Rokh 2e ST4 PDF

Station 4
Communication........... ainpadanntaiasbaiessadcs
taaeahabiashel baeacctianenat peal
- About Communication (Station 4) 3
Ethical and legal issues in COMMUNICATION SKINS ........-escecceecessrseesceeeseereesesteeree 4
- Communication Scheme <e
~ Counseling for chronic disease (Pheachromcytoma) .........c...-c:ccsesseeescecceeceee 9
~ Counseling for chronic disease (Multiple Sclerosis) ..........cccccsescccsecseeceeneseesenee 12
- Counseling for chronic disease (Adult polycystic kidney disease)... 16
- Counseling for chronic illness (Celiac Disease) .........---ccessessecoensnsreesenreesssennsea 20
- Counseling for chronic disease (AddiSOM dis@aSe).........scasssrseneecceeeeererstacecenes 23
- Counseling for chronic illness (Epilepsy) 26
- Breaking bad news (Advanced cancer for palliative care).........-ccscesceceeeeeenees 29
~ Breaking bad news (Meningitis) ........ccscccseressserneesseseesseresseesctsescareeesseenesasereeens 33
- Counseling for chronic disease (Ulcerative Colitis) ........cssseecsssssreseerneenecereree 36
~ Counseling for chronic illness (Hereditary Obstructive Cardiomyopathy) ........ 39
- Breaking bad news (Advanced ILD for palliative care) ............ sab wasancenepecttvens: 42
- Breaking bad news {Mesothelioma with metastasis}

(Disablement COMPENSATION) ..........0.--scsececeserecsstserecsanecessssnecstasecsspagesceenareesssees 45
- Breaking bad news (Hodgkin Lymphoma for Hickman line)............s0-scceeneeeee 48
IX
- Active TB Asking for discharge .........css:scssscssssssssesenssrseseccssssssecerssascorersnseausassenses 5i
- Breaking bad news (Guillain Barre SyNGrome) ............:sscsssseseseerceeceecrsnacentiaess 56
~ Counseling for DNR GecisiOn .........:sssscesssscsssssesorsssceseresessssnsnseseorenseseessassansensvsees 59
- Counseling for Brain stem death and organ donation ...............ccs:ecsssseseneeeeees 63
~ Breaking bad news (Advanced COPD — Not to ventilate) 0.0... cceseerereenseeeeee 66
- Counseling for a procedure (SLE for Renal biopsy) ....-.....:ccscssessersserseeeceeeeneene 69
- Counseling for a procedure (Gastrostomy tube).........cccccssesscececcecssessenesesenerees 72
- Medical negligence(Angry son - Father developed Allergy for codeine)........... 75
- Medical error (Complication of a procedure) Patient died

after-aprocedure (PO) sacsissscsst asec canna
ea hnopaad ness 73
- Angry son (Side effect of a Medication) oo... cccseeeseesseseesseessecseeesnecseessersecees 82
- Counseling for side effects Of Warfarin............cccsccseccsseeeesseccseessseceeeeeennsaeesenee 85
- Counseling for side effects of Steroid therapy ........-..sceccssssssceescssesernreerssesceneess 88
- Counseling for a medication (Bisoprolol for heart failure in BA patient).......... 91
- Drug noncompliance (Diabetic patient on Insullin)................:cssssssesesesseeeeeeeees 93
~ Drug Non-compliance (Anti TB medications) ......:ccccceescccsesseeeereererseseeeeseeeee 36
- Pulmonary embolism asking for discharge.............:ccscssessessssesseceeseeserssessenesnesee 99
- Patient with Suicidal Attempt Asking For Discharge ...........cccsssssserseeeerereeeeee 102
~ Breaking bad news (Subarachnoid hemorrhage asking for discharge) ........... 105
- Breaking bad news Possible medical negligence............csssseessccecesesssensasessesseee 108

- A Nurse with a needle stick injury from a patient with HIV «2.00... seeeeeeeeeeee 111
~ Breaking bad news (Angry patient for delayed diagnosis) ............:cssscssseeeeres 114
~ Deteriorated ischemic stroke Angry daughter for ASDIFIN oo... eeeeeescesseseeeaee 118
- Counseling for Genetic test (Huntington dis@ase)......ccccecesseseeeesseeesssceseeees 121
~ Somatoform Disorder... = is 124
= POST MU COUNSE NING eetewsissiserduearcousswssxenaisiosscarconnsanes

too tnen tovbensdatanapeete suse sbupeceaeaneant 130
- Patient with pneumonia (Daughter refusing discharge) ...........:..scccessssseeeeees 133
SRETUSAL OG CP CEr TION On secesensane cops agnncmacsecasconconeasmnsticrterssite

somcnenenelcsqitinaen trie noes 136
Station 2
FREI CIN it ccs cvcpnentvarduarasatinesavecsacaestsoers eens sopeeanteonees atm
About station=2> (HIStOry: takdig) sevccisssssiccuscaccssvsssesnvessabatsunmvsatesrausouendansssoosstentees 143
- Microcytic Anemia in Young Female ..........0ccccccccccceessesseescccssesseseeeessceecsensees 147
SCTAPONIC DIGIT Ted vin caressaazesas-apycenoeo

sence oavenncaasersenuccteaseree mess -152
- Jaundice........ suaca eas sk pavo speRMa Manieanpesritean 157
- Chronic Cough and Wheezy CheSt ........-..eescsssssesessssossorctssssssssterrsseretesseaseaaseasens 163
~ Chronic cough and hyponatremia ...........cccccessssssscrverseresssssccssetrerereneseaseasseenesses 169
BOUL TITIES SNARES ors les aneersics denon ccensennrnsdvaae sneane guanentiacteasuunnniviessivieasene 173
= Periodic ParalySis......c.cscssccreesssesenesesses aanieagcueSeraeas iy .178
- Abnormal sensation in both Lower limbs............cccccceccecssssssessssceeeesecssesecceereesees 183

Communications is 20 minutes, 14 minutes with the surrogate, | minute to review your
ideas and $ minutes with the examiner.
You are given5 minutes before
the station, in which you have to read he scenario and
prepare yourself. Focus on every word in the scenario to know the patient name, your task
and your position.
These 4 minutes prior the station are very precious to prepare yourself, organize your ideas ,
structure your case and write scheme of the headlines of the case to cover all the important
points in the scenario.
Golden points in communication
Make
a good scheme in your mind and write it on your white paper in headlines to cover all
the important points in the station.
You have to organize your tasks and decide what is the counseling for.
th
Put a good structure and be organized in your thoughts and information during your
w
discussion with the surrogate.
Avoid jargons absolutely. Try to be fluent in your discussion.
You have to be a good actor, with empathic body language and eye contact,
Don’t push a lot of detailed suffocated information

to the patient.
Don’t interrupt the patient when he is talking and let him to express his thoughts, feelings or
querics.
Be interactive with the surrogate. Don’t talk a lot without checking his understanding and
absorption saying: (Are you with me Mr (x) ? ., Does it makes any sense for you?).
If the Surrogate showed any variant cmotions like anger, denial or crying, don’t interrupt him
and try to understand and appreciate his feeling.
10. Show empathy and sympathy from time to the other in breaking bad news and counseling for
chronic illness in empathic body language and eye contact.
11. Avoid confrontation and argument with the patient or any one of the relatives
Ethical issues: |
These ethical issues are fixed for all the cases of communication:
e Autonomy: )
> The patient has the right to know everything about his condition and share in the
management plan.
Beneficence:
we
To do good for the patient.
Non maleficence:
®
Not to harm the patient.

vy
Justice:
e
The patient has the right of management regardless his race, religion or color.
vy
Honesty.
vve
Be honest when explaining the disease, but follow it with reassurance.

{i.e In cancer with metastasis : The patient will ask you : There is no hope doctor? (A Tricky
question).
Always don’t give false hope, but also reassure and don’t make him to lose hope,
vv
In case of cancer with metastasis:

¥ Be honest (I’m sorry to tell you your condition is so advanced).
Y Reassure (But, be sure that we are going to give you all the social, psychological, medical
support and to keep you comfortable
and pain free all the time).
Other Ethical issues according to the case:

Confidentiality:
vw ©
Respecting the privacy of the patient,

The patient is the only one to know the results of his investigations.
Results are not released by mail or telephone and to be delivered to the paticnt himself ( ie.
In cases of HIV and Genetic testing)
Breaking confidentiality:
ve
if the patient is harmful for the others, and insist not to tell his partner about his HIV status
for example (Avoid confrontation and try to convince in a diplomatic way).
Avoidance of confrontation.
we
Avoid argument and confrontation with an angry patient or relative.{i,c. counseling fora
medical error or a side effect of a medication)
Legal issues:
. Consent:
» A signed consent of a procedure after detailed explanation about benefits and complications.
> Patient has the nght to withdraw any time after his signature.
. Advanced directive and living will:
.
r If the patient is competent, he has the right to make @ signed informed decision for his future
treatment plan.
Lasting power of attorney:

Enables the patient to give another person the right to make decisions about his care and
welfare, in case if he lost his mental capacity.
DNR:
The treating team has the right to make DNR decision in the best interest of the patient
condition regardless the decision of the family members (Try to convince them avoiding
confrontation).
The patient has the nght to ask for DNR when he is competent.
The patient or any the relatives doesn't have the right to refuse DNR decision, (Explain
the complications and bad outcome- Avoid confrontation)
Treating life threatening condition:

The treating team has the right to treat the patient in the best interest of his condition to
save his life even without consent, in case of the patient doesn’t has advanced directive or
living will,
Discharge against medical advice (DAMA) :

If the patient is competent, he has the right to sign a form of discharge against medical advice
Vv
after discussion of the risks of discharge.

He has the right to be given home treatment and outpatient clinic appointments.
wv
He has the right to come back to the hospital any time.
Admission under the common low:

If the patient
has active infectious disease and may infect the others and doesn’t have
Vv
suitable circumstances for isolation at home , so that this patient is not allowed to be
discharged until his disease is controlled and not infectious any more (avoid confrontation).
(ic Active TB)
If circumstances at home are suitable for isolation, then isolation can be done at home,
Admission under the mental health act:

If the patient is not competent or has psychological instability, so that he to be admitted
wv
against his or her wishes of discharge until to be assessed by a psychiatrist or a neurologist

(according to the case) to evaluate his or her condition (Avoid confrontation) . (i.e Suicidal
attempt )
Disablement compensation:
we
The patient has the right to claim for disablement compensation if he developed
any disease
related to his job.(i.e. Mesothelioma in shipyard workers}
Refusal of treatment:
If the patient is competent, he has the right to refuse treatment alter counseling for hazards
of
refusal of treatment.
If the patient is not competent and lost his mental capacity, you have to follow his advanced
directive , living will or power of attorney.
If the patient is not competent, and doesn’t have advanced directive, living will or power of
attorney, then the management plan has to be decided by the treating team in the best interest
of the patient condition.
If the patient is not competent , and docsn’t has advanced directive , living will or power of
attorney, then the management plan has to be decided by the treating team in the best interest
of the patient condition. And any of the family members doesn’t have the right to refuse the
treatment plan.
Refusal of discharge:
If the patient or any of the family members refused discharge, explore reasons of refusal and
try to solve them. And try te explain complications of stay in the hospital without need.
Solving all social dilemmas is crucial ( May be the patient is living alone or doesn't have
enough care at home). You can involve social worker and home health team if the patient
lacks medical care at home.
Introduction:
¢ Shake hands.
Introduce yourself,
¢ Confirm the patient identity
¢ Confirm agenda of meeting and take permission to start discussion.
* Ask if he want anyone else to attend the discussion ( If breaking bad news or
counseling for chronic illness ) .. (Absolutely don’t in cases of confidentiality like
Counseling for HIV).
¢ Ask open question how much he knows about his condition,
¢ Ask him about his expectation ( if breaking bad news or counseling for chronic ilincss )
Gradual breaking of the news:

- Start breaking the news gradually with some tragedy:
¢ The results of the blood test or imaging have been released and it’s not as we hope.. Stop
for a while...
e They revealed that you have a condition called (.. } or (Cancer) .. Stop for a while and let
the patient to his feelings.
Showing empathy and sympathy: (If it is cancer, or the patient knows information about the
disease);
e Tm really sorry for these bed news today...
| highly appreciate your feelings.
I know how much these news are hard for you.
Be sure that we are here to give you the full care
and care.
Give the surrogate tissue if start crying,
Explanation of the disease:

Do you want me to explain to you more about your condition?
® Start to explain the discase simply avoiding jargons (medical terms),
e Avoid pushing a lot of suffocated information.
e Explain all symptoms and complications of the disease.
e Explain the management plan:
> Referral to a specialized doctor or to a MDT team to give him the proper care and
management plan,
> Main points of management without details
Social history
May I ask some social questions if you don’t mind?
« What do you do forliving? - How much your symptoms affect your job and usual daily
activities? (Refer the patient to 4 social worker if his social life is affected and to an
occupational health care worker if his work is affected.
© With whom you are living? Who is supporting him or her at home?
¢ Are you financial supported?
Smoking and alcohol history?
- Emphasize again for these bad news today, I know how much it’s hard for you , but be sure
that we will do our best to give you the full care and management.
Concerns: Do you have any concer? (If you didn’t ask about the concerns, you may lose
this station)
Summary: Summarize your meeting with the surrogate in brief: I’m going to
summarize the important points in our discussion today.
Check understanding: By asking: May I know please how much did you get from
our discussion today’?
Help: I'm sorry again for hard news today,
¢ I will give you some leaflets, brochures and websites to know more about the discase.
¢ Iwill give you the contact number of the department to call us any time if you still
have any worries or queries,
e Anyone to drive you home?
-Nice to mect you — Shake hands.

