communication by iqbal khan mrcp.pdf

I dedicate this book to my wife Nuzhat,without whose encouragement this bookwould not have been possible.

Preface vii

About the author ix

How to use this book x

1 1 Basic medical ethics 1

Ethical theory 1

Patient consent 2

Confidentiality 7

Medical negligence 8

End-of-life decisions 10

Research ethics 16

The General Medical Council (GMC)18

Communication skills 21

2 The cases 27

Breaking bad news 29

Case 1 Pancreatic cancer with poorprognosis 33

Case 2 The young patient diagnosedwith malignant melanoma 36

Case 3 Hodgkin's lymphoma 39

Case 4 Multiple sclerosis 42

Case 5 Mesothelioma 45

Case 6 HIV positive 48

Case 7 The Down's syndromepregnancy 51

Case 8 Death of husband 55

Case 9 The sick daughter 58

Counselling patients 61

Case 10 Lifestyle advice for diabetesmellitus 62

Case 11 New diagnosis: rheumatoidarthritis 65

Case 12 Man with TB 68

Case 13 New diagnosis: coeliacdisease 72

Case 14 New diagnosis: asthma 75

Case 15 Following a heart attack 79

Case 16 New diagnosis: epilepsy 82

Case 17 New diagnosis: ulcerativecolitis 87

Case 18 Obesity advice 91

Case 19 The poorly compliant patient 95

Case 20 Counselling for an HIV test 98

Case 21 Man wanting to self-discharge101

Case 22 Delay in review 105

Case 23 Obtaining consent for aspecialist procedure 108

Case 24 Warfarin and the pregnantwoman 111

Case 25 Withdrawal of consent 114

Case 26 Worried about infection afterblood transfusion 118

Case 27 Patient requesting cannabis121

Case 28 Recruiting a patient into aclinical trial 125

Case 29 The aggressive patient 128

Case 30 The near miss: discussionwith the patient 131

Case 31 Herbal therapy for angina135

Discussions with relatives 140

Case 32 Stroke and resuscitationdecision 140

Case 33 Talking about PEG insertion144

Case 34 My father is MRSA positive148

Case 35 Speak with daughter aboutmother's death 152

Case 36 Father diagnosed withHuntington's disease 157

Case 37 Stopping ventilation andorgan donation 162

Case 38 Transplant 1 - The livingdonor 168

Case 39 Transplant 2 - Theparacetamol overdose 173

Case 40 Parkinson's disease 177

Case 41 Requesting a postmortem 180

Case 42 Seeking consent from arelative 187

Case 43 The Jehovah's Witness 191

Discussions with colleagues 195

Case 44 Concern about a colleaguewho is turning up to work drunk 195

Case 45 The hepatitis C positivedoctor 200

Case 46 The needle stick injury 205

Case 47 Bullying 210

Case 48 The distressed medicalstudent 214

Case 49 The near miss: discussionwith the nurse 218

Case 50 The offensive doctor 221

Appendices 224

Appendix 1 Driving and disease 224

Appendix 2 Marksheet 225

Useful web pages 226

Index 227

The Royal College of Physicians (RCP)introduced the Practical Assessment ofClinical Examination Skills (PACES)exam in June 2001. With it theyintroduced a station that is very relevantto the day-to-day practice of medicine.This station is based around acandidate's understanding of ethicalissues and their ability to communicateeffectively with the patient, relative orcolleagues.

The problem for the candidates is thatin most medical schools, studentsreceive little formal training in ethics

and communication skills (although thesituation does seem to be changing in theUK) and naturally find the station verydifficult, and often fail because of it.This situation is not helped by the factthat busy junior doctors working in busyhospitals often cannot afford the time todelve through volumes of material to tryand pass this station and instead focus onthe clinical stations.

This concise text has been preparedwith those busy junior doctors in mind. Itis intentionally not long-winded and Ihope will get you up to speed relativelyquickly. I should say that it is notintended as a comprehensive collectionof all the possible scenarios that may

arise, but instead its aim is to introduceyou to the sorts of scenario you arelikely to meet in the exam and give yousome scope for practice. This in turnwill hopefully help you pass the examand go some way towards helping youwith your medical career.

It is strongly recommend that during theweeks and months leading up to the bigday, you try and spend as much time aspossible in practising role-play withyour colleagues/friends in front of themirror or even with the cat (I'm sure it isimpossible for junior doctors to keep adog!). Some people find the use ofvideoing in role-play very useful. Othersfind that it is a good way to destroy their

confidence.

At this point I should like to emphasisethat all the cases in this book, the namesof doctors, patients and relatives arefictitious and any similarity to realpeople and events is by coincidence.

Good luck!

Iqbal Khan

January 2006

[email protected]

Iqbal Khan is a specialist registrar ingastroenterology and general internalmedicine on the West MidlandsRotation. He was born in Birminghamand studied at the University ofSheffield. After obtaining a dual honoursdegree in biochemistry and physiology,he went on to study medicine. He alsoconducted research with an enthusiasticgastroenterologist for a PhD, and it wasthis experience that initiated his interestin gastroenterology.

Over the years he has helped manysenior house officers to get through their

MRCP exams and medical students toget through their finals and stronglybelieves that the best way to learn is byteaching others.

This book is designed to provide busydoctors with common case scenarios,which they can use to practise anddevelop their communication skills forthe PACES exam. Moreover, this bookshould provide a useful introduction tobasic medical ethics. It is suggested thattwo or more people work together topractise the cases provided. One of theteam can act as the exam candidate andshould only be provided with theinformation given as the scenario.Another can act as the surrogate

patient/relative. It is best to think throughthe roles and try to make the situation asrealistic as possible. Hence, they arebest practised in a quiet, bleep-freeenvironment.

Work through each case following theformat of the exam:

• Spend 2 minutes reading through thecase and mentally preparing for thecase.

• The discussion should take 14 minutes.

• Allow 1 minute for reflection.

• The examiners have 5 minutes to

question you on the case.

• Total time for each case is 22 minutes(20 minutes in the exam room).

Each case begins with a description ofthe scenario. This is very similar to thatwhich will be encountered in the examitself. The candidate must read this andnot have access to the rest of the text.The individual acting as thesubject/patient can review the case andsee their individual information. Theprompts are suggested questions that thesubject may use on the candidate. It isperfectly OK not to use any of them, but Ihave included them to help thediscussion to flow, particularly if you

are practising the case with a non-medical person (spouse, parents, etc.).

Once a case has been conducted, thediscussion and ethical issues can bereviewed. This always includes a`possible interview plan' and otherrelevant issues. The possible interviewplan is exactly that. It is one possibleplan that you can follow while havingthe discussion; you may even come to theconclusion that it isn't the best possibleplan. There are infinite permutations any14-minute medical discussion canfollow and it depends upon a number ofvariables. These include the medicalfacts available and the individual'scommunication and linguistic skills.

Once you start to acquire the relevantknowledge on ethical and NHS issues,and develop communication skills, youwill start to see the patterns in the casesand feel confident that you could tacklesimilar cases presented to you in theexam itself.

By the time you have come to study forthe PACES exam, it will have becomeapparent that much of the MRCP examfollows a format where patternrecognition is the key to success. This isalso true for the PACES exam, includingthe èthics and communication skills'station. Practise and you will succeed.

Along with scientific knowledge, moralissues and value judgements havealways been a very important part ofmedical practice. Over the last 250years these issues have been analysedand two fundamental theories on medicalethics have been particularly influential

in Western medicine:

Consequentialism (utilitarianism):Simplified, this asks for theconsequences of each action to beaddressed and that with the foreseeablemost favourable consequence is thebest path to follow. The mostfavourable consequence is one wherethere is the least human suffering andthe most happiness.

2 Duty-based ethics (deontological):This theory dictates that we are duty-bound to certain actions in our medicalpractice irrespective of theconsequences. For instance, it isimportant to always be honest with our

patients. In contrast, a utilitarian mayargue that it is better to lie to aterminally ill patient about theirprognosis if the truth is likely to add totheir suffering.

In real life, often the two theoriescoexist in medical practice. Forinstance, it is often important that we tellthe patient the truth about a terminaldiagnosis. However, we may not beabsolutely frank about their prognosis.I've often heard colleagues, whendirectly challenged, say things like, `...I'm sorry I don't have a crystal ball thattells me the future', or even, `Well howlong is a piece of string?'

Most doctors, although oblivious tomoral theories, do recognise that thereare some basic principles of medicalethics that are important to our practice.The four principles that are most wellrecognised and used are:

1 Autonomy. Autonomy means self-rule,and this principle urges healthcareproviders to respect the patient'swishes and decisions, even if they arefelt to be wrong.

2 Beneficence. Literally this meansdoing good, and promotes the doctor toact in the patient's best interest.

3 Non-maleficence. To do no harm, even

if we are unable to do good.

4 Justice. To treat all patients equallyand thus to give medical resourcesequally.

In English law the legal position is saidto adopt the famous statement of JudgeCardozo:

Every human being of adult years andsound mind has the right to determinewhat shall be done with his own body;and a surgeon who performs anoperation without his patient's consentcommits an assault [sic. battery] forwhich he is liable in damages.

Valid consent depends on the premisesthat a doctor has disclosed all relevant

information to a competent patient, andthat the patient understands thisinformation and makes the appropriatedecision voluntarily. This should not beconfused with assent, which is meresubmission by the patient to the doctor'sauthoritative order (Faden andBeauchamp, 1986). Under English law,patients can sue their doctor for battery(any intentional non-consensual contact)if a procedure has been performedwithout proper consent. Moreover, adoctor may be found negligent if aprocedure is performed withoutdisclosing all the relevant information.

Competence (or in legal jargon, `to havecapacity')

Any competent patient over 18 years old(16 years in Scotland) can refusetreatment, even if it is likely to be life-saving. When patients are thought to beincompetent, the doctor should act in thebest interest of the patient, according totheir professional judgement. The Bolamtest (i.e. a reasonable body of medicalopinion would support the actions of thedoctor) can be applied in this situation.Under English law, there is no proxyconsent for an incompetent individual byfamily or friends, although they mayprovide valuable information. Someimportant issues to assess a patient'scompetence or capacity are:

• a patient should not be deemed

incompetent just because they make animprudent or unwise decision

• a patient does not have to be globallycompetent to provide valid consent. Itis simply adequate that they understandthe principles surrounding theprocedure to be performed

• when assessing capacity, simply lookat the `balance of probabilities' of apatient being competent, as opposed to`beyond reasonable doubt', which isapplied in criminal cases.

Patients are thought to have capacity ifthey are able to:

• comprehend and retain informationrelevant to making the decision

• believe this information

• weigh the information and make adecision.

It is presumed that 16-17-year-olds havecapacity to give consent, unless thecontrary has been shown. Patients under16 years of age are not presumed to havecapacity unless they satisfy healthprofessionals to the contrary. Thesepatients are then termed `Gillickcompetent', following the landmark case- Gillick v West Norfolk and WisbebechAHA and DHSS (1985) (see landmark

case p. 6) Generally, parents are obligedto act in the patient's best interest and toprovide consent.

Form of consent

Consent is fundamentally a state of mind,where the patient submits to theproposed treatment. The two recognisedforms of consent are èxpress' andìmplied'. The patient may explicitlyagree to a form of treatment either orallyor in writing, for example when signinga consent form for a surgical procedure.In this situation the consent is said to beexpress. During routine clinical practice,most consent is implied because of thepatient's conduct. For instance, if you

wish to insert a venous cannulae into theback of a patient's hand and the patientholds out his hand, clearly the patientconsents to the procedure. The scope ofimplied consent should not be toowidely construed. For instance, if apatient enters a room for a clinic visit,s/he has only consented to theconsultation and not necessarily to aphysical examination.

Lawful treatment without consent

The House of Lords previously (1989)addressed the issue of treating patientswho were unable to give consent eitherbecause they lacked capacity or hadbecome incapacitated (for example

because of illness or generalanaesthesia). They concluded:

In common law a doctor can lawfullyoperate on or give other treatment toadult patients who are incapable ofconsenting to his doing so, providedthat the operation or treatment is in thebest interest of such patients. Theoperation will be in their best interestsonly if it is carried out in order eitherto save their lives or to ensureimprovement or prevent deteriorationin their physical or mental health.

`Common law' (also known as theàdversarial system') originallydeveloped in historical England from

judicial decisions that were based intradition, custom and precedent. Theform of reasoning used in common lawis known as `case-based reasoning' or`casuistry'. The common law wasdevised as a means of compensatingsomeone for wrongful acts known as`torts', including both intentional tortsand torts caused by negligence. It alsoserved as a body of law recognising andregulating contracts. Common law maybe unwritten or written in statutes orcodes.

Treating patients in their `best interest'gives doctors the ability to institute abroad range of interventions,particularly in emergency settings.

Veracity

Truthfulness is fundamental to the trustthe patient has in their doctor andconsent based on deceit and inaccurateinformation is not valid. This isparticularly true if the ìnformed consent'is carried out as a ritual to protectagainst later liability. `Therapeuticprivilege' is an exception to this rule andrefers to information, which may havebeen withheld from a patient because itwas felt to be detrimental to theirwellbeing. Generally speaking, honestyis the best policy.

Advance directive (living will)

This is a formally written and witnessedstatement a competent person may makeregarding treatment they should like toreceive if they were to becomeincompetent. For example, a patient withmotor neurone disease may state thatthey do not want to be resuscitated in theevent of a cardiac arrest when they areseverely debilitated and unable tocommunicate.

LANDMARK CASE

Sidaway 1984

Mrs Sidaway had presented to aneurosurgeon with recurrent pain in herneck and shoulders, which was thought

to be due to nerve root compression. Anoperation was subsequently undertakento release the roots, which unfortunatelyleft Mrs Sidaway with partial paralysis.The risk of this occurring was 1-2 percent, even in the hands of a skilledsurgeon. Mrs Sidaway went on to sue thehospital arguing that she would not havegiven consent to the procedure if she hadbeen told about the possibility of thisoutcome, and as such her surgeon hadbeen negligent. The Bolam test wasapplied at court and Mrs Sidaway lostthe case. The evidence before the courtwas that a responsible body of opinionwould consider the risk of paralysissmall enough not to be presented to the

patient.

LANDMARK CASE

Re C (Adult refusal to medicaltreatment)

C was a chronic schizophrenic and aninmate at Broadmoor Hospital. Hedeveloped gangrene in his right foot andmedical opinion was that his leg shouldbe amputated. C refused to give consentand the case went to court. The judgewas satisfied that although C lackedgeneral capacity, he did have sufficientinsight to refuse the amputation. Thiscase laid down the three stages by whicha court could determine a patient's

capacity, i.e.:

1 Comprehend and retain information

2 Believe it

3 Weigh it in the balance and arrive at achoice

LANDMARK CASE

Gillick v West Norfolk and WisbebechAHA and DHSS (1985)

The concept of Gillick competence cameabout following this case where thecentral issue was the right of a doctor toprescribe contraception to a girl under

the age of 16 years without parentalconsent. During the hearing LordScarman commented that, `... as a matterof law the parental right to determinewhether or not their minor child belowthe age of 16 will have medicaltreatment terminates if and when thechild achieves sufficient understandingand intelligence to enable him tounderstand fully what is proposed'.Hence children of any age can consent toor refuse treatment if they are deemedGillick competent by a court of law.

Confidentiality is the cornerstone of thedoctor-patient relationship, and itsupports the principle of patientautonomy, which emphasises thepatient's right to control over their life.The legal aspects of confidentiality lie incommon law. This basically dictates thata doctor is obliged to maintain patientconfidentiality except under situationswhere it is of greater public interest.Note that this may only be one memberof the public! Examples of situationswhere a doctor mustbreachconfidentiality include:

• births and deaths [Births and DeathsRegistration Act 19531

• notifiable diseases [NotifiableDiseases Act 1984]

• drug addiction [Misuse of Drugs Act19731

• under court orders

• details of a driver alleged to be guiltyunder the Road Traffic Act [1988] tothe police.

There are certain situations where adoctor has the discretion to breachconfidentiality (these are probably those

that are more likely to feature in thePACES exam). Such situations include:

• where there is a third party atsignificant risk of harm, for examplethe partner of an HIV-positive patient

• a driver known to be an uncontrolledepileptic who continues to drive

• sharing information with otherhealthcare workers in the interest of thepatient.

It is important to realise that theobligation to keep informationconfidential applies even after thepatient's death.

The Access to Health Records Act(1990) gives patients the general right tosee their medical records, have themexplained and obtain copies of them. Ifany of the information is inaccurate, thepatient has the right to ask to have thischanged.

LANDMARK CASE

XvY1988

The employees of a health authoritydivulged the names of two practisingdoctors who were being treated forHIV disease to a national newspaper.Publication of the details of thedoctors involved was prevented when

a judge decided that the public interestin maintaining confidentiality wasgreater than the public interest inmaking public the names of doctorswho were practising medicine whileknown to be HIV positive.

All doctors practising medicine need tobe aware of the laws governing medicalnegligence. In cases where medicalnegligence is alleged the plaintiff mustprove three separate points:

1 Duty of care is owed to them. Thisusually means that the defendant wasthe patient's hospital physician orgeneral practitioner.

2 A breach of the duty of care hasoccurred.

3 Damage has occurred as a result of the

breach.

If these three points can be proven thenthe `Bolitho principle' applies and thedefendant has been found negligent. Inthe UK, negligence was traditionallyjudged using the `Bolam test' (Bolam vFriern Hospital Management Committee(1957)) (see landmark case p. 9).According to the Bolam test a doctor isnot negligent if they have acted inaccordance with a practice accepted asproper by a responsible body of medicalopinion. This principle, however, hasbeen perceived as being excessivelyreliant upon medical testimonysupporting the defendant. In recent yearsthere has been a shift from the traditional

Bolam test because of the judgementgiven by the House of Lords in the caseof Bolitho (Bolitho v City and HackneyHealth Authority (1997)) (see landmarkcase p. 9). This ruling imposes arequirement that the standard beinganalysed must have considered the risksand benefits of competing options andhence the court's stance will be muchmore enquiring of the evidence offeredby both parties. As the climate becomesincreasingly litigious medicalpractitioners must have an understandingof this approach and the shift from thetraditional Bolam test.

LANDMARK CASE

Bolam v Friern Hospital ManagementCommittee (1957)

The Friern Hospital ManagementCommittee was sued by Mr Bolamafter his leg was broken during acourse of electroconvulsive therapy(ECT). Mr Bolam argued that thedoctors had been negligent by notproviding a muscle relaxant during theECT. During the subsequent trial itbecame apparent that while somepractitioners felt it was necessary togive a muscle relaxant during ECT,others did not. Mr Bolam lost thecase, as not giving a muscle relaxantwas an acceptable practice. Duringthe summing up of the case the judge

proclaimed:

À doctor is not guilty of negligenceif he has acted in accordance with thepractice accepted as proper by aresponsible body of medical menskilled in that particular art....'

LANDMARK CASE

Bolitho v City and Hackney HealthAuthority (1997)

This is an important landmark case asit modified the Bolam result. A two-year-old child had been admitted tohospital with croup (after initiallybeing discharged the day before with

similar symptoms). Over the course ofhis admission he deteriorated to theextent that he had a cardiac arrestresulting in irreversible brain damage.A case of negligence was brought upagainst the paediatrics registrar whohad been summoned three times, butfailed to attend or send an appropriatedeputy. The doctor was found to beclearly negligent in this respect.Hence it was established that thedoctor had a duty of care and hadbreached this. It finally came to thepoint of whether this had resulted indamage and this is why this case isimportant. As there were eight expertwitnesses called, five said that any

competent doctor would haveintubated the patient and the fact hewasn't intubated had resulted in theharm. However, the other three saidthat on the basis of the history it wasresponsible not to intubate the childand hence the outcome would havebeen the same. However, while therewas a reasonable and responsiblebody of opinion in favour of thedefendant, the judge still declarednegligence as he felt that this opinionwas not logical and `not capable ofwithstanding logical analysis'. This isa subtle but significant change fromthe traditional Bolam test andestablishes that it is a matter for the

court and not medical opinion toestablish the standard of professionalcare.

End-of-life matters such as euthanasia,do-not-resuscitate orders and livingwills have received much publicattention and debate over the last fewyears. There has been great concernregarding doctors hastening death inpatients who are terminally ill.Conversely, there are other people whoare concerned that terminally ill patientsare being kept alive àrtificially', henceprolonging their suffering. There are noeasy solutions here and the debates willcontinue long into the night.

Euthanasia

This comes from the Greek, meaning àgood death'. It can be further brokendown into the following categories:

• Active euthanasia. The doctorperforms an action that leads to thepatient's death.

• Passive euthanasia. The doctorwithholds or withdraws lifeprolongingtreatment leading to the patient's death.

• Voluntary euthanasia. The patientrequests death of the doctor. This is notthe same as an assisted suicide, wherethe patient takes their own life.

• Non-voluntary euthanasia. The patienthas not expressed an opinion, e.g. maybe a newborn.

• Involuntary euthanasia. The doctortakes the patient's life against theirwishes. This amounts to murder.

It is fair to say that in the UK mostdoctors probably practise passiveeuthanasia, where treatment may bewithdrawn from a patient whoseprognosis is futile.

Arguments against active euthanasiainclude:

1 Slippery slope effect. If active

euthanasia were to be legalised then bitby bit it may lead to euthanasia inpatients for whom it would beinappropriate. The practice would varybetween hospitals/hospices, wheresome would be more active thanothers.

2 People may use it as a means ofexploiting the dying.

3 There is no need for euthanasia in asociety where we have excellentpalliative care facilities. With drugslike opiate analgesics, strongantiemetics and laxatives no patientneed suffer greatly.

Arguments for active euthanasia:

I We live in a society where passiveeuthanasia is generally accepted. Somepeople believe that it is a small stepfrom this to active euthanasia, whichwould further alleviate suffering.

2 Suicide is legal now and oftenrational. The people who are the mostdisabled are unable to take their ownlives (viz. motor neurone diseasesufferer Diane Pretty).

3 Dying people are often sedated tounconsciousness; some people wouldargue that this is no different fromdying.

LANDMARK CASE

Diane Pretty

Diane Pretty was a terminally ill womanwith motor neurone disease, which hadbeen diagnosed in 1999. She wasexpected to die because of thiscondition. Mrs Pretty had argued that herhusband should be legally allowed toassist her suicide at the time of herchoosing. She applied first to theDirector of Public Prosecutions (DPP)via a letter written to the Prime Minister,Mr Tony Blair. Her application wasrefused. She then fought her case throughthe High Court, the House of Lords andthe European Court of Human Rights.

Her appeal was rejected in all of thesecourts. The case received massivemedia coverage and public attention.Mrs Pretty eventually died in May 2002at the age of 43 years.

LANDMARK CASE

Annie Lindsell

Annie Lindsell was a 41-year-oldattractive and articulate woman whopreviously had a very active life as anair hostess and actress. This all changedwhen she was diagnosed with motorneurone disease and she spent the finalyears of her life campaigning for achange in the UK law to allow

assistance in dying. Not only did shegive numerous interviews, but alsoaddressed Parliament in 1996. The sameyear she had launched a legal casewhere she demanded reassurance thatwhen she was terminally ill, `brave'doctors would be able to administertreatments to palliate her effectively,even at the cost of shortening her life.She was particularly concerned aboutchoking to death, which she haddescribed as like `living in a coffin'. Itwas felt that symptom control ofterminally ill patients was ethically andlegally permissible and her case wasdismissed. She died naturally in 1997.

LANDMARK CASE:

Dr David Moor

Dr Moor, who died in 2000, workedas a GP in Northumberland. He hadlong been a supporter of euthanasiaand in 1997 in interviews for radio,television and the newspapers heopenly admitted to helping manyterminally ill patients, over a 30-yearperiod, to die by administering fataldoses of diamorphine. Dr Mooradmitted in the interview that he hadprobably broken the law. The policesubsequently charged him with themurder of George Liddell, an 85-year-old man with advanced cancer. DrMoor was acquitted in May 1999.This landmark case emphasised the

importance of the primary intention,i.e the diamorphine was administeredto relieve pain and not to hasten death.

Do-not-resuscitate (DNR) orders

The British Medical Association(BMA), the Resuscitation Council (UK)and the Royal College of Nursing (RCN)have issued guidelines regardingresuscitation decisions (2001). Theguidelines essentially say that:

• timely support for patients and peopleclose to them, and effective, sensitivecommunication are essential

• decisions must be based on the

individual patient's circumstances andreviewed regularly

• sensitive advance discussion shouldalways be encouraged, but not forced

• information about CPR(cardiopulmonary resuscitation) andthe chances of a successful outcomeneeds to be realistic

• information about CPR policies shouldbe displayed for patients and staff

• leaflets should be available forpatients and people close to them,explaining CPR, how decisions aremade and their involvement in

decisions

• decisions about attempting CPR mustbe communicated effectively torelevant health professionals

• in emergencies, if no advance decisionhas been made or is known, CPRshould be attempted unless the patienthas refused CPR, the patient is clearlyin the terminal phase of illness, or theburdens of the treatment outweigh thebenefits

• competent patients should be involvedin discussions about attempting CPRunless they indicate that they do notwant to be

• where patients lack competence toparticipate, people close to them canbe helpful in reflecting their views

• patients' rights under the Human RightsAct must be taken into account whenmaking the decision

• neither patients nor relatives candemand treatment that the healthcareteam judges to be inappropriate, but allefforts will be made to accommodatewishes and preferences

• in England, Wales and NorthernIreland, relatives and people close tothe patient are not entitled in law totake healthcare decisions for the

patient

• in Scotland, adults may appoint ahealthcare proxy to give consent tomedical treatment

• health professionals need to be awareof the law in relation to decisionmaking for children and young people.

Kubler-Ross's Stages of Dying

Elizabeth Kubler-Ross's book On Deathand Dying (1969) helped to popularise acharacterisation of the process of griefas steps or stages through which thedying and, to some extent, those close tothem ordinarily pass. While she was

hardly the originator of the idea, herbook has provided access to this usefultool for thousands of healthcareprofessionals. Used carefully, thesestages can be helpful in recognising andresponding to the psychological stateand needs of those in grief.

A note of caution should be offeredfrom the outset: you should avoidthinking of these `Five Stages of Dying'as necessary elements in an inevitablesequence or as levels to be mastered.The stage of acceptance is not a goal tobe accomplished by means of the othersteps. While patients tend to go through aseries of stages, they may go back andforth, skip about or have periods where

the stages seem to overlap, all accordingto their particular needs. With this inmind, it is helpful to think of grief astending to approximate five stages:

1 Denial of death because they areunable to admit to themselves that thepatient might die and/or they willsuffer the loss death represents.

2 Anger by which the pain of loss isprojected onto others.

3 Bargaining, which represents a lasteffort at overcoming death by èarning'longer life.

4 Depression: when the full impact of

imminent death strikes them.

5 Acceptance: when the grieving cometo grips with the fact of the patient'sdeath and make preparation for it.

These stages reflect the needs of thedying patient and others, and the devicesthey use to cope with them. It is mostimportant for you to remember that theloss by death to and of the patient isprobably the greatest loss those affectedwill ever experience. The prospect ofdeath, then, will be the greatest crisisone can face. For most people, thiscrisis can be endured only with at leastthe temporary help of coping deviceslike those suggested by the stages.

There are, of course, other models forunderstanding this important process,which are well worth reading. One thatdeserves your special consideration is inthe work of Backer, Hannon and Russell(Backer et al., 1994).

Doctrine of double effect

This principle, which was developed inthe Middle Ages by Roman Catholictheologians, is used to justify medicaltreatments; harm or death is a foreseenconsequence. The doctrine applies if thedesired outcome is judged to be `good'(e.g. to relieve patient suffering) and the`bad' outcome (e.g. the patient's death) isnot intended. Hence it is ethically

correct to administer opiate drugs to aterminally ill patient, even though it islikely to bring on their death. Somepeople find this doctrine seriouslyflawed as it offers the doctor aconvenient evasion of responsibility andtakes no account of the patient's wishes.As such, it violates the patient'sprovision of informed consent and theright of self-determination (Quill et al.,1997).

Sanctity of life doctrine

The fundamental principle is that allhuman life has worth and shouldtherefore be preserved, irrespective ofthe quality of that life. This principle is

in keeping with the general perception ofwhat doctors should do, which is to saveand preserve life. The greatest challengeto this doctrine comes from the conceptof quality of life as opposed to quantity.The question remains: Who defines thequality of life - the doctor, the patient,the family or perhaps the nurse? Theanswer is, of course, the patient, but weare back to `square one', when thepatient is unable to communicate theirattitude.

Ìf you steal from one author it'splagiarism. If you steal from many it isresearch.'

(Wilson Mizner, in Alva Johnston'sThe Legendary Mizners)

Moral codes on the conduct of researchinvolving human subjects have beendeveloped to prevent appalling humanabuse in the name of medical research.The best-recognised of these are theèxperiments' carried out on Jewishinmates in the Nazi concentration camps.

Codes of conduct

The Nuremberg Code was developedfollowing the Nuremberg Trials for warcriminals in 1948. It was a 10-pointcode designed to prevent futuremistreatment of people in the name ofresearch. In 1964 these principles wereadopted by the 18th World MedicalAssembly and elaborated into TheDeclaration of Helsinki, so-calledbecause the congress took place in thatcity. The Declaration of Helsinki hasbeen revised on a number of occasionsto incorporate new developments. Themost recent revision was in the USA in2002. The full declaration is a weightydocument and not something to be

committed to memory (you are certainlynot required to know it for the PACESexamination!). But some key excerptsare shown here:

Medical research involving humansubjects includes research onidentifiable human material oridentifiable data.

In medical research on human subjects,considerations related to the well-being of the human subject should takeprecedence over the interests ofscience and society.

Medical research involving humansubjects should only be conducted if

the importance of the objectiveoutweighs the inherent risks andburdens to the subject. This isespecially important when the humansubjects are healthy volunteers.

For a research subject who is legallyincompetent, physically or mentallyincapable of giving consent or is alegally incompetent minor, theinvestigator must obtain informedconsent from the legally authorisedrepresentative in accordance withapplicable law. These groups shouldnot be included in research unless theresearch is necessary to promote thehealth of the population representedand this research cannot instead be

performed on legally competentpersons.

The subjects must be volunteers andinformed participants in the researchproject.

The physician should fully inform thepatient which aspects of the care arerelated to the research. The refusal of apatient to participate in a study mustnever interfere with thepatientphysician relationship.

The ethics committee

The Department of Health (DoH)requires district health authorities to set

up local research and ethics committees(LREC). If more than five LRECs areinvolved in a research project, amulticentre research ethics committee(MREC) needs to be involved. There isno legal requirement for potentialresearchers to submit projects to theLREC. However, most funding bodieswill not give awards without LRECapproval for a project. In addition,without approval, access to NHSpatients and their notes would be denied.

The General Medical Council (GMC) isa registered charity, which wasestablished under the Medical Act of1858 to protect the interest of thepatients. However, it has been accusedof protecting the interest of the doctor.The Council itself is made up of 35members, who include doctors, laypeople and academics. The only officialregister of all the doctors practising inthe UK is kept by the GMC.

The GMC has produced severalpublications to advise doctors. Thesecan be accessed on the GMC website

(www.gmc-uk.org/ index.htm). Thefollowing essential duties of a doctorare promoted by the GMC:

• make the care of your patient your firstconcern

• treat every patient politely andconsiderately

• respect patients' dignity and privacy

• listen to patients and respect theirviews

• give patients information in a way theycan understand

• respect the rights of patients to be fullyinvolved in decisions about their care

• keep your professional knowledge andskills up to date

• recognise the limits of yourprofessional competence

• be honest and trustworthy

• respect and protect confidentialinformation

• make sure that your personal beliefs donot prejudice your patients' care

• act quickly to protect patients from risk

if you have good reason to believe thatyou or a colleague may not be fit topractise

• avoid abusing your position as a doctor

• work with colleagues in the ways thatbest serve patients' interests.

Whistle blowing

As the above list shows, the GMCencourages doctors to act if they feel thata colleague is not fit to practise. In itsguidelines it is particularly keen for adoctor to be referred to the GMC underthe following circumstances:

• local action would not be practical

• you have tried local action and it hasfailed

• the problem is so serious that weclearly need to be involved, or

• the doctor has been convicted of acriminal offence.

LANDMARK CASE

The Bristol heart deaths

This scandal centred on paediatricheart surgery at the Bristol RoyalInfirmary. An anaesthetist (Dr Stephen

Bolsin) alleged that there was a majorproblem with the mortality rates of thepaediatric heart surgeons working atthe Infirmary. His voice was largelyignored and the surgeons continued tooperate. Eventually an independentenquiry was launched in 1995 and theGMC carried out an investigation in1998. It investigated 53 operationsand the results showed that 29children had died and four hadsuffered brain damage. One of thesurgeons (Mr James Wisheart) and thechief executive (Dr John Roylance)were struck off, while another surgeon(Mr Janardan Dhasmana) was bannedfrom operating on children for three

years. The subsequent Bristol publicenquiry was the largest-everindependent investigation into clinicalpractice in the NHS.

LANDMARK CASE

The Alder Hey scandal

During the Bristol Enquiry, ProfessorRobert Anderson, of Great OrmondStreet Hospital, London, reported thatthe largest UK organ collection was atAlder Hey Children's Hospital,Liverpool. The Health Secretary, FrankDobson, ordered a national inquiry. Thisconfirmed that a huge collection oforgans had been built up at the hospital

without the consent of parents. Professorvan Velzen, pathologist, was particularlycriticised and was suspended as it wasreported that during his tenure, the sizeof the collection had grown rapidlywhile the standard of postmortemexaminations declined to unacceptablestandards. Professor van Velzen wassuspended. The subsequent Alder HeyReport recommended that organs beyondthose establishing cause of death shouldnot be retained unless consent has beenproperly obtained. It was also suggestedthat the Human Tissue Act 2004 shouldbe amended to make à failure to obtainfully informed consent' a criminaloffence.

