operation was planned
but the outcome was not. An open verdict is returned if
the coroner believes there is insufficient evidence to reach
a decision. The coroner’s court is a public court and the
press may attend, as do a hospital’s legal team.
CASE 4.41  FITNESS TO PRACTISE
– POOR PERFORMANCE IN A
COLLEAGUE
Candidate information
Role
You are a doctor on the medical ward.
Please read this summary.
Scenario
Re: Dr Stephen Cotton, aged 25 years
Dr Cotton has been your F1 doctor (house officer) for 1 month,
having worked on a different ward for 3 months beforehand. He
has a further 2 months with you. You think his medical knowledge
is sound and do not doubt his genuine intention to be a good
doctor because he clearly works very hard and stays late after work
to complete tasks he has been unable to complete during the day.
However, his work is ineffective. You believe his main problem is
inability to prioritise tasks. He tends to respond to every request
made of him by nursing and other staff immediately, although
dropping what he is doing in the process. If he is on your ward
round, for example, and a nurse tells him a drug chart needs to be
written in the next bay, he will leave to rewrite the drug chart. He
seems to see every task as equally weighted. Furthermore, when he
is on your ward rounds he does not appear to listen to instructions
or advice because he seems too nervous about all of the jobs he
has to do. You can cope with a weaker member of the team, but
are aware that colleagues are increasingly frustrated by his
performance. Some laugh about it behind his back. You feel he
could benefit from confidential support and advice.
Your tasks are to explore his poor performance and offer
constructive advice.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
Dr Stephen Cotton has been an F1 doctor (house officer)
for 4 months. He found his first 3-month post enormously
difficult because there was simply too much work, and he
was constantly being bleeped with more of it. Other staff
seemed not to be pulling their weight. He felt out of his
depth, and he found the F2 doctor (senior house officer)
was never there to help or advise him. He felt he did not
know what he was doing much of the time, and so simply
did what everyone – usually nursing staff – told him to do.
This frustrated him, as he was a very good student and had
great hopes of being a good doctor. For the past month he
has been in a different post where the senior doctor is very
helpful, but he is still not sure that he is performing well.
He has heard colleagues in the hospital mess laughing
about him because of his inefficiency but he does not know
how he could work any harder. His senior colleague is
about to talk to him about his performance.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction and setting
Ensure you have time to talk with him, in a non-pressured
environment, and make it clear the discussion is
confidential.
2.  Open diplomatically
Telling someone they are no good does not open dialogue.
Tell him that you wanted to discuss his experiences of the
post so far. Explain that it is often difficult to judge how
a relatively new doctor is feeling about the job, although
it has become apparent to you that he works exceptionally
hard and feels a sense of duty to respond immediately to
every request.
3.  Make it clear you are there to offer
constructive help
Explain that this is an impossible task for any doctor and
if there are strategies to make the burdens of the job seem
easier, and the remaining 2 months as educationally valu-
able as possible, you would like to try to identify these.
4.  Listen to the experiences of the poorly
performing doctor
Listen supportively, as the last thing he needs is for every-
body to takes sides against him. Allow him to tell you how
717
 Station |4| Communication skills and ethics
he sees the job, which might be very different from how
you or your colleagues see it.
5.  Share the good points
Show understanding of how a house officer’s job is difficult
– doctors must adjust from the learning environment of
medical school to the intensely practical and often mundane
tasks of clinical work; when emergencies happen you can
feel out of your depth; support can sometimes seem lacking;
there always seems to be too much work and not enough
time; and beyond all of this all doctors, as all people, need
personal time and a life outside work. Tell him that you are
in no doubt that he is a very hardworking doctor.
6.  Be honest about where you think
performance falters
Explain that where you think this falters is in his desire to
do everything, and now. Medicine, more than many jobs,
requires many generic skills, and one of these is prioritisa-
tion. Explain that this is not a comment on his medical
knowledge, which is perfectly satisfactory.
7.  Identify problems and possible solutions
Explain that the transition from medical school to house
officer means seeking and using the support of more
senior staff. Perhaps explain that on your next ward round
he should not leave unless a job is urgent, and that you
and he can decide this together. Offer to supervise his work
more closely, constructively correcting any problems and
regularly teaching on ward rounds. Offer to meet at the
end of shifts to see what work is remaining and, of this,
what needs to be done now, what can wait and what
should be handed over. Ensure that he is taking all leave
to which he is entitled.
8.  Invite further questions
Invite him to discuss anything not covered.
9.  Agree a plan
Make and agree a definite plan, using the list of identified
problems and possible solutions.
10.  Offer ongoing help
Ensure he knows you will be an ongoing source of confi-
dential help.
Discussion
Do you have a duty to identify poorly
performing doctors?
Poorly performing doctors should be identified and sup-
ported in a proper manner. There should be a sense of
responsibility for these doctors, even where performance
is not considered abjectly dangerous because doctors are
just as susceptible to personal problems and work difficul-
ties as anyone else and need support rather than being left
to languish in this and subsequent posts. Where patient
718
care is considered to be at risk, these doctors should be
identified with a view to further training or re-education,
or other help as necessary. A plan for this should be con-
structed in a tailored way in conjunction with the consult-
ant in charge and sometimes the postgraduate deanery.
Re-appraisal will be necessary.
What types of problem doctor can
you identify?
The General Medical Council (GMC) identifies the broad
categories of poor performance (incompetence), miscon-
duct (bad behaviour) and problems of physical or mental
health (sickness), although each of these is of variable
significance and often these overlap. It may be preferable
to consider doctors as being in difficulty, often with a
conspiring cluster of causes including personality type,
behavioural predisposition and life events.
Is the problem usually of a doctor in
difficulty or a difficult doctor?
It may be either.
Is the problem usually clinical or
behavioural?
It is invariably behavioural. Complaints about doctors are
usually to do with problems with attitude, communica-
tion, decision making, team working and insight. Behav-
iours may be:
• Work based, e.g. lateness, absence, work backlog
• Performance, e.g. over- or underinvestigating, poor
decision making, poor record keeping, complaints
• Cognitive, e.g. memory, attention and learning
problems
• Language / cultural
• Psychological/personal, e.g. irritability,
unpredictability, forgetfulness, high self-
criticism / perfectionism, arrogance, lack of insight,
excess risk taking
• Social, e.g. isolation, withdrawal, poor personal
interaction.
Stress is largely related to personality (degrees of open-
ness, conscientiousness, extraversion, agreeableness, neu-
roticism), rather than work environment. The strongest
predictors of success at work are emotional stability and
resilience, conscientiousness and intelligence. A high degree
of ‘neuroticism’ is less favourable. All behaviours may of
course be strengths or weaknesses, e.g. diligence can be very
productive or create impossible demands. Further, positive
behaviours may become destructive if they go too far, which
they may do under stress, e.g. enthusiasm becomes volatility,
careful becomes too cautious, focused becomes passive
aggressive, confident becomes arrogant, charming becomes
manipulative, diligence becomes perfectionism.
What are the causes of poor performance?
These are wide ranging, e.g. poor knowledge or skills, dif-
ficulty putting theory into practice, arrogance or failure to
 Case 4.41  Fitness to practise – poor performance in a colleague
know limitations (usually poor insight or overcompen-
sated insecurity), poor communication, poor teamwork,
offhand attitudes, laziness and dishonesty (almost
undoubtedly the worst). Often one problem suggests that
a cluster may be present. Interestingly, those who think
they are good tend to overestimate themselves, and those
who think they are not so good, underestimate! Good
doctors can be bad doctors, e.g. the perfectionist who
cannot delegate, and in general there are five working
styles and we tend to each have a couple – ‘hurry up’, ‘be
strong’, ‘be perfect’, ‘try hard’ or ‘please people’.
What should be done when a doctor in
difficulty is identified?
Early recognition is imperative. One of the worst repercus-
sions of failure to take remediable action as soon as  • Work in partnership with patients
possible is a doctor who becomes alienated and loses
allegiance to their team or organisation.
The principles with any poorly performing doctor are:
• Ensure patient safety – always the first question to
answer (training is always a balance between patient
safety and learning opportunity).
• Let the doctor know; too commonly he or she is the
last to know.
• Be objective.
• Discover the cause (trainee, team or external factors?)
– clarify concerns, identify contributing factors and
assess the capacity to improve.
• Decide what action needs taking.
Action at your stage is to speak to your consultant.
Further action depends on the problem, ranging from
informal action to, at the other extreme, a formal hearing.
The people who might become involved to help with train-
ees are the clinical and educational supervisor, the clinical
tutor, and if ongoing or not resolvable the postgraduate
dean and support services in the deanery, often in conjunc-
tion with the occupational health service if there are health
issues contributing; sometimes the National Clinical Ass­
essment Service (NCAS), an organisation which supervises
doctors with performance or educational problems (often
communication problems), acts on a strictly need-to-know
basis with that doctor, retaining considerable confidential-
ity for the doctor. The NCAS mainly assists consultants and
non-training grade doctors, largely aiming to support them
through the problems and considering fitness for purpose,
but it does get involved with some trainees.
List some duties of a doctor
The GMC advises that to maintain a good standard of
practice and show respect for human life doctors should
respect those duties listed in Box 4.41.
List some key components of good
medical practice
The 2012 GMC guidance on good medical practice involves
four domains (Box 4.42), updated from seven in 2006 –
good clinical care, maintaining good medical practice,
Box 4.41  Duties of a doctor
Patients must be able to trust doctors with their lives and health.