Scenario : Mr.Ahmed is 27 years old. He has been complaining of bouts of
headache and palpitations for the last 6 weeks. Blood investigations including
urinary and plasma metanephrins and CT abdomen confirmed a diagnosis of
pheochromocytoma.
You are SHO of the outpatient clinic today. You have been asked to discuss the
results with Mr.Ahmed.
Introduction:
e Shake hands.
¢ Introduce yourself :(I’m Dr.Rokh SHO in the outpatient clinic today).
e Confirm the patient identity.(May i confirm that you are Mr. Ahmed 27
years old?)
e Confirm Agenda of meeting. .( We are together today to discuss the results
of blood investigations and imaging done for. Id ot alright with you?)
Ask if the patient need anyone else to attend the discussion (for support).
Ask how much he knows about his condition.
Ask about his expectation.
Breaking the news gradually:

e The results of blood tests and imaging have been released. And, I’m sorry
to tell you they are not as we hope.. Stop for a while. tb
e They revealed that you have a disease called (Pheaochromcytoma).. Stop
for a while ( let the patient to express his impression).. Have you ever
heard about this disease before? .. Do you want me to explain for you more
about it?
Explain the disease simply without jargon:

e It's a disease due to increased secretion of a special protein in the body
called adrenaline and noradrenalin hormone due to overgrowth of the
gland located above your kidneys .
© Mostly 90% of the growth is benign. 10% of this overgrowth may be
cancer, 10% could be familial which runs in families , 10% are located on
both glands over your kidneys , 10% could be located in other sites.
Symptoms and complications of the disease:
e Increased level of this hormone leads to some manifestations like loss of
weight, flushing, anxiety, mood disturbance, racing of heart beats, sweating,
shaking of the hands and high blood pressure which may be difficult to
control with increased risk of heart attacks and strokes.
Treatment plan:
What we are going to do:
¢ Referral to a MOT: Refer you to MDT from Gland physician , surgeon ,
psychotherapist . social worker to give you the full care and the proper
plan of management .
e Surgical resection: The main treatment is surgical resection
of the overgrowth.
e Blood pressure control: You are going to receive oral medications for
high blood pressure 10 —14 days before the operation to control your blood
pressure and to ovoid complications of the procedure. The details of this
procedure will be discussed by the surgeon in details involving your
consent for agreement to do the operation.
Showing empathy and sympathy:

e I’m really sorry for these bad news today.
e highly appreciate your feelings.
e¢ [know how hard these news for you
es Be sure that we are going to do our best to give you the full care and
proper management plan.
Sovial history:
Can Lask some social questions if you don’t mind?
e¢ What are you doing for living?.. How much your symptoms affect your
job and usual daily activities? .. Refer the patient-te%h-occupational
health worker if his job is affected, Refer to a social worker if his social
life is affected.
With whom you are living? Are they doing well ? Who is supporting you
at home?
Are you financially supported?
Do you smoke at all? Do you drink alcohol? ,, Didn't you think to
about giving up smoking? - We can help you by referring you to the
smoking cessation clinic if you don't mind.
sit
Concerns : Do
oN = 08-08 ea
e Ifthe procedure done successfully, your hormone will return to normal

range and all your symptoms will be subsided and your blood pressure
will be controlled and even you will be off any medications .. Any other
concems?
e —
CS Sta SO
, aia!
“er Dr?
- az
; 10% of this overgrowth is cancerous. Therefore, during resection of the

growth , we are going to have a snip from the overgrowth do to be analyzed
to be sure about the nature of the growth.
© 10% of the disease is familial, which means it runs in families.

¢ Therefore we will refer you and your children to a genetic counseling team to
discuss this issue in details and for possible screening.
Make summary: About the important points of the disease and management
including referral to MDT.
Check understanding: May | know how much did you get from our
meeting today?
Help: I'm going to give you some leaflets, brochures and websites to read
more about the disease.
1 will give you the contact number of our department to contact us any time if
you have any worries or queries .
- Shake hands.
Notes for the case:
e Ethical issues here

Autonomy — Beneficence — Non maleficence- Justice — Honesty.
« Legalissues here:
Consent if planned for surgical resection.
eee
Introduction:
Shake hands.
Introduce yourself.
Confirm the patient identity.
Confirm Agenda of meeting,
Ask if the patient needs anyone else to attend the discussion (for support).
Ask how much do you know about your condition?
Do you have any expectations?

The result of the imaging has been released, and I’m sorry te tell you that it is
not as we hope .. Stop for a while.
¢ They revealed that you have a condition called (Multiple Scierosis) .. Stop for
a while (let the patient to express his feelings and thoughts).
¢ Have you ever heard about this condition before?
¢ Show your empathy here if the patient knows the disease or has bad
family experience about the disease.
Showing empathy and sympathy :

f the patient knows about the disease or has bad experience with it with onc of
the family members , show you empathy directly.
e I'm really sorry for these bad news today.
e I highly appreciate your feelings.
e 1 know how much these news are hard for you.
¢ But be sure that we are going to give you the full care and support as much
as we can.
Explain the disease simply without jargons:

Do you want me to explain to you more about this disease?
e It's a disease duc to disturbance in your defensive system which supposed
to attack the bugs; in your condition it attacks your brain and main nerve
cable disturbing the electrical impulses in your nerve cables.
e It's coming in attacks on and off with different forms and times.
Symptoms and complications:
It can come in attacks in different forms like visual disturbance, abnormal
speech, shaking of the hands, unsteady gait, muscle weakness or altered
sensation. Some symptoms can come together or separated.
The majority of patients with multiple sclerosis (Approximately85%)
are left without major disability and can live near normal life. Only
minority (Approximately 15%) are left with major disability and might
need walking aid.
Management plan:
Referral to MDT : So we are going to refer you to a MDT team from a
nerve doctor , eye doctor( if visual disturbance ) , a physiotherapist , a
psychiatrist , a social worker and an occupational health care worker to
give you the full care and management plan
Acute attacks: During the sudden attacks you will be given treatment
through a needle called steroids for 3 to 5 days to shorten the course of the
attack.
Prophylaxis: Some medications can be given to reduce the chance of the
recurrence of the attacks, But it needs certain criteria to be given. It will be
discussed and decided by the nerve doctor
Pregnancy:
May i ask if you have a partner?
Are you are planning for pregnancy soon?
You have to inform your women doctor and nerve doctor to make a MDT
to give you the proper advice and full care during your pregnancy and to
review your medications before pregnancy. Some medications might need
to be changed during pregnancy.
Showing empathy and sympathy again:

I'm really sorry again for these bad news.
I understand how you are feeling now.
But be sure that we are going to give you the full care and support
~~
Social history:
© What do you do for living? .. How much your condition impacts your job
and usual daily activities? . Refer the patient to an occupational health
worker if her job is affected. Refer to a social worker if her social life is
affected.
e With whom are you living? Are they doing well? Who is supporting you
at home?
e Are you financially supported?
@ Do you smoke at all, drink alcohol?
Cooncerns: Do you have any concerns?

‘able
a co Paes
Pm sorry to5 tell you that it is not curable, but we are going to do our best
to control it and give you the full care and support and regular follow up
to live near normal life ... Any other concern?
Disease iis presented differently from one patient to the other

But I want to reassure you that the majority of patients with MS
(Approximately 85%) are left without major disability and can
live near normal life. Only minority (15%) are left with major
disability and need walking aid.
= 4 r
© You can béconie cieatane ‘without complications.

¢ Ifyou are planning for pregnancy, you have to inform your women doctor
and nerve doctor to make a MDT, to review your medications before
pregnancy and give you the full care during your pregnancy
Make summary: About the important points of the disease and

management plan.
Check understanding: Cani ask how much did you get from our
discussion today’
Help: Emphasize again.

e i'm going to give you some leaflets, brochures and websites to read more
about the disease.
e Iwill give you the contact number of our department to contact us any time
if you have any worries.
oe
e I will give you also the number of MS society who meet regularly to share
information and experience about the disease.
-Shake hands.
Notes on the case:

e During counseling for any chronic illness with female patient in child
bearing period, you have to rise up the issue of pregnancy. You have to
advise her if she is planning for pregnancy, she has to inform her
specialized doctor and women doctor to make a MDT to give her the best
advice and care.
Patients with MS need showing enough empathy and sympathy.
Explain the disease very simply. Don’t push a lot of suffocated information
to the patient.
Scenario: Mrs. Noha is 25 years old. She has been complaining of recurrent flank pain and
bloody urine, Kidney function done for her and was normal. US abdomen done for her and a
diagnosis of (Adult polycystic kidney disease) is conformed.
You are SHO of the outpatient nephrology clinic today. You have been asked to discuss the
results with her,
Introduction:
Shake hands,
oesee?8e¢@
Introduce yourself.
Confirm Agenda of meeting.
Ask if the patient want anyone else to attend the discussion (for support).
How much do you know about your condition?
Ask about her expectation.
Breaking the new gradually:

¢ The results of blood investigation and imaging have been released, and I'm sorry to tell you
that the imaging result is not as we hopc.. Stop for a while.
¢ The image reveals that you have a disease called (Adult polycystic kidney disease) .. Stop
for a while (let the patient to express hier feclings and thoughts) ..
e Have you ever heard about this disease before?

-Do you want me to explain to you more about the disease?
e It’s a familial disease which runs in families, in which there is enlargement of both
kidneys duc to multiple sacs filled with fluid invading both kidneys, It may be
associated with sacs in other body organs like the liver , spleen and balloon
formation of any of blood supplies in the brain.

¢ The disease has some symptoms and complications like recurrent tummy pain,
recurrent rupture of the sacs causing bloody water work, recurrent infection of your
kidneys and stone formation,
© It may be associated with pradual deterioration of kidney function and kidney failure on the
long ran. In certain stage kidney replacement therapy may be needed...
© 50% of patient with APCKD may need kidney replacement therapy at the age of 60.
¢ Hypertension is one of the complications of the disease which need strict follow up and
control,
© if there is any balloon formation of the blood conduits of the brain may rupture at any
time causing serious complications
she
Management plan:
» Referral to MDT : So we are going to refer you to MDT team from kidney doctor, brain
doctor, physiotherapist, occupational health worker to give you the full care and management
pian.
® Regular follow up : The management plan will be in the form of regular follow up of
your kidney function , aspiration of the sacs if causing pressure symptoms, and treating
any recurrent infection,
* Blood pressure control : Your blood pressure needs to be strictly controlled on
one drug for hypertension. We will do imaging to the brain to confirm any
presence of balloon dilatation of blood conduits.
* Special advices:
>» New medications: if you are going to reccive any new medication especially pain killer,
you have to inform your kidney doctor. As many medications can worsen your
kidney function.
> Vigorous sports: You have to avoid vigorous sports like rugby and football to avoid
rupture of the sacs.
Pregnancy: If you are planning for pregnancy, you have to inform your kidney physician
y
and women doctor to make a MDT, to give you the full care during your pregnancy to
avoid any complications at all.

How do you feel now Mrs. Sara?
I'm really sorry for these bad news today,
[highly appreciate your feelings.
Be sure that we are going to do our best to control your condition and give you regular follow
up.
Social history:
e What are you doing for living? .. How much your symptonis affect your job and usual daily
activity? .. Refer the patient to an occupational health worker if her job is affected , Refer to
the social worker if her social life is affected,
¢ With whom are you living? Are they doing well ? Who is supporting you at home?
e Do you have children, brothers or sisters? Are they doing well? Any family history of sudden
death?
e Screening: As it is a familial condition, we can refer all your family members to the genetic
counseling team to discuss the methods of screening for early detection of the disease and
regular follow up,
ii — se ea Te rs
¢ Are you financially supported?
¢ Do you smoke, drink alcohol?
Concerns: Do you have any concerns?

-Is it curable condition Dr ?
+ I'm sorry to tell you that it is not curable , but we are going to do our best (0 control it and
give you the full care and regular follow up to avoid any complications. .. Any other concem
Con i have kidney transplant now doctor?

¢ You kidney function is within the normal range in the time being. No need to think about
kidney transplant now.
¢ I would like to reassure you that only 50% of patient with this condition develop kidney
failure at the age of 60.
e Weare going to give you regular follow up to check your kidney function from time to the
other,
I'm pregnant doctor any action can be taken to prevent the disease for
my baby?
* The chance of your baby to have the disease is 50%. And I'm sorry to tell you that the
disease can't be prevented , we will refer you to the genetic counscling team to discuss
all the details about screening methods.
© Some reckiitauad can be asd for ova selection. Butsatinisnaiely it is not available in
most of the centers.
What about screening for my children now doctor?