LANDMARK CASE

Harold Shipman

This GP from Manchester was convictedin 2000 of the murders of 15 elderly

women in his care. Subsequent enquirieshave suggested that he may have beenresponsible for the deaths of several

hundred people (predominately elderlywomen). The GMC struck Dr Shipman

off the medical register, but the case hadachieved immense public notoriety and

had a serious long-term effect on thepublic's faith in doctors.

It is accepted that good communicationskills are essential to effective medicalpractice and, as such, are becoming anintegral part of the medical curriculumand quite correctly are now tested duringthe PACES exam. Communication isimportant not only in the context ofdoctor-patient (or family members)interaction, but also between healthcareprofessionals. The benefits to the patientare obvious as effective communicationgives them better insight into theirconditions and may aid compliance andquality of life. Less well cited, but

perhaps just as important, are theadvantages to the doctors. Medicine isan emotionally demanding professionand effective communication skills mayrelieve doctors of some of the pressuresof dealing with the difficult situations.Poor communication with patients isthought to contribute to psychologicalmorbidity, low personal achievementand emotional burnout. Competentcommunication enhances job satisfactionand the satisfaction of patients, who areless likely to complain or sue.

Can you learn communication skills?

There is no doubt that some people areinherently better at communicating than

others. They are not necessarily betterdoctors, but are perhaps more likely topass the PACES exam as theydemonstrate better communication skillswhen at stations 2 and 4 and will bemore effective at communicating theirideas to the examiners. For the othersthere are two possible causes for theircomparatively poor communicationskills. First, the problem is a perceivedone and they are actually bettercommunicators than they will givethemself credit for. It's a matter ofpractice to enhance self-confidence. Ihope the following chapter in this bookwill give scope for practice. The secondpossibility is that they genuinely lack the

skills of an effective communicator. Thisis something that cannot be remediedòvernight' and healthcare professionalsgenerally spend their lives improvingthese skills. However, there is evidence(Maguire et al., 1989) that effectivecommunication skills can be learnt orimproved. The best way to do this is bypractice and feedback. The feedback onyour communication skills can comeback from other colleagues (ideallyseniors), patients and even yourself withthe use of video recording.

Important factors

There are three factors that contribute tothe interaction between the doctor and

the patient. These include, the interviewsetting, the patient-related factors andthe doctor-related factors.

Factor 1: The interview setting

Generally it is important that there isprivacy. It is hard for people to expressemotions if there are third partiespresent. At the PACES station there willbe at least two examiners present, so theprivacy will have to be imagined. Otherimportant factors include comfortablesurroundings (not in your control!) andseating arrangements. It's recognised thatdoctor and patient seating arrangementsaffect communication. For instance,communication is hindered if doctor and

patient sit opposite each other across adesk and helped if they sit close to oneanother where the patient feels at easeand visual cues are easier to pick up.The seating in the interview room willbe in place and the examiners areunlikely to appreciate you moving thefurniture. However, they will not mindsubtle movement of chairs to aidcommunication.

Factor 2: Patient-related factors

The patient's character and pastexperiences have a profound effect onhow they communicate with doctors.Particularly important are psychologicalfactors such as anger and denial and

physical symptoms of the illness. Henceall patients cannot be treated the sameand your approach needs to be suited tothat individual patient.

Factor 3: Doctor-related factors

It is very important to realise that yourown personal experiences andindividual characteristics have animportant bearing upon how you dealwith an individual patient.

The interview

Beginning

Confirm the patient's identity, greet them

by name and, if appropriate, shake theirhand while introducing yourself. Explainthe purpose of the interview.

Middle

Maintain good eye contact and attentivelistening, and appear sympathetic. Bealert and responsive to verbal andnonverbal cues. Ask more openquestions at the beginning and closedand specific questions as facts areascertained. When appropriate, clarifywhat the patient has told you and buildon it. Let the patient talk as long as it isrelevant. Avoid interrupting the patientand don't ask overcomplicatedquestions.

End

Summarise and confirm the facts withthe patient. Ensure there is a follow-upplan. Thank the patient.

It is important that the interview isentirely purposeful. The questionsshould not be simply conversational orleading, but should be probing andrelevant. It is important that you listen tothe patient and at least seem to be veryattentive. Rapport is better and patientsare more forthcoming with information ifthey feel the doctor is listening. Goodlistening aids empathy (putting yourselfin the patient's shoes). Active listening isdemonstrated by the use of eye contact,

posturing (e.g. head nodding) andresponding or asking directly after thepatients last response. For the interviewto be purposeful, it is important that youencourage the patient to remain relevantto the purpose of the interview andredirect them if they go off at a tangent.If there is any doubt about a response itis OK to ask the patient for clarification.Sometimes, patients find it difficult toarticulate their true problems andconcerns, and both verbal and nonverbalcues help to shed more light on theunderlying problem. An example of averbal cue is a patient who haspresented with heartburn and during thecourse of the consultation may say, `my

mother suffered with heartburn andturned out to have stomach cancer'. Thispatient may not be particularly botheredabout the heartburn and instead beseeking reassurance that they do not havecancer. The good doctor can glean muchinformation from a patient's gait, postureand general body language - so-callednonverbal cues. For example, excessiveeye contact may suggest anger andaggression, whereas lack of eye contactcan imply embarrassment anddepression. Appropriate touch(handshake, putting arm around adistressed person) is also a powerfulmeans of communication, buildingrapport and showing empathy. No doubt

some people find it easier to use touchthan others. As a general rule, avoidexcessive touching, particularly if youare someone who is not comfortablewith touching other people.

Giving information to patients: aprotocol

To give information effectively to thepatient it is important that youunderstand the information being givenand convey it using language the patientwill be able to understand. Thefollowing scheme can be used to giveinformation to patients.

1 Know in your own mind what

information you plan to give before theinterview commences.

2 At the start of the interview summarisethe patient's problems to date and findout their understanding of theircondition.

3 Outline the structure of the interview.

4 Give information using appropriatelanguage and even drawings ifnecessary. Try to be as specific aspossible, avoiding vague terms andmedical jargon. It is crucial thatimportant information is given first, asevidence shows that patients are morelikely to recall this following the inter

view. It is OK to say that you will givean information leaflet following theinterview and if appropriate they canbe followed up by a specialist nurse.

5 Explore the patient's views about theinformation they have just received andencourage them to ask any questionsthey may have.

6 Conclude the interview by checkingtheir understanding and, if appropriate,further management plan.

Giving lifestyle advice

It is becoming increasingly clear that formany conditions, disease prevention is

better than cure. Hence doctors are oftenasked to give lifestyle advice and notsurprisingly such cases often feature instation 4 (Communication skills andethics). Common scenarios wherelifestyle advice may be given includesmokers, excessive alcoholconsumption, obesity, unsafe sex, etc.Shown here is one possible scheme togive lifestyle advice taking the exampleof the smoker.

1 Ask the patient about their attitudes totheir health. It is important to get anidea of whether the patient is pursuinga particular lifestyle that is detrimentalto their health through choice orignorance. The `three S' health belief

model can be used to explore further.How does the patient perceive theirsusceptibility to illness because oftheir lifestyle? For instance, a patientwho has lost a close relative thoughlung cancer may be more concernedabout their own habit and may bereceptive to the idea of change. On theother hand, if the relatives survived toan old age despite smoking, the patientwill consider his own habit to be oflow risk. The perceived seriousness ofthe potential risk of their lifestyle alsohas implications on whether the patientwants to modify their lifestyle. Forinstance, the smoker may think ofdeveloping emphysema as an

acceptable risk, but lung cancer asmuch more serious. The final S standsfor solutions. This refers to theperceived benefit of changing theirlifestyle. If we continue with the sameanalogy the smoker may realise that bystopping cigarette smoking, their riskof lung cancer would dramaticallyreduce. Hence, the smoker wouldchoose to make a lifestyle changebecause of the perceived benefit.

2 Once you have an idea about how thepatient feels about their lifestyle andwhether they can be motivated to makea change, you can then move on togiving the patient relevant information.It is crucial to keep the information

specific and concise, without usingmedical jargon.

3 The third stage is to negotiate a plan tomake the lifestyle change. Most peoplefind lifestyle difficult to initiate andeven harder to maintain. Realistic andachievable targets need to bediscussed.

4 You should conclude the interview bygiving the patient a long-term supportmechanism such as a contact with asupport group. Studies show thatwritten information is both desired bypatients and effective, particularlywhen used as an adjunct to verbalinformation. Hence, you can offer to

supply the patient with writteninformation in the form of a pamphletor booklet.

References

Backer B, Hannon R and Russell N(1994) Death and Dying: understandingand care (2e). Delmar Publications,Albany, NY.

British Medical Association, theResuscitation Council (UK) and theRoyal College of Nursing (2001)Decisions relating to cardiopulmonaryresuscitation. J Med Ethics. 27: 310-

16.

Faden R and Beauchamp TL (1986) AHistory and Theory of InformedConsent. Oxford University Press,Oxford, and New York, NY.

Kiibler-Ross E (1969) On Death andDying. Tavistock Publications, London.

Maguire P, Fairbairn S and Fletcher C(1989) Consultation skills of youngdoctors: benefit of undergraduatefeedback training in interviewing. In: MStewart and D Roter (eds)Communicating with Medical Patients.Sage Publications, Thousand Oaks, CA,USA.

Quill TE, Dresser R and Brock DW(1997) The rule of double effect - Acritique of its role in end-of-lifedecision making. N Eng J Med. 337:1768-71.

Guidelines issued by the Royal Collegeof Physicians (RCP) for host centreswhen writing scenarios for station 4(Communication skills and ethics) are asfollows:

1 The scenario should relate to everydayclinical practice and must not be tooobscure and complex. It should not relyon detailed medical knowledge of anyone condition, investigation, currentmanagement or prognosis.

2 The scenario should clearly define thetask involved and what is expected ofthe candidate, e.g. obtaining consentfor a procedure or discussing proposedmanagement following diagnosis.

3 The scenario should be such as tosustain a 14-minute discussion betweenthe candidate and the surrogate/patient.

4 The scenario should not be so complexthat the surrogate/ patient cannot playthe role required.

5 The topic should, wherever possible,be a universal problem applicable toglobal medicine. It must not be suchthat the candidate needs detailed

knowledge of UK law.

6 It is desirable that the scenario shouldhave an ethical component as it isdifficult for examiners to sustain afive-minute discussion based on ascenario entirely confined tocommunication skills.

7 Patient organisations oppose thedescription of patients by theirdiagnoses, believing that thisstigmatises them, e.g. referring toèpileptics', `diabetics' andàcromegalics' is unacceptable.Patients should be referred to aspatients with epilepsy, diabetes,acromegaly, etc.

8 Abbreviations should be avoidedwherever possible. Universallyaccepted abbreviations such as ECGand CXR are allowable, butabbreviations for investigations, e.g.PCR, or organisations, e.g. DVLA,etc., may differ between countries andare therefore not allowable.

9 Emotionally charged topics need notbe avoided provided the surrogate iswell trained and experienced inroleplaying. However, topics thatinvolve particularly sensitive issues,e.g. sexual history, are best avoided.

It is worth taking a little time to studythese guidelines. In particular it should

be noted that the case must be a commonclinical scenario and not obscure andcomplex, and there should be a well-defined task for the candidate. Whilesome appreciation of law is required,you are not expected to have theknowledge of a lawyer.

While there are many possible cases itis perhaps useful to know that in broadterms the sorts of case you are likely toget in this section can be subdivided intofour categories, which include:

• breaking bad news

• counselling patients

• discussion with relatives

• discussion with colleagues.

The following cases are broadlypresented under these headings.However, it must be appreciated that thisclassification is arbitrary and there isoften overlap between these broadcategories. For instance, you may beasked to break bad news to a relative.

`When in doubt, tell the truth'

(Mark Twain)

Bad news is any information that alters apatient's perspective of the future in anegative way. It can come in manyforms, such as the diagnosis of a seriouscondition such as cancer or a chronicillness like diabetes mellitus, orinforming relatives about the illness inor the loss of a loved one. Withholdingbad news from patients was commonlypractised until recently. A surveyconducted in 1961 (Oken, 1961)

revealed that 88 per cent of doctorsroutinely withheld cancer diagnoses, andwhen they did disclose the diagnosis, itwas often through euphemisms such as`growth'. However, the same study andothers since have shown that mostpatients wish to be informed of theirdiagnosis, which allows them to makeinformed choices. Hence, in recent yearsthe paternalistic model of patient carehas been replaced by an emphasis ondisclosure and patient autonomy.

Breaking bad news is not somethingthat most doctors enjoy and there arenumerous stories about how unskilledphysicians blundered their way throughan important conversation, sometimes

resulting in harm to the patient. Iremember well when I was a medicalstudent on an attachment with a breastsurgeon who, during the course of hisward rounds, after a few friendlypreliminaries would then say somethinglike,'... well, we've got the results backand I'm sorry love but you've got cancer'.This was followed by a supposedly kindsmile and sometimes a pat on theshoulder before moving on to the nextpatient. Some physicians contend thatbreaking bad news is an innate skill -like perfect pitch - that cannot beacquired otherwise. This is incorrectand it is certainly something that can beacquired with practice. Physicians who

are good at discussing bad news withtheir patients usually report that breakingbad news is a skill that they haveworked hard to learn. Furthermore,studies of physician educationdemonstrate that communication skillscan be learned, and have effects thatpersist long after the training is finished.

The most important factors for patientswhen they receive bad news are thephysician's competence, honesty and theuse of straightforward language.

A protocol for breaking bad news

There is no straightforward way ofbreaking bad news and it is something

that needs to be adapted to the individualpatient and the news to be given to them.The following is a suggested strategy forcase scenarios where you have to breakbad news. It is based on RobertBuckman's six-step protocol forbreaking bad news (Buckman, 1994;Maguire and Faulkner, 1988).

1 Getting started

Once the consultation has started, doyour best to ignore the examiners.Ideally, manoeuvre the chairs so thatyour back is to them, without making itobvious to them as they may takeoffence! Do your best to imagine that youare in the clinic for real. Greet the

patient enthusiastically, without beingoverfamiliar. You may want to ask themif there is someone else who has comewith them to the clinic. There never is ofcourse, but it shows that you arethinking. It is best to imagine that this isa real patient in a real setting. Avoid thetemptation of getting straight to thebusiness of breaking the bad news.Instead try to establish rapport and getsome background information. This hasto be tailored to each patient andscenario, and the patient will to someextent dictate it. For instance, they mayappear very impatient and demand toknow the results from theirinvestigations. It would thus be

inappropriate for you to `beat about thebush' and move on to stage two. In mostcases, the patient will be morecompliant and willing to listen. Often, itis a good idea to get some insight intothe patient's social set-up and supportnetworks, for example who they livewith, etc. By this time you should haveestablished some sort of rapport with thepatient.

2 Set the agenda

Establish the reason why the two of youare here having this discussion.

3 Finding out how much the patientknows or suspects

By asking a question such as, `What haveyou already been told about yourillness?' you can begin to understandwhat the patient has already been told ('Ihave lung cancer, and I need surgery'), orhow much the patient understood aboutwhat's been said ('the doctor saidsomething about a spot on my chest X-ray'), the patient's level of technicalsophistication ('I've got a T2NOadenocarcinoma'), and the patient'semotional state ('I've been so worried Imight have cancer that I haven't slept fora week').

4 Fire a `warning shot'

You may have the opportunity to hint that

you are about to break bad news, butavoid cliches such as, Ì'm afraid thenews is bad....

5 Breaking the news

Keep it clear. The temptation is to rushinto the diagnosis, but it is best to breakthe news at the patient's pace and inmanageable chunks, and be sure to stopbetween each chunk to ask the patient ifthey understand (Ì'm going to stop for aminute to see if you have any questions').Long lectures are overwhelming andconfusing. Remember to translatemedical terms into English, and don't tryto teach pathophysiology. For the moreaware patient (this is the likely scenario

for the exam) you may simply need totell them the news.

6 The golden silence

Pause to let the news sink in.

7 Responding to the patient's feelings

If you don't understand the patient'sreaction, you will leave a lot ofunfinished business, and you will missan opportunity to be seen as a caringphysician. Learning to identify andacknowledge a patient's reaction issomething that definitely improves withexperience if you're attentive, but youcan also simply ask ('Could you tell me

a bit about what you are feeling?').

8 Planning and follow-through

At this point you need to synthesise thepatient's concerns and the medical issuesinto a concrete plan that can be carriedout in the patient's system ofhealthcare.Outline a step-by-step plan, explain it tothe patient, and contract about the nextstep. Be explicit about your next contactwith the patient ('I'll see you in clinic intwo weeks'), or the fact that you won'tsee the patient (Ì'm going to be rotatingoff service, so you will see Dr Smith inclinic'). Give the patient a phone numberor a way to contact the relevant medicalcaregiver if something arises before the

next planned contact.

What if the patient starts to cry while Iam talking?

You must remember that the patient usedin the exam may well be a professionalactor who takes their role very seriously.In general, it is better simply to wait forthe person to stop crying. If it seemsappropriate, you can acknowledge it(`Let's just take a break now until you'reready to start again'), but do not assumeyou know the reason for the tears (youmay want to explore the reasons now orlater). Most patients are somewhatembarrassed if they begin to cry and willnot continue for long. It is nice to offer a

tissue if they are readily available(something to plan ahead), but try not toact as if tears are an emergency that mustbe stopped, and don't run out of theroom; you want to show that you'rewilling to deal with anything that comesup.

References

Buckman R (1994) How to Break BadNews: a guide for health careprofessionals. Papermac, London.

Maguire P and Faulkner A (1988)Improve the counselling skills of

doctors and nurses in cancer care.BMJ. 297: 847-9.

Oken D (1961) What to tell cancerpatients: a study of medical attitudes.JAMA. 175: 1120-8.

Candidate information

You are the SHO in a gastroenterologyclinic.

Please read the scenario below. Youmay make notes on the paper provided.When the bell sounds enter theexamination room to begin theconsultation.

Patient: Mr James Cummings

Age: 67 years

You are about to see the last patient inthe clinic. Normally, a consultantsupervises you, but she has had toleave early to attend an academicmeeting. This patient was initiallyreferred to the gastroenterology clinicwith jaundice and abnormal liverbiochemistry. At the last visit anabdominal mass could be palpatedand a CT scan was requested. The CTscan has shown a bulky mass in thehead of the pancreas with vascularencasement. There are also enlargedlymph nodes in the coeliac trunk. Thereport suggests that this is likely torepresent an inoperable pancreaticcancer, and further evaluation with

ERCP is advised. If appropriate, astent can be placed. Your objective isto relay this information to MrCummings.

You have 14 minutes to communicatewith the patient followed by one minutefor reflection before discussion with theexaminers. You are not required toexamine the patient.

Patient information

Mr James Cummings

Aged 67 years

This man was referred to the

gastroenterology clinic suffering withweight loss, lassitude and jaundice.During the clinic visit the doctor thoughtthat she could feel a mass in theabdomen. At that visit the doctor didmention the possibility of this turning outto be something serious and thought thebest way forward was to investigatefurther with a CT scan, which has sincebeen carried out. The radiographer whocarried out the CT scan did not commenton the findings, but did look somewhatconcerned about the result. At theappointment today the patient expects tofind out the results of the CT scan and acomprehensive plan for futuremanagement. The patient is extremely

concerned that this may turn out to be acancerous growth, but is optimistic thatif it does turn out to be cancer it can bereadily treated.

Possible prompts

• Can it be cured?

• I used to drink heavily - could thathave caused it?

• What treatments are available?

• What does this ERCP involve?

• How long have I got to live?

• I'm constantly feeling nauseous - will

that get worse?

• Will I experience a lot of pain?

• Will I need to stay in hospital towardsthe end?

Possible interview plan

• Greet the patient and introduce yourselfto him.

• Set the agenda. Confirm that he hadbeen seen by the consultant in herclinic and she had organised a scan andhe is here to discuss the findings.

• Ask about his understanding of his

illness and the tests carried out thus far.If he is completely off the mark, somegroundwork needs to be done beforethe bad news can be broken.Alternatively, if he has a goodcomprehension of the tests done todate, it may be easier to break the badnews.

• `Fire the warning shot.' An appropriateremark may be, `Well, we've receivedthe report from your recent CT scanand it does show an abnormality.'

• Break the bad news, explaining to thepatient that the scan has shown acancer in the pancreatic gland and thatthis is not likely to be curable.

• Pause and let the news sink in (thegolden silence).

• Respond to the patient's feelings in anempathetic manner. Answer anyimmediate questions that he may have.

• Plan the follow-through and the need tocarry out an ERCP examination, whichwill be organised at the next availablelist. If you do not feel confident inexplaining the procedure (specialistknowledge is not required here),simply say that you will provide himwith a detailed leaflet or alternativelygive him the opportunity to speak withone of the endos- copists beforehand.Remember, in the hypothetical world

of the PACES exam, you always haveaccess to leaflets, to specialist nursesand can make an appointment for thepatient to see just about anybody!

Ethical issues and other discussionpoints

The candidate should be asked toidentify the ethical issues raised in thiscase and how they would address them.The framework for discussion shouldinclude consideration of the underlyingethical principles, in particular theautonomy of the patient and their right tobe involved in the decision-makingprocess. Contrast this with the òld-fashioned' paternalistic model of patient

care, where bad news was kept from thepatient.

The candidate should be able to deliverthe bad news in a clear and concisemanner without too much stalling andavoidance of the discussion.

Candidates should understand thatpatients react in different ways to badnews. But generally speaking theyexperience various stages suggested byKiibler-Ross (seep. 15). These stagesinclude denial, anger, bargaining,depression and finally acceptance of thebad news.


You are the SHO in a dermatologyclinic.


Patient: Miss Simone Dudley

Age: 24 years

This 24-year-old holiday rep had beenreferred urgently to the clinic with alesion on her thigh, suspiciously like amalignant melanoma. A biopsy takenat her first visit has confirmed amelanoma. Also, the patient had beencomplaining of lethargy, abdominalpain and distension, and a recentultrasound scan of the abdomen isstrongly suggestive of multiplemetastases. The biopsy and the scanwere reviewed at the weeklydermatology department meeting andit is felt that the patient has advancedmelanoma that cannot be cured. Yourobjective is to explain the diagnosisand answer any questions she may

have.


Patient information

Miss Simone Dudley

Aged 24 years

This holiday rep has spent the last fiveyears working in Greece. Prior to thisillness she enjoyed excellent health, wasa non-smoker and drank 20 units of

alcohol each week. Some months ago,she noticed a dark, itchy lesion on herleft thigh and saw a local doctor inGreece, who felt it was probably just aninsect bite and reassured her. However,over the next two months sheprogressively deteriorated with lethargy,abdominal pain and distension, and thelesion grew larger and more pigmented.Hence she decided to leave her job andcome back to the UK for further tests.Her GP was concerned about the lesionon her leg and organised a promptreview in the dermatology clinic as wellas an abdominal ultrasound scan toinvestigate the distension and pain. Ather first visit to the dermatology clinic a

biopsy had been taken and the doctorhad commented that there was apossibility that the lesion could turn outto be cancerous. Today she has returnedto the clinic to get the result of thebiopsy and the ultrasound scan, whichshe had in the interim. She is keen forher health problems to be cured,enabling her to return to her job inGreece. If she takes much more time offwork, she runs the risk of losing her job.However, she is extremely anxious aboutthe possibility of cancer and when thedoctor confirms that it is cancer, it willcome as devastating news that she willfind very difficult to accept.

Possible prompts

• When can I go back to work?

• Is it serious and can it be cured?

• Will I need an operation?

• Oh my God - you mean it can't becured?

• What about my job? What shall I tellthem?

• How long have I got to live?


• Greet the patient and introduce yourselfto her.

• Set the agenda. Confirm her previousattendance to the clinic when a biopsywas taken and that she has returned todiscuss the findings.

• Ask about her understanding of theinvestigations carried out to date andwhat her expectations are.

• `Fire the warning shot.' One suggestionis, `The results of the biopsy are backand it does show an abnormality.'

• Break the bad news. Say that thebiopsy findings show a cancer. It iscrucial that you are unambiguous. Ifyou feel that the patient wouldunderstand the significance of

malignant melanoma, then this termmay be preferable to cancer as it ismore accurate. However, some patientsmay be falsely reassured that they donot have a cancer.


• Respond to the patient's feelings in anempathetic manner. Answer anyimmediate questions that she may have.

• Go on to explain the advanced natureof the disease inasmuch as that it hasspread to the liver and cannot betreated. Some people may feel that thisbit of the news - i.e. the incurable

nature of the condition - is moredevastating than being told that she hasa cancer. Hence you must again pauseand let this bit of information sink inand respond to any immediateconcerns. It can be appreciated that ina finite amount of time (14 minutes)only a limited amount of informationcan be given. It is best not to feelpressurised and feel that you have toget everything in. They will givecredence to the manner in whichinformation is given to the patient andbe less concerned about the amount ofinformation.

• Plan the follow-through: contact detailsfor a nurse specialist who can be

contacted as the patient requires moreinformation.

Discussion

Similar issues as apply to case 1.


You are the SHO working on aninfectious diseases ward.


Patient: Mr Nilesh Patel

Age: 31 years

This Indian man was admitted tohospital with lethargy, weight loss andnight sweats. He has been living in theUK for nine months and is studying fora masters degree in engineering(MEng). Clinical examination hadshown cervical lymph nodeenlargement, which had beenbiopsied. Upon admission, there wasa high clinical suspicion oftuberculosis and he had been startedon treatment empirically. However,his lymph node biopsy has come backshowing Hodgkin's lymphoma, whichhad not been previously suggested.You need to explain the reviseddiagnosis, and how his management is

likely to alter. You must also answerany questions that he may have.


Patient information

Mr Nilesh Patel

Aged 31 years

This 31-year-old Indian man has beenliving in the UK for approximately ninemonths. He is currently studying for a

masters degree in engineering (MEng).He was admitted to hospital withlethargy, weight loss and night sweats. Inhospital, the doctors felt that he probablyhas tuberculosis and treatment wasstarted. There was a swelling in theneck, which the medical team decided toinvestigate with a biopsy, and the doctorhas now arranged to have a discussionwith Mr Patel with the biopsy results.Mr Patel is very keen to leave hospitaland get back to his studies, which arebeing financed by loans taken out by hisfamily. Tuberculosis carries some stigmain his own community and he is keen thathe is treated confidentially. When thedoctor gives him the news that they have

found a cancer on the biopsy, Mr Patelwill be initially surprised and think thatthey have made a mistake, as hisdiagnosis is TB. However, it will bedevastating when it sinks in that he hascancer.

Possible prompts

• Have you come to tell me I have TB?

• I must please ask you to keep myinformation confidential. I don't wantpeople to find out that I have TB.

• When can I leave the hospital and getback to my studies?

• This is costing my family a lot ofmoney and I don't want to stay inhospital unnecessarily.

• I don't understand; the other doctorstold me I had TB.

• Lymphoma? I've never heard of thiscondition - is it serious?

• Am I going to die? How long have I gotto live?

• Can you cure it then?


• Greet the patient and introduce yourself

to him.

• Set the agenda by saying that you havecome to discuss the biopsy finding withhim.

• Ask about his understanding of theinvestigations carried out to date andwhat his expectations are. He may saythat he expects it to confirm TB, inwhich case you must elaborate andexplain to him that there are otherconditions that can give an identicalclinical picture. Go on to explain thatthis can include a form of cancerknown as lymphoma. This is thewarning shot. He will not be expectingto be told that he has cancer. But at

least now the notion will be there.

• Break the bad news. Say that thebiopsy findings show that he haslymphoma, which is a type of cancer.


• Respond to the patient's responses inan empathetic manner. Answer anyimmediate questions that he may have.

• Go on to explain the nature of thedisease and its implications. It isperhaps appropriate to be optimisticwith this case and emphasise that thereare potentially curative treatments

available. But specialists will need tobe involved and the disease has to bestaged before treatment is initiated.

• Plan the follow-through. Say that youwill organise an urgent review by oneof the haematologists, who may takeover the patient's care and organisefurther management strategies.

Discussion

Similar issues as apply to case 1.


You are the SHO in a neurology clinic.


Patient: Mrs Amanda Wilcox

Age: 32 years

This lady has phoned up and brought

her clinic appointment forward todiscuss the results from recentinvestigations. She was initiallyreferred by her GP with blurredvision. The clinical history wassuggestive of multiple sclerosis.Subsequent investigations included alumber puncture and an MRI scan.Results from both investigations areback now and are strongly suggestiveof multiple sclerosis. Your objectiveis to explain the likely diagnosis andwhat implications this has for her.

You have 14 minutes to communicatewith the patient followed by one minutefor reflection before discussion with theexaminers. You are not required to

examine the patient.

Patient information

Mrs Amanda Wilcox

Aged 32 years

This lady developed blurred vision inone eye some months ago and wasreferred to a neurologist. She was seenby the consultant, who mentioned thepossibility of multiple sclerosis (MS),although said it was probably unlikelyand organised further tests, which havenow been carried out. Since the hospitalappointment, Mrs Wilcox has beenextremely anxious about this turning out

to be MS, especially as she `read up' onthe condition using the Internet. She wasdue to come back to the clinic in twoweeks' time, but because of her anxietyshe has brought the appointmentforward. She normally works as alibrarian and lives with her husband andthree children, the youngest of whom istwo years old. She is concerned that ifshe does turn out to have multiplesclerosis, she will lose her job and endup incapacitated and in a wheelchair.She is particularly concerned about thewelfare of her children and her husbandnot being able to cope with her illness.

Possible prompts

• Am I likely to end up in a wheelchair?

• Am I likely to die from this?

• Will Igo blind?

• But I feel absolutely fine now .. .

• Is there a cure for this?

• Are my children at risk?



• Set the agenda. Confirm with her thatshe has brought her appointment

forward to discuss the results of theinvestigations organised at theprevious clinic visit.

• Ask about her understanding of why theinvestigations were carried out andwhat had been discussed with her atthe last visit.

• `Fire the warning shot.' One suggestionis, `The MRI scan has been reportedand does suggest a problem.'

• Break the bad news. Explain that boththe MRI scan and the lumbar punctureare strongly suggestive of multiplesclerosis.



• Go on to discuss the details withoutgiving her more information than shecan handle. Remember, this is achronic condition, and there will beample opportunity to discuss in thefuture. Be honest, but also try toreassure the patient. Emphasise that itis difficult to predict the course of theillness. Some people do deteriorateand end up in a wheelchair, but otherscan have a normal and productive life

with only intermittent attacks.

• Plan the follow-through: contact detailsfor a nurse specialist who can becontacted as the patient requires moreinformation. It is worth telling herabout self-help groups such as the MSSociety.

Discussion and ethical issues

Generally similar issues to case 1.However, as this is a chronic illnesswhere the patient is alive for many yearsand may gradually deteriorate, it isimportant that issues such as living wills(see p. 5) are also brought into thediscussion.


You are an SHO in a chest clinic.


Patient: Mr Fred Fogarty

Age: 72 years

This gentleman was referred to the

chest clinic with weight loss,shortness of breath and a grosslyabnormal chest X-ray. Clinical historytaken at his first visit showed that hehad worked as a shipbuilder and hadbeen exposed to asbestos. He had alsosmoked 20 cigarettes a day since theage of 16 years. Following theassessment it was felt that his X-rayand clinical history were consistentwith a pulmonary malignancy,associated with asbestosis. Asubsequent pleural biopsy hasconfirmed the diagnosis of a malignantmesothelioma. Your objective today isto explain to him that he has anoncurative malignancy, probably

secondary to his previous exposure toasbestos.

You have 14 minutes to communicatewith the patient followed by one minutefor reflection, before discussion with theexaminers. You are not required toexamine the patient.

Patient information

Mr Fred Fogarty

Aged 72 years

Mr Fogarty was referred to the chestclinic with shortness of breath andweight loss. It was noted that he had an

abnormal chest X-ray and the doctorwho saw him initially had suggested thatthere was a possibility of cancer and thathe should be investigated further with aCT scan and a pleural biopsy. As ayoung man, Mr Fogarty had worked as ashipbuilder and knows that he had beenexposed to asbestos. He had alsosmoked approximately 20 cigarettes aday since the age of 16 years. Today hehas returned to the clinic to get theresults of his biopsy and is anxiousabout the possibility of cancer. Inparticular, Mr Fogarty is concernedabout his wife, Edith. She suffers withacute anxiety attacks and he has lookedafter her over the years. If it turns out to

be cancer, he feels that she will take thenews badly. At his last visit the doctorhad given him a leaflet highlighting thepotential lung diseases that can becaused by asbestos. It had alsomentioned that patients might be able toclaim compensation and he is keen toexplore this possibility.

Possible prompts

• Have you got the results of my test?

• Does it show anything to worry about?

• I've heard this term mesothelioma, but Idon't understand it. Is it serious?

• I'm very worried about my wife, Edith;I don't know how she will take thisnews. I suspect she will be devastated.

• How will we manage? In your leaflet,it mentioned the possibility of making aclaim. Can you tell me more?


• Greet the patient and introduce yourselfto him.

• Set the agenda. Confirm the patient hadpreviously been seen in the clinic andtests including a pleural biopsy hadbeen organised. Go on to say that youhope to discuss the results of the

biopsy with him today.

• Ask about his understanding of theinvestigations carried out and what hisexpectations are.

• `Fire the warning shot.' One suggestionis, The biopsy result is back and itdoes show a problem.'

• Break the bad news. Explain that thebiopsy result shows a cancer, whichwas probably caused by his previousexposure to asbestos.



• Go on to explain that the disease is notcurable and you can only offersupportive and symptomatic treatments.If he specifically enquires about hisprognosis, explain that generallypeople do not live more than two yearsfrom the time of diagnosis, but it isdifficult to predict the course of thedisease in each individual.

• If he asks about claiming industrialbenefits, explain that he is eligible toclaim benefits and the medical teamwill assist in any way possible.