To justify that trust you must show respect for human life and you
must:
• Make the care of your patient your first concern
• Protect and promote the health of patients and the public
• Provide a good standard of practice and care
• Keep your professional knowledge and skills up to date
• Recognise and work within the limits of your competence
• Work with colleagues in the ways that best serve patients’
interests
• Treat patients as individuals and respect their dignity
• Treat patients politely and considerately
• Respect patients’ right to confidentiality
• Listen to patients and respond to their concerns and
preferences
• Give patients the information they want or need in a way they
can understand
• Respect patients’ right to reach decisions with you about their
treatment and care
• Support patients in caring for themselves to improve and
maintain their health
• Be honest and open and act with integrity
• Act without delay if you have good reason to believe that you
or a colleague may be putting patients at risk
• Never discriminate unfairly against patients or colleagues
• Never abuse your patients’ trust in you or the public’s trust in
the profession
Box 4.42  Good medical practice
Domain 1: Knowledge, skills and performance
• Maintain your professional performance
• Apply knowledge and experience to practice
• Ensure that all documentation (including clinical records)
formally recording your work is clear, accurate and legible
Domain 2: Safety and quality
• Contribute to and comply with systems to protect patients
• Respond to risks to safety
• Protect patients and colleagues from any risk posed by your
health
Domain 3: Communication, partnership and
teamwork
• Communicate effectively
• Work constructively with colleagues and delegate effectively
• Establish and maintain partnerships with patients
Domain 4: Maintaining trust
• Show respect for patients
• Treat patients and colleagues fairly and without discrimination
• Act with honesty and integrity
• Openness with legal / disciplinary procedures
719
 Station |4| Communication skills and ethics
teaching and training, relationships with patients, working
with colleagues, probity and health.
A colleague is making small clinical errors.
Who should be made aware?
This starts internally by involving your consultant. The
colleague should be asked for his or her side of the story
from the outset. Depending upon the level of concern, the
matter might be referred to the lead clinician of your
department, the clinical director, the medical director or
the chief executive. It is also possible to report concerns
anonymously to the National Patient Safety Agency, which
can conduct a non-judgemental investigation.
CASE 4.42  FITNESS TO PRACTISE
– MISCONDUCT IN A COLLEAGUE
Candidate information
Role
You are a doctor on an elderly care ward.
Please read this summary.
Scenario
Re: Dr Harry Winter, aged 28 years
Dr Winter, your new junior colleague, is developing a reputation
as a rather arrogant doctor who wants to be an emergency
physician. He has just come from the intensive therapy unit (ITU),
where his advice to colleagues was either that their referred
patients were too sick to come to ITU (‘wouldn’t survive
anyway’) or too well to warrant ITU and he seldom if ever took a
patient. He has just rotated to working on your elderly care ward.
One of your patients, an 84-year-old woman with a total anterior
circulation stroke, developed aspiration pneumonia and was very
distressed. While you were assessing her you asked that Dr Winter
ensure that 5 mg of morphine be prepared and then administered
to relieve her distress. He administered the injection and wrote up
5 mg on the drug chart. Later, the nurse told you that Dr Winter
had asked her for 15 mg. She is sure that she made up 15 mg
with him and it is documented accordingly on the controlled drugs
record. You are aware that not infrequently larger doses of opiates
are prepared than are used and the remnant amounts discarded.
But this is not the first time the same issue has been noted with Dr
Winter.
Your task is to discuss the incident with Dr Winter.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
720
Patient / subject information
Dr Harry Winter is a competent and very confident doctor,
so much so that he often feels his senior colleagues need to
re-train. He has read a lot, knows a lot and gets very frus-
trated when senior colleagues waste time with what he sees
as meaningless interventions and drug doses that do not
seem to make a difference. He wants to be an emergency
physician. He hates his current post on the elderly care ward,
where things are too slow. In fact, he has contempt for most
elderly care physicians, perceiving that a lot of resources are
‘wasted’ on older people who do not seem to get better.
Yesterday, an 84-year-old woman with a total anterior circu-
lation stroke developed aspiration pneumonia and was very
distressed. While his senior colleague was assessing her he
asked Dr Winter to ensure that 5 mg of morphine was pre-
pared and administered. Dr Winter felt this dose stupidly
low and had given much higher doses to young trauma
patients in the emergency department. Dr Winter decided to
give 15 mg and although the woman became extremely
drowsy she is still alive today and this, he feels, vindicates his
decision. He only prescribed 5 mg, however, knowing his
senior colleague would not have approved. The nurse with
whom he prepared the morphine challenged him about the
discrepancy between what he had asked for and what he had
prescribed. Dr Winter does not feel it is a nurse’s place to
question a doctor but to appease her said that he discarded
10 mg as it was subsequently not needed. This is not the first
time he has given bigger doses than recommended or
requested, but he feels he is right. The senior doctor now
wishes to talk to Dr Winter about these episodes, and he will
have to admit the truth, albeit exposing his contemptuous
convictions, because the alternative is that he is perceived as
taking the morphine himself, which he is not. In fact, he
thinks drug addicts should be shot.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction and setting
Ensure you have time to talk with him, in a non-pressured
environment, as much for your sake as his.
2.  Open diplomatically
Tell him that you wish to discuss the discrepancy between
the dose of morphine apparently administered and the
dose given. Make it clear that you are not being judgemen-
tal, and that there are of course numerous potential
reasons this could occur. You should be aware, however,
that if he is lying about drug doses that will be a very
serious issue of honesty and probity.
3.  Make it clear you are there to offer
constructive help
Explain that, whatever the motives, you would hope to be
able to offer constructive help (it is of course more difficult
 Case 4.42  Fitness to practise – misconduct in a colleague

to do this when a doctor with poor conduct does not seem
to appreciate this).
4.  Listen to the experiences of the doctor with
poor conduct
Allow him to tell his story. Try to identify, if he admits to
the act, his reasoning behind it and ask him if he saw any
alternatives, such as discussing his thoughts with his
senior colleagues first.
9.  Agree a plan
Make and agree to a definite plan, using the list of identi-
fied problems and possible solutions. Tell him that the
matter is not one that you can keep to yourself, and you
will need to also discuss it with your consultant.
10.  Offer ongoing help
Offer to be a source of advice and help during his attach-
ment to the elderly care ward.

5.  Share any good points Discussion

Acknowledge that he is generally a knowledgeable and
competent doctor.
6.  Be honest about where you think
performance falters
Explain that you feel his ethical decision making is leading
him into territory that is dangerous to patients and risking
his professional integrity; explain that these actions could
have very serious repercussions, not least threatening his
future career.
7.  Identify problems and possible solutions
With a lesser issue you might advise him that you would
wish him to discuss all treatment decisions while attached
to the elderly care ward with you. Tell him that medical
decisions are always within a framework that puts patient
safety first. Here, you must inform your consultant.
8.  Invite further questions
Invite him to question your suggestions.
What types of professional misconduct do
we sometimes hear about in doctors?
These include (not in any order of importance):
• Lack of probity or honesty
• Lack of reliability and poor time keeping
• Acting under the influence of alcohol or drugs
• Inappropriate or criminal behaviour
• Inappropriate use of NHS facilities
• Failure to follow organisational policies
• Bullying
• Sexual or racial harassment
• Neglect of or disregard for responsibility to patients
• Breach of confidence
• Unprofessional attitudes to work.
What are the possible outcomes of
challenges to a doctor’s actions?
Possible outcomes are listed in Table 4.10. Your first duty
is to speak to your consultant if you have concerns about

Table 4.10  Possible outcomes of challenges to a doctor’s actions

Procedure Who or what Who Purpose Criteria Possible outcomes

instigates conducts
NHS complaints Patients or Hospital To resolve Explanation or apology from
relatives managers or complaints and managers
independent improve service
panel
Negligence claim Patients Civil court Compensation ‘Bolam test’ / prudent Financial compensation to
with a judge patient test patients
Employer’s disciplinary Reports from Trust Protection of Breach of employment Warning, suspension or
proceedings staff managers patients contract or law dismissal
Professional bodies Health Professional Assessing fitness Guidance such as GMC Admonition, registration with
such as GMC professionals committees to practise /  guidance conditions, suspension from
public protection medical register or erasure
from medical register
Criminal negligence Crown Criminal court Prosecution /  Gross negligence Absolute or conditional
Prosecution punishment discharge, suspended
Service imprisonment or imprisonment
Coroner’s inquest A reported Coroner To determine Verdict on cause of death
death cause of death
GMC, General Medical Council.

721
 Station |4| Communication skills and ethics
a doctor. Depending upon the seriousness of the problem,
others involved include the Medical Director, the Chief
Executive, the deanery and the General Medical Council.
The police may be involved if there is criminal action. In
the event of improper use of internet sites, trust IT depart-
ments may not inform the individual but have direct links
to the police who will take it extremely seriously. Other
people who may be involved in misconduct investigations
are outlined in Table 4.10. Depending upon the action,
restriction of practice or exclusion may ensue before inves-
tigations start. It is not acceptable to apply different out-
comes to doctors as to other members of staff. If dismissal
is appropriate for a porter, then it is for a doctor.
Should you accept a gift from a patient?
The general answer is no. Gifts that should not politely be
returned, such as chocolates, might be shared with other
members of the team; money should never be accepted and
the patient might be advised to contact the Trust Patient
Advice Service if they wish to make a charitable donation.
Should you always see a patient if a junior
asks you to?
Patient safety comes first and if there are concerns about
a junior’s level of competence this should be handled
second and your conduct in protecting patients will be
paramount. You should see that patient.
CASE 4.43  FITNESS TO PRACTISE
– HEALTH PROBLEMS IN A
COLLEAGUE
Candidate information
Role
You are a doctor in the emergency medical admissions
unit.