¢ Genetic testing is not of a big value as it may has false positive and false negative results ,
and it will not alter the outcome of the disease
¢ The golden standard of screening is at the age of 20 by imaging for early detection and carly
follow up to avoid complications.
Summary: About important points of the discase and management plan.
Check understanding: How much did you get from our meeting today?
Help : Emphasize again.

¢ I'm going to give you some leaflets, brochures and websites to read more about the disease.
@ | will give you the contact number of our department to contact us any time if you have any
worties OF queries,
~ Shake hands,
Notes on the case:
¢ During counseling of chronic discase with female patient in the child bearing period, you
have to rise up the issue of pregnancy. This is important to refer her toa MDT froma
specialized doctor and women doctor to give her advice and care.
¢ During counseling of chronic familial condition, you have to ask about other family members
and to offer referral to the genetic counscling team to discuss methods of screening.
Legal issues : Screening for children before the age of 18:

> If early diagnosis wouldn’t be of a big value and will not alter the outcome of the disease , it
is better to wait until they reach 18 year old and to decide themselves. (i.e APKD)
> Ifcarly diagnosis is of a big value and will alter the outcome of the disease, early screening
accordingto the parent wishes is considered. (i¢ HOCM)
Scenario
: Mrs. Hala is 27 years
old. She has been complaining of recurrent tummy pain ,
loose motions and loss of weight for the last three months.
Upper endoscopy done for her and a diagnosis of ccliac disease has been confirmed.
You are SHO of the gastroenterology on duty today. You have been asked to discuss the result
with her.
Introduction:
Shake hands.
Introduce yourself.
Confirm Agenda of meeting and take permission to start the discussion (We are together
today to discuss the results of your blood tests and camera test done for you, Is it alright with
you?)
¢ Ask ifthe patient want anyone
else to attend the discussion (for support).
¢ Ask how much the patient knows about his condition.

¢ The results of blood tests and camera test have been released,, And I'm sorry to tell you that
the result of camera
test is not as we hope.. Stop for a while.
¢ It revealed that you have a disease called (Celiac disease) .. Stop for a while (Let the patient
to express his feclings and thoughts) .. Have you ever heard about this disease before?
Explain the disease simply without jargons :

Do you want me to explain for you more about this discase ?
© It isa disease due to bow! allergy to any type of food containing gluten,
© This type of allergy results in disturbance of the defensive system which supposed to attack
the bugs and germs , in your condition it attacks the lining
of the bowls causing long
standing soreness and mal absorption to main nutrients , minerals and vitamins, |
¢ Gluten present in Oates , wheels , ryes , and barley involved in some types
of food like
bread , pasta , pizza and biscuit .

e It has some symptoms and complications in the form of recurrent tummy psin, loose
motions, loss of weight, anemia, fatigue. fragile bone, casy biceding due to mal absorption
of certain vitamins,
© Andon the long run if the condition is not controlled, it may lead to certain type of cancer in
the gut called lymphoma at the late stages of the disease.
e BUT.. ali of these complications can be avoided and chance of cancer can be significantly
reduced if you completely avoided any type of food containing gluten.
20
Management plan:
Avoidance
of gluten: The comer stone of the treatment is to avoid any type of food
containing gluten completely. If you avoid any food containing gluten completely, then you
can avoid all the complications of the disease and live near your life.
Referral to MDT; We will refer you to a MDT team involving a bowel physician to
provide you with essential nutrients, minerals and vitamins, a dictitian to give you the list of
types of food which has to be avoided completely and a social worker to support you socially.
Restaurant: There are some restaurants have special partitions for food free gluten.
Travelling: If you are travelling on airplanes inform the crew about your condition to give
you food free gluten,
Pregnancy: May | ask if you have a partner? Are you planning for pregnancy son? If you
plan for pregnancy anytime, you have to inform your women doctor and bowel doctor to
make2 MDT to give you the proper care during your pregnancy.

How do you feel now Mrs.Amira?
I'm really sorry for these bad news today.
I highly appreciate your feelings.
1 know how much these information are hard for you.
But be sure that we are going to do our best to give you the full social and medical care as
much as we can fo live near normal life.
Social history:
What are you doing for living? .. How much your illness affect your job and usual daily
activity? .. Refer the patient to an occupational health worker if her job is affected. Refer to a
social worker if her social life is affected.
(Ifshe is working as a crew, you have to refer to occupational health care worker to exchange
it with an office job).
° With whom you are living? are they doing well ? Who is supporting you at home?
@ Do you smoke at all, do you drink alcohol? (If the patient drinks alcohol, advise him to
contact the dietitian as most types of alcohol contain gluten and mat trigger his condition.
Concerns: Do you have any concems?

Is it curable condition Dr ?
Unfortunately it's not curable , but it can be controlled , and if you avoided any type of food
containing gluten , your condition will be completely controlled and you can live near normal
life. Any other concern?
May I have cancer in the future dr ?

If you avoided any food containing gluten , your condition will be controlled
and the chance to have cancer will be extremely low .
What about small piece of pizza dr , I like itso much?
e Even small piece of pizza may trigger your symptoms. Therefore, it is better to avoid any
type of food conntaining gluten even with a small piece.
Make a summary: About the important points of the disease and management plan.
Check understanding: Check how much the patient got from the discussion?
Help:
e I'm going to give you some leaflets, brochures and websites to read more about the disease.
e I will give you the contact number of our department to contact us any time if you have
any worries or queries.
¢ Anyone to drive you home?( if not admitted).
~ Shake hands
Scenario : Mr.s liers is 25 years old. She has been complaining of loss of weight and
dizziness for the last six weeks. Blood investigations including short synactin test done for him
and a diagnosis of Addison disease has been confirmed.
You are SHO of thr medical department oncall today . You have been asked to discuss the results
with Mr.Hera
Introduction:
Shake hands,
Introduce yourself.
Ask the patient if he needs anyone else to attend the discussion (for support).

The results of blood investigations have been released, and I'm sorry to tell you that the
results are not as we hope ., Stop for a while.
They reveal that you have a disease called (Addison discase) .. Stop for a while (Iet the
patient to express his feelings and thoughts).
Have you ever heard 2bout this condition before?
Is it serious condition doctor?
Tt can be serious if untreated, but we are going to do our best to control your condition.

Do you want to explain to you more about the disease?
It's a disease due to diminished secretion of a special protein in the body called cortisone .
secreted from the glands located above your kidneys.
Mostly is due to disturbance of your defensive system which supposed to attack the bugs and
viruses, in your condition it attacks your glands.

Cortisone is an important hormone in the body.
Deficiency of this hormone leads to some symptoms and complications like loss of weight,
decreased blood pressure, dizziness, decreased glucose level, electrolyte disturbance, tummy
pain, feeling and getting sick and tanned skin.
If the hormone severely diminished , it may result in severe dehydration , sever hypotension,
coma and cyen can be life threatening.
Treatment plan:
Referral to MDT: What we are going to do is to refer you to a MDT including a gland
physician,, a psychiatrist and a social worker to give you the full care and appropriate plan of
management.
Replacement therapy: The main treatment is replacement therapy of this hormone by oral
tablets; You have to be strictly adherent to-your medications to avoid complications of the
disease to live near normal life. We will provide you with regular fellow up in the outpatient
clinic to be sure of your hormone level and offer you the full care.
Rules of sick days: In special situations like fever, recurrent vomiting, recurrent loose
motions you have to duplicate your cortisone dose. If you felt any time that you are sick and
unwell you have to seek medical emergency al once , as your condition may be unstable at
that time and you may need urgent medical care
Medic Alert Bracelet: You have to wear Medic Alert Bracelet to make the others to know
about your condition and to carry one ampoule of cortisone to be given to you if needed in
emergency situation.
Pregnancy: May i ask if you have a partner?. If you are planning for pregnancy, you have to
inform your women and gland doctor to make a MDT to give you the full care and to avoid any
complications during your pregnancy.

I'm really sorry for these bad news today,
e
¢ [highly appreciate your feclings.

¢ [know how much these news are hard for you.
© But sure that we are going to do our best to give you the full care and proper treatment.
Social history:
¢ Mat I ask what do you do for living? How much your illness impact your job and usual daily
activities? .. Refer the patient to an occupational health worker if his job is affected, Refer to
a social worker if his social life is affected.
¢ With whom you are living? Are they doing well? Who is supporting you at home?
Do you smoke at all? Do you drink alcohol? Didn't you thing about giving up smoking ?
We can help you by referring you to a smoking cessation clinic if you don't mind.
Concerns : Do you have any concems ?

- Is it curable condition
Dr ?
¢ I’m sorry to tell you that it’s not curable but it can be controlled on medication, | you will
be completely compliant on your medications and on regular fellow up , you can live near
normal life. Any other concem ?
-What about complicationsof steroid therapy Dr ?
* Steroids will be given to you as replacement therapy, to reach the normal level, So that,
mostly you will not suffer from complications of the long term use of steroids.
* May be some soreness of the stomach which can be managed by simple medication,
Make summary: About important points of the disease and management plan.

¢ I'm going to give you some leaflets, brochures and websites to be more aware about the
disease.
¢ J will give you the contact number of our department to contact us any time if you have any
worries or queries.
~ Shake hands
Scenario: Mrs. Hend is 24 years old. She had been complaining of 2 episodes of seizures
during the last six weeks. Ct brain done for her, and it was normal. A diagnosis of epilepsy is
confirmed by the neurology consultant.
You are SHO of the neurology department on call today . You have been asked to discuss the
diagnosis with her.
Introduction:
Shake hands
Introduce yourself.
Ask how much the patient knows about your condition?

The results of blood tests and imaging of your brain have been released. And fortunately they
are normal,
But the nerve doctor made a diagnosis of your, a condition called (Epilepsy) .. Stop for a
while( let the patient to express his feelings and thoughts) .. Have you ever heard about this
disease before?

Do you want me to explain to you more about this disease?
Epilepsy is an active focus in the brain , sending abnormal electrical impulses to the body .
causing unpredictable
shaking of the body .
It can be precipitated by strong flashes, voices, stress
and sleep deprivation,
The underlying cause of the disease is unknown for the most cases oand sometimes could be
familial.

e Itcan come in the form of unpredictabie shaking of the body with loss of consciousness,
tongue biting, frothing from the mouth and may be unconatrolied water work,
es and sympathy:
How do fee] now Mrs, Amira?
¢ I'm really sorry for these bad information today,
e [highly Appreciate your feelings , | know how much these news are hard for you , But be
sure that we are going to do our best to give you the full care to control your condition to
live near normal life -
Treatment plan:
« Referral to MDT : So what we are going to do is to refer you toa MDT froma nerve
doctor social worker , occupational health care worker to give you the proper care and
management plan to control your condition .
¢ Medications: Treatment of this condition is by oral medications. You have to be

completely compliant on these medications to control your condition and to decrease the
shance for any further attacks..
Modification of life style: You have to follow some life style modifications:
.
Avoid percipients: Like strong flashes and voices , avoid stress and sleep deprivation.
vy
Avoid life risky situations: If you are going to swim, you should be under supervision.
Avoid presence in high attitudes , beside fire and sharp objects. Don't lock in the door of the
bathroom. If you developed any seizures attacks in these situations,
your life maybe
threatened.
+ Oral contraceptive pills : May i ask if you are receiving any oral contraceptive pills?
You have to inform your women doctor and nerve doctor because anti-epileptic medications
can change the efficacy of OCP and you may get pregnant ant time.
e Pregnancy:
May L ask if you have a partner? Are you planning for pregnancy?
You have to inform your women doctor and nerve doctor to make a MDT to give you the full
care during pregnancy as seizures attacks be harmful for the baby .
Also anti-epileptic medications may be harmful to your fetus. Therefore, they will provide you
with anti-epileptic medications with the least harm for your baby, You may be given folic acid to
decrease the harm.
e Driving: May | ask if you drive?

You have to inform DVLA about your condition. I’m sorry to tell you that you will be banned
from driving for at least 1 year until you will be completely free from attacks. Your condition is
risky on yourself and for the others if you developed any scizures attacks during driving,
Social history:
Can | ask some social questions?
e What are you doing for living? .. How much your illness may affect your job and usual daily
activities? ., I'm going to refer you the to a social worker and An occupational health worker
to manage any social or occupational troubles.
(If the patient job is risky. Like, it requires presence in high attitudes or sharp machines, you
have to contact the occupational health care worker to exchange it with an office job.
¢ With whom you are living? Are they doing well ? Who is supporting you at home?
¢ Are you financially supported? Do you smoke at all? Do you drink alcohol?
(Moderation of alcchol intake is crucial as it may trigger seizures attack)
Concerns: Do you have any concems ?

