Fast Paces ST 4 Fourth Edition

FAST PACES ACADEMY

STATION 4
COMMUNICATION
SKILLS AND ETHICS
Dr. Sadia Nasir

MRCP(UK), MD(USA)
Dr. Imran Babar
MRCP(UK)

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“GATHER” APPROACH FOR STATION 4

G Greeting
A Agenda Setting
Ask if privacy required
Ask about the symptoms (Ask how the patient is feeling after the procedure if done)
Ask the understanding of the patient about the problem
Ask if discussed with anyone else
T Tell the patient about the problem in a clear way

H Help the patient by guiding about the condition, procedure etc.
E Explanation (Following should be kept in mind while explaining the condition, therapy,
procedure etc.)
o Make use of all the information given in the scenario
o May draw pictures to make it more clear to the patient
o Encourage the patient to ask questions throughout the discussion
o Explore the concerns of the patient
o Respond accordingly in short chunks
o Keep asking the understanding of the patient throughout the discussion like by asking Is that Ok
with you? Or Are you with me? etc.
o Be honest i.e. don’t try to be expert about which you don’t know and tell it clearly
o Can arrange another meeting if issues to be discussed are left because of shortage of time
o Can also arrange meeting with the consultant if required
R Reassure
Referrals/Leaflets & societies
Recap
Recall and follow ups with contact details

Dr. Sadia Nasir MRCP (UK) 2
Dr. Imran Babar MRCP (UK)
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COMMON SCENERIOS

1. Consent for a procedure and Treatment (Obtaining informed consent)
I. Lumber Puncture (LP)
II. Upper GI endoscopy (OGD)
III. Colonoscopy
IV. ERCP
V. PEG tube insertion
VI. Angiography
VII. Bronchoscopy
VIII. Nephrostomy
IX. CVP Line Insertion
X. Pleural Biopsy
XI. Renal Biopsy
XII. Chemotherapy
XIII. Radiotherapy

2. Diagnosis Explanation & Treatment options (Diagnosis, Prognosis, Treatment, side effects
& social issues like family, job, livelihood etc.)
a. Celiac Disease
b. IBD
c. First seizure
d. RA
e. Valvular heart disease
f. Insulin therapy
g. Hormone replacement therapy

3. Explanation of a Mistake or error (May face angry patient or Relative & complaint
launching)
Error in drug administration

4. Breaking bad news (Chronic illness or life threating conditions)
In which patient’s autonomy can be discussed if talking to a relative
In terms of treatment consider beneficence
In terms of not treating consider maleficence
I. Diagnosis of cancer
II. Multiple sclerosis
III. Rheumatoid Arthritis
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5. Breaking bad news & end of life decision
I. Breaking bad news and organ donation
II. Breaking bad news and DNAR decision
III. Breaking bad news and requesting a postmortem examination
IV. Breaking bad news and advance directives
V. Coroner’s postmortem

6. Side effect of a therapy (Complaint launching)

7. Risking confidentiality for public /third party protection

8. Negotiating a plan ( Patient or relative may disagree with the plan)

9. Difficult patients/ relatives
I. With functional disorder like IBS
II. A Missed tumor like backache and tumor was not picked by GP
III. Delay in investigation

10. General clinical problems
I. HIV testing
II. Communication of HIV positive results
III. Cases related to TB
IV. Hospital super bug like clostridium difficile & MRSA
V. Genetic counselling

11. Communication with colleague
I. Colleague with Hepatitis B infection
II. A Colleague with needle stick injury

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HOW TO START THE STATION?

• Hello, my name is Dr. ………… and I am one of the doctors in the clinic/
medical ward today.

• Are you Mrs. Jones?

• Are you Mrs. Jones’s daughter Mrs. Peter? (if discussing with a relative)

• Nice to meet you. (smile).
Do not say this if it is a breaking bad news station

• Well, Mrs. Jones. The purpose of today’s consultation is to

o Discuss the results of your tests and further management plan. (if
informing about some investigation result)

o Discuss the condition of your father/ husband and his further
management plan. (if discussing with relative).

• So, how are you feeling now? (if patient has any previous symptoms).

• What do you think is the cause of your symptoms? (check understanding
level)

• Has somebody discussed your test results with you?

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LAWS/ PRINCIPLES OF MEDICAL ETHICS

1. AUTONOMY – patients wishes and self rule.

2. BENIFICIENCE – doing good and promoting what is best for the patient.

3. NON-‐‑MALEFICIENCE -‐‑ do no harm.

4. JUSTICE – fairness in provision of healthcare.

5. DUTY OF CANDOR -‐‑ to inform and apologize to patients if there have been
mistakes in their care that have led to significant harm. (in scenarios like
medical error/negligence).

6. CONFIDENTIALITY ISSUES -‐‑ Issues regarding Driving and informing the
DVLA, major incident reporting, notifiable diseases.