Benefits must be claimed through hislocal Department for Work andPensions office.

• Plan the follow-through. He shouldreceive an appointment to be reviewedagain in the clinic and should be giventhe contact details for a lung cancernurse specialist, who can be contactedas the patient requires help orinformation.

Asbestos and lung disease

In the past asbestos was commonly usedin the building trade. Now it isuncommon and carefully controlled. Thefibres enter the lung by inhalation and

cause fibrosis, which can progress tomalignancy. White asbestos (chrysolite)is the least fibrogenic, while blueasbestos (crocidolite) is the mostfibrogenic. Brown asbestos (amosite) isthe least common and of intermediatefibrogenicity.

Industrial claims

Doctors need to be aware of thepossibility of compensation wheredisease is thought to be secondary tooccupation. Diseases to considercompensation for include:

• asbestos-related disease

• occupational asthma and otherindustrial lung diseases

• noise-induced hearing loss

• vibration white finger

• repetitive strain injury (e.g.tenosynovitis).


You are the SHO in the infectiousdiseases clinic.


Patient: Mr Jeffrey Vaughn

Age: 28 years

You are asked to see this homosexualman. He has returned unexpectedly atthe end of the clinic to find out theresult of his HIV test, which he hadtaken voluntarily the previous week.He is very keen to know the result,which has come back positive. Yourjob is to explain the result to him andhow you will manage him. Also youneed to ensure that his partner is not atrisk of contracting the disease.


Patient information

Mr Jeffrey Vaughn

Aged 28 years

This man has been a practising,anoreceptive homosexual for over 10years. He has had multiple sexualpartners over the years and rarely askedhis partners to use condoms. Now, hehas been in a stable relationship for twoyears and decided to have his HIV statuschecked when he found out that one ofhis previous partners had developedAIDS. He is very concerned about thepossibility of being HIV positive. He isalso concerned about telling his partner,

who is largely unaware of his previouspromiscuity, and about losing his job asa chef, which is a passion for him.

Possible prompts

• Are you telling me I have AIDS?

• Can this be cured?

• Will my partner have the condition?

• Do I have to tell my employers?

• How do I tell my partner?


• Greet the patient and introduce yourself

to him.

• Set the agenda. Confirm that the manhas previously had an HIV test and hasreturned today to get the result.

• Enquire about his expectation. If hefeels that it is likely to be positive, askabout why he feels this way and viceversa.

• `Fire the warning shot.' One suggestionis, `The HIV test result is back and it isof some concern.'

• Break the bad news. Tell him the resultwas positive.



• Go on to discuss the implications thepositive result has for him. Remember,issues such as job and insurancediscrimination do not need to becovered here, as they should have beendiscussed at the pretest counsellingsession (see case 20).

• It is important to emphasise that beingHIV positive is not the same as havingAIDS.

• It is pertinent to advise him to practisesafe sex to reduce the risk of infectingothers. Moreover, he should disclosehis HIV status to his present and (ifpossible) past partners with whom hehas had unprotected sex, so that theycan be tested.

• Plan the follow-through. He should getcontact details for people who cancontinue to give him information, helpand support. Tell him that you will givehim a leaflet, which has the contactdetails for the Terence Higgins Trust,which can offer individuals advice andself-help. Also give him details for aspecialist nurse.

• Ask if he has any other questions andclose the interview.

Discussion points

The candidate should introduce himselfto the patient and establish a rapportwith him. He should agree with him thatthey are here to discuss the patient's HIVtest. The candidate should explore thepatient's concerns in an empathetic andnonjudgemental manner before tellingthe patient that he is HIV positive in aclear manner and ensure that he hasunderstood. It is particularly importantthat the candidate clarifies that this isHIV and not AIDS, and ensures that thepatient understands that this information

is confidential, but if he fails to discloseit to insurers, etc., then the policy may bevoid. The candidate should be able toanswer any questions that the patientmay have and agree a future plan ofaction including information on helpgroups.

A particularly pertinent issue thatrelates to this case is that ofconfidentiality and third-party risk.Remember that confidentiality is thecornerstone of the doctor-patientrelationship, and it supports theprinciple of patient autonomy, whichemphasises the patient's right to controlover his life. The doctor must respectand maintain this confidentiality unless

there is a greater good, such as the riskto the partner of a patient when youknow the patient refuses to practise safesex.


You are the SHO working on a medicalward.


Patient: Mrs Lynn Russell

Age: 45 years

This lady is in hospital with

rheumatoid arthritis and is currentlybeing treated with steroids and seemsto be improving. She is also in thefirst trimester of her pregnancy, whichis being managed jointly with theobstetric team. Initial blood tests andher age put her into the high-riskcategory for her baby to havecongenital defects. She went on tohave an amniocentesis, whichconfirms Down's syndrome. Theobstetrician has called you with theresult and has asked you to inform herof this diagnosis and discuss thepossibility of abortion with her.

You have 14 minutes to communicatewith the patient followed by one minute

for reflection before discussion with theexaminers. You are not required toexamine the patient.

Patient information

Mrs Lynn Russell

Aged 45 years

This lady was admitted to hospital withpain in her hands, thought to besecondary to a flare-up of rheumatoidarthritis. Now the disease seems to besettling with steroid and analgesictherapy. Prior to the admission, MrsRussell had found out that she waspregnant. She has one seven-year-old

girl and very much wants another childand was very happy to find out that shewas pregnant. But the initial assessmenthad put the pregnancy at high risk forDown's syndrome and the obstetricianlooking after her had recommended anamniocentesis. Mrs Russell is extremelyanxious about the result. One of thedoctors has asked to speak with her andshe anticipates that this will be about theamniocentesis result. She will be veryupset when she finds out that the babyhas Down's syndrome. Whether or not toabort the pregnancy will be anincredibly difficult decision to make andone that she will almost certainly not beable to make at this meeting.

Possible prompts

• Was the test normal?

• How can you tell the baby has Down'ssyndrome just by analysing the fluid inthe womb?

• Do I have to have an abortion? Can Ichoose not to?

• Has the baby got Down's syndromebecause of the rheumatoid arthritis?

• Could my treatment have caused it?

• If I became pregnant again, will thebaby have Down's syndrome?



• Set the agenda. Confirm that she hashad an amniocentesis and is awaitingthe result and try to establish a rapportwith the patient.

• Ask about her expectations and followany verbal cues.

• `Fire the warning shot.' One suggestionis, The obstetrician looking after youhas asked me to speak with youregarding the test as he is concernedabout the result.'

• Break the bad news. Tell her that theresult shows a chromosomal defectconsistent with Down's syndrome.



• Go on to discuss the implications of theresult with her. In particular you mustexplore her views.

• Broach the subject of abortion of thefoetus and listen carefully to herresponses. Remember, your job is not

to persuade the lady to have anabortion (some people may evenconsider it outside the remit of aphysician role), but simply to help herto make an informed choice.

• Plan the follow-through. Tell her thatyou will organise for her to speak witha genetic counsellor and anobstetrician.

• Ask if she has any other questions andclose the interview.

Legal issues - abortion

The Abortion Act 1967 dictates abortionlaws in England, Scotland and Wales.

The law basically allows abortion iftwo doctors agree that continuation ofthe pregnancy may result in seriousphysical or mental health problems forthe mother or existing children. Or thereis a substantial risk that if the child wereborn it would suffer from such physicalor mental abnormalities as to beseriously handicapped (what constitutesa `serious handicap' is not addressed inthe legislation). The Human Fertilisationand Embryology Act 1990 amended theAbortion Act, in particular it removedpre-existing links with The Infant LifePreservation Act 1929, which had madeit illegal to `destroy the life of a childcapable of being born alive' (which was

assumed to be 28 weeks). Hencetermination can be carried out at anygestational age, provided it is justifiedby medical reasoning.

According to The Abortion Act 1967,doctors can refuse to participate inabortions because of a conscientiousobjection, provided that, in anemergency, necessary treatment can beprovided to a woman at risk of death.

The pro-abortion lobby base theirargument on the basis that the overridingprinciple is the woman's right to choosewhat happens to her body. Whereas, theanti-abortionists base their case onnumerous ethical, moral and religious

issues, the most compelling of which isthe notion of the sanctity of all humanlife. There are others who choose to `siton the fence' in this debate and argue thatabortion is wrong except in compellingcircumstances such as the diagnosis ofserious disease in the foetus.

Genetic screening and the new eugenics'

The eugenics (Greek, means `goodgenes') movement began at least 100years ago and became a powerful socialforce as it tried to create `better humansthrough better breeding' and evensterilisation of undesirables. Now,similar ethical and moral dilemmas areincreasingly becoming part of modern

medicine. This is because of theavailability of prenatal testing, geneticscreening and, in the future, geneticmanipulation and cloning. In the searchfor the ideal `Citizen', there is a concernthat people will be discriminated againstbecause of their bad genes. For instance,will employers and insurers base theircontracts on the basis of an individual'sgenetic make-up? Perhaps we arealready practising the eugenics mindsetby trying to exclude patients withDown's syndrome from our society.After all, many of these individuals areunique, intelligent human beings whoenjoy great happiness. Should we betesting for this condition and then

aborting high-risk pregnancies? Othersmay argue that knowledge empowersdoctors and patients to make appropriatedecisions.

Clearly this is a minefield of ethicaldilemmas. There are very few right andwrong answers here. It is very importantthat you think through some of the issuesand have opinions on the controversyand debate.


You are a medical SHO on call for thecoronary care unit (CCU). Please readthe scenario below. You may make noteson the paper provided. When the bellsounds enter the examination room tobegin the consultation.

Subject: Mrs Janice Levin

Age: 59 years

Re: husband, Mr Ron Levin, aged 64years

You are asked to speak to Mrs Levinby the sister on CCU. Her husband,Mr Ron Levin, was a 64-year-old manwho was admitted to the CCU on theprevious evening, following an acutemyocardial infarct. Prior to this hehad been fit and well, although wasknown to smoke and suffered withhypertension. Mr Levin had beenthrombolysed, and had been treatedappropriately and urgently. However,during the night he had developedfurther chest pains and had a cardiacarrest from which he could not beresuscitated, despite a prolongedresuscitation, and subsequently died.His wife was informed of the

deterioration over the telephone, butis unaware of the death. Sister hasasked you to inform Mrs Levin thather husband has died and answer anyquestions she may have.

You have 14 minutes to communicatewith the patient followed by one minutefor reflection before discussion with theexaminers.

Patient information

Mrs Janice Levin

Aged 59 years

Re: husband, Mr Ron Levin, aged 64

years

This lady's husband (Mr Ron Levin) wasadmitted to the CCU the previousevening when he developed chest painand was diagnosed with an acutemyocardial infarct. He was treatedquickly and seemed to make a goodrecovery, and was alert and pain-freewhen she left him. Prior to thisadmission, Mr Levin had been a fit man.During the course of the night, Mrs Levinreceived a call from the hospital. Thenurse had told her that her husband `hadtaken a turn for the worse' and suggestedshe should come in to see him. MrsLevin is extremely concerned about herhusband, but is optimistic that he will

make a full recovery. On arrival at theCCU, a nurse greeted her and asked herto wait in the relatives' room where adoctor would give her an update on hiscondition, before she is allowed to seehim. The doctor will explain to her thather husband had another heart attackduring the night and died. Mrs Levinwill be devastated by this news.

Possible prompts

• Can you tell me how my husband isplease? They are not letting me seehim.

• Is he going to be OK?

• The doctor yesterday said he wasgoing to be OK. What went wrong?

• Could anything have been done to savehim?

• Can I see him please?

• Will they need to do a postmortem?


• Greet the lady and introduce yourself.

• Set the agenda. Confirm that she hasbeen called back to the hospital by thenurse to discuss her husband.

• Enquire about her expectations. Briefly

go into what prompted his admissionand how she feels he is progressing.

• `Fire the warning shot.' One suggestionis, `During the night your husbanddeveloped some more chest pain andpossibly had another heart attack.'

• Break the bad news. Go on to explainthat Mr Levin's heart stopped beating,possibly because of another heartattack, and despite the best efforts ofthe medical team he died.


• Respond to the patient's feelings in an

empathetic manner. Answer anyimmediate questions that she may have.

• Do not feel pressured to speak - agentle and empathetic manner may bemore effective than words.


Discussion

Do you feel that you or the sister couldhave informed this lady of her husband'sdeath down the telephone?

It is always ill-advised to break badnews over the telephone for at least two

reasons.

1 It is unkind, as you do not know if therecipient of the news has any supportto hand and how they will cope withthe news.

2 You cannot be sure with whom you arediscussing the matter and it could resultin a serious breach of confidentiality.


You are a medical SHO on call for thecoronary care unit (CCU). Please readthe scenario below. You may make noteson the paper provided. When the bellsounds enter the examination room tobegin the consultation.

Subject: Mrs Nancy Berry

Age: 48 years

Re: daughter, Miss Paula Berry, aged18 years

Paula Berry is an 18-year-old studentwho was brought to hospital after asevere asthma attack. Despiteaggressive treatment by theparamedics, she went on to have acardiac arrest while in casualty.Cardiopulmonary resuscitation wasrapidly commenced, but she had aprolonged arrest of 25 minutes beforeoutput was obtained. She now has anoutput and is being ventilated, but theteam are extremely pessimistic abouther prognosis. Her pupils do notrespond to light and gag reflexes areabsent. The anaesthetist on call hasarranged a transfer for her to the ITU.They plan to monitor her for 24 hours

and if there is no improvement toswitch the ventilator off. Discussionwith her GP over the telephonesuggests that Miss Berry waspreviously well, with her asthmaunder good control, and has neverpreviously required hospitaladmission.

Her mother has just arrived at thehospital and is unaware of herdaughter's condition. One of the nurseshas taken her to the relatives' roomand has asked you to speak with her.Your task is to have a discussion withMrs Berry to explain the situation.

You have 14 minutes to communicate

with the patient followed by one minutefor reflection before discussion with theexaminers.

Subject information

Mrs Nancy Berry

Aged 48 years

Re: daughter, Miss Paula Berry, aged 18years

This lady was alarmed to hear that her18-year-old daughter had been admittedto hospital with an asthma attack and hasnow arrived there to see how she is.Paula is a healthy and happy young

student who only suffers with mildasthma, which is usually well controlledwith inhalers. She is one of fourchildren, but is both the youngest and theonly daughter, and has always been thebaby of the family. Upon arrival at thehospital a nurse has taken Mrs Berry tothe relatives' room to speak with adoctor before seeing her daughter. Shewill be shocked to hear that her daughterhad a severe asthma attack, whichcaused her heart to stop, requiringcardiopulmonary resuscitation. Thedoctor will explain to her that Paula isnow on a ventilator and perhaps theworse news is that she is likely to havesustained irreversible brain damage and

may already be `brain dead'.

Possible prompts

• How is my daughter? Can I see herplease?

• What caused this? She was fine thismorning.

• Oh my God! What do you mean -cardiac arrest? She is only 18 yearsold.

• When can she come off the ventilator?

• Irreversible brain damage? Does thatmean she will never wake up?

• Can I see her now, please?



• Set the agenda. Confirm that she hascome to hospital to see her daughterwho was admitted earlier in the day.

• Enquire about her expectations. Try togain insight into what Mrs Berryunderstands about her daughter'sillness.

• `Fire the warning shot.' One suggestionis, `Your daughter had a severe asthmaattack and was extremely sick when

she arrived at hospital.'

• Break the bad news. Go on to explainthat Paula Berry had a prolongedcardiac arrest, which is likely to havecaused irreversible brain damage andshe will probably never regainconsciousness.


• Respond to the mother's feelings in anempathetic manner. Answer anyimmediate questions that she may have.

• Explain to her that it is difficult topredict her daughter's progress and that

the medical and nursing team will keepher informed of any developments.

• Inform her that she will be able to seeher daughter immediately. Ask if shehas any other questions and close theinterview.

One of our key roles in hospitalmedicine is the diagnosis and treatmentof chronic conditions. To deliver thebest possible care, it is important thatthe patients are appropriately educatedabout their conditions and hence there isa frequent need to communicate with thepatient. Hence, not surprisingly, suchcases have made their way into thePACES exam.

Here follows a few general pointsregarding such cases.

• Patients are often experts on their

conditions and it often helps to get anidea of their understanding beforeembarking on a major counsellingsession.

• Chronic conditions can be thought of interms of the impact they have on apatient's life and conversely thepatient's lifestyle may have an impacton the disease.

• Remember, in the hypothetical worldof the PACES exam, you will haveaccess to almost unlimited resources,which include: specialist nurses,information leaflets, patientassociations, etc.

• Don't be frightened of showinginitiative, for example by drawing adiagram to illustrate the colon inexplaining ulcerative colitis to apatient.


You are the SHO in the diabetes clinic.


Patient: Mr Raymond Royce

Age: 52 years

This gentleman was recently

diagnosed with diabetes mellitus byhis GP and started on metformin. Hehas presented to the diabetes clinic forthe first time. The GP's letter suggeststhat he would like to know howdiabetes is likely to affect hislifestyle. He is particularly concernedabout losing his job as a bus driver.He is overweight, smokes 20cigarettes a day and drinks about fourpints of beer each evening. Pleaseadvise him accordingly.


Patient information

Mr Raymond Royce

Aged 52 years

This gentleman has recently beendiagnosed with diabetes mellitus and iscurrently taking metformin. He isoverweight and leads a very sedentarylifestyle, working as a bus driver andspending his evenings either in the pubor at home watching television. Hesmokes 20 cigarettes a day and onaverage drinks about four pints of beereach evening. He is married with threechildren, although only one still lives athome. Mr Royce is concerned about his

diagnosis of diabetes and how it willaffect his lifestyle. He is particularlyconcerned about any impact it may haveon his vocation as a bus driver as he hasheard of people losing their PSVlicences because they were diagnosedwith diabetes. This gentleman is alsoworried about his eyesight, which hassignificantly deteriorated recently. Hehas not got round to having his eyestested and has not mentioned this toanyone previously.

Possible prompts

• Will I end up on injections? I hateneedles.

• Will I have to give up my job?

• Does my employer need to know aboutthis condition?

• My eyesight has deteriorated - is itlikely to be related?

• Is it a serious condition?


• Greet the gentleman and introduceyourself.

• Set the agenda. Confirm that he hasbeen referred to this clinic after recentdiagnosis of diabetes mellitus.

• Enquire about his expectations. Try togain insight into Mr Royce'sunderstanding of diabetes and whetherhe expects to make lifestylemodifications because of the diagnosis.Remember the three Ss (see p. 25):

- susceptibility: explore his perceptionand understanding of possiblecomplications related to his diagnosisof diabetes and his lifestyle. It isimportant for him to understand thatthis is a chronic condition that hasimplications for the rest of his life. Ofparticular importance is the aim toreduce the risk of macrovasular(cerebrovascular disease, peripheralvascular disease and ischemic heart

disease) as well as microvascular(neuropathy, retinopathy andnephropathy) complications

- seriousness: does he believe thatpoor control of diabetes and hislifestyle is likely to have seriousconsequences for him?

- solutions: does he perceive a benefitin changing his lifestyle and will heconsider doing so.

• Give lifestyle advice and negotiatechange:

- diet: avoid excess sugar in the diet.Eat fresh fruit and vegetables. For

more formal dietary advice refer himto a dietician

- exercise regularly and lose weight

- stop smoking (see case 14) andmoderate alcohol intake.

• Advice regarding driving (see below).

• Long-term support and follow-up.Effective management will involve amultidisciplinary approach, which willinclude doctors (especiallydiabetologists and opthalmolo- gists),specialist diabetes nurse, dietician,chiropodist, etc.

• Ask if he has any other questions andclose the interview.

Diabetes and driving

For specific advice refer to the DVLAwebsite. Patients are allowed to drivecars and motorbikes if the diabetes isdietcontrolled or well controlled onmedication. Of particular importance isthat they do not have episodes ofhypoglycaemia (<4 mmol/1). Patientscan also hold a licence to drive a largegoods vehicle (LGV) or to drive apassenger services vehicle (PSV) if thediabetes is treated by diet alone ortablets, provided they do not have visualproblems. However, since April 1991, it

has been illegal to issue a LGV or PSVlicence if the patient is insulin-dependent. Moreover, patients whochange their treatments and go ontoinsulin automatically lose their licences.Drivers also need to be aware that poorvision as a result of retinopathy mayresult in the loss of their drivingprivileges.


You are an SHO working on a medicalward.


Patient: Mrs Anita Hull

Age: 44 years

This lady was admitted to hospitalwith progressive shortness of breath,which is being investigated. She alsocomplained of joint pains, which hadbeen worsening over some time. Theprevious day she had been seen by arheumatologist, who had confidentlydiagnosed rheumatoid arthritis andstarted her on anti-inflammatorymedication. Mrs Hull is concernedabout her diagnosis and the impact itis likely to have on her lifestyle. Shehas asked to speak to a doctor. Yourobjective is to speak to her andanswer any questions that she mayhave.


with the patient followed by one minutefor reflection before discussion with theexaminers. You are not required toexamine the patient.

Patient information

Mrs Anita Hull

Aged 44 years

This lady was admitted to hospital threedays ago, by her GP, with progressiveshortness of breath. A comprehensivehistory had been taken and Mrs Hull hadmentioned that she had suffered withpain in her joints, particularly her hands,for some time, but had not sought any

medical advice for this although she hadbeen self-medicating with paracetamoltablets. The admitting team hadorganised a rheumatological review anda consultant had seen her yesterday. Hehad commented on the inflammation inher hands and explained that she hasrheumatoid arthritis and had started heron some tablets. He had also said thatthe breathing problems may be related.

This lady has previously been fit andwell, and indeed works as a swimminginstructor. She is divorced and has onedaughter, aged 13 years.

Mrs Hull's grandmother had sufferedwith rheumatoid arthritis and she is

concerned that her hands may becomedeformed like her grandmother's. She isalso worried about the side effects of themedication she is on, the impact it willhave on her lifestyle and whether thereis a chance that her daughter will get thecondition.

Possible prompts

• Yesterday, the doctor told me that I hadrheumatoid arthritis. What exactly doesthis mean?

• Will my hands become deformed likemy grandmother's?

• The other doctor said that my breathing

might be related to the arthritis. Howcan this be possible?

• I'm concerned about the side effects ofthe tablets I'm on. Are they safe?

• Will my daughter get arthritis?

• Can I lead a normal life?



• Set the agenda. Confirm that she hasasked to speak with a doctor afterrecent diagnosis of rheumatoidarthritis.

• Enquire about her understanding of thisdiagnosis and the possible implicationsfor her.

• Information given must be free ofmedical jargon and where possiblespecific. It should include thefollowing:

- The disease causes inflammation inthe joints (you may have to explainwhat you mean by joints). It is thoughtto be autoimmune, i.e. the body reactsagainst the joints. The condition canlead to deformity, but the progress ineach patient is unpredictable. Oftenthere are isolated attacks with longperiods where the disease is inactive.

It is important to emphasise that manypatients can lead normal and healthylives.

- It is not an inherited condition, butpatients with an affected relative aremore likely to get the condition.Hence the risk of her daughterdeveloping the disease is small.

- There has to be a balancing actbetween rest and exercise. As ageneral rule contact sports are bestavoided and patients should beencouraged to protect their joints.However, low-impact exercise (andswimming is probably the best)should be strongly encouraged.

- There are a number of medicationsused to treat arthritis, which includeanalgesics, disease-modifying drugs(e.g. sulphasalazine, methotrexate,azathioprine, etc.) and nowbiologicals (such as anti-TNF drugs).They all have side effects but youneed not go into details.

• Explore the lady's views about theinformation she has received andencourage her to ask any questions shemay have.

• Explain to her that she will befollowed up by a rheumatologist.

• Thank her and close the interview.


You are the SHO working on theinfectious diseases ward.


Patient: Mr Gurmail Singh

Age: 37 years

Mr Singh was initially admitted withweight loss and a productive cough,after a prolonged visit to India. Theinitial chest X-ray was found to beabnormal and he was put into a sideroom (which is causing him to becomeconsiderably frustrated) for barriernursing, pending further investigation.A sputum sample has come backpositive for alcohol and acid fastbacilli. Explain the diagnosis oftuberculosis and what the treatmententails. You are not expected to take ahistory.

You have 14 minutes to communicatewith the patient followed by one minutefor reflection before discussion with the

examiners. You are not required toexamine the patient.

Patient information

Mr Gurmail Singh

Aged 37 years

This gentleman was admitted to hospitalwith a cough and weight loss followinga six-month trip to India. He has beenbarrier nursed since admission, whichwas over a week ago and he is not surewhy, except that it is to prevent thespread of infection. Mr Singh was bornin India, but moved to the UK as a child.He was working as a motor mechanic

until he lost his job eight monthspreviously. He normally lives with hiswife and children, aged 2 and 8 years.Mr Singh is becoming increasinglyfrustrated with being confined to a smallroom and is desperate to find out what'sgoing on and whether it is somethingserious. He is also concerned about anyrisks it may pose to his family.

Possible prompts

• I'm really fed up of being in this room.I wish someone would tell me what isgoing on.

• What exactly is TB and why did I getit?

• Will I infect my family?

• Will I have to take the tablets for therest of my life?

• Do these medicines have side effects?

• Will I be cured after taking thesemedicines?

• Will I be able to get back to my job?



• Set the agenda. Explain that you havecome to speak with him regarding his

hospital admission.

• Enquire about his understanding of thereason for this admission to hospital.

• If he has no comprehension of why heis in hospital and isolated, explain tohim that the admitting team suspectedtuberculosis, which is an infectiveillness, and hence he was isolated.

• Go on to inform him that the test resultsdo indeed confirm that he has TB andthat this will require treatment withantibiotics. Remember your remit hereis to simply inform the man of hisdiagnosis and management strategies.Hence you need not go into details of

his treatments and possible sideeffects. Also, depending on the contextin which the news is given to thepatient and his possible perceptions,you may have to give him the diagnosisin a manner similar to the breaking badnews scenarios previously discussed.

• Remind him that this is an infectiveillness and hence his close contacts,particularly his family, will also needto be screened for the illness and, ifappropriate, treated. Moreover, hemust continue to be isolated until hissputum does not contain the bacteriaresponsible for TB ('smear negative').

• Summarise the discussion and ask

whether he has any final questions.

• Thank him and close the interview.

TB and public health ethics

Tuberculosis is the world's leadinginfectious killer and is responsible forapproximately two million deaths perannum (Dye et al., 1999). People at thegreatest risk of developing the conditioninclude the poor, substance abusers,those infected with HIV and prisonpopulations. These people also have theleast access to treatment. Efforts tocontrol TB include complex ethicalconsiderations involving public healthethics. Generally, medical ethics focuses

on individual patients and thepreservation of their autonomy anddignity. Public health ethics concentrateson the protection and promotion ofhealth in communities. One key ethicalissue is balancing the patient's rights andautonomy with the protection of thecommunity. Treatments such as directlyobserved therapy (DOT), detention andmandatory treatment entail loss ofpatient's autonomy. But these can bejustified on the basis that they preventgreater harm to the community at large.

There has been considerable interest inpublic health ethics in recent years. As ageneral rule, if there is a programme setup to protect the public and it violates an

individual's rights, it must fulfil thefollowing criteria. It must be necessary,effective proportionally and burdensfrom it must be minimised (Childress etal., 2001).

References

Childress JF, Faden RR, Gaare RD,Gostin LO, Kahn J, Bonnie RJ, KassNE, Mastroianni AC, Moreno JD andNieburg P (2001) Public health ethics:mapping the terrain. J Law Med Ethics.30: 170-8.

Dye C, Scheele S, Dolin P, Pathania Vand Raviglione MC (1999) Consensus

statement. Global burden oftuberculosis: estimated incidence,prevalence, and mortality by country.WHO Global Surveillance andMonitoring Project. JAMA. 282: 677-86; 278: 838-42.




Patient: Mrs Jayne Watkins

Age: 36 years

This lady has been investigated for

persistent diarrhoea and weight loss.She had positive endomysial andtissue transglu- taminase antibodiesand a subsequent duodenal biopsyconfirmed a diagnosis of coeliacdisease. You should discuss thediagnosis, its management andpossible implications with her. Youare not expected to take a history fromher.


Patient information

Mrs Jayne Watkins

Aged 36 years

This lady has suffered with persistentdiarrhoea and weight loss for about sixmonths. She was subsequently referredto a gastroenterologist and was seen inthe clinic by a consultantgastroenterologist, who organised bloodand stool tests as well as an endoscopy.She has now returned to the clinic to findout the results of her investigations. Sheis very anxious about her illness and ishoping that the investigations will haveclarified the diagnosis.

Possible prompts

• Will I ever get back to normal?

• Which foods are safe for me to eat?

• I've read that I could get cancer fromthis condition. Is this true?

• Will my children get coeliac disease?Is it inherited?

• I've noticed a very itchy rash on myknees. Is that related?



• Set the agenda. Confirm that sheinitially presented with diarrhoea and

weight loss and has had a series ofinvestigations to find out the cause ofher problems.

• Enquire about any previousdiscussions with the medical team andwhether she was aware of specificillnesses, particularly coeliac disease.

• Explain to her that the tests, includingthe duodenal biopsy, confirm adiagnosis of coeliac disease.

• You need to explain in simple termswhat implications this has for her. Sheneeds to avoid wheat, barley and rye,or any foods that contain these. Oatsare debatable, because they are not

thought to have a direct effect on thedisease, but commercially availableoats are often contaminated by theother wheat germs.

• Say that you will arrange for adietician to see the patient and provideher with a list of safe foods. Emphasisethat the dietary changes are likely to belifelong. The risk of not adhering to astrict diet may result in relapses of thecoeliac disease and the consequences,which include anaemia andosteomalacia/osteoporosis.

• Go on to explain that coeliac disease isassociated with an itchy vesicular rash,particularly affecting the elbows and

shins. This usually settles with thedietary control, but occasionallyrequires drug treatment.

• It may be worth mentioning the slightlyincreased risk of intestinal lymphoma,but reassure her that the risk of this isextremely small and you have informedher because she may hear about itsomewhere else and become alarmed.

• Reassure her that it is not an inheritedcondition, but patients often do have agenetic susceptibility, e.g. if of Irishorigin.

• Tell her about the Coeliac Society.

• Summarise the discussion and let herknow that you will organise a follow-up in the clinic.



You are the SHO on a respiratory ward.


Patient: Mr Phillip Yates

Age: 27 years

The nurse looking after this man has

asked you to speak to him at hisrequest. He was admitted to hospitalwith difficulty in breathing, whichwas diagnosed as acute severeasthma. Treatment with steroids andnebuliser therapy caused a rapidrecovery (ITU was not required).Previously, Mr Yates had been fit andwell and regularly played football.His discharge medication consists ofsalbutamol and Flixo- tide inhalers aswell as prednisolone 40mg once dailyfor one week. Mr Yates is concernedabout the impact this will have on hislifestyle. He smokes 15 cigarettes aday, plays football at the weekendsand works as a book-keeper. Your

task is to discuss the impact that thediagnosis of asthma will have on hislifestyle.


Patient information

Mr Phillip Yates

Aged 27 years

This gentleman was admitted to hospitalwith shortness of breath and was

diagnosed with acute severe asthma.This was treated with nebulisers andsteroid tablets and he made a goodrecovery over the next few days. He isnow on various inhalers and a reducingcourse of oral steroids and is nearlyready for discharge from hospital. Priorto this admission, this gentleman was fitand well, playing football regularly. Hehas been a smoker for 10 years andcurrently smokes 10 cigarettes a day. Heis very keen to give up and has tried toon a number of occasions, but this hasproved unsuccessful. It has beenparticularly difficult as he works as abook-keeper and everybody smokes inthe shop. He is worried about the long-

term damage to health by continuing tosmoke. He is also concerned about thediagnosis of asthma and whatimplications this has for him, and theside effects of the medication he hasbeen started on, particularly whether itis safe for him to continue to playfootball. He has asked to speak to adoctor to discuss these issues further.

Possible prompts

• Why did I have this attack out of theblue?

• What side effects will I get with thesesteroid tablets? I've heard they are verybad for you.

• Could I have died as a result of thisattack?

• Will I be OK with going back to work?

• Will I be OK to start exercising?

• Does smoking set off an asthma attack?



• Set the agenda. Confirm that he hasasked to speak with a doctor and thathe was admitted to hospital withshortness of breath and was diagnosed

with asthma.

• Enquire about his understanding ofasthma.

• If he has a good, sound understandingof the condition, then you can build onit and fill in any gaps. Alternatively,give a clear and concise explanation ofthe condition.

• It is important to emphasise that asthmais a chronic condition, which is wellcontrolled in the majority of patientswho lead normal and healthy lives. It isimportant that `flare-ups' are preventedby regularly using his steroid inhaler.Moreover, if there are obvious

exacerbating factors such as dust, thesemust be avoided.

• Encourage exercise and a healthylifestyle.

• Smoking advice (see below). Ask if hehas ever considered stopping or indeedhas tried stopping. If he has not thoughtabout it, tell him it is very importantthat he tries to stop and that there ishelp available, both in terms ofmedical therapy and counselling.

• Summarise the discussion and ask himif he has any other questions.


Smoking cessation

A report by the Royal College ofPhysicians - Nicotine Addiction inBritain (February 2000) - has shown thatmany people continue to smoke, notthrough choice, but because of theiraddiction to nicotine. Surveys haveshown that the majority of smokers wishto quit, but find it difficult because oftheir addiction and the resultantwithdrawal symptoms. There is also afear of weight gain, which occurs in 80per cent of people when they quitcigarettes.

Smoking cessation aids

There are two proven pharmaceuticalaids to stopping smoking:

1 Nicotine replacement therapy. This isdesigned to help the smoker to breakthe habit while providing a reduceddose of nicotine to overcomewithdrawal symptoms such as cravingand mood changes. It is available invarious forms, which include chewinggum, skin patches, tablets, nasal sprayand inhalers. Studies have shown thatthis form of therapy doubles thechances of a smoker successfullyquitting the habit.