- Is it curable condition Dr ?
© I'm sorry to tell you that it is not curable. But it can be controlicd by avoiding triggers,
complete compliance on your medications and regular follow up.
Any problem if! get pregnant

Or ? |
¢ If you are planning for pregnancy, you have to inform your women doctor and nerve doctor |
to make a MDT to give you the full care during your pregnancy.
e Scizures may be harmful for your baby. Anti-cpileptic medications may be harmful as well.
¢ But outweighing the risk versus the benefits , the risk of seizures attack is extremely more
Make summary: About the important points of the disease and management
plan.
age Emphasize again.
I'm going (o give you some leaflets, brochures and websites to read more about the disease,
© 1 will give you the contact number of our department to contact us any lime if you have any
Worries Or queries.
¢ Anyone to drive you home? (If not admitted)
Scenario: Mr. Kamal is 65 years old. He has been complaining of recurrent
loose motions and loss of weight for the last 2 months.
Blood investigations and CT abdomen, chest and pelvis confirmed a diagnosis
of advanced cancer colon with metastasis to the liver and bones.
The oncologist made decision that Mr. Kamal is not fit for chemotherapy or
radiation and only for palliative treatment.
You are SHO of the medical department on call today. You are asked to
discuss the condition to Mr. .Ahmed son of Mr. Kamal.
Introduction:
Shake hands.
Introduce your self
Confirm the son’s identity.
Ask if he is next of kin of Mr. Kamal.
Ask if he has permission from Mr. Kamal to discuss his condition.
Ask if the he need anyone else from the family to attend the discussion (for
support).
e Ask about his expectation.

¢ The results of blood tests and imaging have been released, and I’m sorry to
tell you that they are not as we hope .. Stop for a while.
¢ They revealed that your father has advanced cancer in his bowels.. Stop for a
while (let the son to express his feelings and thoughts).
Empathy and sympathy:

(Use body language, eye contact and voice tone impressive of sorrow)
e I'm really sorry for this bad news today.
[ highly appreciate your feelings.
But be sure that we are going to give your father the full care and support.
Give a tissue if started crying.
May i explain to you more about your father's condition?
e Unfortunately the blood tests and images done to for your father revealed
that he has advanced cancer in his gut . It seemed to spread out to other
organs like liver and bones.

¢ I'm sorry to tell you that cancer has a lot of complications in the form of
fever , loss of weight , fatigue , decreased appetite , easy infection .
lumps and bumps and may be failure of the affected organs on the long
run.
e Tm sorry to tell you that your fatherss cancer seems to be in advanced
stage. I’m sorry again for these bad information today.
Treatment plan:
¢ So what we are going to do is to refer your father to a MDT from a Tumor
physician, Macmillan nurse, a psychiatrist, a social worker, and pain
management doctor to give your father the full care and proper plan of
management.
e The cancer physician assessed your father. And he believes that the cancer
in your father’s condition is very advanced. And unfortunately, he is not fit
for chemotherapy or radiation, and only for supportive care.
e This decision was taken in the best interest of your father’s condition, as he
is not going to have any benefit at all form such therapies. On the contrary,
he may suffer from the side effects of this treatment and even may shorten
his life.
The son: Why not chemotherapy doctor? Please do everything to keep my

father alive.
I highly appreciate your feeling. This decision was taken by the ancer doctor
in the best interest of your father‘s condition.
Chemotherapy has a lot of side effects and your father is going to sufer from
all the complications of chemotherapy with no chance to improve.
Palliative care:; We are going to give your father the full supportive care in
the form of :
Potent pain killers to keep him pain free all the time.
VV
Providing him with the appropriate nutrients and fluids that he needs.
Correction of any electrolyte imbalance.
VVV
Treating any infection.

Referring him to the home health care team for regular follow up and
management at home.
Social history:
¢ What is your father doing for living? .. How much his illness affect his life? And daily
activities? .. I'm sorry for that we will involve a social worker and occupational health care
worker to solve any social trouble he has.
With whom your father is living? Are they doing well? Who is supporting him at home?
¢ ts your father financially supported?
¢ Does your father has any advanced direction or living well or power of attomey? (This
question is for all cases of cancer).
. Pm s sorry to tell you that the condition of your father seems to be very advanced. ( Honesty)
¢ But, we are going to do our best and give your father the full medical, social, psychologica
medical care and to keep him pain free all the time. (Reassurance)
© raises tela yet fase Beane ti bile baie Ms Sunde is very advanced.
* But be sure that we are going to do our best and give him the full medical, psychological,
and social care and to keep you pain free all the time.
.nditic i eL Py
ondit ion |di octor.
ae
. ‘ayask aie youedt t weet your fiber to> know(Explore reasons)

¢ appreciate vour feeling. But as your father has the full mental capacity, so that he has the
full right to know everything about his condition and to share in the management plan.
¢ We will give him the information in pieces according to his worries.
We will involve a psychiatrist to manage any mood disturbance.
Make summary: About the important points of meeting and management plan..
Check understanding: Check how much the son got from the discussion?
Help: Emphasize again:

® I'm going to give you some leaflets about advanced cancer bowel and palliative care to
be more aware about it.
¢ Im going to going to give you the contact number of our department to contact us any
time if toy have any qucrics.
Notes on the case:
Ethical issues :
Autonomy :
> As long as the patient is competent and has the full mental capacity, he has the right to know
everything about his condition and to share the management plan with bim.
> The son or any of the relative doesn’t have the right to ask for hiding information from the
patient,
> If the paticnt asked about any worries or queries, he has the right to be informed.
Provide the patient with information according to his qucrics.
Beneficence — Non maleficence

— Honesty - Justice
Legal issues :
> Discussion of DNR in cases of advanced disease is a matter of debate. It is different from one
examiner to the other.
> Lassume, it is better to be adherent to your task in the scenario
> IfDNR decision is not mentioned in the scenario , no need to mention it as DNR is a decision
of the consultant.
Scenario: Mr. Jack is 65 years old. He has been complaining of fever and
altered conscious level for the last two days. Ct brain and lumber puncture done
for him. CSF analysis revealed meningococcal meningitis.
You are SHO of the neurology department oncall today. You have been asked
to discuss the results with Mrs sara his daughter.
Introduction:
e Shake hands.
Introduce yourself.
Confirm the daughter identity.
«eee
Confirm agenda of meeting.

Ask if she want anyone else from the family to attend the discussion (for
support).
How much do you know about your father’s condition ?
Ask about his expectation .

e The result of the blood tests done to your mother have been released, and
unfortunately I’m sorry to tell you that it is not as we hope .. Stop for a
while.
e The results revealed that your mother has a serious bug infection of the
covering layers lining his brain, A condition called meningitis.. Stop for a
while (let the daughter to express her feelings and thoughts) .. Have you
ever heard about this condition before
Explain the disease simply without jargons :

¢ Do you want to explain to you more about this condition Mrs. Sare?
e It is infection of the lining of the brain and main nerve cable by germs .
e These germs are normal habitants on our bodies , but can be harmful and
serious with diminished defensive system.
e I’m sorry to say that it is a serious condition and even could be a life
threatening condition if not treated .
Symptoms and complications :
e The condition may be presented in simple symptoms or serious symptoms.
e There are symptoms variation like fever , skin rash, headache , visual
disturbance , feeling sick , vomiting , shaking of the body , altered
conscious level and may be coma.
e The outcome of the disease ismostly good, and most patients make a good
recovery if treated early enough and received the full course of antibiotics.
Management plan :
¢ So that , we are going to refer your father urgently to MDT from a nerve
doctor and infectious disease doctor to give him the proper care and
management plan.
e The treatment plan will be by receiving a course of antibiotics through a
needle,
e As] mentioned before, the outcome of the disease could be good and most
of the patients are completely cured after receiving the full course of
antibiotics.
Isolation :
© Don’t be bothered if your father is isolated with droplet precaution. We are
going to wear a special mask during handling your father to prevent
infection of the care givers.
e During visits, you have to wear this mask as well.
Screening and immunization for close contacts:

¢ Can | ask if your father had close contacts recently?
e All close contacts of a patient with such infection have a risk of catching
the infection . However, the risk is still low.
e Close contacts usually means household members, or intimate kissing
contacts. Thus, it is crucial to give us the list of the close contacts within the
previous seven days. These people are offered a short course of antibiotics
to prevent possible infection.
Notification : Meningitis is one of the noticeable diseases. Hence, we are

going to notify the public health .

e How do you feel now?
e I'm really sorry for these bad information today.
¢ highly appreciate your feelings.
* [know how much these news are hard for you.
* Be sure that we are going to do our best to give your father the best care .
Social history:
* Can I ask some social questions if you don't mind?
* What is your father doing for living? .. How much his illness impact his job
and usual daily activity? .. Refer the patient to an occupational health
worker if his job is affected. Refer to social worker if his social life is
affected.
* With whom your father is living? Are they doing well ? Who is supporting
him at home?
* Is your father financially supported?
Concerns :
ouhaveany concerns?
« Wecan’t guarantee the outcome of the disease . But in general , the

outcome of the disease could be good , and most of the patients are
completely cured after they receive the full course of antibiotics.
Summary: Summarize the important points of the disease and management

plan.
Check understanding: May I know how much did you get from our
meeting today?
Help :
e Emphasize again , I'm going to give you some leaflets , brochures and
websites to read more about the disease.
e | will give you the contact number of ou department to contact us any time if
you have any worries or queries .
~ Shake hands.
35
Scenario: Mrs . Heba is 25 years old. She has been complaining of recurrent
abdominal pain and bloody loose motions for the last 3 months. Blood investigations and
colonoscopy were done for her. A diagnosis of ulcerative colitis has been confirmed.
You are SHO of gastroenterology on call today. You have been asked to discuss the new
diagnosis with her.
Introduction:
Shake hands.
Introduce yourself.
Confirm Agenda of meeting and take permission to start the discussion (We are
together today to discuss the results of your blood tests and camera test .Is it alright
with you?
e Ask if the patient want anyone else to attend the discussion (for support).
® Ask how much the patient knows about hes condition.

e The results of blood tests and camera test have been released. Im sorry to tell you that
they are not-as we hope.. Stop for a while.
e The results revealed that you have disease called (Ulcerative disease) .. Stop fora
while {Let the patient to express his feelings and thoughts) .
e Have you ever heard about this disease before?
Explanation the disease simply without jargons:

May I explain to you more about this disease?
¢ itis a discase due to disturbance of the defensive system causing long standing
soreness of the bowels.

e The disease has some symptoms and complications in the form of recurrent flaring up
with recurrent tummy pain , loose motions , bloody stool , ma! absorption of many
nutrients and vitamins causing significant loss of weight , anemia , fatigue , fragile
bone and casy bleeding -
¢ I’m sorry to tell you that in same cases in the long mun the condition could be
complicated by bowel cancer if not controjled and treated properly.
« BUT.. All of these complications can be controlled and chance of cancer can be
significantly reduced if you received a proper treatment and kept on regular follow
up. (Hard news has to be followed by reassurance)
Management plan:
¢ Referral to MDT: Our management plan mainly will be by referring you to a MDT
team involving a bowel physician, a dietician, a social worker and an occupational
health care worker to give you the appropriate care and regular follow up.
¢ Treatment of the acute attacks: During flaring up of the condition, you may
receive steroids through a needle to shorten the flaring period.
e Long term treatment: You will receive some medications in the long run to
modify your defensive system to control your condition and reduce flaring up of
your illness.
¢ Diet control: The dictician will give you some advices regarding your dict and will
provide you with essential nutrients and vitamins.
¢ Pregnancy: may I ask if you have a partner? If you are going to plan for pregnancy
any lime , you have to inform your women and bowel doctor to make a MDT to stop
some medication which may harm the fetus , and give you the full care to avoid any
complications at all.

¢ How do you feel now?
i highly Appreciate your feelings
Be sure that we are going to do our best to give you the full care and regular follow as
much as we can to live near normal life.
Social history:
May I ask some social questions if you don’t mind ?
¢ What do you do for living?.. How much your illness affect your job and usual daily
activity? .. Refer the patient to an occupational health worker if her job is affected.
Refer to social worker if her social life is affected . For example , if she is working as
air hostess then you have to refer to an occupational health care worker to write a
medical report to change her job to an office work .
¢ With whom you arc living? Are they doing well? Who is supporting you at home?
Do you smoke at all? Do you drink alcohol? (If the patient drinks alcohol , advise her
to contact the dietitian as alcohol may trigger her disease.
pe Tiiatol)
+ oe eu
Is it curable condition Dr ?
-Unfortunately it's not curable , but it can be controlled on strict compliance on
medications , dict control and regular follow up -Any other concem ?
May I have cancer in the future Dr?

I'm sorry to tell you that the chance of bowel cancer
on the long run is higher than
normal pcople. But the chance will be extremely decreased with good control of your
condition and regular follow up,
e Steroid will be given to you in a short term in the acute attacks. Therefore, mostly
you are not going to suffer from the long term complications.
¢ Weare going to give you regular follow up in the outpatient clinic to manage any side
effects of this medication.
e QOutweighing the risk versus the benefits of steroids, the benefits are extremely more.
Make summary: About the important points of the disease and management plan.
Help:
e I'm going to give you some leaflets, brochures and websites to read more about
ulcerative colitis.
¢ J will give you the contact number of our department to contact me any time if you
have any worries or queries .
- Shake hands.
N.B:
e You task here is counseling for a chronic discase.
e If mentioned in the scenario that the patient asked to discuss about side effects of
steroids, then your approach will be different. It will be counseling for side effects of
a medication. That is why, we didn’t focus on complications of steroids here , and we
replied her concem of steroids in short focused way( Counseling for side effects of
steroids is discussed in another scenario),
¢ In counseling for chronic illness in female patient, you have to raise up the issue of
pregnancy to refer the patient for a MDT.
Scenario: Mr. Robert is 25 years old, He had been complaining of syncopal attack which
running in the track today. Echocardiography done for him and a diagnosis of hereditary
obstructive cardiomyopathy has been confirmed.
You are SHO of the cardiology department on call today. You have been asked to discus
the result with Mr. Robert.
Introduction:
Shake hands.
@
Introduce yourself.
#@ @

ee

@ @
Ask how much he knows about your condition?