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CONSENTING PATIENTS

Types of Consent:

1. Expressed: Written or verbal agreement for the procedure.

2. Implied: e.g. the patient’s action in response to a request for exam.

3. Statuary: When the law requites a particular consent e.g. IVF

WHAT IS COMPETENCE (CAPACITY)?

• Understands what he /she is being told

• Can reason about the treatment
• Communicates his/her choice and the reason for this choice
• Understands the consequences of his/her choice.
WHEN CAN YOU EXAMINE/TEST/TREAT WITHOUT CONSENT?

1) For life-‐‑saving procedures when the patient is unconscious/incompetent to indicate
his/her wishes.

2) Where a patient is incapable of giving consent as a result of a mental illness, the
treatment should be based on the patient’s “best interest" principle.

3) Where a minor (<18 years of age) is a ward of Court & the Court decides that a specific
treatment should be given in the child’s “best interest”

TYPES OF CONSENT FORMS:
Consent form 1: Adult patient able to consent themselves.
Consent form 3: An optional form that can be used when consenting patients for a
procedure that does not involve any impairment of consciousness.
Consent form 4: Adult patient who lacks capacity. The ultimate decision in these situations
lies with the Consultant in charge of the patient’s care based on a best interest decision.

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INCOMPETENT/UNCONCIOUS PATIENT
Ask if:
1. If he expressed any wishes
2. Advanced directive / Living will
3. Legal power of attorney
If none of these are available and the patient cannot consent, then the
medical team must make a decision in the best interests of the patient.
If the patient has made an advanced directive/ living will
This is a legal document, which informs medical staff what medical treatment
a patient would not want in the future if they ‘lacked capacity’. The advanced
directive is “situation specific”.
If the patient has made a lasting power of attorney
This is a legal document, which allows a patient to appoint a person to make
decisions about medical care, when the patient is no longer able to make these
decisions (i.e. they are incompetent). Can be revoked in some conditions,
You may involve the medico legal team if there is a conflict with the
patient’s family.

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BREAKING BAD NEWS

Important points
• Find a quiet room
• Confirm the identity of whom you are speaking with.
• Give a warning shot before breaking the bad news.
• Never give false hopes to the patient.
• Avoid information overload.
• State that you and the team did what you could, and say how sorry the
whole team is.
• Demonstrate empathy.
• Wait until asked to explain details, but keep it simple.
• Allow her to cry with dignity, such as by handing her some tissues.
• Do not be afraid of silence, but if this becomes uncomfortable it is
often helpful to make an open statement, such as
‘This must have come as a shock’.
• In finishing the discussion, explain that should further questions arise you
will be happy to answer them.
Sample answers to questions:
“Am I going to die?”
“I am afraid that your cancer is so advanced, that it is likely to shorten your life”

“How long have I got?”
“Different cancers behave differently in different people & it isn’t possible to predict exactly
how they behave in each individual”

Also say that you will have to notify the coroner, which is routine
following any unexpected death, and that the nursing staff will provide
her with information about practical matters such as death
certification.


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DO NOT RESUSCITATE
A DNR decision isn’t necessary to discuss with patients:
1. If the patient is incompetent.

2. If the decision was made on grounds of futility.
3. If a competent patient indicates that he/she doesn’t wish to discuss it.
4. This may also be justified in competent patients, without obtaining
consent, if decision is based on basis of “poor quality of life”.
What facts need to be told to the patient?
• The patient should be fully informed about the diagnosis & prognosis
• That CPR is usually unsuccessful in such cases.
• The possibility of survival with a neurological damage should be pointed out.

However, these are relatively uncommon; 1 –2% survives in a Permanent
Vegetative State.
• Elderly patients with chronic illnesses have < 5% chance of survival to

discharge.
NOTE: DNR is a Consultant decision!!!!!!!!!!

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MEDICAL ERROR REPORTING

NEGLIGENCE:
Three separate issues to be considered.
1-‐‑A duty of care between the doctor and the patient must be established.
2-‐‑ A breach of this duty of care must be evident
3-‐‑ This breach in duty of care should cause harm
MEDICAL ERROR:
It is a preventable adverse effect of care. It is unintentional whether or not it is evident or
harmful to the patient.
STEPS TO HANDLE A MEDICAL ERROR:

• If angry patient/relative, then calm them down by either staying quiet and letting them
vent out their feelings, or by apologizing repeatedly.

“Mrs. Jones, you look really upset. Would you like to share with me why?”

“Mrs. Jones I truly apologize for the medical error made”

“I can understand that you are upset. Any other person in your place would feel the
same way”

“I am so sorry this has happened to you”

• Explain that there may be a break in communication or give some other logical reason.

• File an Incident report form at the Hospital.

• Involve your consultant in charge and also offer the patient / relative that you can
arrange a meeting with your consultant -‐‑-‐‑-‐‑-‐‑-‐‑-‐‑à VERY IMPORTANT !!!!