Please read this summary.
Scenario
Re: Dr Emma Wood, aged 26 years
Dr Wood, your new F1 doctor, has worked with you for 3
months and is persistently late for work. When at work, her
performance is highly substandard. Notably, she is extremely slow,
being able to clerk in one or two patients on days she is ‘on take’.
Initially, you gave her the benefit of the doubt as she told you she
found work very stressful. She feels that doctors do not give
enough time to patients, declaring that patients have ‘emotional
needs as well as physical’. But you now think this a thin excuse.
She arrives at work smelling of alcohol, and colleagues have told
you how she is often at parties all night or in her room with
dubious friends drinking until an hour before work. On two
occasions you have sent her home because she was intoxicated.
Your tasks are to confirm that she has an alcohol problem and
find ways to manage the problem.
722
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
Dr Emma Wood has been an F1 doctor in medicine for 3
months. She was an average student, performing well in
psychiatry, but finds being a doctor exceptionally difficult.
Initially she found it a culture shock to have to see so many
patients, and felt that most doctors did not spend enough
time talking to their patients. She was told by one consult-
ant that this is the modern NHS, there is a service com-
mitment to see patients and it is better to ‘get around all
patients missing irrelevances’ than to see one or two in
depth. She found this infuriating and against what she
found as a student in psychiatry, when she would fre-
quently put in a whole afternoon talking with one patient.
She now feels contempt for physicians. She cannot be
bothered working with the team, which she thinks just
runs around in circles, and feels she is ‘destined for better
things’. She has been drinking more and more alcohol in
recent months – she always drank a lot as a student – and
is aware that she comes to work after one or two morning
drinks ‘to steady her frustration’ but does not think her
colleagues have noticed. In any event, she enjoys it, and
has increasingly been feeling that alcohol is a good thing
for young people earning money and hates being criticised
by people who tell her differently. Her senior is about to
speak to her about his concerns, and she may eventually
see that there could be a problem and agree to seek advice.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction and setting
Ensure you have time to talk with her, in a non-pressured
environment, and make it clear that the discussion is
confidential.
2.  Ask if the sick doctor recognises the problem
Tell her that you are concerned she may be drinking
heavily. Ask if she feels there may be a problem.
3.  Make it clear you are there to offer
constructive help
Explain that you are concerned and that you would like,
and may need, to help or intervene if there is a problem.
4.  Listen to the experiences of the doctor
Listen supportively, but be aware that she may not admit
to having a problem. She may not see that she does.
 Case 4.44  Recruitment to a randomised controlled trial
Box 4.43  CAGE questions
• Have you ever felt you ought to Cut down your drinking?
• Have people Annoyed you by criticising your drinking?
• Have you ever felt bad or Guilty about drinking?
• Have you ever had a drink first thing in the morning, an Eye
opener?
5.  Ask specific questions
Ask the CAGE questions (Box 4.43). Ask if anyone else has
hinted that there may be a problem. Crucially, you are
exploring whether or not she has insight into the problem.
Explore the possibility of depression.
6.  Be specific about your concerns
If she denies a problem, suggest the evidence. Explain you
are concerned that continuing in this way may put patients
at risk. Explain you are also very concerned about the pos-
sible implications for her, including not adequately
making it through house year and, ultimately, a risk of not
obtaining General Medical Council (GMC) registration.
Explain that if patients are at risk she has a duty to seek
help and if she does not then it is necessary for colleagues
to intervene. Explain that you are obliged to speak to her
consultant.
7.  Explore any other concerns
Invite her to discuss anything not covered.
8.  Discuss possible solutions
These include support from you, and help from her regis-
tered general practitioner and/or the occupational health
service, and confidential services for sick doctors including
the British Medical Association, the Sick Doctors’ Trust
and the Doctors’ Support Network.
9.  Agree a plan
Make and agree a definite plan.
10.  Offer ongoing confidential help
Ensure she knows that you will be an ongoing source of
confidential help.
Discussion
If you suspect a colleague’s sickness is
putting patients at risk, how do you decide
when ‘whistleblowing’ overrides the
confidentiality of the colleague?
You must protect patients from harm posed by another
health-care professional’s health, conduct or performance
and this includes problems of alcohol or drug misuse.
Patient safety comes first. Serious concerns should provoke
immediate action to establish if they are well founded. You
must give an honest explanation to an appropriate person
in your health-care organisation, such as your consultant
or the Medical Director. If local systems do not or cannot
resolve the issue, then a professional organisation such as
the GMC may need to be informed of your concerns.
If a colleague smells of alcohol and it is difficult to judge
if he or she is drunk, and this is a first time, then it is more
likely a case of local help and discipline with close obser-
vation. But any professional who smells of alcohol cannot
see patients.
In recent years, gambling has also become a health-
related concern.
In all cases, important considerations are:
• To alert the individual of your concerns
• To ensure patient safety, e.g. is immediate exclusion
from work needed?
• To involve your consultant, who should act upwards
depending upon the level of concern – Medical
Director, Chief Executive, GMC
• The health of the individual, e.g. occupational health
department.
CASE 4.44  RECRUITMENT TO A
RANDOMISED CONTROLLED TRIAL
Candidate information
Role
You are a doctor on the acute medical unit.
Please read this summary.
Scenario
Re: Mr John Walker, aged 54 years
You are conducting a randomised controlled trial (RCT) with
your consultant on inpatient insomnia. You have designed the RCT
to involve four groups: no treatment, an eye-shield alone, earplugs
alone, and an eye-shield plus earplugs. Patients will be randomised
to one group for one night only and report their sleep satisfaction
on the basis of a rating scale.
Your task is to ask Mr Walker, a patient admitted with
dehydration and acute renal impairment, if he might agree to
participate in the trial and counsel him about it.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
Mr Walker is a 54-year-old mathematician who has been
admitted with acute renal impairment caused by
723
 Station |4| Communication skills and ethics
gastroenteritis and dehydration. He is about to be asked if
he might consider participating in a treatment trial, and
will be very interested to know all about it, not least about
the safety aspects and the ethics of it being conducted.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduce yourself and the topic for discussion
Explain that research is vital in improving the care of
patients and that you would like to invite your patient to
participate in research and the reason why. Ask if he is
happy to discuss your project.
2.  Explain the nature of the study
Explain the nature of the research, its aims and an outline
of the method. For such a randomised controlled trial
(RCT), the nature of the randomisation and any reasons
for it should be explained, although by its very nature this
RCT cannot be a double-blind RCT in which neither
patient nor researcher know whether patient is receiving
treatment or placebo.
3.  Discuss ethics approval
Explain that ethics approval has been obtained and that
the research does not come before the best interests of a
patient and that there are legal rights and safeguards. Any
foreseeable risks must never outweigh potential benefits
and developing new knowledge or treatment should never
take precedence over a patient’s interests. An RCT is not
ethical if there is evidence that an intervention is danger-
ous and an RCT must be stopped if evidence emerges for
a benefit or risk before completion. Doctors involved in
research have an ethical duty to respect human life and
people’s autonomy (if that research is an experimental
study into the causes, treatment or prevention of disease,
involving people or their tissues, organs or data; audit is
not experimental study).
4.  Explain potential benefits and risks
There may be potential benefits and risks. Explain these,
and any arrangement for dealing with adverse events.
Explain that the results are not predictable.
5.  Explain data handling
Explain that you will record and report all results accu-
rately. Explain that you will aim to complete the research
unless evidence emerged of a risk or no potential benefit
to participants. Information about outcomes will be
available.
6.  Discuss confidentiality
Explain that all information will fully respect your patient’s
right to confidentiality. Where data or patient information
724
is needed for research, doctors must seek consent for its
disclosure whenever practicable, anonymise data where
this will suffice and keep all disclosures to the minimum
necessary. If consent is not practicable, then the ethics
committee may need to decide whether the likely benefits
of the research outweigh the loss of confidentiality.
7.  Discuss consent
If he would like to proceed then you would wish to obtain
consent. Sometimes it is preferable to give patients time to
think about things. On no account must a patient feel
coercion. They also have the right to withdraw from
research at any time without reason. Any additional infor-
mation given, other than that required to fulfil a doctor’s
obligation to provide informed consent, will depend very
much upon the individual. It should be determined by
effective communication, by not making assumptions and
by asking about specific concerns. An information leaflet is
often very helpful before discussing research with patients.
8.  Consider conflict of interest
Any conflict of interest should be declared from the outset
and research should not be motivated by financial, 
personal, political or other interest. Ethics approval is
mandatory.
9.  Confirm understanding and invite questions
I appreciate we’ve covered rather a lot there. Is there anything
you would like me to go over again or are there any
questions you would like to ask me?
10.  Seek consent or refusal
And do not question his decision if he refuses.
Discussion
What do you understand by the term
evidence-based medicine (EBM)?
EBM refers to the conscientious, explicit and judicious
application of current best evidence in making decisions
about the care of individual patients. Practising EBM must
integrate external evidence with clinician’s expertise and
patient’s beliefs, concerns, expectations, values and
informed choice. Evidence-based health care extends the
application of principles of EBM to all professions involved
in health care.
What do you understand by the term critical
reading or critical appraisal?
The ability to evaluate scientific literature, analyse data,
and base management decisions on the evidence.
What broad types of research are there?
Quantitative research
This is concerned with inferences about populations and
testing theories. A collection of numerical data is subject
to statistical analysis to test hypotheses. Things that are
 Case 4.44  Recruitment to a randomised controlled trial
measurable by quantitative studies include disease fre-
quency (incidence and prevalence), factors that modify risk
of disease, methods for detection and diagnosis of disease,
costs and consequences of health states and effects of treat-
ments and interventions (clinical trials).