The result of the imaging done for you has been released. And I'm sorry to tell you
that it is not as we hope ., Stop for a while.
It reveals that you have a heart condition call (Hereditary obstructive
cardiomyopathy). Have you ever heard about this condition before?
Is it serious condition doctor?
I'm going
t tell-you all the details about that condition if you don’t mind.
Explain the disease simply without jargens:

Hereditary obstructive cardiomyopathy is a familial condition which runs in families.
In this condition, the muscles of the heart is thickened and become weak to the
extent that it can’t supply adequate blood flow to the brain and other body organs .
The thickened muscles of the heart also resull in obstruction to the outflow of the
blood through the cardiac outlets,
It is associated with disturbance of the electricity of the heart(Represent by a simple
drew to the Surrogate if possible} .

The symptoms of the disease vary from one patient to the other according to severity
of the disease.
Symptoms are different and variable, in the form of chest pain , racing of heart beats ,
shortness of breath with exertion , dizziness , syncope , swelling due to retention of
the water and salts in the body and im sorry to tell you may be heart failure in the
long run.
¢ I'm sorry to tell you it can be serious and even can result in sudden heart arrest and
death in severe cases , but be sure that we are going to give you the care and proper
management.

e Haw do feel now Mrs.(Sameer) ?
I know how much these news are hard for you .
Be sure that we are going to do our best to give you the full care ta control your
condition .
Treatment plan:
Let us talk about management plan in your condition
* Modification of life style - Modification of life style is crucial in your
condition .You are advised strongly to avoid vigorous exercise , smoking and alcohol
intake
¢ Referral to MOT : So what we are going to do is to refer you to 2 MDT froma
heart physician , a heart surgeon , social worker , occupational health worker to give
you the proper care and management plan .
¢ Oral medications: Treatment of this condition can be in the form of oral
medications to decrease the blood load on the heart and control the heart rate and
thythm,
¢ ICO: Some Implantable devices can be used in case of heart beats irregularity to
control the heart electricity and therefore control the heart rate.
¢ Surgical intervention: Surgical intervention can be an option in some severe
cases , which don’t respond to oral medications., The whole management plan will
be discussed with the heart consultant in details,
* Avoidance of vigorous sports: You are advised to avoid vigorous exercise and
sports to avoid putting the heart under pressure and complications.
Driving: May | ask if you drive.

e You have to inform DVLA about your condition.
e I'm sorry to tell you that you will be banned from driving until you will be
completely free from attacks , as your condition is risky on yourself and for the others
during driving .
Pregnancy :
e (if femal patient) : You have to raise up the issue of pregnancy in any female patient
with newly diagnosed chronic illness.
¢ Ifyou are planning for pregnancy, you have to inform your women doctor and heart
doctor to make MDT approach to give the proper advice and care.
Social history:
* What are you doing for living? .. If the patient is working as 2 pilot or bus driver:
I'm sorry driving an airplane is very dangerous for your life and for the passengers
48 you may develop syncope anytime during driving.
e So we will refer you to an occupational health worker to exchange your job with
another office job.
© For any hereditary condition , you have to ask about other family members for
referral to genetic counseling team.
¢ Do you have children, brothers or sisters? Are they doing well? We can refer you all
to the genetic counseling team to discuss methods of screening for early detection of
the disease and to start carly management plan if exists.
¢ With whom you are living? Are they doing well? Who is supporting you at home?
Do you smoke, drink alcohol? If smoking: Smoking may worsen your heart condition.
Therefore we can refer you to the smoking cessation clinic to help you to give up
smoking.
If drinking alcohol : Drinking alcohol can worsen the heart condition as well , So, you
are advised strongly to give up drinking alcohol.
Concerns : Do you have any concerns ?

- Is it curable condition Dr?
¢ I’msorry to tell you that itis not curable, but it can be controlled with strict
compliance on medications and regular follow up.
-What about my chlidern doctor?

¢ I’msorry to tell you that every one of your children has chance of 50% to have the
disease.
¢ We will refer them to genetic counseling team to discuss methods of screening either
by genetic test of imaging of the heart.
Make summary: About the important points of the disease and management plan.
Check understanding: Check how much the patient got from the discussion ?
Help:
¢ Emphasize again. I'm going to give you some Icaflets , brochures , websites to read
more about the disease.
¢ | will give you the contact number of our department to contact us as well to contact
us any time if you have any worries or querics.
¢ Anyone will drive you home ? (If not admitted)
-Shake hands
Scenario: Mr. Hady is 55 year old known case of cryptogenic interstitial lung
disease for the last 7 years. He was admitted 2 days back because of
exacerbation of his ILD .
He was assessed by a pulmonology consultant who made a decision to put him
on palliative care on discharge.
You are SHO of pulmonology department on call today. You have been asked
to discuss this issue with Mr. Samir , his son .
Introduction:
Shake hands.
Introduce yourself.
Confirm the son’s identity.
Confirm he is the next of kin of Mr.Hady
Confirm if he has permission from his father to discuss his condition.
Ask if the patient need anyone else to attend the discussion (for support),
Confirm Agenda of meeting (We are together today to discuss the condition
of your father and further plan of management, Is it alright with you?)
Can i know how much do you know about your father’s condition?
Explanation of the condition of the patient:

e Your father has been complaining of long standing scarring of his lung tissue,
a condition called interstitial lung disease.
¢ He was admitted few days ago because of exacerbation of his condition,
which resulted in breathing distress and higher requirements of oxygen and
supportive breathing.
e He was assessed by lung consultant, who see that he reached an advanced
stage of lung scarring. I’m really sorry for that.
e Therefore, he made a decision in the best interest of your father to keep him
on palliative care , which is the supportive care.
¢ Have you any idea about this kind of care?
Explanation of the palliative care:
Palliative care includes:
No need for any active treatment for lung scarring, as it has no role in the
time being.
To support your father with long term oxygen therapy.
To provide him with sedative medications to relieve his stress.
To involve a psychiatrist to manage any mood disturbance.
To include home health team for regular visits for assessment and care at
home,
Showing empathy and sympathy :

I'm really sorry for these bad information today
| highly appreciate your feelings.
But be sure that we are going to give you father the full care and support as
much as we can..
Social history:
What is your father doing for living? .. How much his illness impact his job
and usual daily activity? .. Refer the patient to an occupational health
worker if his job is affected , Refer to a social worker if his social life is
affected .
With whom your father is living? Are they doing well ? Who is supporting
him at home?
Does he has any advanced directive , living will or power of attorney?
Is he financially supported?
Does he smoke at all, drink alcohol?
Concerns: Do you have any concerns ?

- There is no hope doctor?
I’m sorry to tell you that he reached an advanced stage of his condition.
But we are going to give him all the social, psychological and medical
support and to keep him out of stress all the time.
Avoid giving no hope or false hope. (Don’t reply: There is hope or there
is hope)
Make summary: About the important points of the disease and management .
Check understanding: Check how much the son got from the discussion?

e I'm going to give you some leaflets, brochures, websites to read more
about Advanced lung scarring and supportive care.
e | will give you the contact number of our department to contact us any
time if you have any worries or queries.
-Shake hands.
N.B : You have two tasks here :

Breaking bad news of the advanced stage of ILD.
VV
Explanation of the palliative care.
Any patient with advanced condition like cancer with metastasis , Advanced
“+,
ILD or COPD , you have to ask about advanced directive , living will and
power of attorney.
** Discussion about DNR here is controversial if not mentioned in the scenario.
* It is better to be adherent to your task in the scenario, and not to mention
DNR if it is not mentioned in the scenario. DNR is a decision of the
consultant.
Scenario: Mr. Jack is 45 years old. He has been working in shipyards for the
last 10 years. He has been complaining of cough and loss of weight for the last
two months.
CT chest, abdomen and pelvis done for him and a diagnosis of diffuse
mesothelioma with metastasis to the live has been confirmed .
You are SHO in the medical department . You have been asked to discuss the
results with Mr. Jack.
Introduction:
Shake hands.
Introduce yourself.
Ask how much do you know about vour condition?

¢ The result of the imaging done for you has been released .. and I’m sorry
to tell you that unfortunately it is not as we hope .. Stop for a while
e Itrevealed that you have cancer in the lining of your lungs .. Stop for a
while (Let the surrogate to express his feelings and thoughts).

I'm really sorry for these bad news today Mr. Jack.
know how much these news are hard for you .
Be sure that we are going to give you the full and best care . ( Show your
empathy by eye contact , voice tone and body language . Give the surrogate
a tissue if started crying).
45
Do you want to explain to you more about your condition?
Unfortunately the results of the images done to you revealed cancer in the
lining of your lungs, a condition called (Mesothelioma) .
The cancer seems to be advanced and spread to other organs in the body .
This type of cancer is most probably related to your job due to long term
exposure to industrial materials at your work.

This cancer may has variable symptoms like fever , sweating , loss of
weight , cough , shortness of breath and gradual deterioration of the
general condition .
Management plan:
Further management plan will be by referring you to a MDT team including
a cancer doctor , Macmillan nurse , psychiatrist , social worker, social
worker and occupational health worker to give you the proper care and
management plan.
The cancer doctor will discuss with you the details of the management plan
like cycles of chemotherapy or radiation.
Disablement compensation:
I would like to inform you that you have the right to claim for compensation
as your cancer is related to your job.
You have to fill and post a special claim form.
Then you will be assessed by a medical advisor to assess your degree of
disability to decide the amount of benefit you deserve.
And if you are not satisfied with that compensation, you can contact a
lawyer to claim for more compensation benefit.
Empathy and sympathy again:

How do you feel now Mr. Jack?
I understand how much you feel right now.
®@ Be sure that we are going to give you the full social , psychological ,
financial support and keep you comfortable and pain free all the time
Secial history:
Can I ask some social questions if you don’t mind?
® With whom you are living? Are they doing well? Who is supporting you at
home?
® Do you need any social or financial support?
® Do you have advanced directive, living will or power of attorney?
Concerns:
Do you have any concerns?
There is no hope doctor?
e I'm sorry to tell you that your condition seems to be advanced,.Honesty
e However, we are going to give you the full social , psychological , medical
support and to keep you comfortable and pain free all the time.Reassurance
For how long I'm going to live doctor?

e It varies from one patient to other according to the progression of the cancer,
response for treatment and general condition of the patient.
Summa ry: For the important points of the disease, management plan and
disablement compensation.
Check understanding: Can I know how much you did get from our
meeting today?
Help:
e Emphasize again. I'm going to give you some leaflets, brochures , websites
to read more about the disease.
e | will give you the contact number of our department to contact us any time
if you have any worries or queries .
- Shake hands.
N.B:
Your task here is :
e Breaking bad news of methoselioma.
e ‘The right for claim for disablement compensation.
-In a case of cancer with metastasis , ask about advanced directive, living will
and power of attorney
47
Scenario: Mr, Adam is 27 years old. He has been complaining of fever , loss of weight and
lymphadenopathy for the last eight weeks. Blood investigation , open biopsy and Pan CT done
for him.
A diagnosis of Hodgkin lymphoma (Grade 2b) is confirmed. The oncologist decided to insert
Hickman line to regimen of chemotherapy.
You are SHO of the oncology department on call today. You have been asked to discuss the
results and Hickman line with Mr, Adam.
Intreduction:
e Shake hands,
* Introduce yourself.
¢ Confirm the patient identity.
¢ Confirm Agenda of meeting and take permission to start the discussion ((We are together
today to discuss the results of your blood tests and imaging, Is it alright with you ?)
Ask if the patient want anyone else to attend the discussion (for support)
« Ask about his expectation.