• Document the allergies on patients file in bold letters.

“Thank you so much for sharing your feelings with me. Its very important that we
understand each other completely”

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STEPS TO LAUNCH A COMPLAINT

1. Write a formal letter of complaint addressed to the practice manager at
his GP surgery. There are systems in place to deal with the matter
internally at this level.
2. Give contact details of Patient Advisory Liaison Service (PALS). They
will have an office in the hospital.
3. Reassure her that her complaint will be taken very seriously and she will
receive a formal response within 28 working days.
4. If she is still not satisfied and wants to take legal action, tell her that she
would need to consult with the solicitor (PALS team can give her more
information on this).
5. If no PALS team, then consult with the Local community health council.
6. Patient can also contact Independent Complaints Advocacy
Service(ICAS) which is an independent body which can help
patients/relatives in making their complaint.
7. If still not satisfied with the outcome of the complaint, then he/she has a
right to review by the Parliamentary and Health Service Ombudsman
(PHSO).

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BRAIN STEM DEATH

What to say to the patient?????
• There has been severe damage to a part of his brain called the brain stem. This
normally controls the lung’s breathing and other basic functions needed for life.
• Unfortunately, there is nothing we can do to reverse or make it better.
• The only thing keeping the patient alive is the machine which can help with the
breathing for a short time. (ventilator)
Pain in brain stem death
Families can be re-‐‑assured that the body is no longer able to feel pain when the brain stem
has died.
Brain stem death and machine support
In the ICU the patient is being supported, mainly by a ventilator, that breathes for them.
They may also be receiving other medications to maintain other basic functions. Once the
ventilator is turned off they will stop breathing, and shortly afterwards the heart will stop.
(If they stayed on the ventilator the heart would continue to beat by itself for a certain time
whilst the lungs continue to breathe, but it would not continue indefinitely, and eventually
the heart would also stop.)
After the diagnosis
Once brain stem death has been confirmed there is no chance of recovery. The
family should be offered time with the patient to say goodbye, and to have any
religious input if they would like. If the patient is suitable for organ transplant,
the family should also be asked regarding this and the organ donation nurses
informed – enquire about being on the donor register, carrying a donor card,
advanced decisions, lasting power of attorney, beliefs and wishes expressed in
the past.

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Criteria for Brainstem Death (viva question)

• All brain stem reflexes are absent
• Pupils are fixed and non-‐‑responsive to light
• Corneal reflex is absent
• The vestibulo-‐‑ocular reflexes are absent. No eye movements
following slow injection of at least 50mls of ice cold water over
one minute into each external auditory meatus).
• No limb response to supraorbital pressure
• No gag reflex
• No respiratory movements when disconnect ventilator (PaCO2
6.65kPa confirmed on ABG)

Repetition of testing is done by
• 2 medical practitioners
• competent in this field
• registered at least 5 years (at least one of the doctors should be
a consultant)
• not members of the transplant team
• 2 sets of tests should always be performed, can be done by the
two practitioners separately or together.

Although death is not pronounced until the second test has
been completed the legal time of death is when the first test
indicates brain stem death.

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ORGAN DONATION
UK has an opt in program as opposed to the OPT out program in other
countries.
Has the patient registered?
• Check the organ donor registry

• Look/Ask about organ donor card
The patient has registered but the family disagree:
From a legal point of view, if a patient has signed up to the organ donor register they
are deemed to have given legal consent. However, in reality, it is felt necessary to obtain
consent from loved ones as well, and it would be very unlikely that clinicians would ever go
against the family if they had expressed strong wishes against donation.
The patient hasn’t registered, there is no advanced decision, there is no
LPA:
Important to speak to family and friends about the patient’s wishes and beliefs, and what
their decision is likely to have been had they been able to decide themselves. The law then
states that it is ultimately the next of kin’s decision whether or not organ donation is
allowed.
The process of organ donation:
Ideally a member of the transplant team such as the transplant coordinator, specialist
organ donation nurses are with you during these conversations. The family should be
aware that there are occasionally reasons why a patient cannot be a donor (e.g: certain
cancers and infections, or ongoing coronial issues) even if they would wish to be, and that
as part of the process of preparing for organ donation additional blood tests will need to be
taken screening for infections and tissue type. You should inform them that if they do
consent, they can withdraw that consent at any time up until the point that obtaining the
organs in theatre has begun.

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DEATH REPORTING TO THE CORONER

Which deaths require reporting to the coroner?
§ Cause of death is unknown.
§ Deceased was not seen by the certifying doctor either after death or
within the 14 days before death.
§ Death was violent, unnatural or suspicious.
§ Death may be due to an accident (whenever that occurred).
§ Death may be due to self-‐‑neglect or neglect by others.
§ Death may be due to an industrial disease or related to the person’s
employment.
§ Death may be due to an abortion.
§ Death occurred during an operation or before recovery from the effects
of anesthetic.
§ Suicide.
§ Death occurred during or shortly after detention in police or prison
custody.