Qualitative research
This is concerned with understanding the experiences of
individuals and using this to build theories. It is guided
not by hypotheses, but by questions and issues and seeks
to describe culture, beliefs and attitudes and to understand
behaviour. It may generate hypotheses for testing using
survey or intervention designs. It may utilise, for example,
case reports, interviews (structured and non-structured),
health diaries, audio recordings, focus groups or group
interviews.
What types of study design are there?
Study designs may be non-interventional (case reports,
cross-sectional studies, case–control studies, cohort
studies) or interventional, which measure ‘before’ and
‘after’ (RCTs, systematic reviews, meta-analyses). Study
designs are listed below in the order of their ascending
hierarchy of evidence.
Case report
This reports a single patient’s story. A report on a series of
patients with an outcome of interest is a case series.
Cross-sectional (descriptive) study
A representative sample of people (‘subjects’) is studied at
a single point in time. It may be used to determine the
prevalence of a particular disease. Subjects are selected
without regard to the outcome of interest.
Case–control (retrospective) study
This involves identifying subjects with a particular condi-
tion of interest (cases) and comparing or ‘matching’ these
with subjects without the condition of interest (controls).
Retrospective data are collected from patient records to try
to identify a past exposure or potential causal agent of
interest that discriminates between the two groups. It is
not possible to demonstrate causality from a case–control
study; the association of A with B does not prove that A
causes B. Subjects are selected based on the outcome of
interest.
Cohort (prospective) study
This is an observational study of subjects without the condi-
tion of interest; they are selected and then followed up to
monitor the occurrence of the outcome. Two or more
groups (cohorts) are selected on the basis of a difference in
exposure to a particular agent of interest (e.g. drug, potential
toxin, smoking) and followed up to see how many in each
group develop a disease or other outcome. Cohort studies may
take years. A famous cohort study was that by Sir Richard
Doll to investigate smoking as a risk factor for lung cancer.
Subjects are selected before the outcome of interest is
observed. It is not strictly possible to determine causality
from a cohort study (something which tobacco companies
have used in their defence in the face of overwhelming
evidence) but strength of association may be used as a
marker of risk. An RCT is needed to prove causality, but may
not be ethical in the face of a strong association. Cohort
studies may be used to determine prognosis.
Clinical trial
This is a planned experiment designed to assess the efficacy
of a treatment in humans. The RCT is the most powerful
experimental design to obtain evidence of causation or the
impact of an intervention. Patients are randomly allocated
or randomised into an experimental group to receive an
intervention and a control group to receive standard treat-
ment or placebo. These groups are followed up and com-
pared for differences in outcomes of interest and any
differences are tested for significance. The process of infer-
ence from an RCT will typically result in significance tests
(P values), estimates of risk or treatment effect and confi-
dence intervals (below). Advantages of an RCT include the
rigorous evaluation of a single variable in a defined patient
group, the prospective nature eliminating bias, the search
to falsify rather than confirm its hypothesis and the facility
for meta-analysis at a later date. Disadvantages include time
and cost, hidden biases such as imperfect randomisation,
funding sometimes by pharmaceutical companies, and the
use sometimes of surrogate endpoints.
Systematic review and meta-analysis
A systematic review is a summary of the medical literature
that uses explicit methods to perform a thorough literature
search and critical appraisal of individual valid studies and
that uses appropriate statistical techniques to combine
these studies. Meta-analyses pool data from numerous
trials, and the Cochrane Collaboration is one body that
has standardised this approach.
What is a clinical practice guideline?
A systematically developed statement designed to assist
clinicians and patients in appropriate decision making.
Are there guidelines for critically
appraising papers?
Checklists to assist critical appraisal have been developed
for many different types of study and may include a clearly
specified objective, a design appropriate for the objective, a
definition of the target population and whether generalisa-
tion from the study to the target population is possible,
subject selection (how the subjects were selected for inclu-
sion), clearly defined treatments / interventions, whether ran-
domisation was used for allocation (including treatment
masking / blinding and if not whether this could affect
outcomes), justification of the sample size, the outcome
measures (primary and secondary, with statement of
reliability and validity) and completeness (compliance,
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 Station |4| Communication skills and ethics
drop-outs or missing data). Checklists to assist critical
appraisal have been developed specifically for RCTs. One
such is the Consolidated Standards of Reporting Trials
(CONSORT) checklist.
What is bias?
Bias refers to deviation of results from the truth, or proc-
esses leading to such deviation. Selection bias in a sample
is an error caused by systematic differences between groups
of subjects or between those selected and those who are
not. For example, volunteers may differ from non-
volunteers in health terms (motivated, free time, well).
Selection should really be random. Information bias refers
to a flaw in measurement that results in a difference in the
quality of information between groups. There are many
types of information bias:
• Interobserver bias resulting from different observers
classifying outcomes
• Recall bias resulting from incomplete recall, worse in
a case–control study
• Lead-time bias, important in measuring survival if a
new procedure has been introduced (i.e. is an
apparent increase in survival because of early
intervention or a parallel diagnosis?)
• Performance bias, resulting from differences in care
provided apart from the intervention (e.g. a doctor
may or may not counsel as well as prescribing
antidepressants)
• Exclusion bias, which implies systematic differences in
trial withdrawals
• Detection bias, which implies a systematic difference
in outcome assessment.
What information might you need
to determine the sample size necessary
for a study?
Sample size should be calculated by a statistician before
embarking on a study. A larger sample may yield a more
significant result. Sample sizes are determined from:
• An estimation of prevalence of the outcome of interest
in the population being studied or the control group.
• ‘Clinical intuition’ to decide the minimal clinical
difference or smallest change in outcome between
treatment and control groups that would be deemed
clinically relevant.
• The significance level, which refers to the probability
of a significant result, when in fact there is no
difference. The smaller the better, but it could never
be 0% unless we were to study the entire population.
By convention the significance level is 5% or 0.05,
represented as the ‘P’ value (below).
• Power, which refers to the probability that a study of
a given size statistically detects a real difference. The
bigger the better, and the more likely to detect
smaller differences, but power could never be 100%
unless we were to study the entire population; 80%
or 90% are by convention the standards.
726
What is the null hypothesis?
That there is no real difference between intervention and
control (relative risk = 1 or absolute risk = 0). Trials start
with this presumption, and then set out to disprove it. In
other words, evidence is based on an innocent until
proven guilty basis, a rather tortuous approach that
requires a ‘P’ value to be < 0.05 to be beyond reasonable
doubt. We can never prove the null hypothesis, but only
try very hard to reject it.
What is a ‘P’ value?
The P value relates to the confidence that a difference
between intervention and control groups is not the result
of chance alone. Its value is arbitrary, and by convention
< 0.05 (i.e. a < 0.05 or < 1 in 20 chance of the difference
being due to chance alone) is deemed statistically signifi-
cant. Sometimes tiers are considered, < 0.01 being yet
stronger evidence and < 0.001 being very strong evidence.
The smaller the P value, the less likely the difference is to
be the result of chance alone and the more likely it is to
be significant (but only if the sample size is large enough).
A significant result suggests that the author reject the null
hypothesis, and a non-significant result implies either no
difference or too small a sample. The P value must always
be read in the context of the sample size and confidence
intervals. Formerly, P values were often given alone when
reporting studies but, now, confidence intervals tend to be
given also. Importantly, statistical significance need not
necessarily imply practical, real or clinical significance.
Furthermore, absence of evidence is not the same as evi-
dence of absence!
What do you understand by the term
confidence interval (CI)?
If we were to repeat a trial hundreds of times, we would not
get the same results each time but on average we would
establish a level of difference between the two arms of the
trial. In 90% of the trials the difference between the two
arms would lie within certain broad limits; 95% of the
trials would lie within certain, even broader limits and
99% within broader limits still. The CI is the range within
which we would expect the true value of a statistical measure to
lie. It is basically the degree of wobble in a result that is
based on a small sample population (those in the study)
rather than the entire population. The CI is usually accompa-
nied by the percentage value for the level of confidence that
the true value lies within this range. For example, a number
needed to treat (NNT; see Case 4.6) of 20 with a 95% CI of
15 to 25 implies that we are 95% confident that the true
NNT is between 15 and 25. It is standard to have 95% 
CIs. CIs can be applied to any statistical test, e.g. NNT, 
relative risk, absolute risk, odds ratio, or sensitivity. A 
P value might be 0.05, but if, for the sake of example, the
CI for that P value were 1.1 to 25 then the result could
be of almost no significance because this CI is wide and 
1.1 is close to the line of no significance. A wide difference
in results (a wide CI), especially if close to or crossing 

the line of no significance, is less significant. A narrow  Scenario
difference in results (a narrow CI), distant from the line 
of no significance, is more significant. The line of no 
significance is 1 for ratios (negatives are not possible), such
as relative risk or odds ratio, and 0 for absolutes, such as
absolute risk.
What is a type 1 error?
The intervention is shown to work but it does not! This is
equivalent to the P value.
What is a type 2 error?
The intervention is shown not to work but it does! This is
more common than a type 1 error.
What do you understand by the term
generalisation?
Making inferences from a clinical trial involves a process
of generalisation from the sample to the target population.
The extent to which this is appropriate is known as
generalisability.
What do you understand by the term
confounding factors?
Mixing of two or more factors so that their individual
effect upon an outcome cannot be separated.
What do you know about intention
to treat (ITT) analysis?