-The results of blood tests, snip test and imaging have been released, Im sorry to tell you that the
results are not as we hope .. Stop for a while.
They revealed that you have a type of cancer of the lymph gland called (Hodgkin lymphoma} .. Stop
for a while (Let the patient to express his feelings and thoughts)

¢ I'm really sorry for these bad news today.
¢ I highly appreciate your feelings.
¢ IT know how much these news arc hard for you.
¢ But be sure that we are going to do our best and give you the full care.
¢ The good news is that it could be curable condition. A lot of cases are completely cured afler
full course of chemotherapy,

May Lexplain to you more about the disease if you don’t mind?
¢ Hodgkin lymphoma is cancer of the lymph glands, which exist in different sites all over the
body.
¢ [thas some symptoms in the form of loss of weight, fatigue , fever, night sweat, anemia and
easy infection due to disturbance of the defensive system
¢ BUT.. Treatment is available for this discase and a lot of cases were completely cured from
the disease after treatment. (Reassurance after bad news).
Treatment plan:
Referral to MDT:
- What we are going to do is to refer you to MDT from blood physician, Macmillan nurse,
psycho therapist, social worker to give you the appropriate care and plan of management.
Chemotherapy :
The main treatment plan is a course of chemotherapy (explain advantage and disadvantage of
chemotherapy ) chemotherapy can destroy the nasty growth and may cure the cancer
completely ..
It has some complications in the form of feeling or getting sick that can be treated by some
Vv
medications, falling of hair which will grow again, you can use a wig during that time, your
defensive system may be disturbed and you might get easy infection and we will give you a
card and follow your condition and give you antibiotics if had infection any time.
Outweighing the risk versus the benefits of chemotherapy, the benefits are significantly
more.
Hickman line explanation:

Chemotherapy has to be given though a wide bore needle called hickman line ,
Explanation of Hickman line: It is wide bore needle which will be inserted in a large
blood conduit under local anesthesia to numb the area of insertion and under aseptic
condition, done by expert doctor who did such procedure hundreds of times before.
Advantage: This line has advantage of providing easy access for the cycles of
chemotherapy.
Complications: It has some complications in the form of blecding, infection, injury to the
adjacent tissues, or may be blockage of the line, but such complications are rare to happen.
Consent: If you agree to do this procedure you have to sign a consent involving all the
information about the procedure, and if you want to withdraw from the consent any time, you
have the nght.
Social history:
Can I know what are you doing for living? How much your illness impact your job and usual
daily activities? - Refer the patient to an occupational health worker if his job is affected.
Refer to a social worker if his social life is affected.
With whom you are living? Who is supporting you at home?
Do you smoke at all? Drink alcohol?
C oncerns: Do you have any concerns?
"Infertility is.
is one e of the
t seraelicasioas of cheanottiraty. eroneds be irreversible some
times.
But, we can overcome this problem by saving some of your sperms in a sperm bank to be
used in the future. You can bring your wife next time to discuss this issue with both of you.
Make a summary: About the important points of the disease and management plan.
Check understanding: may i ask if you got all the information in our discussion
today? (If you have time)
Heip:
© fm going to give you some leaflets and websites to read more about the disease and Hickman
line.
« Iwill give you the contact number of our department to contact us if you have any worries
or queries.
- Shake hands.
Notes on the case:
You have two tasks here :

« Breaking bas news of Hodgkin lymphoma
¢ Counseling for Hickman line
Ethical issues :
* Autonomy - Beneficence - Non Maleficence ~ Justice — Honesty,
Legal issues :
« Consent
Scenario : Mr.Jack is 35 years old. He has been complaining of fever ,
productive cough and loss of weight for the last 6 weeks . Chest x ray, Acid fast
bacilli and TB PCR revealed a diagnosis of active TB.
You are SHO of the medical department on call today. You have been asked to
discuss the results with Mr. Jack
Introduction:
Shake hands.
Introduce yourself.
Ask how much do you know about your condition.
Ask about his expectation,

The results of blood tests and imaging have been released, and im sorry to
tell you unfortunately they are not as we hope .. Stop for a while.
They revealed that you have a superbug infection in your lungs called
(Lung Tuberculosis).. Stop for a while (Let the patient to express his
feelings and thoughts) .. Have you ever heard about this type of infection
before’?
Is it serious condition Dr ? [t can be serious if untreated, but we are going
to give you full care and proper management plan.

Unfortunately investigations revealed that you have lung infection with a
serious bug called tuberculosis.
Tuberculosis can be transmitted by droplet infection from another patient or
or unhealthy environment.

There are some symptoms and complications of this disease in the form of
fever, night sweating, cough, coughing up blood, loss of weight , shortness
of breath, and my be lung failure on the long run.
I’m sorry to tell you that it even may threaten your life if not treated
properly.
It may spread to other organs like brain, kidneys and the bones if not treated
perfectly.
Treatment plan:
Reassurance: The good news is that it is a curable condition, and most
of the patients are completely cured after receiving their full course of anti
TB medications .
Notification: So what we are going to do is to notify the preventive

medicine department
Referral to MOT : We will refer you toa MDT from a lung physician ,
infectious disease doctor , social worker , and occupational health care
worker to give you the proper plan of management.
tsolation:
This condition needs isolation for at least two weeks until you phlegm is
completely free from the bugs , and you are not infectious any more.
Can i ask if the circumstances at you home are suitable for isolation? May i
confirm if you are going to be adherent to isolation at home?
Anti TB medications :
The management plan will be in the form of a full course of anti TB drugs
which will continue for 6 months with regular follow up in the outpatient
clinic to confirm that your condition is improving .
You have to be completely adherent to your medications to eradicate the
bugs and to guarantee the full cure .
Side effects of Anti TB medications:

These medications have some side effects like pins and needles in the hands
and feet , change of urine color , elevation of liver enzymes. But we will
follow up your condition to detect any side effects to manage at once.
Outweighing the risk versus the benefits of the drugs , the benefits are
extremely more
Screening: We will do screening for the persons in direct contact with

you, to be sure they are free from the infection and to receive prophylactic
medications if there is history of exposure.
52
en and sympathy:
How do feel now Mr.Jack?
I’m really sorry for these bad news today.
Be sure that we are going to give you the full care and the proper
management to live near normal life until your condition will be cured
completely.
(Use empathic eye contact, body language and voice tone)
Social history
e What are you doing for living?.. How much your illness could affect your
job and usual daily activities?
e Ifhe is working in a risky infectious job tell him that you will refer him to
the occupational health worker who will provide him with another job away
from the public in the first few weeks until his sputum is free from the bugs,
Refer to a social worker if his social life is affected.
e With whom you are living at home? Are they doing well? Who is
supporting you at home?
© Do you smoke at all? Do you drink alcohol? ..Didn't you thing about giving
up smoking? .. We can help you by referring you to smoking cessation
clinic if you don't mind. Smoking may worsen your condition and delay
your recovery. Advice to stop alcohol intake too.
Concerns : Do you have any concerns ?

pS en
« “TtisisaSambe condition in nest of the cases after receiving the full course
of anti TB medications.
e Your condition will improve within few weeks, and you can enjoy your
life.
*¢ Compliance and regular follow up is crucial to guarantee the full cure ..
Any other concerns?
- I want to go home and take n s at home please

* Cani ask if the circumstances at youwi home are
a suitable for isolation’?
* Mayiconfirm if you are going to be adherent to isolation at home for two
weeks at least?
@lif the circumstances at you home are not suitable for isolation
or the patient is not going to be adherent to isolation at home:
e Ittis better to stay in the hospital for isolation in a special room until your
condition is stabilized, and you are not infectious any more for the others.
@lf the patient refused isolation at the hospital, clarify

complications of discharge without isolation:
e If you are discharged now without isolation for two weeks at least, you may
infect your close contacts. In addition, your condition could deteriorate
without close observation.
@lif the patient still argues and refusing isolation:

¢ Never mind, I’m going to involve my consultant for another mecting to
convince you more and reply any worries you have. (Avoid confrontation)
Make summary: About the important points of discussion and management

plan.
Check understanding: Check how much the patient got from the
discussion?

e I'm going to give you some leaflets , brochures and websites about
tuberculosis and importance of isolation in the first two weeks
e Will give you the contact number of our department to contact us any time
if you have any worries or queries ..
- Shake hands
Notes on the case:
You have 2 tasks here:

¢ Breaking bad news of Jung tuberculosis.
e Managing the dilemma of refusal of isolation.
>» The patient can be isolated at home if he accepted adherence to isolation,

and the circumstances at home are suitable for isolation
If the patient refused adherence to isolation, and the circumstances at home
Vv
are not suitable for isolation, therefore he is not allowed to be discharged.

Try to convince him kindly to stay in the hospital until his sputum would be
Vv
free from the germs, showing the hazards of being discharged in the time
being on himself and for the others.
Avoid confrontation with the patient.
yv
Involve your consultant at the end if the patient still insisting for discharge
and refusing isolation.
This patient has to be admitted under the common low and not allowe d to
Vv
be discharged against medical advice ifrefusing isolation at home or at the

hospital. ( Legal issue) (Admission under the common low).
Scenario: Mr.Jack is 32 years old has been diagnosed to have Guillain Barre Syndrome
2 weeks ago. He was admitted three days ago with respiratory failure and was intubated.
Now, he is extubated and breathing spontaneously . He was evaluated be neurology
consultant who assumed that his lower limbs is severely disabled and mostly will be
bound to bed.
The wife was informed 2 weeks ago that his condition has good prognosis.
You are SHO Neurology on call today. You have been asked to discuss this Issue with
Mrs Jack his wife.
Introduction:
Shake hands.
Introduce yourself.
Ask if she is the next of kin of the patient.
Ask if she has permission from her husband to discuss his condition.
How much do you know about yours husband's condition?
Wife : My husband was diagnosed to have (Guillain barre syndrome) two weeks ago.
One neurology doctor told me that he going to. walk again and the disease has a good
outcome .
Now doctor, my husband was severely deteriorated, and he was put on assessed
mechanical machine and had severe lower limbs weakness .

I'm really sorry for what happened to your husband.
I know how much this event is hard for you.
Be sure that we are going to give him the best care .
Show your empathy by eye contact, voice tone and body language. Give the surrogate
a tissue if started crying)
* Can [tell you more about your husband’s condition if you don’t mind?
* Your husband has been diagnosed to have a condition called (Guillain Barre
Syndrome).
* A-condition duc to disturbance of his defensive system which supposed to attack
the bugs. In this condition, it attacks the nerve cables of the limbs causing limb
weakness, and sometimes nerves cables of the chest muscles causing shortness of
breath and may be failure of breathing .
* The disease acts differently from one patient to the other. It can be presented with
mild limb weakness to severe limb and chest muscle weakness causing significant
limb weakness and failure of breathing . which could require assessed mechanical
machine to support his breathing, .
* The disease could present in recurrent unpredictable attacks from time to the other .
* Treatment of this disease during the flaring up is by giving a medication through a
needle called (Immunoglobulin) , which sometimes doesn't give a desired results.
Outcome of her husband's condition :

* Fm sorry to tell you that the nerve consultant see that your husband presented this
time with severe form of the disease, and his lower limbs was severely disabled.
Mostly probably he is going to be bound to bed.
Wife Sadly: But I was informed 2 wecks ago that he is going to walk again doctor ???
justification of the neurologist opinion two weeks ago:

* May be your husband presented 2 wecks ago with a mild form of the disease with a
good response for the treatment at that time. That is why, he informed you that he is
going to walk again with a good outcome. However we are going to contact him to
know what was the situation at that time.
e Butas I told you, this discase is unpredictable with recurrent attacks. Unfortunately
he presented three days back with a severe form of the disease , with sever lower
limbs and chest muscle weakness which resulted in failure of breathing and required
assessed ventilation . Now he is off mechanical machine and is breathing
spontaneously.
Management plan :
May I tell you about the future management plan?
® Weare going to refer him to a MDT team including a nerve doctor, psychiatrist to
manage any low mood or depression , a physiotherapist to give his the prober care
and a social worker to manage any social troubles.

e How do you feel now Mrs. Jack ?
@ I'm really sorry again for these bad news today.
® Be sure that we are going to give him the full social , psychological and medical
Support.
Social history:
® What your husband is doing for living?- We will refer him to to an occupational
health care worker to manage any occupational troubles and provide him with
medical reports as needed.
®@ With whom your husband is living? Who is supporting him at home?
®@ Does he need any social or financial support?

There is no hope doctor?
¢ I'm sorry to tell you that the condition of your husband is advanced now, but be sure
that we are going to give his all psychological , physical support , social support.
Make Summary: For the important points of the disease and management plan.
Check understanding: Can I know how much did you get from our mecting today?
Help:
¢ Emphasize again, I'm going to give you some leaflets, brochures and websites to read
more about the discase.
58
Seenario: Mr. Salem is 65 years old. He is known case of advanced multiple
meyeloma. DM, HTN and IHD .
Me was admitted last week because of altered conscious level, His condition
was deteriorated and was put on mechanical ventilation and transferred to
tensive care unit. The treating team made a decision not to resuscitate him in
the best interest of his condition.
You are SHO of the medical department, you are asked to discuss this
seve with his son Mr. Ahmed
Introduction:
Shake hands.
Introduce yourself.
Confirm the son identity.
Ask if he is the next of kin.
Ask if he need any one of the family members to attend this meeting
Confirm agenda of meeting and take permission to start.
Ask the son: May i know how much you do know about your father’s
condition?
Initial question:
May i ask if your father has any advanced directive, living will or
power of Attorney?
Explanation of the condition of the father :

Your father is known to have advanced multiple myeloma which is a
cancer of the blood, DM, HTN, and THD.
He was admitted last week because of altered conscious level,
Unfortunately, his condition was deteriorated and was transferred to the
intensive care unit and, was put on mechanical machine to assess his
breathing.
I’m sorry to tell you that he reached a very advanced stage of his illness.
May I ask , did your father express any thoughts of what to be done
for him in such advanced condition?