Who should be notified following a cardiac arrest?

• The coroner may be required to be notified (see above).
• The patient’s GP.
• The consultant responsible for the management of the patient should be
notified as soon as possible.

Who fills in the death certificate?

• Part 1 should be completed by one of the medical team caring for the patient.
It should include the date of death and details as to the presumed cause.

• Part 2 is completed by a medical practitioner with at least 5 years of
experience.
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GENETIC TESTING
§ Patient must understand how the test is performed (e.g.: a blood test).
§ There should be a cool off period between your discussion with them and the test itself
during which time, they should be encouraged to discuss with families and partners, and to
read through any relevant literature or leaflets.
§ They should receive their results in person.
§ Discuss alternatives (e.g.: screening for breast cancer with mammography).
§ Make them aware of the benefits of testing e.g. Early treatment, prevention, screening.
§ They should be warned about the negative effects of a positive tests on life insurance
policies and mortgages.
§ Implications for other family members (who may not wish to know) and the patient’s
children (who will then be recognized to be at risk).
§ The possibility of an inconclusive test should be raised.
§ Make a referral to the Regional Specialist Clinical Genetics Service
HUNTINGTONS DISEASE:

• That there is no treatment for Huntington’s disease.
• Most physicians with experience of Huntington’s disease feel that it is
inadvisable to test in the following circumstances:
1. Children under18 years
2. For insurance purposes
3. If the patient is reluctant
4. If the result automatically reveals some other family member to have
the disease without their consent.

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STARTING A NEW TREATMENT
ANTI-‐‑ TUBERCULOUS THERAPY:
The four key medications, their baseline tests, monitoring and side-‐‑effects are:
§ Rifampicin: 6 months. Liver dysfunction – warn patients to seek medical

advice urgently if they notice yellowing of skin or eyes, fever, feeling sick, or
itching – re-‐‑assure that mild transaminase disturbance is common at the start
of treatment. Tears and urine become orange colored.
§ Isoniazid: 6 months, with pyridoxine if at high risk of neuropathy (alcoholic,
diabetic, CKD, HIV, malnutrition). Liver dysfunction, neuropathy – warn
patients to report numbness of tingling in the arms and legs.
§ Pyrazinamide: 2 months. Liver dysfunction.
§ Ethambutol: 2 months. Document visual acuity with a Snellen chart before
starting therapy. Visual disturbance – warn patients to stop medication and
seek medical advice urgently if they notice loss of vision or specific loss of
colour vision.
Special situations to consider:
§ Homelessness: Ideally therapy is given at home, but may need to be in-‐‑patient
(in negative pressure side-‐‑room) or as part of Directly Observed Therapy
(DOTs; thrice weekly therapy makes this easier to do). If a patient cannot be
adequately monitored and refuses to stay in-‐‑hospital, they may be kept
against their will as part of the Public Health (Control of Diseases) Act 1984.
§ Alcoholics: Involve the alcohol liaison team, monitor more frequently for liver
dysfunction, give pyridoxine prophylaxis from the beginning.
§ Patients on other medications: Rifampicin will interfere with contraceptives,
warfarin, steroids, and anti-‐‑epileptics.
Additional issues to address in a consultation related to this:
§ HIV testing.
§ Contact notification and informing Public Health England.
§ Informing their GP.
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HORMONE REPLACEMENT THERAPY
Clarify the symptoms the patient is experiencing (hot flushes, dry skin,
itchiness, urinary infections, dyspareunia, low mood) and their
personal/family history (strokes, heart attacks, clots in leg and lung, breast
cancer, osteoporosis). Check when they had their last period and if they have
undergone a hysterectomy. Then go through:
§ Benefits: Reduced symptoms, increased bone strength.

§ Route: Systemic (tablet, patch, implant), local (creams, pessaries, rings).

§ Alternatives: Vaginal lubricants, SSRIs, complimentary therapies (beware,
some contain oestrogen analogues), reducing alcohol, stop smoking; also
tibolone (oestrogen, progesterone, androgens).

§ Combined or oestrogen only: The latter should only be used by women
who have had their uterus removed otherwise there is a high risk of
endometrial cancer.

§ Cyclical or continuous: If women are still having periods you can give it
cyclically to give a withdrawal bleed.

§ Expected side-‐‑effects: Breast tenderness, nausea, leg cramps – tend to
settle after a few months; skin irritation from patches.

§ Dangers: Include breast cancer and thromboembolism, possibly heart
attacks and strokes.