Drop-outs or non-respondents can alter a sample size and
conclusions significantly. ITT is an analysis in which the
results in the control and treatment groups are analysed
with respect to the numbers of patients entering the study
(regardless of whether or not they received treatment or
completed participation in the RCT). By including for
analysis all entrants to the study, ITT analysis avoids biases
because of a failure of concordance and admits side effects
of a treatment causing subjects to drop out. ITT analysis
provides a pragmatic estimate of the overall benefit of
intervention in the population studied.
Other communication, ethical and
legal scenarios
CASE 4.45  GENETIC TESTING
Candidate information
Role
You are a doctor on the neurology ward.
Please read this summary.
Case 4.45  Genetic testing
Mr Roger Molton, aged 58 years
Mr Molton was recently admitted to the neurology ward for
assessment of a movement disorder. Genetic testing has recently
confirmed Huntington’s disease and you are about to speak to his
son, who wants to know more about the condition, particularly
whether or not it is inherited and whether or not he and his
siblings should be tested.
Your task is to explain the diagnosis and counsel him about
testing for this condition.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
You are the son of Mr Roger Molton, a 58-year-old man
who has recently been diagnosed with Huntington’s
disease. You know a little about the effects of the disease
and have heard that it might be inherited. You wish to
discuss the likelihood of being affected and if there is a
test that you could have. You currently have no children
but are concerned about the possible risk of passing the
condition on to any children in future.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself and establish his identity.
2.  Establish area for discussion and background
knowledge
Discover his pre-existing knowledge of Huntington’s
disease.
3.  Establish any family history
Try to obtain a family tree and ask if he knows of anybody
in the family who has had similar symptoms.
4.  Explore ideas, concerns and expectations
Ask if he wishes to know anything else about the disease
or its implications.
5.  Respond to ideas, concerns and expectations
Explain that Huntington’s disease is caused by an abnor-
mal gene that is passed on to 50% of children. Explain
that the disease may not become apparent until later life
727
 Station |4| Communication skills and ethics
in affected offspring, but that there is a tendency for suc-
cessive generations to be affected at an earlier age. Explain
that offspring who do not carry the gene cannot ever be
affected or pass on the condition.
6.  Advise about genetic testing
Explain that genetic testing can determine whether he
carries the abnormal gene. Explain that false-positive and
false-negative tests do occur, but are very unusual. Point
out that there are potential medical, family, occupational,
insurance and financial implications of a positive result.
Point out that there is no current prevention or cure for
those carrying the gene. Point out that for those carrying
the gene there is no means of predicting age of onset of
symptoms, severity of symptoms or rate of progression.
7.  Advise about counselling for genetic testing
All doctors should have a grasp of the principles and be
able to respond to immediate questions and concerns.
However, counselling for genetic testing is a specialised
skill and counsellors should be specifically trained and
part of a multidisciplinary team with psychosocial support.
Having confirmed his understanding of Huntington’s
disease, explored and responded to his concerns, and
explained the nature of testing, advise that a decision
about the test is something he should not make now, but
consider discussing with those close to him. Advise that
he might discuss the implications of the test and the con-
dition further at a regional genetic centre if he wished, and
in the company of someone close to him, but at the very
least your neurology consultant should be involved in the
process. A minimum of 1 month is desirable between
initial pre-test information and testing and results should
always be given in person by the counsellor. Post-test
counselling is mandatory whatever the result.
8.  Consider legal aspects
As with human immunodeficiency virus testing, testing for
Huntington’s disease should never be performed without
counselling and explicit informed consent. Counselling
must include up-to-date information about the condition
and the implications of testing that allow a patient to make
an informed choice. The test is available only to those who
have reached the age of maturity. Ownership of the test
result is with the subject who requested it but ownership
of the stored DNA is with the patient. DNA from another
affected family member may be needed, who of course
must give consent, but asking an affected family member
who is unaware of or unwilling to acknowledge their symp-
toms may be considered an invasion of privacy. Care
should be taken when a test result may provide informa-
tion about a third party who has not requested a test. Oral
and written information should be provided by the team
providing the testing service.
9.  Invite questions
Ask if he has any other questions or concerns that have
not been addressed.
728
10.  Agree a way forward
This may well be for him to think about the above before
contemplating the next steps.
Discussion
What is Huntington’s disease?
Huntington’s disease is an inherited neurodegenerative
disease characterised by progressive motor, cognitive and
psychiatric symptoms. Chorea and loss of balance are early
symptoms that patients notice, although families often
notice cognitive or personality changes first. The disease is
most common in people of northern European origin. The
mean age of onset of symptoms is 40 years, but juvenile
onset (< 20 years) and older onset (> 70 years) forms are
well recognised. Although relatively uncommon, Hunting-
ton’s disease can be devastating for patients and their
families. People who are at risk of developing the disease
because of a family history face difficult decisions about
genetic testing.
What are the clinical features of
Huntington’s disease?
The disease was originally named Huntington’s chorea
after George Huntington, who wrote the first detailed
description in 1872. The name has changed to Hunting-
ton’s disease to reflect the fact that chorea is not the only
important manifestation. Huntington’s disease progresses
over 15–20 years and characteristic symptoms reflect a
triad of motor, cognitive and psychiatric manifestations.
• Motor symptoms can be divided into two categories:
added involuntary movements such as chorea and
impaired voluntary movements, which cause limb
incoordination and impaired hand function. These
symptoms are worsened by loss of postural reflexes.
The pattern of symptoms tends to change over time,
with chorea declining and dystonia, rigidity and
bradykinesia becoming more marked.
• Cognitive impairment includes slowing of thought
processing and deterioration of executive functions  
(high-level cognitive processes that control other aspects
of cognitive function). Typically, patients report difficulty
with multitasking, concentration and short-term
memory. Thinking style becomes more concrete and less
efficient, and the planning, initiation and organisation of
time, thoughts and activities become harder. People with
Huntington’s disease are often impulsive and develop
psychomotor perseveration. Visuospatial perception can
also deteriorate
• Psychiatric symptoms include depression, obsessive–
compulsive disorders, anxiety, irritability, apathy,
hypersexuality (uncommon) and psychosis
(uncommon). Suicide is not uncommon.
What is the genetic basis of
Huntington’s disease?
Huntington’s disease is a single gene disease with auto-
somal dominant inheritance. The genetic abnormality is

an expanded CAG trinucleotide repeat within the hunting-
tin (HTT) gene on chromosome 4, and it can be identified
through genetic testing. The HTT gene encodes the protein
huntingtin, essential for normal neural development,
although its functions are incompletely understood. In
Huntington’s disease the expanded HTT gene encodes a
mutant form of huntingtin protein, which leads to the
development of Huntington’s disease through many path-
ogenic mechanisms. Offspring of an affected parent have
a 50% chance of inheriting the genetic abnormality, and
males and females are affected equally. Huntington’s
disease does not skip generations.
How is genetic testing undertaken?
Genetic testing for Huntington’s disease is performed by
measuring the CAG repeat length in the HTT gene. A ‘posi-
tive’ test result refers to CAG lengths in the pathogenic
fully penetrant CAG repeat range of more than 39 repeats.
Testing falls into two categories.
• Diagnostic testing is carried out to confirm (or
refute) the diagnosis in a patient with symptoms
suggestive of Huntington’s disease. It is a test for
manifest disease and is most commonly undertaken
by neurologists. A positive diagnosis has numerous
implications for family members (especially children
and siblings) and for the patient.
• Predictive testing is carried out in a person who has
no symptoms of the disease, but who is at risk
because of their family history. It determines whether
that person carries the expanded HTT gene and will
develop Huntington’s disease in the future. A
positive predictive test result indicates that they will
certainly develop Huntington’s disease at some point
if they do not die from something else.
What ethical considerations surround
genetic testing?
Confidentiality and consent
Strict confidentiality is observed before, during and after
predictive testing. Written informed consent must be
obtained from the patient before either predictive testing
or diagnostic testing. If the patient lacks capacity to make
the decision him- or herself for diagnostic testing, consent
can be given by an authorised representative.
Having children
Deciding whether or not to have children is often difficult
for people with or at risk of having an expanded HTT gene
and is outside the scope of this text.
What are the implications of a positive
gene test?
There are major emotional and practical implications and
testing and counselling should be undertaken by experts
in the condition.
Case 4.46  HIV testing
How is Huntington’s disease managed?
The aim of treatment is to manage symptoms and improve
quality of life. No current treatments can slow disease
progression. The choice of drugs for symptom relief is
based largely on clinical experience rather than evidence.
Tetrabenazine has the best evidence of efficacy in Hunt-
ington’s disease and has been shown to reduce chorea.
Many non-drug measures are effective, within a multidis-
ciplinary approach. Planning for end-of-life care raises
several ethical problems often relating to how far medical
interventions should be pursued when patients no longer
have capacity to make their wishes known. Advanced deci-
sions to refuse treatment can be extremely helpful. As
Huntington’s disease progresses, it often becomes increas-
ingly difficult to provide care at home, and a nursing home
may be needed. Insertion of a gastrostomy tube may be
appropriate in patients who are unable to maintain ade-
quate nutrition, depending upon extent of disease and
pre-emptive information and wishes.
CASE 4.46  HIV TESTING
Candidate information
Role
You are a doctor on the medical ward.
Please read this summary.
Scenario
Re: Mr Julian Lyons, aged 36 years
Mr Lyons is a 36-year-old ex-intravenous drug user, who has
abstained from drugs for 3 years. He has been admitted to your
ward with a respiratory illness, mild hypoxia and X-ray findings that
would be consistent with Pneumocystis jiroveciI pneumonia. He has
also been losing weight. Your consultant has asked that you
discuss an a human immunodeficiency virus (HIV) test with him.