How do you feel now Mr. Ahmed?
| highly appreciate your feeling,
Be sure that we are here to do the best for your father and to offer him the
full care.
Explain the decision of DNR:
© Therefore, according to the advanced stage of your fathers condition, the
treating team made a decision in the best interest of his condition not to be
resuscitated if he had heart arrest any time.
e What do think about that? Do you have any idea about resuscitation?
Explanation of resuscitation:
Do you have any idea what is resuscitation?
¢ When any patient’s heart stops beating, we start to do resuscitation to
stimulate the heart to beat again.
¢ This is done by repeated compression on the chest, insertion of a tube
through the air pipe and giving some medication through a needle to
stimulate the heart to work again.
Explanation of complications of resuscitation:

e Resuscitation has a lot of complications, like fractures of the bones of the
chest, internal bleeding in the lungs, deformity of the chest and injury to
the air pipe.
The chance of your father to revive again is extremely low.
And even if he revived, he will suffer a lot of comlications and will
have a very bad life quality.
e So that a decision not to be resuscitated was taken in the best of your
father’s condition
¢ Outweighing the complications versus the benefits, the complications
are extremely more of resuscitation. Does it make ant sense for you?

e How do you feel now Mr.Ahmed?
¢ |’m really sorry again.
e Be sure that this decision was taken in the best interest of your father.
Managing the dilemma of rejection of DNR decision:

The son may be unsatisfied with DNR decision and may tell you:
Please doctor , do anything to keep my father alive.
e Your feelings are highly appreciated
e iknow how much your father is precious for you, and be sure that he is
precious for us as well.
e Again, this decision was taken by the medical team in the best interest of you
father.
e It doesn’t mean that we will let him pass away. As long as your father
heart is beating, he will be offered all the medical care..
If the son still not accepting DNR decision, then tell him :
e Wecan arrange another meeting with our consultant, and you can
involve anyone of your family to reply any worries or queries you still
have.(Avoid conformation)
Social History:
e May | ask some social questions if you don’t mind?
e¢ With whom your father was living? Are they doing well? Any one of them
needs any social, medical or financial support?
e Are they financially supported?
alive or.
e J appreciate your father’s thoughts. But this is a decision of the treating
team,
e Itis taken according to the general condition by outwaiting the risk versus
chances of success and complications.
* This decision could be reviewed again if his condition showed any
improvement.
Make summary: About the important points in the meeting.
Check understanding: May i know how much did you get from our
meeting today?
Help:
e I'm going to give you some leaflets about DNR how it is done , benefits
and complications.
e 1 will give the contact number of our department to contact us anytime if
you still have any worries.
e Any one will drive you home?
- Shake hands.
Notes on the case:
Ethical issues:
>» Autonomy - Beneficence - Non maleficence - Honesty- Justice — Avoid
confrontation.
Legal issues:
r DNR is a decision of the treating team, even if the patient expressed his
thoughts to be resuscitated.
The patient has the right to ask for DNR if he is competent.
Any one of the family doesn’t have the right to ask for DNR if the patient
VWv
lost his mental capacity. The treating team have to proceed in the
management plan according to the best interest of the patient condition.
The patient or any of the relatives doesn’t have the right to ask for
Vv
resuscitation.
DNR decision is not a final decision. It could be reviewed if the patient
WV
showed clinical improvement.

ario: Mr. Ibrahim is 52 years old. He has been admitted six weeks ago after extensive
‘Wheachnoid hemorrhage. He and was put on mechanical ventilation since that time. After
“Seeking his brain stem reflexes, the treating team made a decision that Mr. Ibrahim has a brain
‘em ceath and to start withdrawal and cessation of ventilation in the best interest of his
eemtnon.
Yee we SHO of the medical department on call today .You have been asked to discuss this issue
"wth his son Mr, Rami.
Setroduction:
Shake hands,
introduce yourself.
Confirm the son‘s identity.
Confirm he is the next of kin of Mr, Ibrahim.
Confirm agenda of meeting and take a permission to start.
Ask if he want any one of the family members to attend the meeting.
Ask the son: May i know how much do you know about your father's condition?
Do you have any expectation?
Explanation of the father's condition:

Your father was admitted due to extensive bleeding in his brain and was put on assessed
breathing since that time.
I'm sorry to tell you that the condition of your father is very advanced and he had severe
mreversible brain damage.
i'm sorry (o tell you that the treating team taking care of your father made special tests to
check his response. And they confirmed that your father has brain stem death. (With
empathic eye contact , body language and voice tone).
Do you have any idea about brain stem death?
Explanation of brain stem death:

Do you want me to explain to you more about brain stem death?
The brain stem is responsible for regulating most of the body's functions that are essential
for life. These include: breathing, heart beating, blood pressure and swallowing,
Your father has irreversible brain damage and death. He has permanently lost the potential
for consciousness and the capacity to breathe. This may happen.cven when a ventilator is
Keeping the person's heart beating,
This means that your father is technically dead and there is no chance to resume his
consciousness again,

* I'm really sorry for these bad news today Mrr Rami..
* [know how much these news are hard for you.
63
1 understand what you feel now.
| highly appreciate your feeling.
Give a tissue if he started crying,
Explain the decision of ventilator withdrawal:

Therefore, the treating team made a decision in the best interest of your father’s condition to
withdraw the treatment and to stop the mechanical machine to Iet him to die in peace. (Use
empathic body language and voice tone).
Complications of mechanical ventilation

I highly appreciate your feeling again.
Your father heart beating and breathing are only maintained using the mechanical machine,
and no chance to resume his conscious again.
If he continued on the mechanical machine, he will suffer from a lot of complications like
bed sores, recurrent hospital and machine acquired resistant infection which could be
difficult to be treated , with no hope to come back to life again.
Thus, this decision was taken by the treating team in the best interest of your father’s
Discussion of organ donation:

May I discuss with you another sensitive issue if you don’t mind?
May I ask if your father has any advanced directive or living well or power of attomey?
Did your father express any thoughts before about organ donation?
Do you know how would you father behave in such situation regarding organ donation?
Although your father has brain stem death, his other organs are still viable.
So in such cases, we discuss with the relatives the possibility of donating viable organs to
patients who are in strong need for theses organs. What do think about that Mr. Rami?
Explanation of organ donation :

Organ donation is done by a special organ donation team. If you accept we will refer you to
that team to talk in details about that procedure.
A clean regular incisions will be done to the body by an expert doctor and the viable organs
will be taken and kept to be donated to the patients with organ failure.
The wounds will be sutured regularly without any disfigurement at all , Any funeral
ceremonies will not be postponed at all.
We have a long list of patient with end organ failure who are in urgent need for viable
healthy organs . This will improve their life a lot and even will save their life. What do you
think about that Mr. Rami?
You can have some time to think about it .You can involve anyone of your family members
and we can arrange for another mecting for any further worries or querics.
If you agree for this procedure , we will sign @ consent involving all the information about
the procedure, and if you changed your mind you have the right to withdraw from the
consent,
We can keep your father on the ventilator until reaching a decision.
Social History:
My I ask some social questions if you don’t mind.
* With whom your father was living? Are they doing weil? Does any one of them need any
support?
* ls the family financially supported?
Concerns: Do you bave any concerns?
Make a summary: About important the points in the meeting.
Check understanding: Mayi know how much did you get from our discussion today?
Help:
* [will give you some leaflets and websites about brain stem death and organ donation.
* I’m going to give you the contact number of our department . If you have any worries or
queries, please don't hesitate to contact us .
* Anyone to drive you home?
Shake hands.
Notes on the case:

* A very tricky and sensitive situation.
* You have to be very sensitive and to express overwhelming ¢motions.
+ Discussion of organ donation is required in a case of brain stem death, even if not mentioned
in the scenario.
e A decision of brain stem death is a decision of the treating team. As well as the decision of
withdrawal of mechanical ventilation.
e The son has the right to accept or refuse organ donation. It is not obligatory at all.
* Ethical issues here :

> Autonomy — Beneficence — Non maleficence - Justice — Honesty.
e Legal issues:
> Consent if accepted organ donation.
If the son refused the decision, involve your consultant and legal advisor.
Scenario: Mr. Jack is 65 years old known case of COPD for the last 10 years with history of
recurrent exacerbations and admissions. He was admitted 3 days ago duc to respiratory failure
type2 secondary to infective exacerbation of COPD.
Last night, his condition was severely deteriorated and was put on Bi-level positive airway
pressure (BIPAP) with difficulty of weaning.
The pulmonology consultant made a decision that his condition not fit for mechanical ventilation
ifneeded, and only BIBAP will be used.
You are SHO of the pulmonology on call today. You have been asked to discuss this decision
with Miss Christen his daughter,
Intreduction:
Shake hands,
introduce yourself,
Confirm the daughter’s identity.
Confirm she is the next of kin of Mr.Jack.
May I know if you have permission from Mr. jack to discuss his condition today?
Ask if the Miss Christen need anyone else to attend the discussion (for support).
May I know, how much do you know about your father’s condition?

May I explain to you more about your father’s condition?
You father is known to have long standing obstructive lung disease. He was admitted 3 days
ago because of infective exacerbation of his condition. We started antibiotics and
nebulization in the best interest of his statis to control his condition.
Unfortunately, his condition was severely deteriorated last night despite optimum treatment.
Therefore. we put him on non-invasive device called Bi-level positive airway pressure
(BIPAP) to assist his breathing and relieve his symptoms.
His condition may require invasive mechanical device any time , if his condition not
improved on the non-invasive device (BIBAP)
Invasive mechanical device is done by insertion of a tube into the main air passage and to be
attached to a machine to assist breathing.
Explanation of the decision of pulmonoloegy consultant and reasons for decision:

° May | ask if your father has any advanced directive or living will?
° The lung consultant made a decision not to usc invasive mechanical device if required any
time, and only to apply noninvasive device which is (BIBAP).
¢ This decision was taken in the best interest of his condition. As the condition of your father is
so advanced and frail,
Complications of mechanical machine:

* Mechanical machine has a lot of complications because of frailty of his condition.
¢ Mostly probably, there will be difficulty of weaning. Therefore, mostly he will be lifelong
dependent on the mechanical machine with subsequent complications.
¢ On mechanical machine, he will be exposed to frequent acquired lung infection with resistant
bugs which could be difficult to be treated,
¢ On invasive machine, he has extremely low chance to improve and breath spontaneously.
Managing the argument of the daughter:

Daughter:
« Please doctor, I need everything to be done to my father. | don’t want him to die.
You:
¢ [appreciate your feelings. The decision not to use mechanical machine was taken in the best
interest of you father’s condition.
* Most probably, he will suffer more on mechanical machine. Instead, he will be on
noninvasive machine to avoid all the bad consequences of the mechanical device.
¢ A decision not to use mechanical machine doesn’t mean that we are going to ict him die. We
are going to put him on noninvasive machine instead to avoid all the bad consequences of
invasive device.\Be sure that we are going to offer him the best care and relieve his stress.

¢ I'mreally sorry for these bad news today,
¢ highly appreciate your feelings,
¢ Iknow bow much these news are hard for you.
¢ Be sure that this decision was taken in the best interest of your father’s condition » and we
are going
to give him the full care and support as much as we can .
Social history:
¢ What is your father doing for living? .. How much your illness impact your job and usual
daily activity? ., Refer the patient to an occupational health worker if his job is affected ,
Refer to a social worker if his social life is affected -
¢ With whom he is living at home? Are they doing well? Who is supporting him at home?
¢ Is he financially supported?
* Does he smoke at all, drink alcohol? (If he smokes , give strong advice to give up smoking
and offer help by referring him to the smoking cessation clinic).