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DRIVING REGULATIONS
• It is the patient’s duty to inform the DVLA of the changes in their health,
it is your duty to tell the patient this and ensure they understand why.
• If you were to find out that the patient was driving despite this advice,
you should discuss it with the patient again, and tell the patient that if
they don’t inform the DVLA, you may do so on their behalf.
• If they still continue to drive, you should contact the DVLA medical
advisor in your hospital.
Heart attacks
Group 1:
You need to stop driving for 4 weeks, but do not need to tell the DVLA.
Group 2:
You need to stop driving, and can only get your license back if you pass stage 3 of an ETT
off anti-‐‑anginal treatment i.e. you will be off work for a while.
Seizures – First unprovoked epileptic seizure/isolated seizure
Group 1:
Must not drive for 6 months from the date of seizure.
Clinical factors that indicate that there may be an increased risk of seizures require the
DVLA not to consider licensing until after 12 months from the date of first seizure.
Group 2:
Driving will be prohibited for 5 years from the date of the seizure. If after 5 years a
neurologist has made a recent assessment and given clearance, then the license may be

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restored.
Diabetes
Group 1:
This is generally fine, as long as you do not have poor vision, frequent hypos, severe hypos
(enough to bring you to hospital) or hypoglycemic unawareness.
Group 2:
Until recently, you could not have this type of license and be on insulin treatment. This rule
has recently been relaxed. You can drive a group 2 vehicle on insulin if:
1. You have stable glycemic control over a 3-‐‑month period.
2. You can demonstrate evidence of this using a glucose monitor with a memory
function for at least 3 months.
3. You are checking your blood sugars at least twice daily.
Remember, these regulations mean that if you want to start insulin, you must take 3
months off driving your lorry.
Vasovagal Syncope
If reflex vasovagal of unknown origin – no need to inform DVLA.
If cardiac origin, then do not drive fro 6 months.
If accompanied by seizure, then no driving for 1 year.

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FLYING REGULATIONS

Generally, you need to advise patients with certain disorders to discuss it
early with their airline and insurance company; and if you need further advice
you can clarify with the UK civil aviation authority health unit.

Deep venous thrombosis
General advice to reduce the risk includes keeping well hydrated (non-‐‑
alcoholic), keep mobile, avoid tight fitting clothing on the lower limbs and
consider using compression stockings. Some may need aspirin (e.g:
polycythemia) or LMWH (e.g.: malignancy, personal/family history of VTE,
recent major surgery).
Chronic obstructive pulmonary disease
If oxygen saturations are over 95% at rest and the patient can go up a flight of
stairs or walk 50m without becoming overly short of breath they should
tolerate a flight ok. If less than this, they may need to consider further
investigation by a respiratory physician to see if supplemental in-‐‑flight oxygen
is required. They will gauge this via arterial blood gases and hypoxic
challenges.
Diabetes
If they are on insulin they will need a cool bag or cooled vacuum flask to carry
the insulin with them. It should not go into the hold as it can freeze. They
should also carry something sugary with them in case of a hypo, and look into
adjusting their dose of insulin for a long haul flight across time zones (East –
take fewer units, West – take more units or additional short acting insulin

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SOME SIMPLE SENTENCES TO LEARN

• Hi, I am Dr……. I understand you wanted to see me to discuss about
………….

• May I confirm your ID details before we further discuss about

• If I were in your shoes, I most probably will do the same

• Mr. ……..with your investigation reports completed now, I am afraid I
don’t have good news with me……… (pause and break news when asked
by the patient ‘what is it doctor?’)

• I understand that this isn’t what you wanted to hear. I wish the news
was better.

• Do you want someone with you right now while we discuss about your
condition.

• I understand your concern, but let me assure you……….

• This question is rather difficult for me to answer. Please let me discuss it
with my consultant and I shall get back to you.

• We are trying the best we can be hoping that your mother will get
better, unfortunately ………

• I know its rather too much to know in one sitting. If you have further
questions, I will be available in the evening too today.

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SAMPLE CASE SCENERIOS

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CASE 1: BENIGN INTRACRANIAL HYPERTENSION AND
CONSENT FOR LUMBAR PUNCTURE

1. What is the cause of my symptoms?
2. Will I go blind?
3. What is Benign Intracranial Hypertension?
4. So, how will you treat it?
5. What is a lumbar puncture?
6. Will the procedure be painful?
7. Are there any chances of infection?
8. Will I be awake during the procedure?
9. After the procedure, how long will I have to stay in the hospital?
10. Will I have to ask someone to accompany me to the hospital?
11. Since you will be putting a needle in my back, are there any chances of paralysis?
12. What if I decide not to have the LP? Are there any other options?


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CASE 2: NSAID INDUCED ULCER AND CONSENT FOR ENDOSCOPY

1. Why do you think I am bleeding from my gut?
2. What can you do to stop the bleeding?
3. What is an Upper GI Endoscopy?
4. Is this a surgical procedure?
5. Will it hurt?
6. Will I be awake?
7. What are the complications of this procedure?
8. After the procedure how long will I have to stay in the hospital?
9. What would happen if I don’t agree to have the procedure done? Are there any other
options?
10. Can you give me some pills to stop the bleeding?