2 Bupropion (Zyban). This drug worksby desensitising nicotine receptors

within the brain and again doubles thechances of a smoker successfullyquitting the habit. However, it is onlyavailable on prescription undermedical supervision because ofpossible side effects, the most seriousof which is the risk of fitting. This riskis estimated to be less than 1 in 1000,but other less serious side effects suchas insomnia, dry mouth and headachesare more common.

Other cessation methods tried bysmokers include acupuncture andhypnosis, but there is little in the way ofscientific evidence for their efficacy.Herbal cigarettes are not recommendedas an aid to giving up smoking because

they produce both tar and carbonmonoxide, and reinforce the habit ofsmoking, which smokers need toovercome. Clinics and self-help groupscan be extremely beneficial in helpingpeople quit. Indeed, a review of smokingcessation products and services foundthat smokers are up to four times morelikely to stop smoking by attendingspecialist smokers' clinics than by usingwillpower alone. Charitableorganisations such as QUIT (Tel: 0800002200) and Action against Smokingand Health (ASH) can be used to gainfurther support and get details of localself-help groups.


You are an SHO working on thecoronary care unit (CCU).


Patient: Mr Frank Collins

Age: 52 years

You are asked to speak to a 52-year-

old man who has been under your carefollowing an acute myocardial infarct.He was treated promptly withthrombolysis and now, three dayslater, is making a very good recovery.He is concerned about changes that heneeds to make to his lifestyle. He waspreviously known to be a diet-controlled diabetic, smoker of 30cigarettes per day and worked as along-distance lorry driver. Your taskis to speak to him and recommend anylifestyle adjustments and answer anyquestions that he may have.



Patient information

Mr Frank Collins

Aged 52 years

This lorry driver was admitted tohospital with severe chest pain and wassubsequently diagnosed with an acutecoronary syndrome. He is known tosuffer with diabetes, which isdietcontrolled, although he generallyavoids checking his blood sugars andknows that he eats badly. This includesfrequent stops at cafes for `greasy' meals

and sugary snacks, washed down withpots of coffee. He drinks approximately20 units of alcohol per week and smokes30 cigarettes per day. He is married andlives with his wife of 28 years and fourchildren. Mr Collins does not understandthe term àcute coronary syndrome' andhas asked to speak to a doctor to clarifythis and to understand what implicationsit has for him. He is particularly worriedabout any impact on him working as alorry driver.

Possible prompts

• Can you explain what a coronarysyndrome is please?

• Will I have another heart attack?

• Is it OK to start exercising?

• How soon can I get back to my regularactivities?

• How often should I exercise?

• When can I go back to work?

• It's an embarrassing question doctor,but will sex be safe?



• Set the agenda. Confirm that he hasasked to speak with you regarding hisdiagnosis.

• Enquire about his understanding of hisdiagnosis.

• If he has no insight into his diagnosisthen you have to explain to him insimple lay terms that he has had a heartattack, which occurs when the bloodvessels supplying the heart areoccluded. Reassure him that he wastreated effectively in good time and isexpected to make a good recovery.

• Question him about his lifestyle andask whether he is motivated to improve

it. Remember the three Ss (seep. 25):

- susceptibility explore his perceptionand understanding of possiblecomplications related to his lifestyleand the possibility of him havinganother myocardial infarct

- seriousness: does he believe that hispoor lifestyle is likely to have seriousconsequences for him?

- solutions: does he perceive a benefitin changing his life tyle and will heconsider doing so?

• Give lifestyle advice and negotiatechange:

- diet eat a calorie-controlled diet lowin fat (I'm sure you all know aboutgood and bad fats!). Eat fruit andvegetables. For more formal dietaryadvice, say that you will refer him toa dietician

- medications: explain that a number ofmedicines such as aspirin and a`cholesterol-lowering drug' have beenstarted to prevent further heartdisease and he must not stop themeven if he feels well in himself

- exercise regularly and lose weightthis needs to be developed at agradual pace and should besupervised by a specialist (e.g. a

post-MI rehab nurse). Warn him thatoverexertion may put a strain on theheart muscle and lead to a furtherheart attack. Warning signs includechest pain, prolonged shortness ofbreath, dizziness, blotchy skin, nauseaand vomiting. Remember, exerciseincludes sexual activity, which needsto be avoided in the first few weeksafter a heart attack

- stop smoking (see case 14) andmoderate alcohol intake.

• Advice regarding driving. As a generalrule there is a 4-week ban for group 1licences and a 6-week ban for group 2licences.

• Reassure him that his rehabilitation is agradual process that will be supervisedand assisted by the medical team. Butremind him that he is ultimatelyresponsible for his health and it isimperative that he makes lifestyleadjustments to avoid a further heartattack in the future.

• Ask if he has any other questions and ifnot close the interview.


You are an SHO in a neurology clinic.


Patient: Miss Rosa Fletcher

Age: 29 years

This lady had presented to a hospitalcasualty department following two fits

and was reviewed by the medicalregistrar. She diagnosed epilepsy andstarted the patient on sodiumvalproate and discharged her with anoutpatient CT scan of the head and anEEG. A consultant neurologist hasreviewed the case notes and theinvestigation results and feels that theyare in keeping with a diagnosis ofepilepsy. Miss Fletcher has now cometo her first outpatient appointment.Your task is to explain the diagnosiswith her and discuss the relevantissues.



Patient information

Miss Rosa Fletcher

Aged 26 years

This lady presented to casualty somemonths ago following two fits. She hadhad a similar, but less severe, episodepreviously, but had not sought medicaladvice. The doctor who had seen her inhospital had told her that she had had afit and started some tablets (sodiumvalproate 200 mg twice daily). After ashort period of observation she had been

discharged from hospital withinvestigations organised as an outpatient.There had been no further fits and shehas arrived at the clinic to get the resultsof her investigation. Normally, she liveswith her long-term boyfriend in arecently purchased house. There are noplans to have children at present (andshe is on an oral contraceptive), but indue course they would like to getmarried and have children. At the timeof her diagnosis she had been askedabout any medication she might be onand had said that she was not, as shedidn't consider the contraceptive pill asmedication. The doctor had also advisedRosa that she must inform the DVLA of

her diagnosis, and that she would not bepermitted to drive until she was deemedmedically fit. She had chosen to ignorethis advice as she drives for a living,transporting children to and from school.She also holds a part-time job as a steelpress operator. As a matter of routineher employers (who operate the minibusshe drives) insist on a health insuranceform to be countersigned by a doctorevery three years. Her own GP hasrefused to sign the form and she broughtit to the hospital, planning to ask theconsulting doctor to sign it during thecourse of the interview. The doctor willexplain to Miss Fletcher that it is illegalfor her to continue driving and that she is

putting her own and others lives, at riskand she must explain this to the DVLA.Reluctantly she agrees to stop drivingand to inform the DVLA.

Possible prompts

• The doctor in hospital said I had a fit.Is epilepsy the same?

• I plan to have children in the future.Will that affect my epilepsy?

• I can't stop working, especially aswe've now got a mortgage.

• Will you please sign this form for me?

• Do I have to inform the DVLA? Whathappens if I don't?



• Set the agenda. Confirm that shepreviously presented to hospitalfollowing a fit and this appointmentand the investigations she has had wereorganised as a result of this.

• Enquire about any discussions she hadwith the doctors at the time of herpresentation and what she feels may bethe cause of her fit.

• Explain to her that her symptoms andinvestigations are suggestive ofepilepsy. Ask her how much she knowsabout this condition.

• If she lacks insight into the condition,explain to her that epilepsy is acondition where there is alteredelectrical activity in the brain, whichcan cause fits. There is medicationavailable to control fits, but it must betaken regularly, even when patients arefit-free. Emphasise to her that it isimportant that we prevent fits fromoccurring as they can causeirreversible brain damage and evendeath.

• Advice regarding driving. As a generalrule, diagnosis of epilepsy leads to anautomatic ban from driving. For Group1 licences this is one year, for group 2,10 years. The licence holder is legallyobliged (Road Traffic Act 1988) toinform the DVLA of any medicalcondition (including epilepsy) that mayimpair their driving.

• Ask Miss Fletcher if she drives. Shetells you that she does and transportschildren to and from school, andindeed shows you a healthquestionnaire form that is required byher employers, which she would likeyou to sign.

• Explain to her that you certainly cannotsign the form and that she needs to stopdriving straight away and if sherefuses, you will have no option but toinform the DVLA yourself. She isendangering not only her own life, butalso the lives of others.

• Upon reflection, she reluctantly agreesto stop driving and inform the DVLA.

• Also tell her to avoid using heavymachinery. She will tell you that sheoperates a steel press. Iterate the pointthat if she has a fit while operating thepress it could result in serious injury.

• Tell her that anti-epileptics

(anticonvulsants) can interact withother medicines such as antibiotics andthe oral contraceptive pill, and it isbest to inform the doctor andpharmacist about all of your medicinesbefore starting new ones.

• She goes on to tell you that she is onthe pill, but doesn't know which sort.Advise her to use an alternative formof contraceptive until she has had theopportunity to have a discussion withher GP.

• Moreover, tell her that if she does planto have children it is worth telling theneurologist, who can ensure she is onthe safest medication possible, as

anticonvulsants can potentially affectthe developing baby, leading tocongenital defects.

• Briefly summarise the main discussionpoints from the consultation.

• Inform her that you will organise afurther follow-up in the clinic in a fewmonths' time.


Ethical issues

Confidentiality

See p. 7. Confidentiality is a cornerstoneto the doctor-patient relationship.However, in certain situations (such asan epileptic who continues to drivesvehicles despite medical advice to thecontrary) confidentiality may bebreached.

Driving

Refer to Appendix 1.

Epilepsy and pregnancy

Most anticonvulsants (particularlyphenytoin, phenobarbital andcarbamazepine) increase the risk ofpregnancy in women on the oral

contraceptive pill. In one study it wasestimated that there was a 25-fold rise inthe risk of pregnancy when an oralcontraceptive was combined withphenytoin in comparison to those nottaking phenytoin.

Generally speaking, it is recognisedthat women who suffer with epilepsy aremore likely to have babies with birthdefects in comparison to normal healthycontrols. This is particularly true ofwomen with poorly controlled epilepsy,resulting in frequent and severe fitsduring their pregnancy and also those inlow socioeconomic groups. In additionto this, anticonvulsants may also causecongenital defects, which include

developmental abnormalities of heart,face (e.g. cleft lip and palate), skull,limbs, abdominal organs and mentalsubnormality. It has been estimated thatthere is an approximately 1 per cent riskof birth defects with sodium valproate.Phenytoin and phenobarbitone can leadto vitamin K deficiency and bleedingdiatheses in the newborn, who mayrequire a vitamin K injection shortlyafter birth.

For these reasons, it is crucial thatduring pregnancy, women are given thesmallest effective dose ofanticonvulsants and are closelymonitored.




Patient: Mrs Elaine Winters

Age: 27 years

You review this geography teacher.

She has previously been seen by yourconsultant, when she was referredwith several months' history of bloodydiarrhoea. A flexible sigmoidoscopywas arranged, which showed featuresof ulcerative colitis, and she wasempirically commenced on a reducingcourse of prednisolone andmesalazine. The result from a biopsytaken at the time is now available andshows features strongly suggestive ofmoderately active ulcerative colitis.The diarrhoea is now settling on themedication. Your objective is toexplain the diagnosis and the long-term management strategy.


with the patient followed by one minutefor reflection before discussion with theexaminers. You are not required toexamine the patient.

Patient information

Mrs Elaine Winters

Aged 27 years

This 27-year-old geography teacher hassuffered with bloody diarrhoea forseveral months and was seen in clinic afew weeks ago by a consultant. He hadassessed her and had suggested that theproblem may be an infection as thesymptoms had started shortly after

returning from a holiday in Sri Lanka.The other possibility was inflammatorybowel disease (IBD). Mrs Winters hadnot fully understood this term, but hadnot enquired further at the time. Thedoctor had arranged a `camera test' aswell as blood and stool tests, and afollow-up for today. Mrs Winters hasnever smoked and drinks alcoholinfrequently. She lives with her husband.They have no children at present, but aretrying for a baby. The only other medicalproblem she suffers with is an ongoingbackache, for which she is taking anincreasing amount of ibuprofen. Shedidn't mention this on the last occasion,but is keen to discuss it today. Her main

concerns, however, relate to a recentdiscussion she had with her cousin, MrsTania Watts, who suffers with severeCrohn's disease and has had multipleoperations including a colostomy. Shehad also suffered from severe sideeffects from steroid therapy, whichincluded obesity, the development ofosteoporosis and diabetes. Mrs Wattshad told Mrs Winters that IBD was thesame as Crohn's disease. Now she isextremely anxious that she will end uplike her cousin. She is particularlyworried about having a stoma bag andwhat impact the condition will have onher prospect for having children.

Possible prompts

• I don't understand what IBD means.Can you clarify this term please?

• My cousin has Crohn's disease. Is thisthe same condition?


• Will I need to stay on the steroids forthe rest of my life?

• Do I need an operation?

• Will changing my diet help at all?

• Is this an inherited condition?

• Will I be able to have children?



• Set the agenda. Confirm that she hadpreviously seen your consultant forbloody diarrhoea, and he hadorganised a series of investigations tofind the cause for her problem.

• Enquire about her previous discussionin the clinic and what information hadbeen given to her. She will probablysay that she was told that she either hadan infective illness or IBD.

• Ask her what this term means to her.She may volunteer that she has had a

discussion with her cousin who sufferswith Crohn's disease and that she isworried that she has the same problem.

• Explain to her that Crohn's disease isindeed one form of IBD orinflammatory bowel disease, but thereare others. One of the other sorts is acondition called ulcerative colitis andsay that the investigations aresuggestive of ulcerative colitis as thecause for her illness. Elaborate bysaying that colitis differs from Crohn'sdisease by affecting only the largebowel, whereas Crohn's can affect thewhole length of the bowel. However,often it can be difficult to discriminatebetween the two conditions and the

treatment for them is similar.

• She may raise concerns about hercousin and the operation she has hadleading to a stoma and the possibleside effects of steroid medication.

• Agree with her that these are potentialcomplications of the illness, butreassure her that the vast majority ofpeople with ulcerative colitis have anormal life without ever requiring anoperation. Explain that steroid tablets(these are not to be confused withanabolic steroids that body buildersuse) are known to be the most effectivetherapy in the short term for difficultsymptoms (which often include

abdominal pain, bloody diarrhoea,fatigue and weight loss). Reassure herthat even patients who are steroid-dependent (i.e. have flare-ups whenthey come off steroids) can be treatedeffectively with steroid-sparing drugs(such as azathioprine andmethotrexate), which are less likely tohave long-term side effects.

• Explain to her that some tablets such asibuprofen and other non-steroidal anti-inflammatory drugs (NSAIDs) shouldbe avoided in patients with colitis as itmay cause an exacerbation of thecondition and should be avoided.

• Reassure her that this disease is

compatible with having children and isnot inherited, although you are morelikely to get the condition if you have a`first-degree' relative who suffers withit.

• Tell her about the National Associationfor Crohn's and Colitis (NACC). Thisis a charitable organisation, which is agood source for information and self-help advice.

• Summarise the discussion and let herknow that you will organise a follow-up in the clinic. Also give her contactdetails of your specialist IBD nurseand tell Mrs Winters to get in touchwith her if her symptoms deteriorate.



You are the SHO in an endocrine clinic.


Patient: Mrs Mary Sidebottom

Age: 44 years

This lady was referred to the clinic by

her GP with a raised blood sugar,suspicious of diabetes. She normallyruns a chip shop with her husband andgenerally leads a very sedentarylifestyle. She was reviewed by aconsultant, who has diagnosed herwith insulin resistance secondary toobesity. Endocrine causes for obesityhave been excluded. The doctor hadrecommended weight loss by regularexercise and sticking to a calorie-controlled diet. Following her lastclinic visit, an appointment was madefor her to see a dietician. Thedietician has reviewed her and givendietary advice, but did mention to thepatient that there were drugs available

that can help her to lose weight. Yourobjective is to discuss the patient'sobesity and encourage her to loseweight. You must also answer anyquestions she has.


Patient information

Mrs Mary Sidebottom

Aged 44 years

This lady was found to have a raisedblood sugar by her GP and was referredto a diabetologist for assessment. Theconsultant reviewed her and felt that itwas related to her obesity. MrsSidebottom has always struggled withher weight, but it has escalatedconsiderably over the last few years,particularly since opening a chip shopwith her husband. In the past she triedvarious diets, but was unable to stickwith them. She snacks throughout theday, which includes nibbling on the foodin the chip shop, but because she doesn'thave three regular meals, she feels thatshe hardly eats anything. Exercise hasnever been a part of Mrs Sidebottom's

life and she rarely leaves her home. Shehas never cycled and doesn't know howto swim. The doctor who initiallyassessed her had referred her to adietician. The dietician had given herinformation on calorie-controlleddieting, but also mentioned that therewere tablets available to help peoplelose weight. Moreover, she alsomentioned that operations could be done,which can lead to dramatic weight loss.With her lack of previous success withdieting the lady has not bothered to stickto the calorie-controlled diet prescribedfor her. Instead, Mrs Sidebottom is verykeen to explore the medical and surgicaloptions. At the consultation today she

intends to ask the doctor about themedicines available and the possibleoperations that can be performed.

Possible prompts

• Diets never seem to work for me.

• The dietician mentioned that therewere tablets available to help peoplelose weight. Can I try these?

• What operations are available andwould you be able to refer me for anoperation?

• What's the Atkins diet? I hear that it isvery effective.



• Set the agenda. Confirm that she wasdiagnosed with diabetes, which hasbeen attributed to her weight and wasadvised to lose weight by exercise anddiet. Ask how she is getting on andwhether she has lost any weight.

• She will say that she has tried lots ofdiets and they have never worked andshe is fed up of them. She may also addthat she doesn't feel that she eats verymuch.

• Briefly take a dietary and exercise

history. This is likely to confirm hersedentary lifestyle. She may be evasiveabout her intake so it is crucial that youask about her exact intake andspecifically ask about snack foods suchas crisps, biscuits, fizzy drinks,chocolates and cakes. Ask about freshfruit and vegetables.

• Reiterate that she must stick to a well-balanced, caloriecontrolled diet andtake regular exercise such as a briskwalk, which can be increased inintensity as her level of fitnessincreases. Emphasise the long-termbenefits of losing weight, which willinclude reduced risk of heart disease,stroke and cancer. She must not assume

that she is not eating very much, butinstead keep a careful diary andattempt to adhere to her prescribeddietary regime.

• At this stage she is probably going totell you about her conversation with thedietician who had told her abouttablets that can help people loseweight.

• Agree with her that there aremedications available that canpotentially help people to lose weight,but they can only be used in peoplewho are considered motivated andhave exhausted other options.Moreover, the treatments are not

without side effects and cannot be usedindefinitely (see below).

• She may then ask about surgery as ameans of treating obesity.

• Explain that surgical intervention isonly carried out as a last resort if diet,exercise and medical management havebeen deemed to have failed. It can bevery risky, with both anaesthetic andsurgical risks.

• Summarise the discussion and explainto her that you will organise a follow-up appointment to ensure her progressis monitored.


NICE guidance

The National Institute of ClinicalExcellence (NICE) has issued guidanceon the use of surgery and drugs(sibutramine and orlistat) to help peoplelose weight. Full guidance is availableon the NICE website. According to thisguidance, these drugs can only beprescribed by hospital specialists, whoshould regularly review the patient. Andthen only if-

e diet and exercise have failed; or

• the patient's BMI is >27-28 withcomplications such as hypertension ordiabetes; or

• the BMI >30.

Then they can only be continued beyondthree months if there is documentedweight loss.

Surgery may be considered when non-surgical strategies have failed. NICErecommends that surgery should only beoffered:

• to patients who are > 18 years

0 where there are no contraindications to

the surgery

• to patients who are fit for the surgery.


You are an SHO in a chest clinic.


Patient: Miss Rachel Robbins

Age: 24 years

This lady has had poorly controlledasthma for some years. She has been

prescribed a beta agonist and asteroid inhaler. However, she haspreviously intimated that she does notlike using the steroid inhaler and thereis a suspicion that she doesn't use it atall. Your task is to discuss hercompliance with her medication andadvise her accordingly.


Patient information

Miss Rachel Robbins

Aged 24 years

This lady was diagnosed with mildasthma two years ago when she wasstarted on a salbutamol inhaler. Herasthma was troublesome despite this anda year ago she had a steroid inhaleradded to her prescription. However,about six months ago she read an articlein a magazine highlighting the sideeffects of steroids, which had alarmedher, and now she rarely uses the steroidinhaler. She is particularly worriedabout weight gain, which was listed as apossible side effect. Miss Robbins isvery conscious of her body image andfrequently diets. She does not smoke.Her asthma is troublesome at present,

particularly in the morning, but sheattributes this to a change in the seasonand thinks that it will get better withtime. She has now come to the clinic andis about to see one of the doctors.

Possible prompts

• My asthma is getting worse; I think it isbecause of the warm weather at themoment.

• I am worried about the steroids andtheir side effects and so don't like usingmy brown inhaler.



• Set the agenda. Confirm that she wasdiagnosed with asthma a few years agoand is being followed up in the clinic.

• Ask about her asthma symptoms andwhether she feels they aredeteriorating. She will reply in theaffirmative and say that it isparticularly bad in the morning. Shewill say that she suspects this isbecause of a change in the weather andit will probably get better with time.

• Ask her whether she uses theprescribed inhalers regularly andwhether her technique has been

reviewed.

• Her technique has been checked andshe uses her blue inhaler regularly, butadmits that she tends not to use thebrown inhaler, as she is worried aboutside effects associated with steroiduse, which she read about in amagazine. She is particularly worriedabout weight gain.

• Reassure her that only a tiny amount ofsteroid gets into her bloodstream frominhalation, and that this will have anegligible effect on her weight or causeany other systemic side effects.Conversely, it has a profound effect onreducing the inflammation within her

lungs and would be a great help inhelping with her asthma symptoms.Remind her that asthma can deteriorateand occasionally become lifethreatening and hence it is veryimportant that we try and control it atan early stage. Also, it is worthemphasising the point that when it doesdeteriorate, patients often have to starttaking oral steroids and they can havethe side effects she is concerned about.

• Ask her whether her views havechanged at all and if she is likely tocomply with her medication.

• If she agrees, then proceed; otherwisereiterate the above points before

proceeding.

• Summarise the discussion. Explain thatyou will ask the asthma nurse to checkon her in a few days' time and sheshould keep a record of her peakexpiratory flow rates to ensure herasthma is improving.



You are an SHO on a medical ward.


Patient: Mr Daniel Brown

Age: 27 years

This man was admitted with severeshortness of breath upon returning

from a holiday in the Far East.Investigations show that he hasPneumocystis carinii pneumonia, andis now making a good recovery withmedication. You know from hishistory that he works as a bank clerkand lives with his mother. He drinksabout 30 units of alcohol a week andsmokes 10 cigarettes a day. He hasconfessed to èxperimenting' withdrugs, although denies injecting them.He is a heterosexual male, but doesnot have a steady girlfriend. However,in the past he has had a number ofcasual and short-term relationships.Your task is to counsel him for an HIVtest.


Patient information

Mr Daniel Brown

Aged 27 years

This bank clerk was admitted to hospitalwith severe shortness of breath and hewas subsequently diagnosed withPneumocystis carinii pneumonia, whichis being treated, and he is making a goodrecovery. The illness started shortly

after return from holiday in Thailand. Hesmokes 10 cigarettes a day and drinks 30units of alcohol per week. He lives withhis mother and is not in a steadyrelationship. In the past he hasexperimented with drugs, but has neverinjected them. He is a heterosexual manand over the years he has had manyshort-term and casual relationships withunprotected sex. He has also onoccasions used the services ofprostitutes. He does not consider himselfat high risk for developing HIV becausehe considers it a disease that affectshomosexual men and those that abusedrugs with IV injections. He is about tosee a doctor who will counsel him for an

HIV test. Although initially Mr Brownwill be reluctant, he will eventuallycome round to the idea of having the test.

Possible prompts

• What has my pneumonia got to do withHIV?

• Why should I undergo an HIV test? I'mnot gay and have never injected myselfwith drugs.

• If I'm HIV positive, does that mean thatI have AIDS?

• Will my mother be told of the result?

• Will my employers have to beinformed?



• Set the agenda. Explain to him thatyou've come to speak to him regardinghis recent diagnosis of a rare sort ofpneumonia, which is often associatedwith an ùnderactive' immune system.Ask him if he had any concernsregarding his immunity to infectionsand whether he was aware of anyillnesses associated with poorimmunity.

• If he says that he is aware of HIV orAIDS causing this problem, confirmhis belief and proceed. Alternatively,explain that one cause of having a poorimmune system and acquiring this rarerespiratory tract infection was thehuman immunodeficiency virus (HIV).

• Wait for a response from him andbriefly go into his perceived risk foracquiring HIV and his understanding ofthis infection. He is likely to say that itis a condition that affects homosexualmen and intravenous drug abusers.

• Explain to him that anybody canacquire this infection, which includesheterosexual men, particularly if they

practise unprotected sex. And it isworth testing for as there is a verygood therapy available and potentiallyit can prevent the infection passing onto others.

• Go on to explain that being HIVpositive is not the same as havingAIDS and briefly explain thedifference. Tell him that the disease isless stigmatised these days, but beingfound positive may have implicationsfor future employment and the prospectof obtaining health insurance.

• Explain that the test is carried out byobtaining a sample of blood from himand the result would be given to him in

person. He must give his writtenconsent before the test, and reassurehim that the result will be treated withstrict confidence.

• Ask him if he agrees to have the test orwhether he would like more time tothink it through and perhaps haveanother discussion.

• He is likely to agree to the test, inwhich case conclude by saying that youwill obtain a consent form that he cansign before you proceed to the test.

• Thank him and conclude the interview.


You are an SHO on call for the medicalwards.


Patient: Mr Nathan Charleston

Age: 41 years

This gentleman was admitted to

hospital after an alcoholic binge and abenzodiazepine overdose. There hadbeen no suicide note. At the time ofadmission, history taken from thepatient's girlfriend suggests that thepatient has been depressed for sometime after the loss of his job and hasfrequently commented on taking hislife and considered himself a failure.On the following day Mr Charlestonhas made a full medical recovery, butthe team looking after him are verykeen that he has a comprehensivepsychiatric assessment. However, thegentleman, who is now alert andoriented, is adamant that he does notwant to stay in hospital and will

discharge himself. You have decidedto speak with the gentleman topersuade him to stay in hospital until apsychiatrist has seen him.


Patient information

Mr Nathan Charleston

Aged 41 years

This gentleman was admitted to hospital

the previous night after he had taken alarge overdose of sleeping tablets(benzodiazepines) and a large amount ofalcohol. The overdose had not beenpremeditated, but he had fantasisedabout taking his life for some months andhad experienced problems withsleeping, occasionally finding it difficultto fall asleep and often waking up earlyin the morning. He had visited his GP,who was a little concerned aboutclinical depression, but had decided toinitially try sleeping tablets and reviewhim again to see how he wasprogressing. Mr Charleston's problemshad started after he had lost his job as ahighly paid marketing executive. He had

been working in the same company for22 years and considered himselfextremely successful. Now his futurelooks bleak and he feels that he is acomplete failure and has taken todrinking heavily. He was previouslymarried and had one child, but themarriage broke down and ended up indivorce. He has been with his currentgirlfriend for nine months. Now, on theday after the overdose, he feels someremorse for his actions and generallyfully recovered, and wants to leave thehospital. However, the medical teamwould like him to see a psychiatristbefore he is discharged. Mr Charlestondoes not think that he is going mad and

does not feel the need for a psychiatrist.One of the doctors looking after him willhave a discussion and try to persuadehim to stay. Although initially reluctant,Mr Charleston will finally agree to stayfor psychiatric assessment.

Possible prompts

• No, I'm fine and I want to go home.

• Yes, I do regret my actions last night,but I don't I need to see a `shrink'; I'mnot mad.

• Yes, I have been feeling depressed oflate - probably more so after losing myjob.

• Well, I suppose it maybe worthspeaking with a psychiatrist.



• Set the agenda. Explain to him thatyou've decided to speak with himbecause you are worried about himdischarging himself from the hospitalbefore a psychiatrist has assessed him.

• Ask him why he wants to leave and notwait to be seen by a psychiatrist.

• He is likely to say that he regrets his

actions and feels that he has made afull recovery and does not now want tostay in the hospital. Moreover, he doesnot think that he is mad and in need of a`shrink'.

• Explain to him that the medical team donot think that he is mad, but are simplyconcerned that he has untreateddepression and is likely to attemptsuicide again. Go on to say thatdepression is considered a mentalillness and there are very goodtherapies available.

• Ask him whether he feels that he isdepressed and whether he has everthought about ending his life, and could

he see himself potentially benefitingfrom the help of a psychiatrist.

• He may go on to confirm that he isdepressed and has had suicidal ideasand perhaps seeing the psychiatristcould benefit him. In this casecongratulate him for staying and closethe interview.

Alternatively:

• He may choose to ignore your adviceand leave despite the consequences.You cannot keep him in hospital againsthis wishes and must allow him toleave, but ask him to sign a self-discharge note. You can come to a

compromise by saying that you willrefer him to the psychiatrist as anoutpatient and asking whether he wouldbe interested in attending. If he agrees,thank him and close the interview.

Suicide risk factors

• male sex

• older age, although there is a peak inadolescence

• psychiatric illness, e.g. depression,schizophrenia

• substance abuse

• diagnosis of serious and particularlychronic painful conditions

• life-altering events, e.g. loss of job

• bereavement

• past experiences, e.g. sexual abuse aschild.


You are an SHO in a cardiology clinic.


Patient: Mr Ashok Shukla

Age: 57 years

This gentleman was admitted tohospital with severe chest pain and a

subsequent coronary angiogramdemonstrated triple-vessel disease,not appropriate for angioplasty. Thecardiologist looking after him wasconcerned and explained that he couldhave a fatal heart attack if he didn'thave prompt bypass surgery. Hence hewould be referring him to one of thelocal cardiothoracic surgeons for anassessment soon as an outpatient.Today, three months later, Mr Shuklahas arrived at the cardiology clinicand he is angry and upset that he stillhas not received an appointment to seeone of the thoracic surgeons. Your taskis to have a frank discussion with MrShukla regarding the delay in his

treatment and how you intend toexpedite his surgery.


Patient information

Mr Ashok Shukla

Aged 57 years

Mr Shukla was admitted to hospitalthree months previously with pains in hischest and a subsequent angiogram

confirmed triple-vessel disease. At thetime the cardiologist told him that hewas at a significant risk of having a fatalheart attack and required prompt referralto a cardiothoracic surgeon (as anoutpatient) for bypass surgery. However,three months later, Mr Shukla has stillnot received an appointment to see asurgeon. He is concerned that he will diebefore he has an operation and today at afollow-up cardiology clinic he fullyintends to express his frustration andconcerns to the doctor about to see him.

Possible prompts

• I am still getting chest pains and havenot received an appointment to see a

surgeon.

• It has been three months since myhospital admission and I am worriedsick that I will drop dead before theappointment arrives.

• Will you be able to find out when theyare likely to see me?


• Greet the patient and introduceyourself.

• Set the agenda. Confirm that this is afollow-up appointment and that he haspreviously been diagnosed with heart

disease and is awaiting bypass surgery.

• Ask how the patent is getting on.

• Acknowledge the patient'sdisappointment with the delay in histreatment and allow him to vent hisfrustration. This could be a drawn-outprocess and the examiners will be keento observe your skills that demonstrateempathy and rapport building as wellas bargaining and negotiation.

• Explain that you too are disappointedwith this delay and intend to rectify thesituation by calling the surgical teamand getting a date for the review beforethe man leaves today.

• Close the interview by asking thepatient to wait outside while you get incontact with the surgical team and get adate for him. Alternatively, you can askhim to call you back and you will havea further management plan.

Government targets

The government set up National ServiceFrameworks (NSFs) in order to improvepatient care and reduce inequalities in aseries of identified priority areas, whichincludes the Coronary Heart Disease(CHD) NSF (published in 2000). Thissets out a 10-year programme totransform the management of patientswith heart disease and it has been

estimated that as many as 20 000 lives ayear should be saved.

As part of the modernisation of theNHS, the controversial star ratings wereintroduced to show how well anorganisation is performing. For mosttrusts this is based on performanceindicators, which are made up of fourkey targets:

• patient waiting times

• patient focus: patient's views on thetrust

• clinical focus: outcomes after treatmentsuch as surgery

• capacity and capability focus: trustresources, running and staffsatisfaction.


You are an SHO on call for medicine.


Patient: Mrs Rahila Hussain

Age: 38 years

Mrs Hussain is a housewife with three

small children. She is normally fit andwell, but for the past few weeks shehas suffered with a backache. Sheconsulted her GP who prescribedibuprofen tablets, which she has beentaking with good result. However,earlier in the day she had an episodeof frank haematemesis and passedsome dark stools. Clinicalexamination has confirmed melaenaand shows postural hypotension, butshe is otherwise a well-lookingwoman. You are the RMO òn call'overnight and she was `handed over'to you by the admitting doctor. It isnow 2am and you have just spokenwith the endoscopist on call who feels

that an urgent endoscopy is warranted,but to save time he would like you toconsent her for the procedure. Heexplains that it is a very safeprocedure with only a tiny risk ofbleeding or perforation. Your task isto convey this information to thepatient and, if you feel it isappropriate, obtain her consent.