Your tasks are to explain the possible diagnosis, approach the
possibility of HIV infection and counsel him for an HIV test.
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
Mr Julian Lyons is a 36-year-old man who used intravenous
heroin until 3 years ago. He admits to having shared
needles. He has been admitted to hospital with a short
respiratory illness and his doctors suspect human immuno-
deficiency virus (HIV) infection as a possible underlying
cause. He has been slowly losing weight over the last few
months. He is heterosexual, currently unemployed, and
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 Station |4| Communication skills and ethics
lives with a dog. He smokes 20 cigarettes a day and drinks
a moderate amount of alcohol. He has never had an HIV
test. The possibility of HIV has crossed his mind and he is
willing to undergo an HIV test but first would like to know
more about implications of the test.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself, confirm his identity and ask how he is.
2.  Explain the results of tests
Explain that the chest X-ray suggests pneumonia, and that
there are a number of possibilities underlying it.
3.  Explore risk factors, suggesting possible
implications of the results
Ask about his heroin use. Did he share needles? Were any
of his associates known to be HIV positive? When did he
stop using intravenous drugs? Ask about other risk factors
for HIV acquisition, especially the sexual history. These
questions suggest that HIV is on your mind and if he does
not respond suggest that HIV is something that must
always be considered.
4.  Explore ideas, concerns and expectations
Ask him if this is something that has crossed his mind, or
if he has ever considered the possibility of HIV infection.
5.  Respond to ideas, concerns and expectations
Explain what HIV and acquired immunodeficiency syn-
drome (AIDS) are, and how HIV is transmitted (and how
transmission can be reduced).
6.  Counsel with respect to HIV testing
Pre-test counselling should prepare an individual for
receiving, understanding and managing a result. Discus-
sion should embrace the consequences of a positive result,
including impact on partners, pregnancy, employment
and insurance (Box 4.44).
7.  Give an assurance of confidentiality
This is essential.
8.  Invite questions
Ask if he has any other questions or concerns that have
not been addressed.
9.  Seek consent to proceed with the HIV test
Agree that he should decide whether or not to go ahead
with the test, and if he goes ahead who will inform him
of and explain the result, and that you will continue to
investigate and treat his pneumonia.
730
Box 4.44  Counselling with respect to human
immunodeficiency virus (HIV) testing
• Ask if he has ever had an HIV test.
• Ask if he would consider one, reassuring him that the test is
entirely confidential. Emphasise that it is a test for the presence
of HIV, and not an ‘AIDS test’.
• Explain how the test is performed – a simple blood test, the
result usually available the next day.
• Ask what impact he suspects a positive result would have on him.
• Emphasise the benefits of the test (early treatment, knowledge
of infectivity to others).
• Ascertain if he has a regular sexual partner. Explain that, if
positive, it would be essential to tell his partner and desirable
that his general practitioner be informed. He may ask whether
life assurance policies would be affected. Generally, if negative,
individuals are not discriminated against. If positive, all previous
policies should be honoured, provided all relevant information
was faithfully disclosed at the time. Future policies may be
difficult take out.
• He may ask if he has acquired immunodeficiency syndrome
(AIDS). Explain that the test is for HIV, but that if positive and
tests confirm Pneumocystis pneumonia, then that is an
AIDS-defining illness. Tell him that he does not have to decide
immediately as to whether or not to proceed, but you will
continue investigating and treating his pneumonia.
10.  Discuss what would happen after the test
Post-test counselling is mandatory, whether a positive or
negative result, and the pre- and post-test counsellor
should really be the same person.
Discussion
Does a negative test exclude HIV infection?
No. The window period means that testing must be
repeated if there is a possibility that infection has been
acquired in the last few months. The management of HIV
infection is further discussed in Case 2.39.
CASE 4.47  NEEDLESTICK INJURY
Candidate information
Role
You are a doctor in the emergency medical admissions
unit.
Please read this summary.
Scenario
Re: Dr Tess Martin, aged 25 years
Dr Martin is an F1 doctor (house officer) working with you. She
comes to you extremely upset because she has sustained a
needlestick injury while taking blood from a patient she has just
clerked, who is an intravenous drug user.
Your tasks are to calm the situation and advise about
managing the needlestick injury.

Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
Dr Tess Martin is an F1 doctor (house officer) working on
the emergency medical admissions unit with her senior
(the candidate). She has just sustained a needlestick injury
from a patient who is a known intravenous drug user,
admitted with a soft-tissue infection. The patient told her
that tests for human immunodeficiency virus (HIV) and
hepatitis 2 years previously were negative, but that his status
had not been checked since and he has continued to use
intravenous drugs. Dr Martin wore two pairs of gloves for
the procedure. After withdrawing the green needle it punc-
tured her gloves and ‘pricked the end’ of her left index
finger, drawing blood. She immediately, quite correctly,
washed the area with soap and water without scrubbing,
and allowed the injury site to bleed freely. She is not sure
about the risks of HIV and hepatitis C in this situation, nor
what she should do next. She is fully immunised against
hepatitis B with an excellent antibody response.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Ask Dr Martin exactly what happened and reassure her
that you will help and follow the hospital guidelines for
dealing with a needlestick injury.
2.  Advise on immediate management
Advise her to wash the contaminated area thoroughly and
allow the wound to bleed freely (if she has not already
done so).
3.  Establish details of the incident
Establish the nature of the injury, the type of needle used
and the time of the incident.
4.  Establish details about the patient and the
staff member
Establish whether HIV and hepatitis B and C status are
known. Ask if Dr Martin has been immunised against
hepatitis B.
5.  Remain calm
Explain immediately that the risk of infectious disease
transmission is not all that high from a positive patient,
and that she has acted quite correctly so far to reduce any
risk even further.
Case 4.47  Needlestick injury
6.  Explain what you will do next
Explain that you will counsel and take a blood sample
from the patient for HIV and hepatitis B and C (this
should not be done by the individual who was exposed).
Explain to Dr Martin that she should be encouraged to
have a blood test also for HIV and hepatitis B and C and
offer to counsel her to do this (or, as is common these
days, these duties are performed by the emergency depart-
ment staff, who will arrange counselling and testing of
patient and staff member for baseline bloods and repeat
testing of staff member 3 months later; if the patient lacks
capacity blood may be taken and stored).
7.  Respect confidentiality and consent
Assure her of confidentiality. Advise that, without a test
now, if she were later found to be positive it might be dif-
ficult to claim compensation (industrial disablement
benefit). Confidentiality for both parties is essential and
of course counselling and consent for HIV testing are
mandatory.
8.  Explore outstanding concerns
Explore any other concerns she may have or if there is
anything she is not sure about.
9.  Invite questions
Ask if she has any other questions.
10.  Consider the remainder of the shift
Suggest that she might wish to go off duty and that you
will arrange the necessary cover.
Discussion
What is the risk of HIV transmission
from a positive patient following
needlestick injury?
Around 0.3%, but individual risk depends upon the
nature of the inoculation and viral load transmitted,
together with the HIV subtype and immunological factors
in the person sustaining the injury.
What action is indicated in the setting of
needlestick injury if a patient is known to
be positive for HIV?
Action points are listed in Box 4.45.
What factors increase the risk of
occupationally acquired HIV transmission?
These include deep injury, visible blood on the device
causing the injury, injury with a needle that has been
inserted in the source patient’s vein or artery and terminal
HIV-related illness in the source patient.
731
 Station |4| Communication skills and ethics
Box 4.45  Action for needlestick injury from a
human immunodeficiency virus (HIV) infected
individual
• An anti-HIV triple therapy starter pack should be given within the
first hour. The occupational health department can advise on up-
to-date local guidelines (national guidelines have been developed
on post-exposure prophylaxis for health-care workers by the Chief
Medical Officer’s Expert Advisory Group on AIDS), and if outside
normal working hours the hospital senior nurse should know
where the latest guidelines are and where treatments are kept.
• Health-care workers exposed to infectious patients should be
given the opportunity to discuss the balance of risks with
appropriate psychological support, particularly allowing
informed decisions about post-exposure prophylaxis.
• Post-exposure prophylaxis employs combination therapy for 4 weeks.
• Pending follow-up and absence of seroconversion, health-care
workers need not modify their work.
• All exposed individuals should be given advice on safe sex and
avoiding blood donation.
• Follow-up is through the occupational health department and
HIV retesting is performed at 6 months.
Would your management be any different if
your house officer were pregnant?
She should tell her obstetric consultant of the incident,
and this is essential if the incident involves an infected
patient. Zidovudine and lamivudine are considered safe in
the second and third trimesters of pregnancy but experi-
ence with other treatments is limited. However, the advan-
tages are generally deemed to outweigh the risks and
reduce the risk of vertical transmission.
CASE 4.48  MEDICAL OPINION ON
FITNESS FOR ANAESTHESIA
Candidate information
Role
You are a doctor on the medical ward.
Please read this summary.
Scenario
Re: Mrs Beth Evans, aged 80 years
Mrs Evans was admitted to hospital 10 days ago under the
care of the orthopaedic surgeons following a fractured neck of
femur. On admission her course was complicated by right lower
lobe pneumonia from which she is recovering well on your ward.
Her past medical history includes osteoporosis, ischaemic heart
disease and heart failure and current medications are antibiotics,
aspirin, furosemide, a nitrate spray and topical hormone
replacement therapy. Blood pressure is currently 160 / 90, heart
sounds are normal with no added sounds or murmurs and there
are bibasal crackles. Renal function and blood haemato-
biochemistry are normal, and her total cholesterol is 5.6 mmol / l.