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CASE 3: PATIENT RELUCTANT TO RECEIVE INVESTIGATION
&TREATMENT (ANTI-‐‑HYPERTENSIVE)

1. I feel very well and went to the doctor for an OCP prescription, I have never had high
blood pressure.
2. What will happen if I don’t do anything for the high blood pressure?
3. What is the cause of my high blood pressure?
4. How can you tell if the high blood pressure has damaged my body?
5. What are the treatment options I have?
6. Will a single tablet dose cure me?
7. What if I get the side effects from the pills?
8. Can I still take the OCP’s?

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CASE 4: POSSIBLE CANCER (SHADOW ON CXR)

1. This was discovered at a routine check and I feel fine, so this can’t be anything
serious. Can it?
2. What could the shadow be caused by?
3. What are the chances that this is cancer?
4. Is it because of my smoking history?
5. How are you going to find out what it is?
6. If its cancer, will you be able to cure it?
7. Has the cancer spread?
8. Is there anything I could have done to prevent it?
9. Am I going to die?

TELL PATIENT ABOUT THE MACMILLAN NURSES
Macmillan Cancer Support -‐‑ is one of the largest British charities which
provides specialist healthcare, information and financial support to
people affected by cancer.

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CASE 5: POSSIBLE LIFE THREATENING ILLNESS
(PULM. EMBOLISM AND PT. WANTS TO GO HOME)

1. I am feeling a bit better, so there cannot be anything seriously wrong.
2. So what is the cause of my symptoms?
3. How will you find out that pulmonary embolism is the cause of my symptoms?
4. Is having a pulmonary embolus dangerous?
5. How will you confirm your diagnosis?
6. What treatment will I need?
7. Well, I really need to go home as my children are with my sister and she can’t stay
long. There is no one to care for my children.
8. Another reason is that I do not like the hospital food!
9. I understand your point, but I have decided to go home. Can you give me the
injections at home?

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CASE 6: SIDE EFFECTS OF CARDIAC MEDICATION

AMIODARONE

1. What is the cause of my breathlessness? Is it because of my heart?
2. Do you have the result of my CT scan of chest?
3. You mean to say that the medication you gave me for my heart has damaged my lungs?
4. Why was I not informed of this side effect by the heart doctor before being put on
Amiodarone?
5. I was put on a medicine to keep me well, now its made me sick and you are telling me to
stop taking it. Does this mean that I am going to become even sicker than I am at the
moment? (tell that the effects are reversible)
6. So, will you give me any medications for my lungs now?
METHOREXATE (for RA)
1. Is there any alternative medication you can start me on?
2. I am thinking of starting a family. Is that ok?
3. Why is it essential that I start the medication right away? Can’ I delay it for a few
months?
4. What if I get side effects of Methotrexate?

FAST PACES Academy

CASE 7: PRESENTATION OF A FIRST SEIZURE AND
DRIVING ISSUES

1. What happened to me? I cannot recall anything?
2. Does this mean I have epilepsy?
3. How did it happen?
4. What will you do to stop it from happening again?
5. Do I have to tell my employer?
6. What do you mean “I cannot drive for 6 months”!!! That’s not possible. I am a mail
delivery man and my job involves driving in my truck and delivering packages.
7. What will happen to my job? I am the only earning hand in my family.
8. What if I do not inform the DVLA and keep driving?
(Inform her that her insurance will not be valid)
9. Will you tell the DVLA?
10. How can you do so? You cannot break confidentiality!!!!

FAST PACES Academy

CASE 8: PATIENT REFUSED MECHANICAL VENTILATION
BUT DAUGHTER WANTS IT.

1. As you mentioned that my mother is not in her senses at the moment, obviously she
cannot make important decisions concerning her life and death issues. (say that she
made this decision when she was fully competent).
2. Exactly what has been discussed in the past?
3. Did you discuss with her the exact situation that she is in right now?
4. I am the next of kin. I feel that I have the right to overturn my mother’s decision as she
cannot decide at this time what is best for her. (inform her gently that she cannot do so)
5. If she does not go on a breathing machine, then is it definite that she will die?
6. I find it very difficult to accept my mother’s decision. She never told us that she did not
want to be put on a life support machine. (Empathize with her and tell her that we need
to respect her decision).
7. Will you just let her die like this?
IMPORTANT POINTS TO REMEMBER:

§ Demonstrate an understanding of the daughter’s wishes, in particular if she
wants to do everything to keep her mother alive.
§
§ Ensure that the daughter understands that her mother’s decision against
mechanical ventilation in the future was her own, and was made on the basis
of a full understanding of her condition and the probable consequences of not
proceeding to mechanical ventilation.