Patient information

Mrs Rahila Hussain

Aged 38 years

Mrs Hussain is a housewife with threesmall children. She has suffered with abackache for some time now, which sheattributes to lifting her children. A fewweeks ago she asked her GP for adviceand he prescribed her ibuprofen tablets,which she has been taking with goodresult. Earlier in the day she had passedsome very dark stool, which looked likemelaena, and later had vomited blood,which had prompted her to seek medicaladvice. The admitting doctor felt that sheprobably had an ulcer in her stomachand was going to organise an endoscopy

and had put her nil by mouth. He hasnow gone off duty and one of hiscolleagues (the candidate) is going tospeak with you about the procedure. MrsHussain is frustrated by her ordeal andthe fact that it is the middle of the nightand she has not had an endoscopy andnot had any news as to when it is goingto happen. She feels hungry and thirstyhaving been nil by mouth for so manyhours. Above all she is worried abouther three children.

Possible prompts

• How long will it be before I get myendoscopy?

• Will I be able to leave hospitaltonight?

• Will I be able to eat and drink after theprocedure?

• Do you think it was the ibuprofentablets that caused the trouble?



• Set the agenda. Confirm that she wasadmitted to hospital within the last daywith a suspected peptic ulcer bleed.

• Ask how she is feeling now.

• She is likely to be angry that she hasnot yet had her endoscopy test and isfinding it very difficult being off foodand water.

• Listen to her concerns empatheticallyand explain to her that often there is adelay in obtaining an endoscopicexamination as it requires a specialistto perform the procedure and sheshould not worry about it being 2o'clock in the morning as hospitalswork round the clock. Further explainthat although it is uncomfortable not tohave any food for some hours, it is notlikely to cause her any significantharm. It is, however, important thatfluids are replaced and hence she is on

a drip.

• Go on to say that you have spoken withthe endoscopist on call and he willperform the endoscopy soon, but tosave time has asked you to obtainconsent from her. Explain thatgastroscopy is a safe procedure, butthere is a small risk of complicationassociated with perforation andbleeding. There are also complicationsassociated with the sedation oftenused.

• She is likely to ask you about thedegree of risk.

• Be very honest and say that you are not

an expert in this area and couldn'tcomment on the details of theprocedure, and perhaps she shouldhave a chat with the endoscopist beforegoing through the procedure.

• Say that you will document yourdiscussion with her in the notes so thatthe endoscopist knows that he needs toobtain consent before proceeding to thegastroscopy.

• Summarise the discussion.



You are an SHO in the haematologyclinic.


Patient: Mrs Patricia Murray

Age: 31 years

This lady was diagnosed with a largedeep vein thrombosis (DVT) in herleft leg three weeks previously andwas commenced on warfarin. She hasnow presented to the anticoagulationclinic and has told the nurse that shehas recently found out that she ispregnant. The nurse has asked you tospeak with her to counsel herregarding the possible teratogeniceffects of the drug and to come upwith an alternative managementstrategy.

You have 14 minutes to communicatewith the patient followed by one minutefor reflection before discussion with theexaminers. You are not required to

examine the patient.

Patient information

Mrs Patricia Murray

Aged 31 years

Mrs Murray had presented to hospitalthree weeks previously with a swollenleg and had been diagnosed with a DVT.She had been commenced on warfarinand discharged from the hospital on thesame day. One week ago she had foundout that she was pregnant. She hadpreviously had a period seven weeksago. She has come to the anticoagulationclinic today and had told the nurse that

she was pregnant. The nurse had lookedalarmed, which concerned Mrs Murray,and had asked her to speak with one ofthe doctors in the clinic (the candidate).This pregnancy is very precious to MrsMurray as she has been trying to have ababy with her partner for some years andthey had even contemplated in vitrofertilisation (IVF). When the doctorexplains the possible risks involved toboth the baby and the pregnancy, MrsMurray will become quite upset andsomewhat angry. She will question whyshe had not been informed of thepossible risks at the time she started thewarfarin.

Possible prompts

• Is this serious?

• Is my baby going to be handicapped?

• Is this likely to increase my risk ofmiscarriage?

• Whose fault is this?

• Is there a chance that my pregnancycould still be normal?



• Confirm that a nurse has asked her tospeak with you regarding her warfarin

therapy, because she had found out thatshe was pregnant.

• Enquire what her understanding wasregarding the use of warfarin inpregnancy and what additionalinformation the nurse had given her.

• Listen attentively to her concerns andanswer any immediate questions shemay have.

• Apologise for her not being informedabout the possible side effects ofwarfarin at the time of commencement.Confirm (if she is already aware) orexplain that warfarin is a teratogenicdrug, i.e. can cause birth defects and

problems with pregnancy, such asbleeding and miscarriage. It isappropriate perhaps to only go intodetails of the sorts of defects that occur(see below) if she specifically asksabout them.

• Give her a chance to respond andanswer any queries. Listen carefully toher concerns and anxieties.

• Discuss future management plan, i.e.that you will be discussing the casewith the consultant and can organisefor Mrs Murray to speak with him also,if she has any further questions. Alsoexplain that you will write to herobstetrician to ensure that she receives

appropriate followup with them. Go onto tell her that she will probably needto go on to low molecular weightheparin injections until it is felt that hertreatment is complete.

• Summarise the discussion and close.

Drug use in pregnancy

Drugs given during pregnancy can affectthe developing foetus by producing alethal, toxic, or teratogenic effect. Henceit is imperative that drugs are carefullyreviewed before prescribing to pregnantwomen. Risks must also be assessed inany women of childbearing age and youmust always assume that a woman is

pregnant until there is evidence (or herword) to the contrary. The effect of anypotential teratogenic agent is determinedby the age of the foetus. The main periodof organogenesis is between the 3rd and8th weeks after conception, andteratogenesis is most likely at this stage.Commonly used drugs that may causeproblems include variousanticonvulsants, antibiotics andanticoagulants. Warfarin (coumarin) isknown to be teratogenic. Effects on thefoetus include saddle nose, frontalbossing, short stature, midfacehypoplasia, cardiac defects, blindnessand mental retardation. Warfarin shouldbe avoided during the first trimester. It

should also be avoided around the timeof delivery and unfractionated or moreconveniently low molecular weightheparin provide a safer alternativewhere anticoagulation is needed.


You are an SHO working on a liver unitin a large teaching hospital.


Patient: Mr Tom Waters

Age: 53 years

This gentleman has been followed upas an outpatient for one year withabnormal liver biochemistry. He isobese and known to drink alcoholexcessively, and has arrived today toundergo a liver biopsy to investigatethis further. Consent for the procedurehad previously been obtained at theoutpatient clinic. Potential risks suchas bleeding, pneumothorax, pain andfailure to obtain liver tissue had beendiscussed and documented in thenotes. He was also given a leaflet totake away with him giving full detailsof the procedure. Although he hasarrived at the department, he isconcerned about the safety of the

procedure and not proceeding with it.To discuss things further he has askedto speak to a doctor. The registrar,who normally performs the procedure,is busy on the liver ITU and has askedyou to talk with the patient. Yourobjective is to discuss the patient'sconcerns and to ascertain whether ornot he wishes to proceed with theprocedure.


Patient information

Mr Tom Waters

Aged 53 years

This gentleman is overweight and hasbeen drinking 60 units of alcohol perweek for many years. He was admittedto hospital with abdominal pain, whichwas thought to be gastritis. But bloodtests showed deranged liverbiochemistry and hence he was referredto a hepatologist for an opinion. Theinitial liver screen proved normal andhence it was decided to proceed to aliver biopsy, which was discussed withMr Waters at the previous clinic visit bya consultant. He mentioned potentialrisks associated with the procedure such

as: bleeding, perforation of bowel, pain,pneumothorax and failure to obtain livertissue. Then he had arranged a date forthe procedure and sent the gentlemanaway with a leaflet to read at his leisure.During the previous evening, Mr Watershad got round to reading the leaflet andwas horrified to find out that there was asignificant risk of death associated withthe procedure. He had difficulty going tosleep overnight and now, after arrivingat the department, would like to discussthe procedure again before making hismind up. He will directly question theinterviewing doctor and ask him abouthis experience of liver biopsies. Duringthe course of the discussion, Mr Waters

makes his mind up and is adamant that hedoes not want to undergo the liverbiopsy procedure.

Possible prompts

• I read that you can die after having thisprocedure?

• How bad is the pain after theprocedure?

• How many liver biopsies have youcarried out?

• I refuse to have the procedure. Whatwill happen now?



• Set the agenda. Confirm that he hasasked to speak with a doctor becausehe is concerned about the liver biopsyprocedure.

• Ask him what specific concerns he has.He will say that he is worried about allthe side effects, but reading the leafletthat was given to him shows that thereis a significant risk of death. Also, heis not keen on a procedure that can bevery painful.

• Agree with him that there is a smallrisk of death, but the procedure isnecessary to investigate the cause ofhis liver disease. The pain, which isoften referred to the shoulder, can betroublesome in a small minority ofpatients. Most patients suffer very littlepain and have analgesics prescribed.

• At this stage Mr Waters will ask you ifyou have ever carried out any liverbiopsies and what experience you haveof them.

• Explain to him honestly that you havehad very little experience of them(unless of course you have had lots ofexperience!), but you can organise for

him to speak with a doctor whoroutinely performs the procedure.

• Mr Waters will have made his mind upand decide that he does not want tohave the procedure and wants to leavethe hospital soon.

• Say that you will inform your seniorsof his decision.


The liver biopsy

The liver biopsy needs to be carried outfor a wide variety of conditions affectingthe liver. This is particularly true when

there are diagnostic uncertainties andfurther management strategies need to bebased on the results of the liver biopsy.However, there is a significant mortalityassociated with the technique (at around0.1 per cent, usually secondary tohaemorrhage) and hence it should not beundertaken lightly. Moreover, there ismorbidity associated with the procedure,the most common of which is pain (ataround 30 per cent). The safety of theprocedure can be optimised byperforming the procedure either duringan ultrasound scan or having had onerecently. Also, most authorities agreethat prior to the procedure the plateletcount should be greater than 60

000/mm3 and prothrombin time less than4 seconds prolonged.

Consent

Refer to p. 2. But essentially, aprocedure cannot be carried out on acompetent adult without their consent.


You are the medical SHO òn call'.


Patient: Miss Emma Rutledge

Age: 19 years

This lady presented to hospital with

abdominal pain and was diagnosedwith a ruptured ovarian cyst that hadbled profusely and caused a drop inher haemoglobin. She was adequatelyresuscitated (which included a bloodtransfusion with three units of blood)and taken to theatre where emergencysurgery was performed. Now she isfive days post procedure and hasmade a good recovery and is nearlyready to be discharged from theobstetrics and gynaecology ward.However, she told the dischargingdoctor that she is concerned about theblood transfusion she received. She isparticularly worried about the long-term prospect of having acquired an

infection. The SHO looking after herhas asked you to speak with her. Yourobjective is to listen to her concernsand if possible to reassure her.


Patient information

Miss Emma Rutledge

Aged 19 years

This English literature student presented

to hospital with abdominal pain and wasfound to have a ruptured ovarian cyst,which had required surgicalintervention. Prior to the operation shehad received three units of blood.Previously she had been fit and well andnot on any regular medication. Now, fivedays postoperatively, she had made agood recovery and is ready to bedischarged from hospital. However, sheis concerned about infection riskassociated with the blood transfusion. Inparticular she is concerned abouthepatitis, as her sister had developedjaundice after returning from a holiday inIndia. At that time the doctors hadenquired about blood transfusions and

had explained that there was a risk ofdeveloping hepatitis after receiving ablood transfusion. She is also aware thatHIV can be transmitted through blood.Miss Rutledge had raised her concernsto the doctor looking after her. But hefelt unable to answer her questions andhas instead referred her to the medicalSHO, who is about to see her.

Possible prompts

• I'm worried about a risk of developingan infection from contaminated blood.

• My sister developed hepatitis after aholiday and the doctor said that peoplecould get hepatitis infections through a

blood transfusion.

• Is there a chance that I could contractHIV from this transfusion?

• How can I be sure I haven't got thesediseases?



• Set the agenda. Confirm that she hasasked to speak with a doctor becauseshe is worried about the bloodtransfusion.

• Ask about specific concerns that she

may have. She is likely to go intodetails about her concerns regardingHIV and hepatitis infections.

• Reassure her that blood and bloodproducts are tested for hepatitis andHIV infections and it is highly unlikelythat these viruses would contaminatethe blood she received.

• She may say that she remainsconcerned and ask if there is a way tobe certain.

• Explain to her that she could have HIVand hepatitis tests. But there needs tobe a three-month gap between thepotential exposure and testing, as it

takes that long for the antibodies tobecome positive in the blood.However, she would have to see acounsellor before a test could becarried out, as particularly being HIVpositive has serious longtermimplications for a patient. Of course, inthe unlikely event of her being found tobe positive for one of these viruses, itwould be a moot point as to whethershe acquired the infection before orafter the blood transfusion.

• Summarise the discussion and ask ifshe has any more questions.

• Close the interview.


You are a medical SHO in a clinic.


Patient: Ms Helen Cummings

Age: 49 years

This lady has suffered with long-standing severe back pain for a

number of years and has triednumerous medications and aids (suchas a `TENS' machine) with onlylimited benefit. She has beenextensively investigated and reviewedby both a pain specialist and anorthopaedic surgeon, who could notfind an obvious cause to explain thepain. At present, she is taking codeineand paracetamol and is complainingof severe constipation. She has cometo the follow-up clinic today todiscuss further options to relieve herpain. In particular, she wants todiscuss the possibility of cannabisbeing prescribed for her pain. Yourtask is to discuss this and other

treatment options with her.


Patient information

Ms Helen Cummings

Aged 49 years

This lady has suffered with back pain formany years. She has previously beeninvestigated - including an appointmentwith the orthopaedic surgeons - and no

obvious cause was ever found. Over theyears she has tried numerousmedications and alternative therapiessuch as acupuncture and a `TENS'machine with only limited benefit. She iscurrently on paracetamol and a high doseof codeine phosphate, which does giveher pain relief, but she tends to get veryconstipated and has to take laxativesregularly. A few weeks ago she saw atelevision programme that followed agroup of patients with intractable painand it had demonstrated the benefits ofcannabis (and drugs derived from theplant) in the management of painsymptoms. Ms Cummings had got veryexcited by this programme and is very

keen to explore this option at the clinicvisit today.

Possible prompts

• My pain is reasonably controlled but Isuffer with awful constipation.

• I saw a television programme about theuse of cannabis in patients with painsymptoms like mine. Is that somethingyou can prescribe for me?



• Set the agenda. Confirm that she isbeing followed up in the clinic as shehas ongoing back pain.

• Ask her how she is getting on. She willtell you that she still suffers with theback pain, but the medication affordsher some relief. But she is verytroubled with constipation when shetakes the codeine. However, she isable to open her bowels with the aid oflaxatives.

• Explain that the constipation is a well-recognised side effect of opiate drugslike codeine. And you can do one oftwo things:

- either persist with the current regimeand use laxatives as required, or

- you will discuss the case with yourconsultant and decide whether thereneeds to be a change in medication.But you note that she has usednumerous medications withoutbenefit.

• At this point she may tell you about atelevision programme she has seenwhere people with intractable painwere using cannabis with good result.And she asks you whether this issomething that she would be able to try.

• Explain to her that while there is some

anecdotal evidence for cannabis as atreatment in various medicalconditions, including pain, there is noclinical proof for its use. Moreover,the drug is not licensed for clinical use(indeed remains an illegal substance)and is only used in clinical trials.

• She agrees to stay on her currenttreatment, but would like to befollowed up in the clinic.

• Ask her if she has any other concernsor questions.

• If she does not, thank her and close theinterview.

Cannabis

The legal position

Cannabis was first declared illegal inthe UK in 1928 following the DangerousDrugs Act. It primarily outlawed privateuse, but allowed medical use. TheUnited Nations Single Convention onNarcotic Drugs 1961 failed to recogniseany medical indications for the drug andin 1971, the Misuse of Drugs Act madepossession and supply unlawful. At thetime of writing cannabis and itsderivatives are not licensed for use forany medical condition in the UK.

In January 2004, cannabis was

reclassified from a Class B to a Class Cdrug. Put simply this means that the drugremains illegal, but you are less likely togo to prison for possession and, moreimportantly, supply of the drug. At thepresent time, there are a number of casesworking their way through the courts toestablish the legal position of thedefence of `medical necessity' used bypeople who supply cannabis only forsymptom relief to people with chronicmedical conditions such as multiplesclerosis.

Medicinal use

The drug is obtained from the plantCannabis sativa, which has been used

for medicinal purposes for manycenturies. Its uses have included thetreatment of asthma, nausea, pain,muscular spasms and as a sleep aid.Although there is considerable interest,at present there is no absolute clinicalevidence, which proves that cannabis isbeneficial in any of these conditionsexcept perhaps nausea and vomiting.

Perhaps the greatest interest is incannabis and its active derivatives(particularly delta-9tetrahydrocannabinol - THC) in thetreatment of multiple sclerosis. Thelargest study to date was the CAMS(Cannabis in MS) trial, which wascoordinated from Plymouth and funded

by the Medical Research Council, andpublished in November 2003. It was arandomised, controlled, double-blindtrial involving 660 patients. Patientswere randomly allocated to one of thefollowing groups:

• cannabis extract (Cannador) -standardised to contain 2.5 mg THC

• dronabinol (Marinol) - synthetic THC

• placebo.

Then they were followed up for a totalof 15 weeks initially and enrolled intothe extension trial. Although patientssubjectively noted an improvement in

their spasticity and mobility, objectivemeasures (such as the Ashworth scale)failed to show significant improvement.


You are the medical SHO in agastroenterology clinic.


Patient: Mr Hugh Trotter

Age: 36 years

This gentleman has been referred byhis GP with persistent symptoms ofgastro-oesophageal reflux, despitetreatment with antacids and H2antagonists. A gastroscopy wascarried out, which shows moderateoesophagitis. Your consultant hasreviewed his notes and has asked youto start him on a proton pump inhibitor(PPI). However, he is conducting aclinical trial at present comparing theefficacy of PPI A versus PPI B forsymptomatic relief of reflux symptomsand is keen for you to recruit thispatient into the study. The studyprotocol simply involves randomlystarting either PPI A or B and then for

the patient to complete a postalquestionnaire in two months time.Your objective is to have a discussionwith this gentleman and if possiblerecruit him into the study.


Patient information

Mr Hugh Trotter

Aged 36 years

This gentleman has suffered withheartburn and dyspepsia for about 12months. He initially saw his GP, whoprescribed him an antacid, which proveduseless. The GP then prescribed an H2antagonist and despite this and lifestyleadvice (lose weight, not to eat late atnight, raise the head of the bed) hissymptoms persisted and he was finallyreferred to the hospital and hassubsequently had a gastroscopyperformed. He wasn't told the result ofthis, but instead had a follow-upappointment to which he has come totoday. The doctor he is about to see willsuggest that he goes on a PPI. However,the doctor will attempt to recruit Mr

Trotter into a clinical trial comparing theefficacy of two PPIs (A and B) in themanagement of gastro-oesophagealreflux disease. Although, the gentlemanwill carefully consider taking part in theclinical trial, in the end he will decline.

Possible prompts

• Did they find the cause of mysymptoms?

• What does the term oesophagitis mean?

• Is there treatment available for refluxdisease?

• Do I have to take part in the clinical

trial?

• What advantage is there for me?

• If I decline to take part, will that countagainst me in the future?



• Set the agenda. Confirm that he wasreferred by his GP because of hissymptoms of heartburn andsubsequently had a gastroscopyperformed.

• Explain that the gastroscopy and thesymptoms are strongly suggestive ofacid reflux disease, which has causedinflammation of the gullet. Explain thisin simple, lay terms without using anycomplex medical jargon and checkwith him that he understands.

• Go on to explain that an effectivetreatment for this condition is use ofdrugs that reduce the amount of acid inthe stomach known as proton pumpinhibitors and that we need to start oneof these drugs. Confirm that heunderstands this.

• Now, further explain that thedepartment is currently conducting an

experiment where the strength of oneacidreducing drug is being comparedwith another. And that you would liketo enrol him into a trial, which is beingsupervised by your consultant,comparing one drug with another. Sayto him that you would like to enrol himinto this trial, but his consent isrequired.

• At this point he may enquire whetherhe is obliged to enrol into this studyand whether he is likely to bediscriminated against if he does not,i.e. would he still get optimumtreatment.

• Reassure him that his treatment would

not be affected by whether he decidesto enrol into the study.

• He will say to you that he does notwish to take part in the study andwould simply like to be treated for hiscondition.

• Reassure him that you will start him ona proton pump inhibitor and arrange afollow-up appointment to ensure thathis symptoms are improving.

• Ask him if he has any further questions.

0 If he does not, thank him and close theinterview.

Research and ethics

Seep. 16.


You are the SHO on a diabetes ward.


Patient: Mr Lance Riddell

Age: 49 years

The nurse looking after Mr Riddell

has asked you to speak with himbecause of his behaviour earlier in theday. At lunchtime, he had become veryaggressive towards the auxiliary nurseserving food. He had been verballyabusive and had threatened to hit her.The young nurse involved had beenvery upset. Mr Riddell had finallycalmed down after security had beencalled to the ward. Prior to thisepisode the gentleman had been wellbehaved. He is a knowninsulindependent diabetic, who isbeing treated for an ulcer on his foot.Your task is to have a discussion withMr Riddell and explain to him thatabusive behaviour will not be

tolerated.


Patient information

Mr Lance Riddell

Aged 49 years

This gentleman is known to suffer withinsulin-dependent diabetes mellitus andis in hospital receiving treatment for anasty foot ulcer. One of the doctors

looking after him is about to speak withhim regarding an incident that took placeearlier in the day. At lunchtime he wasfeeling very hungry and the nurse servingfood had walked past him twice withoutserving his dinner. This had caused himto become agitated and eventually he hadlost his temper and shouted at her andhad threatened to hit her. Securityofficers were called to the ward (whichMr Riddell had thought unnecessary) andthe gentleman had calmed down. Thisbehaviour is out of character for him andhe regrets his action. He thinks that hemay have been hypoglycaemic, whichtends to make him temperamental. Whenhe speaks with the doctors he will

express his remorse.

Possible prompts

• I'm sorry I was aggressive atlunchtime.

• I would like to apologise to the nurse.

• I suspect it was low blood sugar thatcaused me to behave in this manner.



• Set the agenda. Tell him that you havebeen asked to speak with him regarding

his behaviour at lunchtime.

• Ask him to tell you his side of thestory. He will explain to you that hefelt agitated at lunchtime, whichescalated when the food trolley hadgone past him twice, without him beingserved. He attributes his actions to apossible episode of hypoglycaemia.

• Ask him if he has any animositytowards the nurse in question andwhether this behaviour was out ofcharacter for him. Also enquire if hefeels that the nurse had purposefullyfailed to serve him food. If there is nointentional animosity on either side,proceed.

• Ask him if he regrets his actions andwhether he would like to apologise tothe nurse he was aggressive towards.

• If he does regret his actions thenreassure him that the matter does notneed to be taken any further and he willbe given the opportunity to apologiseto the nurse in question, provided thisis acceptable to her.

• Ask him if there are other concerns.

• If not, thank him and close theinterview.

Managing aggressive patients

Unfortunately, verbal and occasionallyphysical aggression against NHS staff isnot uncommon. To combat this, thegovernment and the profession haveagreed on zero tolerance towardsaggression. The NHS Zero ToleranceZone is a nationwide campaign initiativeto reinforce this policy. As part of thispolicy all trusts must develop a policy totackle aggression against staff, whichshould include a policy on withholdingor withdrawing treatment fromrepetitively violent and aggressivepatients. This should only be carried outwhen warnings have failed. If thesituation is serious, the police may haveto be involved.

(Review this case with case 49: Thenear miss: discussion with nurse)


You are a medical SHO working on achest ward.


Patient: Mr John Powell

Age: 39 years

This gentleman has asked to speakwith you to complain about a nearmiss, which could have beenpotentially fatal. He is known to sufferwith asthma and is currently on theward recovering from an attack. Hehas been commenced on oralprednisolone. He is known to have asevere allergy to aspirin, which haspreviously resulted in an ITUadmission because of laryngealoedema. This morning the nurseadministering the drugs had got herprescription sheets mixed up andgiven him aspirin, which was intendedfor the patient in the next bed. He had

spotted the mistake and scolded thenurse and demanded to speak with adoctor. Your objective is to have adiscussion with Mr Powell regardingthis error and how you plan toproceed.


Patient information

Mr John Powell

Aged 39 years

This gentleman is in hospital recoveringfrom a severe attack of asthma. He is onoral prednisolone and is making a goodrecovery. Mr Powell is known to have asevere allergy to aspirin, which hasprevious required admission to the ITUwith laryngeal oedema. This morning thenurse on the drug round hadinadvertently given him aspirin(intended for another patient) instead ofhis prednisolone tablets. Luckily he hadspotted the mistake in time and hadavoided a potential disaster. He hadscolded the nurse and demanded tospeak with a doctor, who is about to seehim now. Mr Powell will relay hisconcerns to the doctor and demand that

some sort of action is taken against thenurse who he holds responsible.

Possible prompts

• I'm very upset by this mistake.

• I could have died because of this.

• How can I be sure it will not happenagain?



• Set the agenda. Confirm that he hasasked to speak with a doctor regarding

an incident with his medication.

• Briefly ask him to relay the incidentand his specific concerns. He will tellyou about the mix-up with the tablets,which could have resulted in a life-threatening emergency.

• Ask him whether the nurse had verifiedhis identification (either verbally or bychecking his wristband) prior toadministering the drug.

• Reassure him that you will speak withboth the nurse involved and the sisteron the ward to investigate the matterfurther, and tell the consultant lookingafter him about the mistake. Moreover,

you will ensure that a clinical incidentform is completed and further actiontaken as necessary.

• Ask him if he has any further questionsor concerns.

• If he does not, thank him and close theinterview.

Clinical governance in a `nutshell'

The concept was first introduced by theDepartment of Health (DoH) in 1997 inresponse to public concerns aboutaccess to, and quality of, healthcare indifferent parts of the country. The chiefexecutive takes ultimate responsibility

for clinical governance and theHealthcare Commission (CHAI,formerly known as the Commission forHealth Improvements, CHI) will assessevery trust and primary care trust (PCT)to review clinical governancearrangements. Clinical governance isabout having mechanisms in place todeliver the best-quality care within theNHS. This is done through the followingkey aspects.

Quality standards

Professional bodies and the NationalService Frameworks (NSFs) candevelop standards and milestones forservice improvements both locally and

nationally, while the merits of individualdrugs and treatments are being assessedby The National Institute for ClinicalExcellence (NICE). Through clinicalaudit, healthcare professionals cancompare their practice with these agreedstandards. It is important for doctors andother health professionals to continuallydevelop their practices by using anevidence-based approach and bycontinued professional development.

Risk management

Many adverse incidents are potentiallypreventable. Risk management is aproactive approach, which identifies therisks that exist, and attempts to eliminate

them. A crucial element is to learn fromexperience of adverse events. Lessonscan be learned from:

• clinical incident reporting

• near misses

• complaints from patients, families andcaregivers.

Patient satisfaction

An important aspect to this is the PatientAdvice and Liaison Services (PALS),which should be available in all trustsand provide confidential advice andsupport to patients, families and their

carers.


You are an SHO in a cardiology clinic.


Patient: Mrs Jasmine McBride

Age: 52 years

This 52-year-old librarian has beenreferred by her GP with intermittent

chest pains. An exercise tolerance testpreviously carried out haddemonstrated ECG changes consistentwith a diagnosis of angina. The GPhad commenced her on aspirin, a beta-blocker and a sublingual nitrate. Thelady had refused to take theprescribed medication because she isa firm believer in holistic medicine.Your task today is to have adiscussion with her and persuade herto take her conventional medicines.


Patient information

Mrs Jasmine McBride

Aged 52 years

This lady presented to her GP with chestpains. She was very reluctant to see him,but had been persuaded to go by herhusband and teenage sons. He hadorganised an exercise tolerance test, andon the basis of this had confidentlydiagnosed angina secondary to ischemicheart disease (IHD), which candeteriorate and result in a heart attack.Mrs McBride under stands that angina iscaused by reduced blood flow to theheart muscle.

A prescription for various medicines(aspirin, a beta-blocker and a sublingualnitrate) had been issued, but MrsMcBride had refused to take thembecause she is a firm believer inholistic, and particularly, herbalmedicine. Her interest in àlternativemedicine' had started some yearspreviously when her sister haddeveloped breast cancer and the doctorswere unable to save her. She had died ahorrible agonising death and after thattime Mrs McBride's faith inconventional medicine had ceased. Mostof her knowledge of alternativetherapies comes from her research intothe subject on the Internet. Today she has

come to the hospital, again at herhusband's request, and is rather reluctantto be here. The doctor in the clinic willtry to persuade her, but despite his bestefforts, Mrs McBride will refuse to starttaking the prescribed medicines, insteadpreferring to take her herbal remedies.She will, however, agree to come backto the clinic in due course.

Possible prompts

• Yes, I understand that I have angina andI know this is caused by reduced bloodflow to the heart.

• I believe that holistic and herbalremedies are much more effective than

what you can offer me at the hospital.

• Your medicines didn't do my sister anygood; she died in agony of breastcancer.

• I've seen lots of evidence for theeffectiveness of herbal remedies inbooks and on the Internet.

• Yes I do know that angina can lead to aheart attack, but I think my medicineswill prevent this happening.

• I am happy to come back to the clinicagain.



• Set the agenda. Confirm that she hasbeen referred by her GP because ofdiagnosis of angina.

• Ask her what she understands about herdiagnosis. She will tell you that it ispain secondary to a reduced bloodflow to the heart.

• Tell her that you understand that the GPhad started her on some medicines inan attempt to treat the angina, but shehad refused to take them.

• Ask her to tell you the reason for this

(perhaps it is better not to put this interms of non-compliance). She will tellyou that she prefersholistic/complementary medicine. Shemay choose to tell you the reason forthis, inasmuch as the failure ofconventional therapy to treat her sister,who died in agony through breastcancer.

• Say that while there is good evidencethat complementary therapy can beeffective in a wide variety ofconditions, you are not aware of anyevidence that advocates its sole use inischemic heart disease. On the otherhand there is much evidence andexperience in the use of conventional

drug therapies in the treatment of thiscondition and therefore it is importantthat she takes the prescribedmedications.

• She will choose to disagree and saythat she has seen lots of evidence onthe Internet, which validates the use ofherbal treatments in angina therapy.

• Ask her if she realises that angina candeteriorate and can lead to a heartattack. She will tell you that she does,but does not expect her condition todeteriorate as she is treating itappropriately.

• Say that you respect her wishes and

will not press the point, but willarrange for her to be followed up inclinic. She will say that she does notmind this and agree to come back to theclinic.

• Thank her for coming to the clinictoday and close the interview.

Alternative/complementary therapy

Although most of these treatments havebeen around for a very long time, theyhave only become popular in the Westover the last 30-40 years. They consistof a heterogeneous group of therapiesthat are often viewed with scepticismand suspicion by doctors. Also included

are a wide variety of disparatedisciplines that exist largely outsideconventional, hospitalbased medicalpractice. Many alternative therapies(such as acupuncture, chiropractictherapy, hypnotherapy and nutritionaltherapy) are becoming an accepted partof healthcare practice. But others (suchas reflexology, reiki, yoga, etc.) remainvery much on the fringe of our practice.One of the reasons why doctors do notreadily use complementary therapy isbecause of the lack of scientificevidence. Research tends not to becarried out on these treatments for anumber of reasons, which include thefollowing.

Funding and facilities

First, there is little or no funding,particularly as there is no commercialinterest for pharmaceutical companies toinvest in complementary medicine.Moreover, generally speaking,complementary practitioners have notraining in critical evaluation of existingresearch or practical research skills andhave a lack of an academicinfrastructure, which means limitedaccess to, for instance, computer andlibrary facilities.

Difficulty in data interpretation

Because of the nature of these

treatments, it is very difficult to isolatethe individual component, which may beresponsible for the favourable endresult. Take for example herbal remedies- these tend to be concoctions made upof many individual drugs and it is oftenimpossible to know what the effectivecomponent is.

Regulation

Another problem faced bycomplementary practitioners is the lackof regulation. Apart from osteopaths andchiropractors, practitioners are notobliged to join any official registerbefore setting up in practice. For thisreason they are often perceived as

quacks', who are not qualified to give aprofessional opinion. However, theclimate is changing and manypractitioners are now members ofappropriate registering or accreditingbodies.

Internet therapy

The Internet is often used as a powerfulsource of medical information. There aremany very useful sites out there and it'snot unusual for medical practioner's todirect patients to specific sites for moreinformation on their particularconditions and ideas for self-help.However, for patients, the sheer size ofthe `World Wide Web' makes it a

difficult task to isolate the helpfulinformation and they run the risk of beingmisguided. The problem is that most ofthe medical information on the Internet isnot put there by medical practitioners,but instead by well-meaning individualsor self-help groups and, unfortunately,often by charlatans, whose soleobjective is to make money from peopleseeking a medical solution.


You are the RMO on-call at a busydistrict general hospital.


Subject: Mrs Una Watkins

Age: 46 years

Re: father, Mr Arthur Whiteman, aged78 years

You have just finished reviewing MrArthur Whiteman, who is a 78-year-old man brought to hospitalunconscious. Subsequent clinicalexamination and CT scan of the headhave confirmed a massive stroke. Youhave discussed the case with theconsultant on call and his feeling isthat this man is not likely to survivethe night and should be for `TLC', andnot for resuscitation. The man'sdaughter (Mrs Una Watkins) is verykeen to speak with you about herfather's illness. Your objective is toconvey the poor prognosis and to

discuss the resuscitation status.

You have 14 minutes to communicatewith the subject followed by one minutefor reflection before discussion with theexaminers.