Your task is to assess the lady’s medical condition with a view
to whether she might undergo hip surgery.
732
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
Mrs Beth Evans is an 80-year-old widow, hitherto living
alone in a bungalow. She was admitted to hospital 10 days
ago following a fall on her steps (there are three steps up
to the front door of her bungalow). She has fractured her
left neck of femur and this requires surgery. Surgery has,
however, been postponed so far because of pneumonia,
confirmed when she came into hospital. This has been
treated successfully, and now the orthopaedic team would
like a medical assessment, mostly to see whether Mrs Ever-
dene is fit to undergo surgery. Her past medical history
comprises osteoporosis confirmed by a bone densitometry
scan, angina (only on exertion) and heart failure, and her
medications are aspirin, furosemide and a nitrate spray.
She also takes a hormone replacement patch, and has done
for 20 years, as it relieves hot flushes and she was once told
that it helped osteoporosis. Her general practitioner once
suggested stopping it but she does not think ‘she could live
without it’. Mrs Evans will accept the opinion of the medical
team as to whether she is yet fit for surgery but is worried
about her heart and will ask the doctor for an honest view.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself, confirm her identity and ask how 
she is.
2.  Clarify the task
Explain that you are a physician and are here to advise on
her medical problems and help optimise her treatment
before any operation. Explain that you are not the anaes-
thetist, who would be responsible for deciding whether or
not she is fit for an anaesthetic.
3.  Explore symptoms
Explore the symptoms of ischaemic heart disease and
heart failure and how these may limit her and what medi-
cations she has taken in the past.
4.  Explore the past medical history
Explore the history of osteoporosis, how it was first diag-
nosed (e.g. previous fractures, strong family history of
osteoporosis or fractures) and enquire about the hormone
replacement therapy – how long she has been on it, and

for what reason (osteoporosis, symptoms of oestrogen
deficiency such as flushes). Ask about other medical prob-
lems or medications. Ask about previous operations and
anaesthesia. Ask about any allergies.
5.  Explore ideas, concerns and expectations
Explore any concerns she may have about her medical
problems or the operation.
6.  Explain and advise as clearly as possible
Suggest that you would like to examine her, especially her
heart and lungs, and review the electrocardiogram (ECG)
and chest X-ray. Suggest that you may recommend optimis-
ing treatment of her problems, notably with a view to
reducing the future risk of heart attacks and fluid on the
lungs. Ask if she is willing for you to adjust her medication
regimen, and that the adjustments will probably include
adding in a drug known as an ‘ACE inhibitor’ (beware pre-
operatively) and a statin (to reduce cholesterol and stabilise
endothelium) and possibly another diuretic (spironolac-
tone). A beta blocker may be considered later. An echocar-
diogram would be useful. Explore the past diagnosis of
osteoporosis (presumptive or confirmed by bone densit-
ometry) and the reason for her taking hormone replace-
ment therapy (osteoporosis or symptoms of oestrogen
deficiency such as flushes and atrophic vaginitis). Suggest
that you would strongly advise the hormone replacement
therapy being withdrawn, as the risks (venous thromboem-
bolism, arterial disease, breast cancer) now very much
outweigh any potential benefits (osteoporosis prophylaxis)
and that there are now better treatments for osteoporosis
than hormone replacement therapy (a bisphosphonate
with calcium and vitamin D supplementation).
7.  Repeat important information
This can be an effective way of emphasising ‘take home’
messages.’
8.  Confirm understanding
Ensure that she understands your advice.
9.  Encourage feedback and invite questions
I appreciate we’ve covered rather a lot there. Is there anything
you would like me to go over again or are there any
questions you would like to ask me?
10.  Agree a way forward
Physicians are frequently asked to give an opinion on
whether or not a patient is ‘fit for surgery’ or ‘fit for anaes-
thesia’, and the crucial decisions as to whether the patient
would tolerate anaesthesia and the appropriate mode of
anaesthesia must be made by an anaesthetist. Explain to
patients (and the team making such a request) that you
are not an expert in anaesthesia or the right person to
judge anaesthetic fitness, but that you are delighted to
advise on optimising medical care. Your role is to give a
medical opinion that can be used to optimise a patient’s
health prior to surgery.
Case 4.48  Medical opinion on fitness for anaesthesia
Discussion
List some risk factors for anaesthesia
Age is an independent risk factor (a strong predictor for
adverse cardiorespiratory outcomes such as arrhythmias,
hypotension and death) but anaesthetists look more
closely at factors such as comorbidity, obesity, reflux and
a difficult airway. Exercise tolerance in daily life reflects
biological age and functional status can be measured in
metabolic equivalents or METs (Table 4.11): 1 MET cor-
responds to oxygen consumption of 3.5 ml / kg / min
(70 kg 40-year-old man at rest). Excellent functional
reserve is > 7, moderate 4–7 and poor < 4 (Table 4.11).
Why are surgery and anaesthesia
such a threat?
Surgery causes blood loss and fluid shifts. Post-operatively
surgery causes pain (with reduced coughing and increased
risk of respiratory infection), limits movement and triggers
the stress response of sympathetic activity, glucocorticoid
activity and fluid and salt retention. There is also reduced
enteral absorption, altered immune function and altered
coagulation. These changes peak in the first 2 days but
linger for weeks.
Most intravenous anaesthetic drugs have adverse cardio-
vascular effects, reducing afterload and having negative
ionotropic effects. They cause apnoea necessitating posi-
tive pressure ventilation and inhibit mucociliary function
for 24 hours. They adversely affect renal function. Propo-
fol, an induction agent, reduces systolic pressure by 40%
on average in elderly patients. Regional anaesthesia vasodi-
lates the affected area and interrupts sympathetic innerva-
tion of the heart and can result in marked bradycardia and
hypotension if near the higher thoracic outflow.
Anaesthesia affects thermoregulation. A drop of 2°C
centrally in the first 20 minutes is normal but can take an
hour or two to recover with active warming. This hypo-
thermia has a profound effect on cardiorespiratory, cere-
bral, clotting and immune function.
What cardiovascular problems are provoked
by anaesthesia?
Increased arterial stiffness with age increases afterload
such that there is little change in cardiac output with an
Table 4.11  Exercise tolerance measured in metabolic equivalents
(METs)
MET Activity
1 Self-care
Using toilet
Walking at 2–3 mph
4 Light housework
Climbing a flight of stairs or a hill
Walking at 4 mph
Running a short distance
> 10 Dancing, golf
Highly strenuous sports – swimming, football
733
 Station |4| Communication skills and ethics
increase in as the left-ventriclar end-diastolic volume
increases. Consequently:
• Atrial systole is even more important in situations
where it is less likely (!) and anaesthetists do not
like to anaesthetise patients with fast or variably
controlled atrial fibrillation except in emergencies.
• Reduced diastolic time reduces coronary flow and ST
changes on the ECG are common, especially at
induction. These changes, often associated with
hypotension and tachycardia, may respond to fluid
challenges but the sting in the tail is that elderly
patients are less tolerant of this.
Post-operative myocardial ischaemia remains the biggest
cause of death and morbidity in elderly patients. Myocar-
dial infarction tends (anecdotally) to occur on the second
post-operative night. Systolic murmurs are extremely
common. A good exercise tolerance and ECG are usually
reassuring pre-operatively, but significant aortic stenosis
combined with anaesthesia can lead to a disastrous drop
in afterload. Heart failure does not blend well with anaes-
thesia for all of the reasons outlined.
Is hypertension a risk factor for
anaesthesia?
For every 10 mmHg in systolic pressure above 140, there
is an odds ratio of 1.2, such that a systolic pressure of 180
doubles the risk of infarction.
What medical problems are relevant to
anaesthesia?
Other important problems include respiratory problems
with reduced functional residual capacity or low oxygen
saturation (higher inspired oxygen is needed and positive
pressure ventilation increases ventilation / perfusion mis-
match), respiratory tract infection, reflux, confusion,
alcohol misuse, electrolyte disturbance, obesity, hypothy-
roidism and drugs.
CASE 4.49  FITNESS TO DRIVE
Candidate information
Role
You are a doctor in the diabetes clinic.
Please read this summary.
Scenario
Re: Mrs Julie Blyth, aged 36 years
Mrs Blyth has type 1 diabetes and takes insulin. She has
problems with hypoglycaemic unawareness. She is still driving and
you are immediately concerned by this.
Your task is to explore the issue of driving with her and make
some recommendations.
734
Your examiners will warn you when 12 minutes have
elapsed. You have 14 minutes to communicate with the
patient / subject followed by 1 minute of reflection. There
will then follow 5 minutes of discussion with the examin-
ers. Do not take the history again except for details that
will help in your discussion with the patient / subject. You
are not required to examine the patient / subject.
Patient / subject information
Mrs Julie Blyth is a 36-year-old single mother of three
children. She has type 1 diabetes and takes the combina-
tion of long- and short-acting analogues glargine and
Novorapid respectively. She is very afraid of long-term
diabetes complications and runs her blood glucoses very
tightly between 3 and 4 mmol / l, which she believes to be
the normal range. She has frequent hypoglycaemic symp-
toms (sweats, light-headedness), but does not recognise
these as such. She feels she must drive. She drives a car to
pick her children up from school and a small delivery van
for an income. She is very concerned that the doctor in the
diabetes clinic could ‘take her licence away.’
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself and confirm her identity.
2.  Provide initial reassurance
Reassure her that you wish to try to establish why she is
having symptoms and aim to correct these, rather than
recommend that she does not drive.