§ Explain that patients have a legal right to decline specific treatment,
including treatment that is life prolonging. (AUTONOMY)
FAST PACES Academy

CASE 9: HIV TESTING & CONFIDENTIALITY

1. Can you just treat me for my oral thrush and fever?
2. Are you saying that I have AIDS? (explain the difference between HIV and AIDS)
3. If I do come out as HIV positive, does that mean I am going to die?
4. But I just had a single sexual encounter with a person I did not know and had just
met in a club. Can I be positive with just a single encounter?
5. I used to have a boyfriend whom I have not seen in a long time. What should I do?
6. Will you tell all my previous sexual partners?
7. Can there be some other cause of my symptoms?
8. If I am positive for HIV, will you tell my wife?
9. If I don’t tell my wife, will you tell her? Aren’t you bound by confidentiality?
10. If I am positive for HIV, will you tell my GP?
11. Will you tell my employer?
12. What will happen to my insurance? Will I be financially disadvantaged?
13. What medications will you give me if I am tested positive for HIV?

• In the mentally competent this must always be performed with
consent.
• Testing without consent is only acceptable if the patient is not
competent and the test is in their best interests.
• Pre-‐‑ and post-‐‑test discussion should be available.

FAST PACES Academy

§ You have a duty of care to inform the wife (especially if she is your
patient).
§ You will not tell the GP unless the patient allows you to do so.
§ You will do a contact tracing to inform all the previous sexual
contacts, but you will keep the identity of the patient anonymous

FAST PACES Academy

CASE 10: EXPLAINING A MEDICAL ERROR
(TRANSFUSION REACTION)

1. What happened to my husband?
2. What do you mean he was given the wrong blood type?
3. How did the blood bags get mixed up? Aren’t they labelled?
4. Who is responsible for this?
5. How can such a serious mistake be done by you and your colleagues? My father is
already in so much suffering and unwell and did not need to be put through any
more suffering!! (apologize profusely)
6. How is she doing now? Has she recovered from the transfusion reaction?
7. I would like to launch a complaint. (if patient insists, then explain the steps).
8. What systems does the hospital have in place to make sure such an error does not
happen again?
9. Can I speak to your consultant? Is he aware of this?

FAST PACES Academy

CASE 11: BREAKING BAD NEWS (HODGKINS LYMPHOMA)

1. Is it cancer?
2. Are you sure these are my results/ reports?
3. How far advanced is it?
4. Will my children get this from me as well?
5. My aunt died of colon cancer and she had a very miserable quality of life and death,
is that going to happen to me?
6. Will you be looking after me and treating me for the cancer?
7. You said that this is a curable cancer, once it is treated and gone, is there a chance
that it will ever come back?
8. What does the treatment involve?
9. While I am on cancer treatment, will I be able to get pregnant?
10. Doesn’t the chemotherapy make you sick and ill?
11. How will you know that the chemotherapy is working?
12. What if the treatment does not work?
13. While I am on treatment, who will be supporting my family financially?

FAST PACES Academy

CASE 12: A CHRONIC ILLNESS (MULTIPLE SCLEROSIS)

1. Is it cancer?
2. What is multiple sclerosis?
3. Are you sure these are my results? It can’t be!
4. How did I get this?
5. Will you be able to cure it?
6. What complications will I get from MS?
7. Will I end up in a wheel chair? (don’t give false hopes)
8. How will I tell my boyfriend? I am getting married next month. (offer to arrange a
meeting with boyfriend).
9. Will I have to tell my employers? Will I have to quit my job? (ask what job she does
and answer accordingly).
10. Will I be able to have children?
11. What treatment will I be put on? (tell about MS society)
12. Can I get a second opinion?


FAST PACES Academy

CASE 13: FUNCTIONAL ILLNESS -‐‑IRRITABLE BOWEL SYNDROME

1. How can you be so sure I don’t have cancer?
2. You are saying that all my tests are normal. Then what is the cause of my symptoms?
3. Why don’t you just get a colonoscopy done on me. I’ll feel better.
4. My aunt had similar symptoms, and she was diagnosed with cancer on a colonoscopy.
What if I have cancer?
5. What do you mean you cannot? I am a patient and I can demand treatment!!!!!
6. You think that I have gone crazy and all the symptoms are in my head? (tell her that her
symptoms are real.).
7. What is the cure for this? Are there any pills?
8. Are you going to put me on anti depressants?
9. Don’t they have any side-‐‑effects?
10. I would like to speak to your consultant.

FAST PACES Academy

CASE 14: PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG)
(Patient is in a nursing home with stroke but is able to consent)

1. Cant you just let my father eat and drink on his own?
2. But putting a PEG tube sounds horrible, isn’t there any other option?
3. So how is a PEG tube put in?
4. How can you be sure he understands what a PEG tube insertion involves?
5. Will he need a PEG tube for the rest of his life?
6. What are the complications of putting in a PEG tube?
7. Will he be able to do things during the day if he is attached to a PEG tube?
8. What will happen if I decide not to allow for a PEG tube to be put in. I am his next of
kin.
IMPORTANT POINT
Anorexia nervosa is considered a psychiatric condition and a patient may be
detained and treated (eg. artificially fed) under the terms of the Mental Health Act.