Subject information

Mrs Una Watkins

Aged 46 years

Re: father, Mr Arthur Whiteman, aged 78years

This lady's father, Mr Arthur Whiteman(aged 78 years), was admitted to

hospital after he collapsed at home andbecame unconscious. He has notregained consciousness since. Normallyhe is a fit and well man whooccasionally smokes a pipe and drinks afew pints of mild each week. He is awidower, lives alone and is self-caring.Mrs Watkins has always been close toher father and checks on him on a dailybasis and this sudden collapse has comeas a great surprise for her. She is aboutto speak with a doctor who has admittedher father and will be horrified to hearthat he has had a massive stroke and isnot likely to recover from this. Prior tothis interview, she will have no idea asto why he suddenly collapsed. She will

find it hard to accept the medicaldecision that her father should not beresuscitated if his heart stops beating.Her father had never made a living will/advanced directive, but she recalls thatwhen her mother was dying withterminal cancer he had said that if histime ever came he would not want any`messing around'. Upon reflection, shefeels that he would prefer to die withdignity if there was no real chance ofreasonable recovery.

Possible prompts

• Will Dad get better?

• Is he going to die?

• He's always been very active and ingood health. Why has this happened sosuddenly?

• Is he in pain?

• Is there nothing you can do for him?

• Will you stop all the treatment?


• Greet the subject and introduceyourself to her.

• Set the agenda. Confirm with her thatshe has asked to speak with youregarding her father's condition.

• Ask her what she knows about thecause of her father's illness and how heis getting on.

• She will not know the cause of herfather's collapse or have any idea ofhis prognosis. However, it is importantthat you listen to her both carefully andempathetically, and without too muchinterruption.

• Explain to her in plain English that theclinical examination and the CT scanshow that her father has suffered amassive stroke. Pause and let herabsorb this information.

• Go on to explain that it is unlikely that

he will regain consciousness and in allprobability he is likely to deteriorateand die. It is especially important thatyou pause and let her comprehend thisinformation.

• She may ask you how much time he hasbefore he dies. Be honest and say thatit is difficult to predict, but given theseverity of the stroke it will probablybe in the next 24 hours (there must beabsolutely no mention of crystal ballsor pieces of string!).

• Carefully breach the subject ofresuscitation. Explain to her that youhave discussed her father's case with aconsultant physician and he feels that it

would be futile to attemptcardiopulmonary resuscitation and thatit is best that he is declared not-for-resuscitation.

• Ask her if the patient had everexpressed an opinion on this subject orwhether she was aware of a living willthat he had left. She may tell you thatwhen her mother was terminally ill hehad said that if he were ever in asimilar position then he would not liketo be `messed about'. So, in heropinion, he probably would not want tobe resuscitated and instead die withsome dignity.

• Reassure her that in the unlikely event

of her father making any sort ofrecovery, the resuscitation decisionwould be reviewed. And even thoughhe is not for resuscitation his basicmedical and nursing care will not beaffected.

• Ask her if she has any other concernsor questions.

• If not, thank her and close theinterview.

Ethical issues

For a discussion on CPR and other ènd-of-life decisions' including resuscitation,see p. 10.

Advance directives (living wills)

A mentally competent adult may decidehow they would like to be treated in theevent of them not being able to makethese decisions. These àdvancedirectives' carry the same force ascontemporaneous statements made bythat individual.


You are an SHO working on a strokeunit.


Subject: Mr Colin Banks

Age: 37 years

Re: mother, Mrs Sofia Banks, aged 76

years

A 37-year-old man, Mr Colin Banks,asks to speak to you about his motherwho is having a percutaneous (PEG)feeding tube inserted. She had beenadmitted several weeks previouslyfollowing a dense stroke. Prior to thisepisode, the 76-year-old lady hadbeen well, except for hypertensionand obesity. There has been someimprovement since her admission andshe has become alert and gained someuse of her right arm and leg, whichhad been effected by the stroke. She iscurrently being fed via a nasogastric(NG) tube and has recently had anassessment by a speech and language

therapist (SALT), who has deemed herswallowing unsafe. Agastroenterologist has reviewed herand agrees that it is appropriate toinsert a PEG feeding tube, although itwill be technically challengingbecause of her obesity. The lady wasunable to sign her consent form, buthas given a verbal consent. Yourobjective is to speak to Mr Banks andinform him of what the procedureentails and to answer any questionsthat he may have.

You have 14 minutes to communicatewith the subject followed by one minutefor reflection before discussion with theexaminers.

Subject information

Mr Colin Banks

Aged 37 years

Re: mother, Mrs Sofia Banks, aged 76years

This gentleman's mother (Mrs SofiaBanks) was admitted to hospital someweeks ago following a stroke. Prior tothis the 76-year-old lady had onlysuffered with hypertension and obesity.Since her admission, there has beensome improvement in her symptoms andin particular Mr Banks is encouragedthat she is more alert now and able to

move her previously paralysed arm. Atpresent, she is being fed by a nasalfeeding tube, but the plan is to insert agastrostomy feeding tube through theabdominal wall. The nurse looking afterhis mother told Mr Banks that theprocedure can have seriouscomplications, but was unable to giveany specific details. Mr Banks hastherefore asked to speak to a doctor, andthe nurse has summoned the SHO. Hespecifically intends to ask the doctorabout the complications associated withthe procedure and the need to have thetube inserted. He is also aware that hismother is not able to sign the consentform and he wants to know if he needs to

sign a consent form on her behalf.

Possible prompts

• Mother already has a tube coming outof her nose for feeding. Why does sheneed another one?

• How is the tube inserted?

• Will it be permanent?

• Are there any problems with theprocedure?

• Can she go home with it?

• Do I need to sign her consent form?


• Greet the subject and introduceyourself to him.

• Set the agenda. Confirm with him thathe has asked to speak with youregarding his mother and the insertionof a feeding tube.

• Ask him what he knows about theprocedure and why the tube is beinginserted.

• Explain to him that the insertion of afeeding tube through the abdominalwall is a common procedure carriedout in patients who are unable to feed

themselves. A common reason for thisis strokes that can affect theswallowing process, which is thereason his mother is having the tubeinserted. Further, explain that thenasogastric tube, which is currentlybeing used, can be very uncomfortablefor the patient and hence is notappropriate for long-term use.

• He may then ask you aboutcomplications. Briefly explain that theprocedure is not without complications(particularly because of the obesity),which include bleeding, perforationand damage of other intra-abdominalorgans and infection, but they are rare.It is important to emphasise that you

are not a specialist and you couldeither speak with one to get an exactidea of potential complications ororganise a discussion with thespecialists.

• He may then ask you whether he needsto sign a consent form on his mother'sbehalf, as she is unable to.

• Say that would be helpful and that youwould arrange an appropriate consentform for his signature, but explain thathe is not legally obliged to sign aconsent form.

• Ask if he has any other concerns orquestions.

0 If not, thank him and close theinterview.

Ethical issues

Consent issues are extremely importantand have previously been covered on p.2. An important aspect relevant to thiscase is that of close family membersgiving consent for medical procedures.When patients are unable to give consentfor themselves, it is a common practiceto seek consent from family members.However, there is no medicolegal basisfor this practice. But it is common senseand good practice to inform closerelatives and particularly the next of kinof any medical procedures to be

performed.

PEG tubes

These are inserted in patients who areunable to feed for more than a fewweeks. For periods less than this,nasogastric feeding tubes can be used.The most common indication for a PEGtube is swallowing difficulties, whichmay occur after a stroke and withneurological conditions such as motorneurone disease and multiple sclerosis.Other indications include head and neckcancers, and severe motility problems,particularly if the oesophagus is affected(for example in scleroderma). Rarely itmaybe used in psychiatric patients with

eating disorders.


You are the SHO working on arespiratory ward.


Subject: Mr Eamonn Robertson

Age: 32 years

Re: father, Mr Herbert Robertson,

aged 58 years

The sister on the ward asks you tospeak to Mr Eamonn Robertson, whois a 32-year-old man. He has beentold that his father (Mr HerbertRobertson), who is a patient withCOPD, has been moved to a sideroom on another ward because he wasfound to be MRSA positive. He isconcerned about what impact this willhave on his father's health and whetherhe and his family are at risk, as theyhave been visiting him. Your task is todiscuss his concerns with him.

You have 14 minutes to communicatewith the patient's son followed by one

minute for reflection before discussionwith the examiners.

Subject information

Mr Eamonn Robertson

Aged 32 years

Re: father, Mr Herbert Robertson, aged58 years

This gentleman's father (Mr HerbertRobertson) was admitted to hospital aweek ago with shortness of breath. He isknown to suffer with emphysema andwas a smoker until last year. He wastreated with steroids, antibiotics and

nebulisers and is making a gradualrecovery. However, Mr Robertson hascome to visit his father today only to findout that he has been moved from hisnormal bed. Upon enquiring, the sisterhas told him that his father was found tobe MRSA positive and was moved to aside room on another ward to contain theinfection. Mr Robertson's initial reactionwas of anger as he attributed the MRSA(which he knows as the `super-bug')infection to the general lack of hygieneon the ward. On a previous occasion hehad noted that a demented man in anotherbed had been incontinent of urine and ithad taken 20 minutes before a nurse hadchanged him. On another occasion, he

had noticed a doctor examining anunkempt patient and then examininganother patient without stopping to washhis hands. He expressed hisdissatisfaction to the sister, who hassuggested that he should speak with adoctor. He is also worried about theprospect of him and his young children(who regularly visit their grandfather)acquiring MRSA and the potential risksit may pose to them.

Possible prompts

• Where did he catch this bug?

• Is it because of lack of hygiene in thehospital?


• Will my children be affected?

• How do you know they haven't got thebug?

• Does my family need treating?

• Can we continue to visit my father?



• Set the agenda. Confirm with him thathe has asked to speak with you regardinghis father's transfer to another ward.

• Ask him whether he knows why hisfather was transferred to another ward.

• Confirm that the move was because hisfather had been found to be MRSApositive and the move to a side roomwas to contain the spread of this.Explain that MRSA is a bacterium thatnormally does not cause problems, butis difficult to treat in vulnerablepatients, particularly those with poorimmune systems, and hence measuresare taken to prevent spread of theinfection within hospitals.

• Further explain that he was moved toanother ward because of availability ofa side room.

• He may suggest that the infection wasspread because of poor hygiene. Agreethat hygiene certainly plays animportant role in the spread ofinfection, including MRSA, andnowadays hospital policy dictates thatall staff observe a strict code ofpractice for hand washing and the useof alcohol hand rub, which can bemore effective than washing.

• If he is not satisfied, allow him toexpress his concerns regardinghygiene, but reassure him that you willspeak with the sister/ward managerand ensure that hand-washing policy isreinforced or adhered to.

• Reassure him that MRSA poses verylittle risk to him and his family. But ifhe wants, you can organise for swabsto be taken and if positive, prescribetreatment. Explain to him that becausehis father is `barrier nursed' it isimportant that when they see him theywear aprons and gloves and use thealcohol hand rub provided.

• Ask if he has any other concerns orquestions.

• If not, thank him and close theinterview.

Healthcare-associated infections

In England approximately 1 in 10 peopleare admitted to hospital with an infectionthey developed at home and a further 1in 10 people admitted to hospitalsdevelop an infection after admission(National Audit Office Report, 2000).Since 2001 hospitals have been requiredto report certain types of infection to theDepartment of Health. These include:

• methicillin-resistant Staphylococcusaureus (MRSA) septicaemia

• Clostridium dif icile-associateddiarrhoea

• vancomycin-resistant enterococci(VRE) septicaemia

• infections following knee and hipreplacements.

Over the last decade there has beenconsiderable media interest on this topicand the general consensus has been thatpoor hygiene was leading to a surge inthese infections, increasing patientmorbidity and mortality. These concernshave led to the Department of Health's`Towards cleaner hospitals and lowerrates of infection' programme. Thisprogramme sets out a strategy toimprove the general state of cleanlinesswithin hospitals and thereby reduce therisk of hospital-acquired infections(described as healthcare-associatedinfections). Key elements to this

programme include empowering patientsand the public, the matron's charter,independent inspection and learningfrom the best.

The Department of Health has alsosuggested that tackling healthcare-associated infection requirescommitment from all levels of NHSorganisation and cannot be left toclinical staff alone. To this end,directors of infection prevention andcontrol should be employed, who reportdirectly to the trust board. It would bethe role of these directors to ensure thatinfection control is a key part of theNHS organisation.


You are an SHO working on a generalmedical ward.


Subject: Mrs Jean Timbury

Age: 51 years

Re: mother, Mrs Eleanor Hodgetts,aged 86 years

Mrs Jean Timbury, a 51-year-oldsocial worker, has arranged to speakwith you to discuss the circumstancesof her mother's death. The consultantwho had looked after her mother hadagreed to see her, but unfortunately isaway today due to illness and hissecretary has asked you to speak toher instead (the team does not have aregistrar). Her mother, Mrs EleanorHodgetts, was an 86-year-old womanwho was known to have long-standingischemic heart disease and heartfailure. Ten days previously she hadbeen admitted with shortness of breath

secondary to pulmonary oedema andinvestigations had shown a likelymyocardial infarct. Despite beingtreated aggressively, includingthrombolysis, intravenous diureticsand a nitrate infusion, she deterioratedand died. The medical team haddiscussed her with the ITU team and itwas considered inappropriate tointubate and ventilate. Prior to herdeath, a registrar had documented MrsHodgetts as not for resuscitation, afterdiscussing this with the patient. Thedeath had been expected and had notbeen referred to the coroner. Yourobjective is to discuss these issueswith Mrs Timbury and to answer any

questions she may have.

You have 14 minutes to communicatewith the patient's daughter followed byone minute for reflection beforediscussion with the examiners.

Subject information

Mrs Jean Timbury

Aged 51 years

Re: mother, Mrs Eleanor Hodgetts, aged86 years

This lady's 86-year-old mother (MrsEleanor Hodgetts) was admitted to

hospital 10 days ago with shortness ofbreath and had died the next day. Theonly significant past medical history isof a heart attack three years previously,which had left her with very mild heartfailure and shortness of breath. MrsTimbury lives in a town 50 miles awayand was not able to see her motherduring her final illness. She is deeplyupset by her sudden death, particularlyas she had spoken to her on the day ofher admission and she had seemed hernormal self. She also feels somewhatguilty because she is an only child andwasn't there at the end. There are lots ofquestions she would like to haveanswered and had arranged to speak

with the consultant who had looked afterher mother. However, Mrs Timbury isannoyed to find out on her arrival at thehospital that the consultant is unable tosee her and instead the secretary hasarranged a junior doctor to speak withher. Because she has taken the day offwork and it has taken her nearly twohours to get to her appointment, sheagrees to see the junior doctor. She isparticularly anxious to enquire about hermother's management and whether shehad been resuscitated. She will be upsetto find out that resuscitation had not beenattempted and thinks that if it had beenshe would have been there at the end.However, when the doctor explains the

inappropriateness and futility ofattempting resuscitation, she will acceptthis decision.

Possible prompts

• What caused mother's death?

• Could anything have been done to saveher?

• One of the nurses told me that she hadnot been sent for intensive care. Canyou tell me why?

• Did you try to resuscitate her?



• Set the agenda. Apologise that theconsultant is not here to speak with hertoday because of illness and confirmthat she would like to speak about hermother's illness and death.

• Ask her what she knows about hermother's illness. She will tell you thather mother had been well and she hadspoken with her on the day she cameinto hospital. Her understanding is thather mother was brought into hospitalwith shortness of breath and diedshortly afterwards.

• Confirm that her mother had come intohospital with shortness of breath,which was thought to be because ofheart failure. Explain thatinvestigations carried out at the timeshowed that her mother had suffered aheart attack, which had caused thesudden deterioration. Upon admissionshe had been treated promptly, butdespite the best efforts of the medicalteam had deteriorated and died.

• At this point she may enquire ifresuscitation had been attempted.

• Say that it had not. Explain that this isan important decision that the team hadmade after discussion with the

intensive care unit. It was felt that thesituation was futile and the lady wasunlikely to make a recovery. Gentlyexplain to her that resuscitation in suchcircumstances generally has a pooroutcome and can be an extremelyundignified death.

• At this juncture it would be reasonableto pause and allow the subject toexpress her emotions, and respond toher emotions with empathy and answerany questions she may have.

• Ask if she has any other concerns orquestions.

• If not, thank her and close the

interview.

Bereavement

Bereavement is a universal humanexperience and is associated with a highmorbidity, where up to one-third of thosebereaved may go on to develop adepressive illness. It is well recognisedthat there are stages in the grief process.But these stages are not often ordered orstructured. The basic stages of grief are:

• initial shock - there is numbness andshock and the person accepts thereality of the loss

• pangs of grief- common emotions

experienced here include sadness,vulnerability, anxiety, anger as well asregret, guilt and anger. Insomnia andsocial withdrawal are also commonexperiences

• despair- the subject feels a loss in theirlife's direction and is a way ofadjusting to a new environment,without a loved one

• adjustment - this is the final stagewhere the bereaved person begins toform new relationships andemotionally relocate the deceased to animportant, but not central, place in theirlife and move on.

This is the normal bereavement processand the bereaved person will go thoughit and eventually get back to a normallife. The time period over which thishappens is variable and depends onmultiple factors. Similarly, there arefactors that lead to a poor outcome fromthe process and the bereaved person ismore likely to end up clinicallydepressed and even commit suicide.This is said to be `complicated grief'.Factors that are likely to lead tocomplicated grief include:

• close relationship with the deceased

• sudden and unexpected death,particularly of a young person (or

worse still, a child), for examplefollowing a road traffic accident. Thismay be even worse if the death had asocial stigma attached, for example bysuicide, taking a drug overdose ordying of AIDS

• previous mental illness and low self-esteem

• inability to carry out religious/culturalrituals. For instance, ethnic minoritypatients often prefer their burial orcremation to take place in the land oftheir birth with their ancestors. Thisisn't always practical or possible andthe surviving relative may feelimmense guilt

• multiple bereavements and life crises

• caring for the deceased for longer thansix months

• generally speaking, men fare worse incomparison to women

• lack of social support.

Assessing and treating complicated griefcan be complex and is beyond the scopeof this present text. Suffice it to say thatthe therapeutic process encourages thegrieving process.

CPR decisions

For a discussion on CPR and other ènd-of-life decisions', includingresuscitation, see p. 10.


You are a neurology SHO.


Subject: Mrs Amy Martinez

Age: 29 years

Re: father, Mr Ronald Crichton, aged59 years

A 26-year-old woman asks to speak toyou regarding her father. She normallylives in Canada and is keen to speakto someone as she is flying back homethe next day. Her father was admittedseveral weeks previously withclumsiness and forgetfulness.Although the admitting team felt thathe might have had a stroke, yourconsultant was suspicious ofHuntington's disease. Genetic testswere carried out and have confirmedthe diagnosis of Huntington's disease.Your task is to explain the diagnosisand its implications to the patient's

daughter. She has told one of thenurses that she has recently gotmarried and is keen to start a family.

You have 14 minutes to communicatewith the patient's daughter followed byone minute for reflection beforediscussion with the examiners.

Subject information

Mrs Amy Martinez

Aged 31 years

Re: father, Mr Ronald Crichton, aged 59years

This lady normally lives in Canada andcame to the UK when her 59-year-oldfather (Mr Ronald Crichton) wasadmitted to hospital with forgetfulnessand clumsiness. The initial diagnosishad been of a stroke, but he wasundergoing further tests. Mrs Martinezhas recently got married, works as apublishing assistant and normally enjoysgood health, working out at the gym threetimes per week. Both she and herhusband are keen to have children. Herflight back to Canada is scheduled forthe next day and she has organised tospeak to a doctor regarding her father'sprogress. When she speaks to the doctor,it comes as a shock that her father may

have an inheritable condition that hasimplications for her and her family.

Possible prompts

• Will my father get better?

• Are there any treatments for thiscondition?

• Will I develop this condition?

• How can I tell if I have the condition?

• Can I be tested now?

• Is there a chance that my children willdevelop this?



• Set the agenda. Confirm that she hasasked to speak with you regarding herfather's progress.

• Ask her what she has been told abouther father's illness thus far. She willtell you that her father is being treatedfor a suspected stroke, but the doctorshave told her that they are carrying outfurther tests. She does not know whatthese are for.

• Confirm that there was an initial

suspicion that her father had had astroke. However, your consultantwasn't convinced and was suspiciousof a condition called Huntington'sdisease. Ask her if she has heard of thecondition. She will tell you she has not.

• Explain to her that this is a seriouscondition, which causes a progressivedeterioration in both the ability to carryout physical tasks and mental functionto the extent that people developadvanced dementia. Say that there is nocure for this condition, but insteadmanagement focuses on optimumnursing care and symptom relief.

• Now carefully explain to her that this

is an inheritable condition, which hasimplications for the patient's children,including the lady herself.

• Pause and let her absorb thisinformation and the significance forher.

• Further explain that the risk ofdeveloping the disease if one of yourparents is affected is 50 per cent andtests are available that will showwhether or not an individual is likelyto develop the condition. However,testing can only be carried out afterformal genetic counselling.

• She may tell you that she is flying to

Canada the following day and isworried that she may not be able toseek further advice or geneticcounselling. Reassure her thatcounselling and testing can be carriedout in Canada, which can be organisedthrough her own general practitionerand that you would be happy to write aletter for her to take beck to her GP toorganise the necessary referral andtesting. Remind her that this is aninherited condition and a delay intesting will not make any difference.

• Ask if she has any other concerns orquestions.

• If not, thank her and close the

interview.

Inherited disease

With scientific advances in molecularbiology such as the `Genome Project',the mechanisms behind inherited diseaseare becoming clearer and tests arebecoming available to test for thepresence of genes in a number ofconditions. Huntington's chorea ordisease (HD) is a condition inherited viaan autosomal dominant trait. Theresponsible gene is present onchromosome 4 and encodes a proteinknown as huntingtin. This proteinprogressively accumulates within braincells and damages them by as yet

unknown mechanism.

Patients often present with involuntarymovements (e.g. piano-playing motion ofthe fingers or facial grimaces) or rigidityor mental changes, which in the earlystages appear as increased irritability,moodiness, or antisocial behaviour.Patients who develop HD by the timethey are aged 35 years often becomebedridden within 15-20 years anddementia develops as the diseaseprogresses. At present there is no curefor the condition and management isaimed at symptom control and socialsupport. Family history is of paramountimportance in making the diagnosis.

Genetic test counselling

Individuals may wish to be tested if:

• they develop symptoms of a heritablecondition

• there is a family history of a heritablecondition

• they are worried about passing on aheritable condition to their children.

In real life genetic test counselling canbe a complex process involving amultidisciplinary team, including forinstance, in the case of Huntington'sdisease, neurologists, geneticists,

psychiatrists and counsellors. However,for the purposes of the exam it isimportant to emphasise that the result ofthe test has implications for the rest ofthe patient's own life and theirdescendants. In addition to personal andfamily issues, genetic disease orsusceptibility may have implications foremployment and insurance. Therefore,careful consideration in the handling ofthis information is very important.Critical issues include:

• informed consent - patients must haveknowledge of the risks, benefits,effectiveness and alternatives to testingin order to understand the implicationsof genetic testing. The findings may

affect the future employability orinsurability of the individual

• confidentiality and privacy - the patientmust be reassured that access togenetic information will be limited tothose authorised to receive it.

The advantage of having the test is toobtain information that will enable thepatient to take control of their life. Forinstance, if it is negative then they can bereassured and lead a normal life and notfeel that they have the `sword ofDamocles hanging over their head'*. Ifon the other hand the test comes backpositive, then it will empower thepatient to make appropriate lifestyle

choices regarding their vocation andstarting a family, etc. It is important thatyou explain the nature of the test, whichis usually a blood test, and your follow-up plan. As a general rule, the resultshould always be given in person andnever over the phone or by letter.


You are the SHO working on a busy ITU.


Subject: Mr Robert Declan

Age: 63 years

Re: son, Mr Simon Declan, aged 24

years

Simon Declan collapsed at a party. Hewas subsequently diagnosed with amassive intracranial haemorrhage,possibly secondary to a ruptured berryaneurysm, and required admission toan intensive care unit. He is currentlysupported on a ventilator and themedical team have conducted tests,which show that he is brainstem deadand that the ventilator should beturned off. You are asked to discussthis with the man's father, who is thenext of kin, and also breach thesubject of organ donation. There is noother close family. The father, MrRobert Declan, works as a long-

distance lorry driver and has justarrived at the ITU after beinginformed on his mobile phone that hisson had been admitted.

You have 14 minutes to communicatewith the patient's father followed by oneminute for reflection before discussionwith the examiners.

Subject information

Mr Robert Declan

Aged 63 years

Re: son, Simon Declan, aged 24 years

This gentleman works as a long-distancelorry driver and had been away on a jobwhen he received a call on his mobilephone from the police who had simplyinformed him that his son (SimonDeclan, aged 24 years) had beeninvolved in an ìncident' and had beenadmitted to hospital. Mr Declandivorced his wife many years ago andlives with his son, who is his only child.He arrived at the hospital to find out thathis son was in the ITU. Before seeing hisson, the nurse has asked him to speakwith the SHO. The SHO will inform himthat his son collapsed and was broughtto hospital, and subsequent tests showedthat he had suffered a massive

intracranial bleed. The SHO should alsoexplain that tests show that his son isbrainstem dead and the ventilator iscurrently keeping him alive. This newswill be devastating, and made worse bythe fact that the team intend to turn theventilator off. In addition, the SHO willdiscuss the prospect of organ donationand, in particular, seek Mr Declan'sconsent. Mr Declan will find it all toooverwhelming and be unable to give hisconsent.

Possible prompts

• Will he get better?

• Is it a stroke that he has had?

• But if he is breathing and his heart isbeating, how can he be dead?

• Would he be able to hear me if I spoketo him?

• I can't let you cut my boy up.



• Set the agenda. Confirm that you havebeen asked to speak with the gentlemanbecause his son was admitted to theITU.

• Ask what he knows about his son'sadmission to hospital. He will tell youthat he received a call from the policewho said his son had been involved inan ìncident' and admitted to hospital.On arrival at the hospital he wassurprised to find out that he had beenbrought to the intensive care unit.

• Gently explain to him that his son wasadmitted to hospital after he collapsedat a party and was unconscious whenhe was brought into hospital and putonto a ventilator (explain what this is).A subsequent scan of his head hadshown that he had suffered a largebleed into the brain.

• Pause and let him absorb thisinformation.

• Tell him that further tests were carriedout, which suggest that his son is braindead and not likely to recover from thisevent; indeed, if the ventilator wasstopped he would not be breathing.Further, explain that the situation isfutile and that the team plan to switchthe ventilator off.



• If the man is relatively calm, breach thesubject of organ donation. Ask if hisson had ever mentioned organ donationor had carried an organ donor card andwhether the gentleman would consentto the use of his son's organs fortransplantation.

• Mr Declan will find this subject highlyemotive and will be unable to giveconsent. It is important that you do notpressurise him into giving consent andit may be appropriate to simply askhim if he would like more time to thinkabout it. If he is adamant that he doesnot want his son's organs to betransplanted, then reassure him that hiswish will be respected.

• Briefly summarise the discussion andask if he has any further questions.


What are the criteria for brainstemdeath and how is it established?

Brainstem death can be establishedwhen the following brainstem reflexesare absent:

• no pupillary response to light

• absent corneal reflex

• no motor response within cranial nervedistribution

• absent gag reflex

• absent cough reflex

• absent vestibulo-ocular reflex.

Persistant aponea must be confirmed asfollows:

• the patient must be pre-oxygenatedwith 100 per cent oxygen for 10minutes and PaCO2 allowed to riseabove 5.0 kPa

• disconnect the patient from theventilator

• during the test while maintaining

adequate oxygenation, allow PaCO2 toclimb above 6.65 kPa and confirm thatthere is no spontaneous respiration

• reconnect the ventilator.

Two experienced physicians must carryout these tests, at least one of whom mustbe a consultant and neither should bepart of a transplant team. The tests haveto be carried out on two separateoccasions.

What criteria need to be excluded beforebrainstem death can be diagnosed?

Neurological examination to determinewhether a patient is brain dead can

proceed only if the followingprerequisites are met: the ruling out ofcomplicated medical conditions that mayconfound the clinical assessment,particularly severe electrolyte, acid-base, or endocrine disturbances; theabsence of severe hypothermia, definedas a core temperature of 32°C or lower;hypotension; and the absence ofevidence of drug intoxication, poisoning,or neuromuscular blocking agents.

What do you understand by theterms `locked-in syndrome' and`persistent vegetative state'?

The locked-in syndrome is a state ofunresponsiveness, due to massive

brainstem infarction. The patient has afunctioning cerebral cortex, and is thusaware, but cannot move or communicateexcept by vertical eye movement. Thepersistent vegetative state, a sequel of,for example, widespread corticaldamage after head injury, implies loss ofsentient behaviour. The patient perceiveslittle or nothing but lies apparentlyawake, breathing spontaneously.

Do you think there should be amandatory organ-donor system?

The advantage of a `mandatory organ-donor system' is that it would allowviable organs to be salvaged from deadpatients without the requirement for

consent. This would solve the nationalshortage of organs. The problem withthis is that it violates patient's autonomyand is against the basic principles ofmedical ethics.

Are you aware of any legislationrelated to organ donation?

In previous years two key lawsgoverned organ donation andtransplantation:

1 The Human Tissue Act 1961, and

2 The Human Organ Transplants Act1989.

However, following recent scandalssuch as that at Bristol Royal Infirmaryand Alder Hay, where human tissue wasremoved without consent, thegovernment reviewed and repealed theseActs in favour of the Human Tissue Act2004. Under this Act consent is thefundamental principle underpinning thelawful use of, and retention of, organs,body parts and tissue. The Act alsoestablished the Human Tissue Authorityto advise on and oversee compliancewith the Act. Àppropriate consent' isrequired for lawful storage or use ofhuman tissue, which includes tissueobtained for transplant purposes.Appropriate consent can be obtained as

follows:

• from a living competent adult, orcompetent child willing to make adecision

• from a person with parentalresponsibility for an incompetent child

• for a deceased person (as in this case),where consent has not been obtainedfrom the patient during their life,consent may be obtained from aqualifying relative. A qualifyingrelative may be any of the following:

- spouse or partner

- parent or child

- brother or sister

- grandparent or grandchild

- child of a brother or sister

- stepfather or stepmother

- half-brother or half-sister

- friend of long standing.

What does the term `presumed consent'mean to you?

There is a chronic shortage of organs fortransplantation. This is despite the fact

that most people when polled say thatthey would be happy for their organs tobe used after their death. One potentialsolution is to institute a law where thereis `presumed consent' for organs to beused after their death, unless the patienthas specifically stated to the contrary.This is not a new idea and indeedFrance has had such a policy since 1976.Other European countries, includingAustria, Belgium, Denmark, Finland,Italy, Norway and Spain, have laws thatgive physicians the right to presume thata deceased person is an organ donorunless they have signed a writtendirective, or have registered in acomputer data bank, indicating that they

do not wish to do so.

Reference

Wijdicks EFM (2001) The diagnosis ofbrain death. NEJM. 344: 1215-21.


You are the SHO working on a renaltransplant unit.


Subject: Mrs Kathleen Hoole

Age: 58 years

Re: daughter, Miss Neve Hoole, aged19 years

This lady's daughter (Neve Hoole) hasbeen a patient under regular follow-upfor four years and has now developedendstage renal disease, requiringdialysis three times per week. Herrenal disease is thought to besecondary to chronicglomerulonephritis. Although she is ona waiting list for a cadaverictransplant, it has been previouslyexplained to the patient and her familythat there was no guarantee that shewould get a suitable kidney andpeople can be waiting for a transplantfor years before one is found. The

possibility of getting a kidney from aliving donor has been mentioned, butnot discussed. The patient's mother,Mrs Kathleen Hoole, has come to theclinic today to explore this optionfurther. Your consultant has asked youto have a frank discussion with themother about living/related donationof a kidney, while he sees the patientand continues with the very busyclinic. Your task is to give Mrs Hoolean overview, including any pros andcons, of acting as a living donor andto answer any questions that she mayhave.

You have 14 minutes to communicatewith the patient's mother followed by

one minute for reflection beforediscussion with the examiners.

Subject information

Mrs Kathleen Hoole

Aged 58 years

Re: daughter, Miss Neve Hoole, aged 19years

This lady's daughter was diagnosed withrenal failure secondary to chronicglomerulonephritis four years ago and isnow on haemodyalisis three times perweek. She has been placed on a waitinglist for a renal transplant, but the doctor

looking after her has previously said thatit was impossible to predict how longshe would have to wait before a kidneybecame available, and often peoplewere waiting for years and indeed manypeople never receive a transplant. Hehad also mentioned the possibility ofrelatives donating one of their kidneys,but because of constraints of time hadbeen unable to elaborate on this. MrsHoole is very worried about herdaughter and her future and thinks that arenal transplant is the only hope for anormal quality of life for her. Because ofthis, she is seriously consideringdonating one of her kidneys to herdaughter, but needs more information.

Today she has accompanied her daughterto a follow-up appointment at the renalunit to discuss this option further. Theconsultant at the clinic has arranged forher to have a discussion with one of thejunior doctors.

Possible prompts

• I would like to discuss my daughter'skidney disease.

• We have been waiting for a long time.What is the prospect of her getting akidney transplant?

• I am seriously considering thepossibility of giving one of my kidneys

to her. Can you give me someinformation on this?

• If I gave one of my kidneys, would Iend up on dialysis?

• Is it a safe procedure?

• How long would I have to take offwork to donate a kidney?

• What happens next?

The interview

• Introduce yourself to the subject.

• Confirm that she is here to discussrenal transplantation and possibly

acting as a donor, and enquire aboutany specific questions that she mayhave.

• Explore her motivation to act as aliving donor.

• Explain, in non-medical jargon what arenal transplant involves and why thereis a need for living donors. Discusspotential complications, including theprospect of the transplant failing tofunction. However, medical data showthat 95 per cent of transplants arefunctioning at one year and thiscontinues to improve. It is importantthat the donor realises that theassessment process (as outlined

below) is a long one and that thesurgery involves a major operation thatcan result in life-threateningcomplications and at the very least,pain.