3.  Review her diabetes treatment and any
complications to date
Be aware that insulin is a contraindication only to driving
a heavy goods vehicle and not to other driving provided
she is not having hypoglycaemic episodes.
4.  Be alert to ideas, concerns  
and expectations
Establish the discrepancy between her idea of normal
blood glucose readings and what is in fact normal.
5.  Reframe her ideas
Explain that she should be aiming for a blood glucose
reading of 4–7 mmol / l, and that she is currently aiming
too low and this is likely to be giving rise to symptoms.
Reassure her that resetting her target should not increase
her risk of long-term complications.
6.  Keep it clear
Keep your explanation as clear as possible.

7.  Repeat important information
If she is anxious this may be especially important.
8.  Confirm understanding
Ensure that she understands that her blood glucose target
was too low.
9.  Encourage feedback and invite questions
I appreciate we’ve covered rather a lot there. Is there anything
you would like me to go over again or are there any
questions you would like to ask me?
10.  Agree a way forward
Assure her that she will be able to drive, but only when
her blood glucoses are normal. Ensure that there are
arrangements for treatment and follow-up.
Discussion
Who is legally responsible for deciding
whether a patient is unfit to drive?
The Driver and Vehicle Licensing Agency (DVLA) is respon-
sible. The DVLA should be informed if a patient who holds
a driving licence has a medical condition that now or at
some future date may affect driving safety. The legal basis
of fitness to drive lies in the Road Traffic Act of 1988 and
subsequent regulations
When might it be a doctor’s responsibility
to inform the DVLA?
These are outlined in Box 4.46.
Do you know the differences between a
prescribed disability, a relevant disability
and a prospective disability?
• A prescribed disability is condition that legally bars
the holding of a driving licence unless certain
conditions are met, e.g. epilepsy.
Box 4.46  Situations when a doctor might need
to inform the Driver and Vehicle Licensing
Agency (DVLA)
• If a patient lacks capacity to understand advice not to drive,
e.g. dementia.
• If a doctor is aware that a patient continues to drive against
medical advice, every reasonable step may be made to
persuade the patient to stop, and this may include breaching
confidentially and speaking with a relative. If a doctor is unable
to persuade, or becomes aware that such a patient is
continuing to drive, then the relevant medical information
should be disclosed immediately to a medical adviser at the
DVLA. Before disclosure, a patient should be informed of the
decision to do so, and afterwards informed by letter. The
patient’s general practitioner should also be informed.
Case 4.50  Industrial injury benefits
• A relevant disability is a condition that probably
renders a person unsafe to drive, e.g. visual field
defect.
• A prospective disability is a progressive or
intermittent condition that may in future lead to a
relevant or prescribed disability, e.g. type 1 diabetes.
May a patient with a prospective
disability drive?
Yes, subject to medical review at defined intervals.
What are the visual requirements for driving?
The visual acuity requirement for driving a private car is
based on the number plate test. A person should be able to
read in good light a number plate of letters or numbers
79.4 mm high (binocular vision with correction for any
refractive error) at 20.5 m. This equates to a visual acuity of
between 6 / 9 and 6 / 12 on a Snellen chart. Failing to meet
the requirement constitutes a prescribed disability and a
licence must be refused or revoked. The minimum field of
vision for safe driving is at least 120° on the horizontal
measured by the Goldmann perimeter.
What are the rules on driving after
a seizure?
Current legal rules for drivers (of non-heavy goods or
public transport vehicles) are that they must be seizure free
for more than 12 months or free of daytime seizures for
more than 3 years if seizures are purely nocturnal. These
rules apply on or off anti-epileptic drugs. Patients must not
drive for 6 months following any dose adjustment. Patients
have a legal duty to inform the DVLA of their condition.
CASE 4.50  INDUSTRIAL INJURY
BENEFITS
Candidate information
Role
You are a doctor in the respiratory clinic.
Please read this summary.
Scenario
Re: Mr Andrew Hopkins, aged 77 years
Mr Hopkins is a retired shipyard worker, and has been
progressively breathless. His chest X-ray suggests pulmonary fibrosis
and there is pleural thickening with calcified pleural plaques.
Pulmonary function tests reveal moderate restrictive lung disease
and a thoracic computed tomography scan confirms interstitial lung
disease. All of this suggests asbestos-related lung disease. Mr
Hopkins is here for results and says that a friend told him he might
claim industrial disablement benefit were asbestos the cause.
Your task is to explain the results and discuss the way forward
for industrial disablement benefit.
735
 Station |4| Communication skills and ethics
Your examiners will warn you when 12 minutes  information would help determine the level of benefit.
have elapsed. You have 14 minutes to communicate  Explain that benefit may be backdated up to 3 months.
with the patient / subject followed by 1 minute of reflec-
tion. There will then follow 5 minutes of discussion with
the examiners. Do not take the history again except for
details that will help in your discussion with the
patient / subject. You are not required to examine the
patient / subject.
Patient / subject information
Mr Andrew Hopkins is a 77-year-old retired shipyard
worker, exposed to asbestos for at least 25 years of his
working life during handling of construction materials. He
has been progressively breathless over the last 18 months
and a chest X-ray, pulmonary function tests and thoracic
computed tomography scan have confirmed asbestos-
related lung disease. He is aware that industrial disable-
ment benefit is available from the Department of Social
Security (DSS) and wishes to discuss this.
How to approach the case
Communication skills (conduct of interview,
exploration and problem negotiation) and
ethics and law
1.  Introduction
Introduce yourself and ask how he is.
2.  Explain the results of tests
Explain that there is thickening of the lining of the lungs
with plaques (hard patches) due to asbestos exposure, and
also scarring of the lungs almost certainly due to asbestos
(asbestosis).
3.  Explore occupational history
Obtain details of different occupations and length of expo-
sure with each.
4.  Explain the implications of the results
Explain that treatment options are limited and that asbes-
tosis tends to progress, albeit slowly, but reassure him that
there is no evidence of lung cancer or cancer to the lining
of the lung (mesothelioma) which can occur in asbestos
lung disease.
5.  Establish knowledge of eligibility   Box 4.47  Asbestos lung disease eligible
for compensation
Ask if he aware of his eligibility to claim for industrial
disablement benefit.
6.  Explain the legal position
Explain that people with asbestos lung disease are entitled
to compensation. Explain that a DSS medical officer
would visit to assess the degree of disability and that this
736
Explain that he could appeal within 3 months, if he disa-
greed with the verdict
7.  Explain what to do in practice
Explain that he should go to his local social security office
and collect form B1 (100Pn). This covers occupational
lung diseases. Say that you will write this down for him
later.
8.  Explore any outstanding concerns
Ensure that you have addressed all of his concerns.
9.  Invite questions
Ask if he has any other questions.
10.  Agree a way forward
Agree a clear course of action, ensuring that medical 
follow-up at clinic or with his general practitioner is in
place.
Discussion
What types of asbestos lung disease
make a patient eligible for compensation?
These are listed in Box 4.47.
Can compensation be considered for any
other lung diseases?
Patients with a wide range of pneumoconioses, including
coal worker’s pneumoconiosis and silicosis, are eligible.
Can patients sue previous employers?
Yes, but many patients will have been exposed to asbestos
from various workplaces and it may be difficult to prove
that exposure in one workplace caused disease. Further,
many employers no longer exist and legal expenses make
legal action untenable.
for compensation
• Mesothelioma
• Asbestosis
• Bilateral diffuse pleural thickening to a thickness of 5 mm or
more at any point on chest X-ray
• Primary lung cancer with evidence of asbestosis or diffuse
pleural thickening

FURTHER READING
Communication skills and ethics
British Medical Association. Online.
Available: www.bma.org.uk.
Chochinov, H.M., 2007. Dignity and the
essence of medicine: the A, B, C and Wynne, H.A., 2003. Sensible prescribing
D of dignity conserving care. BMJ
335, 184–187.
General Medical Council. Online.
Available: www.gmc.org.
Hope, T., 2004. Medical ethics; a very
short introduction. Oxford
University Press, Oxford.
Hope, T., Savulescu, J., Hendrick, J.,
2008. Medical ethics and law: the
core curriculum, revised second ed.
Churchill Livingstone, Edinburgh.
Neighbour, R., 1987. The inner
consultation. MTP Press, Lancaster
(revised 2nd edn, Radcliffe
Publishing Ltd; 2004).
Tate, P., 1984. The doctor’s
communication handbook. Radcliffe
Press, Oxford (6th revised edn,
Radcliffe Publishing Ltd; 2009).
The Oxford Centre for Ethics and
Communication in Health Care
Practice. Online. Available:
www.ethox.org.uk.
The UK Clinical Ethics Network. Online.
Available: www.ethics-
network.org.uk.
Discussing clinical management
Explaining an investigation
Adler, B.J., Stott, D.J., 2003. How far to
investigate older people? Clin Med
3, 418–422.
Discussing treatment
Davies, E.C., Green, C.F., Taylor, S.,   Available: webarchive.
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Available: www.plosone.org/doi/
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Medical Research Council Centre for
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Available: www.mrc.ac.uk.
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Available: www.mhra.gov.uk.
Pirmohamed, M., James, S., Meakin, S.,
et al., 2004. Adverse drug reactions
as a cause of admission to hospital:
a prospective analysis of 18,820
patients. BMJ 329, 15–19.
Stroke Prevention in Atrial Fibrillation
II Study, 1994. Warfarin versus
aspirin for prevention of
thromboembolism in atrial
fibrillation. Lancet 343, 687–691.
for older people. Clin Med 3,
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Communication in special
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Delayed discharge
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