FAST PACES Academy

CASE 15: ILD AND PALLIATIVE CARE

1. Cant you do anything more to help with his breathing?
2. Can he get a lung transplant?
3. What do you mean he will not benefit from any more treatment?
4. Will he just receive the oxygen?
5. What is palliative care?
6. Will his condition worsen over time?
7. Will you put him in a nursing home?
8. Is he going to die?
9. How long does he have to live?
10. Can I have a second opinion?

FAST PACES Academy

CASE 16: DIAGNOSIS OF TUBERCULOSIS

1. What are the results of my tests?
2. Are you sure these are my results?
3. Can you cure this?
4. Where did I get Tuberculosis from?
5. Will I have to tell my employer?
6. Does this mean I have to quit my job? (ask what job she does and answer
accordingly).
7. What will I do if I can’t work? How will I support my family financially?
8. Can I pass this on to my family members?
9. What is the treatment for this?
10. Will I have to stay in the hospital?
11. What if I don’t want to stay in the hospital?
12. What if I decide not to take the pills? You can’t force me.

FAST PACES Academy

List of notifiable diseases
Diseases notifiable to local authority proper officers under the Health Protection (Notification)
Regulations 2010:
• Acute encephalitis
• Acute infectious hepatitis
• Acute meningitis
• Acute poliomyelitis
• Anthrax
• Botulism
• Brucellosis
• Cholera
• Diphtheria
• Enteric fever (typhoid or paratyphoid fever)
• Food poisoning
• Haemolytic uraemic syndrome (HUS)
• Infectious bloody diarrhoea
• Invasive group A streptococcal disease
• Legionnaires’ disease
• Leprosy
• Malaria
• Measles
• Meningococcal septicaemia
• Mumps
• Plague
• Rabies
• Rubella
• Severe Acute Respiratory Syndrome (SARS)
• Scarlet fever
• Smallpox
• Tetanus
• Tuberculosis
• Typhus
• Viral haemorrhagic fever (VHF)
• Whooping cough
• Yellow fever


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FAST PACES ACADEMY

Dr. Sadia Nasir

T Tell the patient about the problem in a clear way

1. AUTONOMY – patients wishes and self rule.

• Understands what he /she is being told

Consent form 1: Adult patient able to consent themselves.

1. If he expressed any wishes

2. Advanced directive / Living will

3. Legal power of attorney

If the patient has made an advanced directive/ living will

directive is “situation specific”.

If the patient has made a lasting power of attorney

Dr. Sadia Nasir MRCP (UK) 9

A DNR decision isn’t necessary to discuss with patients:

1. If the patient is incompetent.

What facts need to be told to the patient?

• That CPR is usually unsuccessful in such cases.

• The possibility of survival with a neurological damage should be pointed out.

• Elderly patients with chronic illnesses have < 5% chance of survival to

NOTE: DNR is a Consultant decision!!!!!!!!!!

Three separate issues to be considered.

harmful to the patient.

STEPS TO HANDLE A MEDICAL ERROR:

Dr. Sadia Nasir MRCP (UK) 11

internally at this level.

will have an office in the hospital.

receive a formal response within 28 working days.

information on this).

6. Patient can also contact Independent Complaints Advocacy

Service(ICAS) which is an independent body which can help

patients/relatives in making their complaint.

Pain in brain stem death

Brain stem death and machine support

After the diagnosis

Dr. Sadia Nasir MRCP (UK) 13

Has the patient registered?

• Check the organ donor registry

The patient has registered but the family disagree:

The process of organ donation:

read through any relevant literature or leaflets.

§ They should receive their results in person.

§ Discuss alternatives (e.g.: screening for breast cancer with mammography).

policies and mortgages.

§ The possibility of an inconclusive test should be raised.

§ Make a referral to the Regional Specialist Clinical Genetics Service

Dr. Sadia Nasir MRCP (UK) 17

§ Rifampicin: 6 months. Liver dysfunction – warn patients to seek medical

Special situations to consider:

Additional issues to address in a consultation related to this:

HORMONE REPLACEMENT THERAPY

§ Benefits: Reduced symptoms, increased bone strength.

Dr. Sadia Nasir MRCP (UK) 19

Seizures – First unprovoked epileptic seizure/isolated seizure

Dr. Sadia Nasir MRCP (UK) 20

(enough to bring you to hospital) or hypoglycemic unawareness.

1. You have stable glycemic control over a 3-­‐‑month period.

function for at least 3 months.

months off driving your lorry.

If cardiac origin, then do not drive fro 6 months.

If accompanied by seizure, then no driving for 1 year.

Dr. Sadia Nasir MRCP (UK) 22

Dr. Sadia Nasir MRCP (UK) 23

2. Will I go blind?

1. You have stable glycemic control over a 3-‐‑month period.