• It is easy to be negative, but perhaps itis also worth bringing up the positiveaspects of becoming a donor, such asbeing able to give a loved one a near-normal quality of life.

• Don't forget to mention the practicalimplications for the donor, such ashaving to spend a week in hospital anda further 8-12 weeks off work. Also,they may need to speak to their insurersto see what implications there are for

any life cover, etc.

• Confirm and summarise information ateach step.

• Offer to answer any further questions.

• Give a follow-up plan to the lady, suchas giving her contact details of thetransplant coordinator, and a detailedleaflet giving her more information tobe read at leisure.

• Thank the subject and close.

Donor assessment

This is a long drawn-out process (and

rightly so!) where the donor is carefullyevaluated in terms of medical andpsychological well being before atransplant can be carried out. Theessential process is as follows:

1 Review by nephrologists, whereinformation and literature are supplied.An opportunity may be given to visitthe transplant unit. The donor's bloodgroup must be shown to be compatiblewith the recipient. Discussion shouldinclude the sensitive nature of the teststo be performed and their potentialimplications. For example, HIV andhepatitis B and C have to be tested for,which has long-term implications forthe donor. Moreover, the tests may

reveal that individuals are notbiologically related!

2 The full biochemical andhaematological profile of the potentialdonor is obtained as well as chest X-ray, ECG and urinanalysis. A detailedvirology screen and tissue typing testsare also carried out.

3 If the results from the above tests areacceptable then detailed radiologicaltesting of the kidneys is carried out.This should included a renal ultrasoundscan as well as nuclear medicine scans(GFR as well as MAG3 or DTPAscans).

4 At this stage the donor should beformally referred to a transplantsurgeon by the recipient's nephrologist,with the involvement of a transplantcoordinator. The surgeon will thenreview the donor and request a renalarteriogram, which can be analysedwith the aid of a radiologist. At thisstage the donor may be reviewed by anindependent professional such asanother nephrologist or a counsellor.

5 If the whole of this process is carriedout satisfactorily, only then can itproceed to a renal transplant.

The whole process may take 3-6 monthsto complete.

Ethical and legal issues

There are many ethical issuessurrounding live organ donation, ofwhich perhaps the most significant is theright to remove an organ from a healthyindividual and the potential risks thatcarries. Does the principle of `non-maleficence' (doing no harm) to thedonor outweigh the `beneficence' (doinggood) for the recipient? There are manydiffering opinions surrounding thisargument. There is a real concernregarding possible pressures or evencoercion placed upon donors byfamilies, recipients, or even thetransplant teams. This is particularly sobecause of the altruistic nature of acting

as a living donor, be it a related donor(parent, sibling, etc.) or an unrelateddonor (such as spouse or close friend).But perhaps true altruism only occurswhen there is no emotional attachment tothe patient.

Perhaps the most controversial issuesurrounding live organ donation is thesale of organs - so-called `trafficking'. Itis well recognised that there is anunderground industry in exploiting poorand vulnerable people across the globefor this purpose. Indeed, even in Britain,trafficking of organs by a surgeon led tothe formation of the Human OrganTransplants Act in 1989. This clearlystates that organs cannot be exchanged

for money. The World HealthOrganization (WHO) (1991) says that a`Rational argument can be made to theeffect that shortage has led to the rise ofcommercial traffic in human organs,particularly from donors who areunrelated to recipients .... There is alsoan argument that with the severe shortageof donor organs are we morally justifiedin denying patients the option of buyingorgans, if others are willing to sell theirorgans (Bartucci, 1990).

References

Bartucci MR (1990) ANNAgrams Q:A.

ANNA J. 17(4): 325.

World Health Organization (1991)Guiding principles on human organtransplantation. The Lancet. 337: 1470-1.


You are the RMO on-call.


Subject: Mr Todd Panos

Age: 49 years

Re: daughter, Miss Natasha Panos,

aged 18 years

You had admitted this 18-year-old girlearlier in the day. Two days ago, shehad taken 50 paracetamol tablets afterlearning that she had failed her À'level exams and would not be going touniversity. She had been admittedtoday with nausea, vomiting andjaundice. Blood tests had confirmed araised bilirubin and abnormal ureaand electrolytes. Her clotting was alsofound to be deranged with a raisedprothrombin time. N-acetyl cystine(Parvolex) had been promptlycommenced and you had chosen todiscuss the case with the registrar oncall for the liver unit. She had been

extremely concerned about this girl'sfailing liver and after discussing thecase with her consultant, has agreed totransfer her to the liver unit as shealmost certainly will require a livertransplant. Natasha's father, Mr ToddPanos, has asked to speak to you abouthis daughter's progress. He is unawareof the paracetamol overdose, andNatasha has asked you not to discussthis with him, but she is happy for youto relay other information to him,including the prospect of a livertransplant. Your objective is to dothis.

You have 14 minutes to communicatewith the patient's father followed by one


Subject information

Mr Todd Panos

Aged 49 years

Re: daughter, Miss Natasha Panos, aged18 years

This man had been informed at work thathis daughter had become `poorly', andhad required hospital admission. Uponarrival at the hospital he was surprisedto find her looking very unwell withvomiting, and she appeared confused

and drowsy, to the point where shebarely recognised him. He also noticedthat she appeared yellow. Normally hisdaughter was an intelligent and vibrantgirl, but had recently been a little downafter doing badly with her À' levelexams. He normally lives with his wife,who is away on business, and Natasha,his younger daughter. His other daughteris away at university. He loves hischildren very much and is concernedabout this sudden illness. The nursecaring for Natasha is unable to clarifythe cause and degree of illness, exceptthat it is related to her liver andorganised for him to have a discussionwith the admitting doctor, who he is

about to meet. He is particularly keen tofind out about the cause for the suddendeterioration and will ask the questiondirectly.

Possible prompts

• I wanted to talk to someone about mydaughter. Can you tell me how she isdoing?

• I understand it's something to do withher liver. Can you tell me more?

• What caused this problem with herliver?

• I noticed that she was quite drowsy. Is

this likely to be related?

• When will she get better and go home?

• A liver transplant sounds very serious.Is it a risky procedure?

• When will she have her livertransplanted?


• Greet and introduce yourself to thesubject.

• Confirm that he is the father of thepatient and would like to discuss theprogress of his daughter.

• Ask what he knows of her currentcondition.

• If he is unaware of the severity of hisdaughter's condition, then explain thenature of and severity of her illness,i.e. acute onset liver failure, withoutgoing into the details of the suspectedaetiology.

• However, it may become difficult if heasks the question directly. You couldeither say that you are not able to givehim an answer, as the information isconfidential, or instead say that it isunder investigation.

• Explain that the patient has been

discussed with the liver specialistswho plan to take over her care. But itis likely to proceed to a livertransplant. You do not need to know thedetails of the operation, except that itcarries a high morbidity and mortality,and depends upon finding a suitabledonor. The team working at the liverunit would clarify the details of theoperation.

• Answer any other questions withoutbreaching the patient's confidentiality.

• Close the discussion.

Ethical issues

Any information related to a patient isconfidential and cannot be divulged tothird parties except under certaincircumstances (see p. 7). Often a doctorhas to use their discretion and judgementas to who can have what information,and in real life we have to have frankdiscussions with close relatives andexplain to them that their loved one issick and may die. However, if the patienthas specifically stated that information isto be kept confidential then this wish hasto be respected.

The ethical issues surrounding liveliver donation are even more complexthan renal transplantation (refer to theprevious case). This is particularly

because partial-liver donation carries amuch higher morbidity (Surman, 2002)in comparison to live renal donation. Inaddition, liver failure is often self-inflicted, for example alcohol abuse andparacetamol overdose.

Reference

Surman OS (2002) The ethics of partial-liver donation. NEJM. 346: 1038.


You are the SHO on a care of the elderlyward.


Subject: Mrs Sheila Hopkins

Age: 69 years

Re: husband, Mr Peter Hopkins, aged

73 years

You are asked to speak to Mrs SheilaHopkins, whose husband is a patientunder your care. He is a 73-year-oldman, who had originally presentedwith a lobar pneumonia. Uponrecovery, he was diagnosed withParkinson's disease, by a veryexperienced consultant, andcommenced on therapy with Sinemet.Your objective is to explain thediagnosis, the management and thelikely prognosis.

You have 14 minutes to communicatewith the patient's wife followed by oneminute for reflection before discussion

with the examiners.

Subject information

Mrs Sheila Hopkins

Aged 69 years

Re: husband, Mr Peter Hopkins, aged 73years

This lady's husband, Mr Peter Hopkins,was admitted to hospital withpneumonia, and after treatment has madea good recovery. However, it was notedthat he had a tremor and an experiencedgeriatrician has confidently made thediagnosis of Parkinson's disease and has

initiated treatment with Sinamet. Thistremor has been present for some timenow and Mr Hopkins' mobility has alsobeen worsening. Previously he has beenfit and well and enjoyed an activelifestyle. Mrs Hopkins has found herhusband's increasing disability a greatstrain, as she has had to help him withmany of his activities of daily living.They live alone, receive no additionalhelp and have one son, but he lives inAustralia. She is concerned about herhusband's diagnosis, particularly as shehas a brother who has Alzheimer'sdisease and is very confused. Sheunderstands Parkinson's disease to be asimilar condition, which causes

progressive confusion and disability,and is worried about her abilities tocope. She has asked to speak to a doctorand the SHO is about to discuss herhusband's diagnosis and answer anyquestions she may have.

Possible prompts

• I have a brother with Alzheimer'sdisease, who has become very confused.Is my husband likely to go the sameway?

• Will he lose power in his arms andlegs?

• Can he die from this?

• Is there any effective treatment?

• We live alone - our only son lives inAustralia. How will we cope?



• Confirm that she is here to discuss herhusband's diagnosis.

• Explore her understanding of thediagnosis and explore any specificissues that she may have.

• Confirm or refute any preconceptions

and explain the nature of the diagnosisand its management. In particular,reassure her that there is good therapyavailable for Parkinson's disease andpatients often make a dramaticimprovement with their mobility.

• Explore concerns regarding socialsupport and reassure her that herhusband will be referred to anoccupational therapist for assessment.The occupational therapist may visittheir home and, if appropriate, willrefer to a social worker to organisesupport services.

• Answer any remaining questions.


Parkinson's syndrome

The syndrome essentially consists of atriad of tremor, rigidity andbradykinesia. Classically the rigidity atthe elbow joint is described as `clasp-knife', and when combined with thetremor at the wrist, is said to be `cog-wheel'. Parkinson's disease per se is dueto degeneration of dopiminergicneurones in the substantia nigra. Othercauses of the Parkinsonian syndromeinclude:

• drugs: particularly neuroleptics (e.g.stemetil, metoclopra- mide)

• brain damage, for example from carbonmonoxide poisoning, anoxia, tumours,etc.

• arteriosclerosis

• rarely postencephalitic (c.£encephalitis lethargica pandemic 1916-1928)

• neurosyphylis

• Wilson's disease

• Parkinson plus syndromes, see below.

Parkinson plus syndromes aremultisystem disorders with some

features of Parkinson's disease. The twotypically described are:

1 multisystem atrophy (formerly Shy-Drager syndrome): a combination ofParkinsonism with orthostatichypotension, atonic bladder, impotenceand urinary incontinenece

2 supranuclear gaze palsy (Steel-Richardson-Olszewski syndrome):there is absent vertical gaze, correctedby moving the head itself. This isassociated with axial rigidity and atendency to fall backwards. Often thereis associated dementia.

Benign essential tremor

Patients are often given a presumptivediagnosis of Parkinson's disease, whichcauses unnecessary distress. The tremortends to be exacerbated by stress andhelped by alcohol (drinking should notbe encouraged however!). Occasionallypatients find betablockers andbenzodiazepines useful.


You are an SHO on an infectiousdiseases ward.


Subject: Mrs Alice O'Mally

Age: 75 years

Re: husband, Mr Callum 0' Mally,

aged 73 years

This man has been under the care ofyour team for about a month. He wasoriginally admitted with pyrexia andlethargy. Multiple investigations hadfailed to show any evidence of sepsis,although the team had elected to treathim blindly with broad-spectrumantibiotics. Other investigations hadalso been unrewarding, apart from aCT scan of the abdomen, which haddemonstrated enlarged lymph nodesaround the coeliac axis, which weresuspicious of lymphoma. Despite thebest efforts of the team, Mr O'Mally isdeteriorating and expected to die.Throughout the illness his wife, Mrs

Alice O'Mally, has been visiting on adaily basis and you have spoken withher on a number of occasions,including recently when you hadexplained that his prognosis wasextremely poor and that the team haddecided that he should not beresuscitated in the event of a cardiacarrest. Now he has Cheyne-Stokerespiration and is expected to diesoon. Because a firm diagnosis hasnever been established, the consultanthas asked you to speak to his wifewith a view to obtaining her consentfor a postmortem examination. Youarrange a discussion with MrsO'Mally in a side room. Your

objective is to have a frank discussionwith the lady and try to obtain herconsent for a postmortem.

You have 14 minutes to communicatewith the patient's wife followed by oneminute for reflection before discussionwith the examiners.

Subject information

Mrs Alice O'Mally

Aged 75 years

Re: husband, Mr Callum 0' Mally, aged73 years

Mr O'Mally was admitted to hospitalabout a month ago with a pyrexia andlethargy. The team looking after himsuspected an infection and carried outmultiple investigations to find thesource. This proved unsuccessful, butthey chose to treat with antibioticsanyway. A CT scan of the abdomen hadshown enlarged lymph nodes around theaorta, but there was no easy way tobiopsy these. The SHO (the candidate)looking after her husband has had a fewdiscussions with Mrs O'Mally over thecourse of the month to keep her informedof his progress. During their lastdiscussion she was depressed to hearthat the team considered his prognosis

futile and had declared him not forresuscitation in the event of a cardiacarrest. Mrs O'Mally is a deeply religiouswoman and has accepted her husband'simminent death and simply wants himnow to die with dignity and in peace.However, as she sits at her husband'sbedside, she is surprised that the SHOhas asked to speak with her again.During the course of their discussion sheis horrified to hear that he is proposing apostmortem examination, which willinvolve a pathologist opening him up,and possibly retaining his organs. Herinstincts tell her that he should be buriedwhole. Although she finds the idea of apostmortem abhorrent, during the course

of their discussion she understands therationale for conducting the procedureand reluctantly agrees to it being carriedout, but on the proviso that no organs areremoved prior to his burial.

Possible prompts

• Yes I realise he is extremely poorlyand will die soon.

• What exactly does a postmortemexamination involve?

• Does that mean they will cut him up?

• Would they keep his organs? I couldn'tcope with him not being buried whole.

• Will this postmortem definitely giveyou the cause for his illness?

• I understand the importance of this testand agree to it being carried out, but noorgans should be removed under anycircumstances.


• Greet the subject and thank her forhaving this discussion with you.

• Explain that your consultant has askedyou to speak with her regarding herhusband's illness and the team notbeing able to get a firm diagnosis.Reiterate the fact that over the course

of the month multiple investigationshave been carried out, which have notyielded the diagnosis but a CT scan ofthe abdomen had shown evidence ofenlarged nodes, which could be acancer.

• Allow her to respond during the courseof this discussion. She may say that sheunderstands all this, but what is thepoint of the discussion today.

• Go on to explain that the consultant hasproposed a postmortem investigation togain further insight into his finalillness.

• Pause and allow her to reflect on this

information and respond. She is likelyto be upset and very much against theidea of him undergoing a postmortemand argue that it's not going to makeany difference to him after his death.

• Explain the rationale for conducting apostmortem, namely that it'sunsatisfactory for the team not to havemade a diagnosis and to be certain thathe was not denied any treatment thatcould have potentially saved his life.Moreover, the results could influenceour practice if placed in a similarsituation in the future and could havebearing upon the treatments of otherpatients. Also, families often feel iteasier to deal with bereavement if the

cause is identified and they have theknowledge that nothing else could havebeen done to alter the course of theillness.

• Allow her to respond. She is likely tobe concerned about the disfiguringaspect of the examination and thepossibility that organs may be retained.She will be adamant that she wants himto be buried whole and not to have anyorgans retained.

• You should reassure her that anexperienced pathologist will carry outthe procedure and generally there areno visible wounds at the funeral. Itwould be inappropriate to go into the

gory details unless she specificallyrequests the information. Also, youshould explain that occasionally organsneed to be retained to aid diagnosisand for research purposes, but if shedoes not agree, then this will not bedone. Explain that the postmortem isgenerally done within a few days of thedeath and need not delay the funeral.

• If she still declines for the postmortemto go ahead, respect her wishes andreassure her that it will not be carriedout. If, on the other hand, she agrees tothe postmortem then suggest that youwill obtain a consent form and get herconsent before the procedure. You willalso organise a follow-up appointment

with the consultant to discuss theresults of the postmortem.


The postmortem examination

The postmortem is a detailedexamination carried out by a pathologist,looking for evidence of a diseaseprocess. This starts off as an externalinspection before proceeding to theinternal examination. Incisions are keptto a minimum, depending on whichorgans are to be examined. During a fullexamination, all the organs of the bodyare removed and inspected beforereturning them to the body. If a limited

examination is to be conducted thencertain organs may not be inspected,depending upon the constraints of theobtained consent. Organs may be keptfor a number of reasons, which include:

• where further analysis is deemednecessary to determine cause of death.This may for instance occur if thepathologist wishes to seek the adviceof a second pathologist or tests arebeing carried out, which take time toprocess

• for research purposes

• for education and training, includingplacement in a medical museum.

Families and postmortems: a code ofpractice

Following the Alder Hay and Bristolscandals in recent years, there has beenmuch public debate on postmortemexaminations and particularlytissue/organ retention. New legislationin this area is pending, but as an interimmeasure, `Families and post mortems: acode of practice' has been published(available on the DoH website -www.dh.gov.uk/assetRoot/04/05/43/12/04054312.pdf). This website also showsconsent forms that can be used to obtainconsent from next of kin. After looking atthe consent forms it should be veryobvious whether permission is granted

for a full or limited examination andwhether permission has been given fororgan retention.

Important passages from this code ofpractice are shown here:

Post mortem examination is cruciallyimportant in informing relatives,clinicians and legal authorities on thecause of death, and in telling bereavedfamilies (who wish to know) about thepossibility of acquired and geneticdiseases which might need care andtreatment. More widely, it is importantin improving clinical care, maintainingclinical standards, increasing ourunderstanding of disease, preventing

the spread of infectious diseases, andin supporting clinical research andtraining. Respectful and sensitivecommunication with bereaved familiesis essential, both to help them takeimportant decisions at a difficult time,and to ensure continuing improvementsin future care.

In any setting (NHS, academic orother), human tissue or organs may onlybe removed, retained, or used if thereis a proper accountability framework inplace which ensures that valid authorityis obtained. Before commencing theprocedure, the pathologist isresponsible for checking that the postmortem examination and any retention

or use have been properly authorised,either through the completion of aconsent form which must at least meetthe standards required by thisdocument, or by the coroner.

A hospital, or consented, post mortemexamination is carried out at the requestof the family or the hospital to gain afuller understanding of the deceased'sillness or the cause of death, and toenhance future medical care. During thepost mortem examination tissue or wholeorgans (e.g. the heart) may be preservedfor diagnosis, for therapeutic purposes,for future medical education (includingassuring the quality of clinical carethrough audit) or for research. If this

happens, it must be in accordance withthe provisions of the Human Tissue Act1961. The valid consent of the family orthose close to the deceased person mustbe given before the post mortem isundertaken to ensure proper compliancewith the Act (unless the person who hasdied has already made a request).

... consent MUST be obtained for ahospital post mortem, and for theretention and use of organs and tissue inresearch or education following either ahospital or coroner's post mortem. The1961 Act used the term `spouse' or`surviving relative' to define those to beconsulted. Contemporary families mayoften involve more complex

relationships than the traditional spouseor blood relatives - for example, co-habitation without marriage, includingwith a same-sex partner, or alongstanding relationship withoutcohabitation. Professionals involved intalking with families and others aboutconsent need to be aware that identifyingthe most appropriate person to giveconsent may not be straightforward andstaff must be careful not to makeassumptions. Careful judgment is neededin each individual case. All competentadult patients are asked to nominate theirnext-of-kin formally on admission tohospital. Wherever possible, trustsshould make clear to patients the reasons

for this nomination, and its potentialsignificance (i.e. that this is not simply acontact number). They ought also tomake clear that the person nominated asnext-of-kin does not necessarily need tobe a blood relative or spouse, and maybe a same-sex partner, or even a closefriend. The last may be particularlyappropriate where the individual doesnot have a close relationship with anyfamily members. Where an individualdoes nominate such a person, he or shemust consider the nominated person'swillingness to act in the event of theindividual's incapacity or death. It maybe helpful for all concerned for NHStrusts to provide such information and

advice clearly and routinely in a shortinformation leaflet.

There is no legal obligation to obtainconsent from the family if, in accordancewith Section 1(1) of the Human TissueAct 1961, the deceased has left clearinstructions, preferably in writing, thathis or her body or tissues should be usedfor transplantation, medical education orresearch. However, hospitals mightprefer nevertheless to discuss this withthe family and consider not going aheadwith a post mortem or other procedure inthe face of refusal or strong oppositionfrom them, in order to avoid anyupsetting conflict at a difficult time, orexacerbating the sense of loss. In any

case, they will need to discuss the timingof the funeral, and how this might beaffected by a post mortem examination.

In some religions (including the Jewish,Muslim and Hindu faiths), it is importantthat a funeral should take place as soonas possible, usually within 24 hours. Insuch cases, every effort should be madeto carry out a post mortem examinationwithin that period (if one is required). Ifthis is not likely to be practicable, or iforgans cannot be returned within thatperiod, this should be explained torelatives. The family will need the helpof hospital staff to get the necessarycertification completed urgently beforethe funeral. In the case of a coroner's

post mortem, relatives do not have theoption of refusing it, but may want todiscuss with the coroner's staff thepractical or spiritual implications of anydelay.


You are the SHO on call for medicine.


Subject: Mr Colin Steel

Age: 48 years

Re: sister, Miss Lucy Steel, aged 52years

Miss Lucy Steel is a 52-year-oldpatient with Down's syndrome. Shewas admitted to hospital with apresumed urinary tract infection,which was treated with antibiotics.However, routine blood tests showeda pancytopenia, suggestive of bonemarrow failure. A haematologist whosuspects malignant pathologyinfiltrating the bone marrow hasreviewed her. He has thereforerecommended a bone marrow biopsy.The problem is that the lady hascognitive impairment and possibleearly dementia, and is unable toconsent to the procedure. Hence yourregistrar has asked you to call in the

patient's documented next of kin, herbrother Mr Colin Steel, in an attemptto obtain his consent for theprocedure. Mr Steel has arrived in theward and your task is to discuss thepros and cons of the procedure andobtain his consent. A significant issueis that the procedure will be doneunder heavy sedation and perhapseven under a general anaesthetic.

You have 14 minutes to communicatewith the patient's brother followed byone minute for reflection beforediscussion with the examiners.

Subject information

Mr Colin Steel

Aged 48 years

Re: sister, Miss Lucy Steel, aged 52years

Miss Lucy Steel is a 52-year-old patientwith Down's syndrome, who normallyresides in a care home, where she isvery happy. She has cognitiveimpairment, which is progressivelydeteriorating and it is suspected that shehas early dementia. This admission tohospital was arranged by her GP after adeterioration that was thought to besecondary to a urinary tract infection.She was treated with antibiotics and is

slowly recovering. However, routineblood tests have shown a pancytopenia,which the team plan to investigate with abone marrow biopsy after consulting ahaematologist. Because of her poorinsight, Lucy is unable to give consent tothe procedure and hence the team havecalled her brother Colin in for adiscussion. He is four years her juniorand the only living relative. Despite herdisability, Colin has always been fond ofhis sister and is keen to make the rightdecision on her behalf. The SHO lookingafter her (the candidate) will have adetailed discussion with Colin about hissister's illness. In particular, he shouldexplain the procedure (the bone marrow

biopsy) and that it will be done eitherunder heavy sedation or even a generalanaesthetic, and the risks this entails. Heshould go on to explain that Colin is notunder any obligation to give consent onhis sister's behalf and indeed, anyintervention is decided by the consultantlooking after her, who acts in her bestinterest. Colin will understand all thisand agree that all decisions should beleft to the medical team, but he is keen toemphasise that his sister should notsuffer unduly.

Possible prompts

• I understand Lucy has a waterworksinfection, which is getting better.

• What does this bone marrow biopsyinvolve?

• Will it be painful for her?

• Are there any risks?

• Will it show the problem?

• Do I have to sign the form?

• Of course I want the best for Lucy and Ileave her care in the doctor's hands.

• I really don't want her to sufferanymore.


• Greet the subject and thank him forhaving this discussion with you.

• Establish that he is Lucy Steel's next ofkin.

• Enquire into his current understandingof her illness and investigation plan.

• Confirm the aspects of his responsewith which you agree and correct anymisconceptions. Expand on importantissues in detail, particularly the need tocarry out a bone marrow biopsyfollowing a specialist review, as yoususpect that there is bone marrowfailure.

• Explain that a bone marrow biopsy isan invasive procedure that can bepainful and requires a cooperativepatient. Hence, because of his sister'slack of insight into her illness and theprocedure, it is probably best carriedout with heavy sedation or generalanaesthesia, and explain the risks thisentails. Explain the alternatives(obtaining a fine needle aspirate or notdoing an investigation of any kind) andtheir pros and cons. Remember thisdiscussion could get very drawn outand the skill is to do it within the 14-minute time-frame.

• Confirm his understanding.

• Go on to explain that legally onlycompetent adults are allowed to giveconsent for themselves. Where thepatient lacks capacity, the consultantlooking after the patient must makedecisions on her behalf, but as ageneral rule we like to discuss anymajor treatment issues with thepatient's family.

• Again confirm understanding.

• If the subject agrees to the proposedtreatment of his relative, then thank himand offer to answer any furtherquestions. If he has strong objectionsthen reiterate the point that it is amedical decision made in the patient's

best interest, but that you can organisea further appointment with theconsultant looking after the patient todiscuss the issues further.


Ethical issues

The key ethical issue surrounding thiscase is of consent (seep. 2). Aspreviously stated, an adult andcompetent patient can make decisionsabout their treatment and refusetreatment even if it is potentially life-saving. However, when the patient lackscapacity, decisions about theirmanagement must be made ìn their best

interest' by the doctor in charge of theircare, under the auspices of common law.However, it is always a good idea andindeed good practice to maintain goodcommunication with the family andparticularly the next of kin. It is crucialto respect the patient's confidentialityand dignity, even if the patient isincapacitated. Any informationdisclosed must be appropriate to thediscussion and never unnecessary.


You are the SHO on call for medicine.


Subject: Mrs Linda Harbottle

Age: 51 years

Re: son, Brian Harbottle, aged 27

years

You have been asked to speak withMrs Linda Harbottle, who is themother of Mr Brian Harbottle. Brianis a 27-year-old man who is a strictJehovah's Witness, although hisparents are atheists. He normallyworks as a motorcycle courier, andwas admitted earlier in the dayfollowing an accident that had resultedin a significant bleed from his leg;there was no injury to the bone. Hewas treated by the casualty staff andhad required stitches. The bleed hasstopped now and no further surgicalintervention is needed. However, hewas referred to the medical team as

his haemaglobin was estimated at 5.6g/dl. A blood transfusion was planned,but after a lengthy discussion with theconsultant looking after him this wasrefused, and now he is simply beingtreated with ferrous sulphate andobservation. His mother is concernedthat without a blood transfusion hemay die. Your objective is to discussthe management of Brian Harbottle(who has consented to this discussion)with his mother and answer anyquestions that she may have.

You have 14 minutes to communicatewith the patient's mother followed byone minute for reflection beforediscussion with the examiners.

Subject information

Mrs Linda Harbottle

Aged 51 years

Re: son, Mr Brian Harbottle, aged 27years

This lady's son was involved in amotorcycle accident that resulted in asignificant bleed from his leg. Herequired stitches to his leg and thebleeding has stopped. However, hishaemaglobin was found to be 5.6 g/dland hence he has been admitted tohospital. The admitting team suggested ablood transfusion, but Brian refused as

he is a strict Jehovah's Witness andaccepting blood products is against hisfaith. Instead, he has elected to take irontablets and be observed in hospital for ashort period. His mother is veryconcerned, especially as she was told incasualty that a man normally hashaemoglobin above 13 g/dl. She is alsoangry with the medical team for notgoing against her son's wishes andtransfusing him anyway by way ofapplying a section. She knows aboutsections as her sister who suffers withschizophrenia once underwent one aftershe became delirious. Mrs Harbottle haslittle time for her son's faith and feelsthat he has been brainwashed by

religious fanatics. She herself is anatheist. She has organised anappointment with one of the doctorslooking after her son to find out moreabout his medical problems and tosuggest that they should transfuse himagainst his wishes.

Possible prompts

• I don't understand what haemoglobin of5.6 means. Is that very low?

• Is this life-threatening? Can he die?

• Why can't you force him to have ablood transfusion, if it is in his bestinterest?

• I thought doctors could sectionpatients. Is that not the case?

• How long will these iron tablets taketo work?

• What if his leg starts to bleed again?



• Enquire about Mrs Harbottle'sunderstanding of her son's medicalcondition and her specific concerns.She will tell you that he is anaemic,following his bleed and in her opinion

requires a blood transfusion.

• Agree that haemaglobin of 5.6 g/dl islow, but reassure her that people witheven worse anaemia have made a fullrecovery.

• Explain to her that a blood transfusioncannot be given to a competent adult ifhe refuses to give consent, even if thisis life-saving treatment.

• She may ask why the blood transfusioncannot be given against his wishes byapplying a section.

• Say that a section can only be appliedunder the Mental Health Act to patients

with psychiatric problems and is notapplicable in this case.

• Reassure her that the leg has stoppedbleeding and as there is no clottingproblem is not likely to start bleedingagain, although this cannot beguaranteed. Iron therapy is likely tocorrect the anaemia but it is likely tohappen very slowly and may take manymonths before it is back to normal.

• Enquire about any other concerns andanswer them.


Jehovah Witnesses' beliefs about blood

Jehovah Witnesses refuse to acceptblood transfusions and blood products.This includes transfusion of wholeblood, packed red blood cells andplasma, as well as platelet infusion.Witnesses are also urged to discontinuetheir chemotherapy treatments whenplatelet transfusions are needed.Because Witnesses believe that anyblood that leaves the body must bedestroyed, they do not approve of anindividual storing his own blood for alater autotransfusion. This doctrine isbased upon four passages in the Bible:

1 Genesis 9:4 `But flesh (meat) with ...blood ... ye shall not eat'

2 Leviticus 17:12-14 `... No soul of youshall eat blood .. . whosoever eateth itshall be cut off'

3 Acts 15:29 `That ye abstain ... fromblood ...'

4 Acts 21:25 ' . . . Gentiles ... keepthemselves from things offered to idolsand from blood ....

It is important to appreciate that thedecision to accept blood products is anindividual one and not to be based on theassumption that all Witnesses will neveraccept blood transfusions. Indeed, thereare dissident groups who choose to haveblood, but do so anonymously as

discovery may result in expulsion fromtheir church. Hence confidentiality isextremely important, even with closefamily members.


You are a medical SHO.


Subject: Dr Mark Adams

Your house officer

You have been asked to speak withyour house officer, Dr Mark Adams.The ward manager has beenconcerned about his performance, ashe has arrived at work on a number ofoccasions smelling of alcohol. Shewas particularly concerned about arecent occasion when he was asked tospeak to a lady whose mother hadunexpectedly died and he lookedbedraggled and smelt strongly ofalcohol. On another occasion one ofthe staff nurses had found him trying toremove drugs from the controlled drugcabinet. Your objective is to have afrank discussion with your colleagueand identify any problems.

You have 14 minutes to communicatewith the house doctor followed by oneminute for reflection before discussionwith the examiners.

Subject information

Dr Mark Adams

House officer

Dr Adams has been working as a houseofficer for four months now, and hates it.He particularly dislikes the long hoursand resents being òn call'. He wasnever keen on studying medicine and felthe was pressurised into it by his fatherwho works as a general practitioner. He

has always enjoyed a drink and finds it agood way to unwind after work. But thedrinking often continues into the smallhours of the morning, when he wouldend up in one of the city's nightclubs. Itis difficult to quantify the amount ofalcohol consumed, but it is not unusualto get through seven pints of beer and afew `shorts' during the course of anevening. There have been a number ofoccasions when he has had norecollection of how he got home. Oftenin the morning he has had to haveanother couple of drinks to get over theterrible headaches, and then drive towork. He has been lucky not to bestopped by the police, as he is certain

that he would have failed thebreathalyser test. Also, of late, whenpossible Dr Adams would go to a pubclose to the hospital for lunch, whichusually included a few quick drinks. Hewas careful to brush his teeth anddisguise his breath with mints. However,some of the nurses at work havecommented that his breath smelt ofalcohol, but he had told them that he hadhad a `heavy night'. On one occasion hehad got quite angry when one of thenurses had accused him of trying to stealdrugs from the drug cabinet. He hadsimply been looking for paracetamol tohelp him with his terrible headache. Hehas never taken drugs and despises them.

Dr Adams himself feels that he is youngand should be enjoying life to the full,and he does not think there is anythingwrong with his drinking, particularly asit helps him relax and be able to speakwith girls. He is not in a steadyrelationship at the present. His SHO hasasked to speak with him and he will behorrified to hear that there are concernsabout his alcohol intake and worse still,he is suspected of attempting to removedrugs from the ward. He will protest hisinnocence regarding the drugs chargeand indeed emphasise that he is anti-drug abuse. He will also start off bydenying excess alcohol consumption, butafter the SHO raises concerns about

patient care will accept that he probablydrinks too much and agree to seek help.

Possible prompts

• I do not feel there has been a majorconcern with my performance.

• In all honesty I probably do not enjoymedicine as much as I should.

• Yes, I enjoy a drink and should be ableto at my age. I don't feel that I drinkexcessively.

• On occasions I have had a drink in themorning to get over a hangover.

• I have never tried to take controlleddrugs - in fact I despise drug use.

• Yes, I probably do drink excessivelyand should think about cutting back.


• Greet your house officer and shake hishand.

• Ask him whether he knows why youhave asked to speak with him.

• If he does not know, then explain tohim that there have been complaintsthat he may be drunk at work and alsothat he has been accused of trying to

take controlled drugs from the cabinet.

• Listen to his response carefully,particularly trying to take note of anyinconsistencies.

• Specifically enquire about any drugabuse if he has not volunteered thisinformation thus far.

• Enquire about his alcohol consumption.Try to quantify the amount consumed.You can employ a tool such as theCAGE questionnaire, but you shouldremember that you are talking with adoctor and a colleague, and you mustnot sound patronising. It may be best tobe very frank and upfront and ask the

questions directly. Ask whether hefeels that he drinks excessively andwhether he has ever sought help for it.

• Explain that you feel that he drinksexcessively and that it is likely toaffect his clinical judgement and skills.Go on to explain that because of thesafety of patients and GMC guidance(see below), you will have to have adiscussion with more senior staff,confidentially, which may then go on toa discussion with the GMC itself.

• You should try to be supportive andsuggest that Dr Adams needs help withhis alcohol consumption and advisehim to get in touch with a self-help

group such as Alcoholics Anonymous,Aquarius, etc.

• Thank the doctor for having thisdiscussion and close the interview.

Good medical practice

The GMC has published excellent andrelatively straightforward guidance forall registered practitioners. This isavailable upon request to the GMC or ontheir website. Points particularlypertinent to this case are numbers 26-28,shown here:

26. You must protect patients from riskof harm posed by another doctor's, or

other healthcare professional's,conduct, performance or health,including problems arising fromalcohol or other substance abuse. Thesafety of patients must come first at alltimes. Where there are seriousconcerns about a colleague'sperformance, health or conduct, it isessential that steps are taken withoutdelay to investigate the concerns, toestablish whether they are well-founded, and to protect patients.

27. If you have grounds to believe thata doctor or other healthcare professionalmay be putting patients at risk, you mustgive an honest explanation of yourconcerns to an appropriate person from

the employing authority, such as themedical director, nursing director orchief executive, or the director of publichealth, or an officer of your localmedical committee, following anyprocedures set by the employer. If thereare no appropriate local systems, orlocal systems cannot resolve theproblem, and you remain concernedabout the safety of patients, you shouldinform the relevant regulatory body. Ifyou are not sure what to do, discuss yourconcerns with an impartial colleague orcontact your defence body, aprofessional organization or the GMCfor advice.

28. If you have management

responsibilities you should ensure thatmechanisms are in place through whichcolleagues can raise concerns aboutrisks to patients.


You are a medical SHO working in abusy district general hospital.


Subject: Mr Nick Stewart

Surgical SHO

This doctor who works in your

hospital has asked to speak with youconfidentially. He is a third-yearsurgical SHO, undergoing his basicsurgical training. He has obtained theMRCS, and has been shortlisted for aninterview leading to a training numberin vascular surgery. He is extremelyambitious and career-minded. Duringthe consultation he will tell you thatabout a month ago he presented to hisGP with lethargy and was found tohave mildly abnormal liverbiochemistry. Further tests werecarried out and a few days ago hefound out that he is hepatitis Cpositive. He has not told anyone aboutthis, but is concerned about the long-

term implications and hence hascontacted you today to seek someadvice. Your task is to discuss hisconcerns with him and advise himappropriately.

You have 14 minutes to communicatewith the surgical SHO followed by oneminute for reflection before discussionwith the examiners.

Subject information

Mr Nick Stewart

Surgical SHO

This doctor is a third-year surgical SHO

about to complete his basic surgicaltraining. He is extremely ambitious andhas passed the MRCS exam and hasbeen shortlisted for an interview leadingto a specialist registrar (SpR) number invascular surgery. His long-term ambitionis to become a transplant surgeon.Approximately one month ago he sawhis GP with symptoms of lethargy andwas surprised to find out that his liverbiochemistry was abnormal. He drinksalcohol only occasionally and swimsregularly to keep fit. Further tests werecarried out and a few days ago he wasshocked to find out that he was hepatitisC positive. He is a heterosexual maleand has never had unprotected sex, and

his last sexual relationship was twoyears previously. Over the years he hashad a few needle stick injuries(including a couple in India while on hiselective) and suspects this is how he hasacquired the virus. Over the past fewdays Mr Stewart has becomeincreasingly anxious about his diagnosis.His concerns particularly relate to hislong-term health and what effect thediagnosis may have upon his futureemployment prospects. In his own mindhe has decided to keep the informationsecret from his present and futureemployers. However, he remains veryconcerned about the effect the virus willhave on his own health and has decided

to contact the RMO for advice. Heknows that this doctor is reliable andtrustworthy, and has previously workedwith a hepatologist. During the course ofthe discussion he will inform the doctorthat he does not intend to inform hisemployers of his diagnosis because he isafraid of the implications it will have onhis employment prospects. But if thedoctor is able to give good reasons, suchas exposing patients to the risk ofdeveloping hepatitis C and the fact that itis a notifiable condition, Mr Stewartwill consider changing his mind andagree to discuss his diagnosis withoccupational health.

Possible prompts

• It came as a big surprise to find out thatI was Hep C positive.

• I think I probably picked up the virusafter a needle stick injury.

• I do not plan to tell any body aboutthis, but thought it was worth gettingyour advice as you have worked with ahepatologist.

• Would you have to report my diagnosisto anyone?

• But I thought the information wasconfidential.


• Greet the doctor by name and shake hishand.

• Ask him how you can be of assistance.

• He will explain that he was recentlydiagnosed with hepatitis C and thesequence of events leading to it. Hewill elaborate and express his fearsand anxieties regarding the diagnosis,particularly in relation to his futurehealth and the implications it has uponhis chosen career as a vascularsurgeon, hoping to specialise as atransplant surgeon. He explains that theinformation that he is giving you is tobe treated with the utmostconfidentiality, as he does not want

anyone to know that he has hepatitis Cand certainly does not intend to informhis employers of his diagnosis.Remember this should be a two-waydiscussion with the candidate, teasingout some of this sensitive information.

• Explain to the patient that there istherapy (usually with a combination ofinterferon a and ribavirin) available,which can successfully eradicate thevirus in up to 40-50 per cent ofpatients. The therapy is prolonged (upto 12 months) and does have verysignificant side effects. It is costly andcan only be initiated by a consultanthepatologist, usually after a liverbiopsy.

• Emphasise that hepatitis C is a blood-borne infection (remember that you arespeaking with a professional colleagueand hence very simplistic terminologyas used with the lay public should notbe necessary) and he potentially runsthe risk of infecting patients as asurgeon. Hence it is crucial that thehospital's occupational health team arenotified, who can then advise himaccordingly.

• Also hepatitis C is a notifiablecondition and as such, doctors inEngland and Wales have a statutoryduty to notify a `proper officer' of thelocal authority of suspected cases (seebelow). All of this information needs

to be relayed in a considerate andunderstanding manner and not in athreatening way.

• Agree on a plan to proceed. This maybe agreeing to meet again in a few daysto see what has transpired.

• If Mr Stewart categorically refuses todisclose his diagnosis, say that youmay have to seek the advice of a seniorcolleague.

• Thank the subject and close.

Ethical issues

Confidentiality

Confidentiality (see p. 7) is extremelyimportant in any doctorpatientrelationship. When a doctor is seen as apatient, exactly the same rules apply.This includes the possible breach of thecodes of confidentiality because otherpeople may be at risk.

Doctors with infectious illness

The GMC has published excellent andrelatively straightforward guidance forall registered practitioners. This isavailable upon request to the GMC or ontheir website (www.gmc-uk.org/).Points particularly pertinent to this caseare shown here:

If you know that you have a seriouscondition which you could pass on topatients, or that your judgment orperformance could be significantlyaffected by a condition or illness, or itstreatment, you must take and followadvice from a consultant inoccupational health or another suitablyqualified colleague on whether, and inwhat ways, you should modify yourpractice. Do not rely on your ownassessment of the risk to patients.

If you think you have a seriouscondition which you could pass on topatients, you must have all thenecessary tests and act on the advicegiven to you by a suitably qualified

colleague about necessary treatmentand/or modifications to your clinicalpractice.

Notifiable disease

There are certain infectious conditionsthat doctors have a statutory duty toinform a `proper officer' of the localauthority about. The Centre for DiseaseSurveillance and Control (CDSC)collates this information and publishesanalyses of local and national trends ofthese conditions. Notifiable diseases arelisted here (note this list is periodicallychanged/added to):

• acute poliomyelitis

• anthrax

• cholera

• diphtheria

• dysentery (amoebic or bacillary)

• food poisoning (or suspected foodpoisoning)

• leprosy

• leptospirosis

• malaria

• measles

• meningitis

• meningococcal septicaemia (withoutmeningitis)

• mumps

• ophthalmia neonatorum

• paratyphoid

• plague

• rabies

• relapsing fever

• rubella

• scabies

• scarlet fever

• smallpox

• tetanus

• tuberculosis

• typhoid fever

• typhus

• viral haemorrhagic fever

• viral hepatitis

• whooping cough

• yellow fever.


You are on call as the RMO during anight acute medical take. Please read thescenario below. You may make notes onthe paper provided. When the bellsounds enter the examination room tobegin the consultation.

Subject: Dr Alison Lucas

Medical house officer

While on a coffee break, your houseofficer approaches you quite upset

following a needle stick injury. Sheexplains to you that shortly afterobtaining the blood from the patient,she had accidentally stabbed herselfin the palm with the dirty needle. Shehad not been wearing gloves. Hermain concern was that the patient wasa vagrant, who had been admitted in asemiconscious state and was a knownintravenous drug abuser. His HIVstatus is not known and no previoushepatitis serology is available. Yourtask is to counsel the house officer andto suggest any treatment that may benecessary.

You have 14 minutes to communicatewith the house officer followed by one

minute for reflection before discussionwith the examiners. You are not requiredto examine the house officer.

Subject information

Dr Alison Lucas

Medical house officer

Dr Lucas has been working as a houseofficer for the past three months. She is apleasant and cheerful girl, who is veryconscientious and hard-working. She hasbeen on call during the night, busyclerking patients on the medicaladmissions unit. During the course of thenight she saw a patient who was a

vagrant and had been admitted after hewas found collapsed on the street. He isa known IV drug abuser and frequentlyattends the accident and emergencydepartment. She was able to elicit verylittle history from him, but attempted totake blood. While she was attempting todo this, the patient moved suddenly andshe stabbed herself in the palm with adirty needle. She had not been wearingany gloves at the time. She is alwaysvery cautious while taking blood and isangry with herself for not wearinggloves, which she normally does. Nowshe is very worried about the possibilityof having contracted an infection fromhim, particularly as he is an IV drug

abuser. HIV is of particular concern, butshe is also worried about hepatitis,although she knows she has beenimmunised to hepatitis B. Upon checkingthe man's medical records, there is nodocumentation of any previousserological tests. She decides to have adiscussion with her SHO (the candidate)and ask them if they can carry out an HIVtest on the patient and whether she needsany prophylactic treatment.

Possible prompts

• What is the chance of me developingHIV?

• What is the chance of me developing

hepatitis?

• Do I need prophylactic treatment?

• Can we do an HIV test on him?

• Will I have to take time off work?


• Greet the doctor and ask her how youcan help her.

• She will tell you about her needle stickinjury and the circumstances in whichit happened. The person she receivedthe injury from is a vagrant who isknown to be an IV drug abuser. She

will go on to tell you that she is veryconcerned about the possibility of aninfective illness, particularly HIV.

• Ask whether she was wearing glovesat the time and ensure that she has beenimmunised to hepatitis B. She will tellyou that she wasn't wearing gloves, butis immunised to hepatitis B.

• Also ask how much blood there was onthe needle before she stabbed herselfwith it.

• Explain to her that the risk oftransmission of infectious diseasethrough a needle stick injury issignificant, but small, and depends on

numerous factors such as the amount ofblood on the dirty needle, depth ofpenetration, etc. Generally speaking therisk of transmission of hepatitis C is 3per cent and HIV is 0.3 per cent.Hepatitis B is the greatest risk at 30per cent, but she will be immune tothis.

• Say that you will discuss the case withthe microbiologist/ infectious diseaseconsultant on call to decide whethershe requires post-exposure prophylaxis(PEP - see below) to reduce thechances of her acquiring HIV.

• And advise her to inform occupationalhealth of the incident. Baseline bloods

need to be taken and then bloods at 3and 6 months to look forseroconversion. If they remainnegative, she can be given the all clear.She will also have to have her hepatitisB and C serology checked.

• She may go on to suggest that maybewe should take blood from the patientto check for the presence of theseinfections and that she would bereassured if these came back negative.Tell her that this is not possible,without prior consent and counsellingof the patient. But when he wakes upyou will discuss this with him(reassure her that the discussions willbe strictly confidential and see if he

agrees).

• Ask her to look out for signs of acutehepatitis, particularly jaundice, and bevigilant to symptoms suggestive of aseroconversion illness. These includefevers, malaise, lethargy, rashes andenlarged lymph nodes.

• Remind her that, while the risk issmall, there is a possibility of hercarrying an infectious illness and itwould be prudent to use a barrier formof contraception until she can be surethat she is not infected.

• Reassure her that many, if not most,doctors have a needle stick injury

during the course of their careers andthe risk of acquiring serious illness isextremely small.

• Ask her if she has any other concernsor questions and whether she feelswell enough to carry on with her work.

• If she can continue and has no furtherconcerns, close the interview.

Needle stick injuries

The rates of transmission of blood-borneviruses vary, but generally speaking canbe remembered by the rule of 3s:

• hepatitis B is 30 per cent (if the source

patient is highly infectious)

• hepatitis C is 3 per cent

• HIV is 0.3 per cent.

HIV tends to cause the most anxietyamong healthcare professionals (andindeed the lay public who are injured bydiscarded needles), but hepatitis B andhepatitis C are more infectious. Severalfactors are significant in the transmissionfrom an infected source. These include:

• the depth of the injury and size of theneedle

• the level of contamination of the sharp

• the site of the injury, e.g. higher risk ifstraight into a blood vessel

• the ìnfectiousness' or viral load of thesource patient.

Where the source patient is known, it isimperative that their consent is obtainedbefore testing for their hepatitis and HIVstatus. This point is made very clear inthe GMC guidance on seriouscommunicable disease.

Post-exposure prophylaxis (PEP)

Where individuals have been exposed tohepatitis B or HIV, the possibility of postexposure prophylaxis should be

considered as soon as possible.

• In the non-immune subject, prophylaxisfor hepatitis B is hyper immune gammaglobulin. This should be administeredas soon as possible and followed up byan accelerated course of hepatitis Bvaccination.

• Where the donor is known to be HIVpositive, prophylaxis should becommenced as soon as possible andpreferably within the hour. For thisreason, many hospital accident andemergency departments carry a kit forrapid access. The drugs generally usedinclude a cocktail of zidovudine,lamivudine and indinavir. These have

to be taken for 28 days and may causesevere side effects such as nausea andlethargy, which may mean that thedoctor is unable to work.

• Currently there is no recommendedpost-exposure prophylaxis followingpotential hepatitis C exposures.However, there is data that shows thatif acute hepatitis C infection isconfirmed in the exposed person, earlytreatment with alpha interferon may behighly effective in preventing thedevelopment of chronic hepatitis Cinfection.

Other issues

• Confidentiality (see p. 7).

• Counselling for a HIV test (see case20).


You are a cardiology SHO working on abusy CCU.


Subject: Dr Amanda Walters

House officer

Dr Walters has been working as yourhouse officer for the past threemonths. She previously worked as anENT house officer and had a greattime, but is really finding it tough inher current post, even though she hasaspirations of becoming acardiologist. She has asked to meet upwith you to discuss her difficulties.During the discussion she tells youthat she feels that she is being bulliedby the registrar, who belittles her atevery opportunity and on occasionshas made remarks in public that shefound extremely offensive: he hadjoked with the nursing staff that itwasn't too late for her to become a

nurse as the patients would alwaysassume that she was a nurse anyway.On another occasion he had suggestedthat she should try wearing shorterskirts if she wanted to get ahead. Theconsultant she works for is veryapproachable, but is rarely on theCCU. Moreover, he is very friendlywith the registrar and Dr Walters isconcerned that complaining may havenegative repercussions for her career.Hence she has chosen to consult youfor advice. Your task is to listen to herconcerns and give her appropriateadvice.

You have 14 minutes to communicatewith the house officer followed by one


Subject information

Dr Amanda Walters

House officer

Dr Walters has been working in hercurrent post as a cardiology PRHO forthree months and is finding it verydifficult. This is despite the fact that shewants to specialise as a cardiologist.The main reason for her difficulties isher registrar, who constantly belittles heropinion and has even made offensiveremarks about her in public. On one

occasion he had joked with the CCUnurses that it wasn't too late for DrWalters to retrain as a nurse as patientswould always assume she was a nurseanyway. Worse still, he had on anoccasion suggested that she should wearshorter skirts if she wanted to get aheadin cardiology. There have beennumerous other comments and DrWalters is finding it difficult to copewith it now. She has always pridedherself on being hard-working, diligentand having the ability to get along withevery one. Indeed, she had excelled asan ENT house officer beforecommencing this present post. DrWalters does not want to come across as

a whiner and is reluctant to approach theconsultant, who is friendly andapproachable, but rarely on the wardand also seems to be on very friendlyterms with the registrar. Hence she isconcerned that this could have negativerepercussions for her career aspirations.Instead she has chosen to speak with hersenior house officer who will advise heraccordingly.

Possible prompts

• I'm not happy in this post.

• The registrar often belittles me in frontof others.

• He has made many inappropriatecomments.

• I'm concerned that if I complain it willaffect my career.


• Greet the doctor and shake hands withher

• Set the agenda. Ask her how you canhelp her.

• Listen to her concerns in a non-judgemental manner. She will tell youthat she is finding her current postdifficult and attributes this to the

registrar, who belittles her and hasmade inappropriate remarks.

• Say that this is a very serious matterand ask if she is absolutely confidentthat this is not a simplemisunderstanding.

• Ask whether she has provoked thisbehaviour in any way. She will tell youshe has not.

• Ask her if anyone else had noticed hisanimosity towards her and if she knewof other members of staff who had beensimilarly aggrieved by his attitude.

• Explain to her that this behaviour is

inappropriate and that she should nothave to put up with it and ask her (ifshe has not already volunteered theinformation) if she has any reservationsabout relaying this information to theconsultant. She will tell you that she isconcerned about the potentiallynegative effect this may have on hercareer.

• Ask her if she would mind youspeaking with the consultant.

• If she does not mind then tell her thatyou will take the matter up with theconsultant, who can then decidewhether it is a disciplinary matter.

• If she does not want you to speak withthe consultant, then explain to her thatyou can anonymously discuss thematter with another consultant or themedical director. Alternatively, theBritish Medical Association can beapproached for advice.

• Also tell her that there are excellentanonymous counselling servicesavailable for doctors and you canobtain a contact number for her if shefeels that she is having difficultycoping.

• Tell her that you will contact her onceyou have had the opportunity to discussthe matter with a consultant.

• Ask her if she has any other questionsor concerns.

• If she does not, close the interview.

Bullying and harassment

Junior doctors are particularly prone tobullying and harassment in theworkplace. One study (Quine, 1999)found that 37 per cent of junior doctorshad experienced some form of bullyingwithin the previous year. Of greatest riskwere female doctors and those from theethnic minorities. Bullying is defined interms of its negative effect on therecipient and not the intention of theprotagonist. The behaviour has to be

persistent and it can affect the victim in anumber of different ways (Rayner andHoel, 1997):

• threats to professional status (e.g.belittling opinion, public humiliation)

• threats to personal standing (e.g.insults, teasing)

• isolation (e.g. withholding information)

• overwork (e.g. impossible deadlines)

• destabilisation (e.g. meaninglesstasks).

In the UK there is no specific law in

relation to bullying, but cases are triedunder related laws such aspersonal/psychiatric injury, breach ofcontract, negligence and evenmanslaughter, where bullying led tosuicide.

The GMC, in its good practiceguidelines, makes it clear that you mustalways treat your colleagues fairly andin particular must not discriminateagainst colleagues on grounds of theirsex, race or disability. Moreover, theguidelines go on to say that a doctormust not allow their views ofcolleagues' lifestyle, culture, beliefs,colour, gender, sexuality, or age toprejudice their professional relationship

with them.

References

Quine, L (1999) Workplace bullying inan NHS community trust: staffquestionnaire survey. BMJ. 318: 228-32.

Rayner C and Hoel H (1997) A summaryreview of literature relating toworkplace bullying. J Comm App! SocPsychol. 7: 181-91.


You are the SHO working on theintensive care unit.


Subject: Miss Elaine Mayfield

Medical student

This 21-year-old medical student has

been on an àttachment' on the ITUforthe past three weeks. This is one ofher first clinical attachments and overthe past three weeks she has spentmuch of her time looking after MrsSandra Micheals, who was admittedto the ITU after she had developedsevere septicaemia. Since admissionshe has made good progress and wasextubated a few days ago. Both themedical team and her family wereoptimistic that she would be wellenough to be discharged from the unit,before too long. However, during theprevious night she deterioratedsuddenly and despite the best effortsof the ITU team, died from a presumed

pulmonary embolus. The followingmorning, Elaine Mayfield is extremelydistressed by her sudden death and hasspent a considerable amount of timecrying in the sister's office. The sisterhas been trying to console her, and hasnow asked you to speak with theyoung student to reassure her thatnothing else could have been done.

You have 14 minutes to communicatewith the medical student followed byone minute for reflection beforediscussion with the examiners.

Subject information

Miss Elaine Mayfield

Medical student

This 24-year-old medical student hasbeen attached to the ITU for the pastthree weeks. This is only her secondclinical attachment, the first one beingwith a general practitioner. During hertime on the ITU the student has spentmuch of her time helping to look afterMrs Sandra Micheals. This 28-year-oldlady had been admitted to the ITU aftershe had developed severe septicaemia,which required aggressive managementwith antibiotics, inotropic andventilatory support. Since her admissionto the ITU, Mrs Micheals had beenmaking a slow and steady recovery andhad been extubated a few days ago. Both

the medical team and her family wereoptimistic that she would be well enoughto be discharged from the ITU before toolong. Her family consisted of herhusband and two children aged two andfour years. Her parents and two sisterswere also very devoted and visitedregularly. Over the weeks the studenthad developed a close bond with thefamily. However, one morning shearrived to find Mrs Micheals bed wasvacant and she was very distressed tofind out that during the night she hadsuddenly deteriorated and died. Elainehas never previously had to deal withdeath either of a patient or relative, andher inability to deal with it has come as

a real shock. The sister on the ITU hadbeen very supportive and had asked herto sit in the office until she felt better andhad also asked one of the doctorsworking on the ITU (the candidate) tohave a chat with her to reassure herfurther and to explain that little couldhave been done to change the outcome.The chat will help and Elaine will feelmuch better at the end of it.

Possible prompts

• I'm finding it very difficult to cope withMrs Micheals' death.

• It was so sudden.

• I should be grown up about it.

• It will be impossible for me to work asa doctor if I break down every time Ilose a patient.

• Speaking about it does seem to help.


• Greet the student and shake hands withher.

• Set the agenda. Explain to her that thesister has asked you to speak with herabout the death of Mrs Micheals. Askif she minds talking about it.

• Ask if she has ever had to deal with thedeath of anyone previously. She willtell you she has not.

• Now go into the reasons for her beingso upset.

• Let her speak at her own pace with yougiving prompts:

- `Was it the sudden nature of MrsMicheals' death?'

- `Do you feel the death could havebeen prevented?'

- `Do you feel that you wereoverattached to the patient?'

• Tell her that while this patient's deathwas sudden and unexpected, it isunlikely that anything could have beendone to prevent it.

• In sympathetic terms, remind her thatdeath is the natural end to life and issomething that we have to regularlyconfront during the course of ourmedical practices. Often death istotally unexpected and seeminglyunfair.

• With time no doubt we get better atdeveloping coping mechanisms.However, we are not only doctors, butalso human and often let personalfeelings creep into our work. This is

OK and can make us more caringdoctors.

• Ask gently if speaking about the deathof this patient is making it easier forher. Tell her that talking about the deathwill help her come to terms with it.

• Follow up. Tell her that you will speakwith her again in a few days' time andsee how she is getting on. Remind herthat there are counselling servicesavailable through her GP and throughthe university and if she has difficultycoping long term, she should seek helpearly.


Ethical issues

Loss of someone (particularly suddenand unexpected loss) leads to griefreactions and the bereavement process.Doctors and other healthcareprofessionals are not immune to thisprocess. Seep. 155 for further discussionon bereavement.

Support for the doctor

As part of their workload, doctors areconstantly forming emotionalrelationships with patients and theirfamilies, and are then exposed to theirhelplessness, suffering, uncertainty,occasionally anger and death. This can

have profound long-term effects on thedoctor's well-being leading todepression, substance abuse and evensuicide.

Regrettably, the culture of the healthservice in the UK (and perhaps mostparts of the world) has been such thathealthcare professionals found itdifficult to express personal emotionsregarding the death of patients. It wasseen as a weakness and the difficulty incoping may have implications on acareer within the hierarchical structureof the NHS. Personal observationsuggests that doctors are much worse atdealing with the death of patients thannurses, who tend to talk about and often

mourn the loss of a patient. Fortunately,the climate does seem to be changingand both individual doctors and thetrusts they work for are becoming moreaware of the stressful nature of ourwork, and help in terms of eithercounselling or an informal chat with acolleague is not frowned upon thesedays.

(Review this case with case 30: Thenear miss: discussion with patient)


You are a medical SHO working on achest ward.


Subject: staff nurse Jo Nesbitt

Age: 28 years

Re: Mr John Powell, aged 39 years

You have decided to speak with thisnurse after the patient had complainedthat she had made a potentiallylifethreatening error. The patient is a39-year-old man who was admittedfollowing a severe attack of asthmaand had been commenced onprednisolone. He was known to havea severe allergy to aspirin and hadpreviously been admitted to the ITUafter ingestion of aspirin. He hasalleged that during the morning druground the nurse had got herprescription sheets mixed up and

given him aspirin, which was intendedfor the patient in the next bed. He hadspotted the mistake just before takingthe tablets and had been very upset bythe incident. Your objective is to havea discussion with the staff nurseinvolved to hear her side of the storyand to devise an action plan.

You have 14 minutes to communicatewith the staff nurse followed by oneminute for reflection before discussionwith the examiners.

Subject information

Staff nurse Jo Nesbitt

Aged 28 years

Re: Mr John Powell, aged 39 years

The SHO working on the medical wardhas asked to speak with this nurseregarding an incident earlier in the day.She had been giving out medicationduring the drug round and had given MrJohn Powell aspirin instead of hisprescription, which was prednisolone.Mr Powell, who is a 39-year-oldasthmatic, had spotted the mistake andwas very angry with the nurse and hadthreatened to make an official complaint.He is known to have a severe allergy toaspirin, which had previously resulted inan ITU admission. The nurse had

acknowledged her mistake and hadapologised immediately, but she had notbeen able to calm him down and thesister on the ward had to intervene. Thisepisode had been very upsetting for theyoung nurse, who normally pridesherself on her caution and can onlyattribute her mistake to the fact that hermind has been preoccupied withpersonal matters. She has been verydepressed of late because of her father,who has recently been diagnosed withterminal cancer, and the break-up of along-term relationship with herboyfriend, who had `dumped' her. Whenshe speaks with the doctor, SN Nesbittwill not hesitate in admitting her mistake

and will attribute her mistake to her owndifficult personal life.

Possible prompts

• Yes, I gave the wrong medication to thepatient.

• No, I had not checked his identity and Ididn't realise he was allergic toaspirin.

• I'm having a lot of personal problemsof late and am finding it difficult toconcentrate on the job.


• Greet the nurse.

• Set the agenda. Tell her that you needto speak with her regarding an incidentwhere a patient claimed that he hadbeen given the wrong medication.

• Ask her to tell you about the incident.She will honestly tell you that a patienthad been given aspirins by mistake, buthad noticed the error and not takenthem.

• Check whether she had verified thepatient's identification before givinghim the drug and whether she wasaware that the patient who had beengiven aspirin was severely allergic to

this drug. She will reply in the negativeto both of these points.

• Ask her to tell you why this mistakeoccurred and how it could have beenprevented. She may tell you that shehas a lot of personal problems, whichare affecting her ability to work.

• Tell the nurse that this was potentiallya very serious mistake and it isimportant that an incident form iscompleted to ensure that steps aretaken to prevent it happening again. Forthe same reason it is important that thesister in charge of the ward and theconsultant looking after the patient areinformed, particularly as the patient is

likely to complain to them.

• Regarding her personal problems, tellher that she should seek help throughher GP and occupational health. Shemay need time off work or perhapsonly carry out low-risk tasks for awhile.

• Reassure her that the purpose of anyfuture investigation is not to look forevidence to incriminate her, but toreview practice on the ward to preventa similar mistake happening again.

• Summarise the discussion and close theinterview.

Important issues

Review case 30 (p. 131) and the briefdiscussion on clinical governance.

Àccidents hardly ever happen withoutwarning. The combination or sequenceof failures and mistakes that causes anaccident may indeed be unique, but theindividual failures and mistakes rarelyare.

(Mike O'Leary (British Airways,UK), Sheryl Chappell(NASA, UnitedStates))


You are an SHO working on a care ofthe elderly ward.


Subject: Dr Robert Ling

Your house officer

You have been asked to speak withyour house officer, Dr Robert Ling,because of an outburst recently. Thesister on the ward was very concernedwhen Dr Ling lost his temper andshouted at the nursing staff. The sisterhas told you that the young doctor isgenerally unapproachable and oftenrude. In particular, she is concernedabout an episode where he was askedto catheterise an elderly male patientand he had refused point-blank, sayingthat he didn't catheterise stinkingpatients and the nurses should besufficiently trained to carry out suchduties. Unfortunately there hadn't beena trained nurse to carry out the

catheterisation and the man had beenleft in agony with urinary obstructionbefore another doctor could be foundto carry out the task. You havearranged to speak with the doctorabout the sister's concerns.

You have 14 minutes to communicatewith the doctor followed by one minutefor reflection before discussion with theexaminers.

Subject information

Dr Robert Ling

House officer

Dr Ling has been working as a houseofficer for nine weeks on the care of theelderly ward. He was an outstandingstudent at medical school, regularlyachieving distinctions. Towards the endof his training he became certain that hedid not enjoy clinical medicine anddecided to have a career in eitheracademic medicine or perhaps leavemedicine altogether and go into analternative vocation. His parents hadbeen extremely proud of him becoming adoctor and he is worried about whateffect him changing career will have onthem. Working as a house officer hasconfirmed his resolution, and as eachday goes by he is finding the task more

difficult to cope with. He is unhappyabout the hours he has to work and thedemoralising conditions of the ward andhe feels unappreciated as a juniordoctor. He particularly dislikes clinicaltasks and although he does not usuallylose his temper, was unable to controlhimself when one of the nurses hadasked him to catheterise a patient. Hehas always understood this to be anursing duty and had no intention ofperforming the task. The nurse hadbecome very upset and he was halfexpecting today's discussion with hissenior house officer. During thediscussion, Dr Ling will be honest abouthis difficulties with clinical medicine

and his plan to either go into academicmedicine or leave the professionaltogether. He will listen to and accepthis colleague's advice.

Possible prompts

• Yes, I was asked to catheterise apatient, but refused to do this as I feltthis was a nursing duty.

• I feel that I don't enjoy clinicalmedicine and am thinking aboutchanging my career. Perhaps go intoacademic medicine or leave theprofession all together.


• Greet your house officer.

• Ask him whether he knows why youhave asked to speak with him.

• If he does not know then explain to himthat there have been complaints that hehas been unapproachable and refusedto catheterise a man who was left inagony for a number of hours.

• Ask him to relay his version of theincident. He is likely to tell you that hewas indeed asked to catheterise theman, but he felt it was an inappropriateduty and one that nurses shouldperform.

• Tell him you disagree on this point. Saythat the duties of doctors and nursesoften overlap, depending upon thetraining of the staff involved. Theproblem here is that there were notrained nurses and a patient was left tosuffer, and the urinary retention couldpotentially cause irreversible damage.

• Move on to the complaints about hisgeneral behaviour and ask him whetherhe felt there was a problem.

• At this point he may tell you that he isunhappy working as a house officerand is thinking about an alternativecareer. In particular he will say that hefeels that he has poor working

conditions and feels unappreciated as adoctor.

• Say that you respect his views andworking as a doctor can be verychallenging at times. Workingconditions are often difficult, but thereseems to be a real push to improvethem, and perhaps he hasn't been in thejob long enough to develop a broaderpicture (you must not sound patronisingat this point).

• What's more, medicine is a verydiverse speciality and most people finda niche within it. He may choose todisagree with you on this point.

• Say that he needs to speak with hisclinical supervisor about his futurecareer and the options open to him. Butwhile he is working as a doctor, it isvery important that he does not do thetask half-heartedly, which maypotentially endanger patients. Tell himthat as his SHO you will help andsupport him to the best of yourabilities.

• Ask him if there are any other issues hewould like to discuss.

0 If not, thank him and close theinterview.

Page numbers in italic refer to landmarkcases

* Ancient legend about a man namedDamocles who swapped places with aking to enjoy his riches only to find asword hanging over his head, held by asingle horse hair, ready to drop anymoment.

Documents

communication by iqbal khan mrcp.pdf