‘ar 1
pA ai
nel ey a
od his wish
ae to be int
67
¢ The decision not to use mechanical machine is a decision of the treating team, and it is taken
in the best interest of the patient's condition, this decision is taken to avoid all the subsequent
complications of mechanical machine that i mentioned before.
e Instead, he will be on noninvasive machine to avoid all the bad consequences of the
mechanical device,
° Cieereaalaiba We will assess

a ge condiicer bekine: te ceremony. If we see that re
condition is fit, then he can attend the ceremony even on the non-invasive device
(BIBAP),
Make summary: About the important points of the disease and the decision of not to ventilate.
Check understanding: Check how much the daughter got from the discussion ?
Help: Emphasize again,

e I'm going to give you some leaflets, brochures, websites to read more about the use of
invasive machine in advanced COPS and its complications.
e | will give you the contact number of our department as well to contact us any time if you
still have any worries or queries.
-Shake hands.
Notes on the case:

You have two tasks here:
> Breaking bas news of advanced COPD.
> Counseling regarding the decision of not to ventilate.
eae: issues here:

Decision not to ventilate is a decision of the treating tcam.
vw
If the patient has the full mental capacity, he has the right to ask not to be ventilated or
resuscilated. But he doesn't has the right to ask to be ventilated or resuscitated. This decision
of the treating tcam according to the general condition of the paticnt in the best interest of his
condition,
Also, daughter doesn’t has the right to change the decision of the treating team. Avoid
wv
confrontation.
Factors fortify the decision of not to ventilate in COPD :

» History of recurrent exacerbation and frequent hospital admissions.
» History of frequent nebulization at home.
» History of recurrent intubation,
> General condition of the patient.
Scenario: Mrs Hala is 35 years old has been diagnosed as a case of Systemic
lupus erythematous three years ago. Recently she has been complaining of
morning eyes puffiness and frothy urine. 24 h urine protein done for here and a
diagnosis of nephritic syndrome has been confirmed, The nephrology
consultant decided to do renal biopsy to know the staging of her kidney
involvement to start the proper treatment.
You are SHO in nephrology department on call today. You are asked
to discuss this issue with here.
Introduction
Shake hands.
Introduce yourself.
Confirm the patient identity
Confirm Agenda of meeting and take permission to start.
Ask if the patient needs anyone else to attend the meeting
Ask open question: May i know how much do you know about your
condition?
Explanation of the disease briefly:

May i explain to you more about your condition?
e Systemic lupus is a multi-system disease due to disturbance of your
defensive system which supposed to attack the germs and viruses, in your
condition it attacks your own body organs like the joints, lining of the heart
and lungs, the skin and kidneys.
e Unfortunately, blood and urine tests done for you revealed that you have
protein in urine. That means that your kidney are involved .
* That is why, the kidney consultant asked for a kidney snip to assess your
kidney condition to start a definitive plan of management.
* Do you have any idea about kidney snip procedure?
Explanation of the procedure:
May | explain to you more about this procedure?
¢ It is a procedure done by an expert doctor who did such
procedures hundreds of times before.
e tis done by inserting a special needle into your back while you are laying
on your tummy. It is done by image guided or camera and local pain killer
to numb the area of insertion to decrease the pain. A sterilized condition is
guaranteed to decrease any chance of infection. The snip will be taken and
will be sent to a pathologist for analysis .
¢ You may stay in the hospital for 24 hours after the procedure to be sure
you are free from any complications -
Advantages of the procedure:

e This procedure is decided in the best interest of your condition.
e It is crucial for us as it will give us idea the stage of your kidney disease.
And accordingly, you will receive the definitive treatment.
e Without this procedure, we can’t diagnose the stage of your kidney disease.
Therefore, we can't give you the proper treatment. Consequently, your
kidney function will be deteriorated. And I’m sorry to tell you that you
may even have kidney failure and may need renal replacement therapy in
the future.
Disadvantages of the procedure:

¢ ‘This procedure has some complications like bleeding, infection, injury to
internal organ and inappropriate snip.
But such complications are extremely rare.
Outweighing the risk versus the benefits, the benefits are extremely more
¢ May i ask if you receive any blood thinner medications like aspirin, plavix
or warfarin?
Consent:
e Ifyou agree to do this procedure, you have to sign a consent in which all
the information is mentioned.
e If you changed your mind, you have the right to withdraw anytime. .
If the patient is still hesitated or refusing the procedure:

(The task of the surrogate is be difficult and reluctant)
e | will give you some time to think about it, and may be to share opinion
with some one of your family members to support your decision.
¢ [| will involve my consultant as well in another mecting to reply any further
worries you have.
Social History:
May i ask some social questions if you don’t mind?
* What are you doing for living? How much your illness impact your job and
usual daily activities? - Refer the patient to an occupational health care
worker if job is affected. Refer the patient to a social worker if his social life
is affected.
* With whom you are living? Are they doing well? Who is supporting you at
home?
* Are you financially supported?
* Do you smoke? Drink alcohol?
Concerns: Do
eee alll ieee tae ea ae eS eee >
ere any aicterna'’a PeaACOCTOr:
— te .
* I'm sorry to tell you this is the only way to know staging of your kidney
disease to start the proper treatment. This procedure is prescribed to you by
the kidney consultant who is an expert of such cases.
Make summary: About the important points of the meeting
Check understanding: May i know how much did you get from
our meeting today?
Help:
« | will give you some leaflets, brochures and websites to be more aware
about this procedure.
* | will give you the contact number of our department also, if you have any
worries please contact us.
-Shake hands.
Notes on the case:
* Your task here is to explain the condition, the procedure , the advantages
and the complications of the procedure.
¢ The patient has the right to accept or refuse as she is competent. (patient
autonomy)
Legal issues here :

¢ Consent: Ifthe patient agreed to do this procedure, she has to sign a
consent in which all the information is mentioned.
e Ifshe changed her mind, she has the right to withdraw anytime. .
Scenario:
Mr. Josef is 60 years old; He has been diagnosed to have motor neuron disease 6 years ago.
He was admitted two days ago because of aspiration pneumonia; He had been admitted many
times in the Jast year because of recurrent chocking. The Gastroenterology consultant decided
that he is candidate for gastrostomy tube inscrtion to avoid choking and for adequate nutrition.
You are SHO of the gastroenterology department on call today. You have becn asked to discuss
this issue with Mr. Josef.
Introduction:
* Introduce yoursclf.
e Ask if he needs anyone else to attend the meeting.
¢ Confirm agenda of meeting (We are together today to discuss some issues related to your
condition and further plan of management.
e Ask the patient how much he knows about his condition.
Explanation of the father's condition:

May | explain to you more about your condition?
« You have been known to have of long standing motor neuron discase,
¢ Motor neuron disease is a progressive condition, affecting mainly the nerve cables of lower
and upper limbs causing progressive muscle weakness,
¢ In your condition, it progressed to involve the muscles of swallowing causing difficulty of
swallowing and recurrent chocking,
¢ Recurrent chocking result in aspiration of the food particles inside the air passages.
Consequently, this would trigger imitation and infection of your air passages. I'm sorry to tell
you that recurrent lung infection may precipitate failure of breathing cven may threaten your
life.
¢ That's why the bowel consultant made a decision in the best interest of your condition to
insert a gastrostomy tube for feeding, Have you ever heard about this procedure before?
Explanation of gastrostomy tube procedure:

May I explain to you more about gastrostomy tube?
@ tis. special tube which can be inserted through the tummy wall te reach the stomach,
® tis done by an expert doctor, who did such procedure hundreds of times before,
© It can be inserted by image guided or camera test guided under local pain killer to numb the
area of insertion to decrease the pain. A sterilized condition is guaranteed to decrease any
chance of infection.
importance of the procedure:
* This tube is so crucial to avoid recurrent chocking, subsequent lung infection and hospital
admissions.
* Also it supplies you with adequate feeding to avoid malnutrition.
Complications of the procedure:

* Like any procedure, this procedure has its own complications such as bleeding, infection,
mury to an adjacent organ and may be obstruction of the tube in the future.
* Such complications are rare to happen and can be managed casily.
* Outweighing the risks versus the benefits, the benefits are extremely more.
* May Lask if you receive any blood thinner medications like aspirin, Plavix or warfarin?
Consent:
* [you agree to do this procedure, you have to sign a consent ia which all the information is
mentioned,
* You can have some time to think about it and involve any one of your family members. I can
mvolve my consultant as well if you need.
* Ifyou changed your mind, you have the right to withdraw anytime.
M the patient is still hesitated or refusing the procedure:

(The task of the surrogate is be difficult and reluctant)
* Iwill give you some time to think about it, and may be to share opinion with some one of
your family members
* Iwill involve my consultant as well in another mecting to reply any further worries you have.
Secial History:
May i ask some social questions if you don’t mind?.
* With whom you are living? Who is supporting and giving you care at home? Do you need
any more support?
* We have social worker and home health care team here (o give you support at home if
needed any time.
How can we feed him by this tube doctor?

* The nutritionist will teach you how to feed him, and will provide you with special ensures for
feeding per gastrostomy tube.
Is there any alternative doctor?
¢ Nasogastric tube is alternative method of feeding. A tube inserted through the nose to reach
the stomach.
e Butit has to be changed within short times. You will not feel comfortable with it.
¢ thas a lot of complications and may predispose you for aspiration too if pulled out.
Make a summary: About the important points of the meeting.
Check understanding: May 1 know how much did you get from our meeting today?
Help:
e I will give you some Icaflets, brochures and websites about this procedure.
¢ 1 will give you the contact number of our department. If you have any worries please don’t
hesitate to contact us.
~Shake hands.
Notes about the case:

Your task here is to convince the patient for gastrostomy tube,
You have to be honest, explaining all the benefits and risks.
As long as the patient has the full mental capacity, he has the right to be counseled and to
refuse or accept the procedure.
¢ Ifthe patient lacks mental capacity and judgment, then you can discuss the procedure with
his next of kin.
Ethical issues here:

Autonomy, Beneficence, Non-maleficence, Justice and Honesty -
Legal issues here:

© Consent: Ifhe agrees to do this procedure, he has to sign a consent in which all the
information is mentioned,
e Ifhe changed his mind, be has the right to withdraw anytime.
Scenario: Mr. Sami is 60 years old. He was admitted two days ago because
of pneumonia . His condition was improving.
Yesterday night he developed back pain , codeine was given to him in the best
interest of his condition , Unfortunately he developed allergy to codeine with
skin rash and hypotension . he was given anti allergic medication and his
condition was stabilized and was put under close observation. He is known cse
of allergy to codeine before , which is written in the records.
You are SHO of the medical department on call today. You have been asked to
discuss this issue with his son Mr. Amr who is very angry for what happened to
his father.
Introduction:
e Shake hands.
¢ Introduce yourself.
« Confirm the patient identity (May i confirm that you are Mr. Amr son of
Mr. Sami?
Are you next of kin of Mr. Sami?
(We are together today to discuss what happened to your father. Is it ok
with you?)
* Ask the son: May i know how much do you know about your father
condition?
(Let the son to express his feeling and anger without interruption).
Apologizing a lot and admitting the error:

« Fmreally sorry for what happened to your father
¢ I apologize a lot for that incident.
¢ Be sure that any harm was not intended at all.
¢ J admit that what happened is something wrong and not acceptable.
Explain the incident:

May | explain for you more about what happened exactly?
¢ Your father was admitted two days ago because of lung infection. He was
given the proper treatment and his condition was improving.
Yesterday night, he developed back pain, and he was given codeine in the
best interest of his condition. Unfortunately he developed allergy for
codeine with some skin rash and low blood pressure. Codeine was stopped
and he was given anti allergic treatment at once and his condition was
stabilized, and he is under our close monitoring now.
He is known case of allergy to codeine before. This happened mostly
because of breaking of communication or missed information.
Apologize again:
I’m really sorry again for what happened to your father.
1 know how much your father is precious for you.
Your feeling is highly appreciated.
Be sure that we are going to investigate this incident seriously
Explain what actions will be done:

So what we are going to do is:.
Write incident report for what happened.
Inform the consultant and nurse in charge.
Write in clear obvious notes in your father’s file that he is allergic to
codeine not to be given to him in the future.
Discuss this issue in the next morbidity and mortality meeting to avoid this
to happen in the future
Refer this issue to the risk management team to investigate what happen
seriously. Is it OK with you?
The son might be still angry - Apologize again and clarify for him that we are
here to help your father as much as we can , and any harm for your father was
not intended at all.
Social History:
What is your father doing for living? Does his illness impact his job and
usual daily activities? I’m sorry for that I’m going to refer him to a social
worker to solve any social troubles he has, and occupational health care
worker if his job is affected.
With whom your father is living? Are they doing well? Who is supporting
your father at home? Does he need more support at home?
Does he smoke? Drink alcohol?
76
* I'mnot
‘nob defends my colleague, but we are working here as one team, and
all team members are responsible for your father’s condition.
. This iiss dcfinitely olinspore We willties you by referring you to the

patient liaison office, and we will follow up and appreciate the result of
your complaint. And be sure that the plan of management of your father will
not be affected at all
Make summary: About the important points in the meeting. Apologize

and emphasize again.
Help: I'm going to give you the contact number of our department. Please
don't hesitate to contact us any time if you still has any worries..
- Shake hands.
Differences between medical negligence and medical error:

-What is Medical Negligence?
Medical negligence occurs when a doctor, nurse, or other healthcare
professional fails to provide a patient with an acceptable standard of care. This
encompasses many different situations, for example:
* Surgeons and anesthesiologists may be negligent in mistakenly clearing a
patient for surgery; by performing procedures that the patient did not
consent to; or by making mistakes during the procedure that could have
been prevented.
* Radiologists and oncologists may be negligent when they fail to timely
diagnose cancer.
* Hospital nurses and nursing home staff may be negligent when they fail to
communicate important information about a patient to the attending
physician; when they fail to record important data in the patient’s medical
chart; or when they fail to properly position a bedridden patient in order to
avoid bedsores and ulcers.
* Primary care physicians may be negligent when they prescribe the wrong
medication for a patient, or by failing to consult with a medical specialist
regarding a patient’s condition.
e Finally, some of the most regrettable medical malpractice cases involve
birth injuries. This is when infants are permanently disabled, disfigured or
die because of mistakes made by the obstetrician and or the labor and
delivery team.
-What Are Medical Errors?

¢ Medical errors are adverse consequences that occur during the course of
medical treatment but are not the result of negligence on the part of a doctor
nurse or healthcare professional. In many cases, these errors were
unforeseen, unavoidable and due to inherent risks that could not have been
prevented. In other words, the doctor, nurse or healthcare professional did
not fail to provide the patient with an acceptable standard of care.
e Ancxample of a medical error would be a situation in which a patient who
has developed an infection is prescribed a common antibiotic to which he or
she is allergic. Because of this, the patient might, for example, suffer other
medical complications. But unless there was something in the patient's
chart or medical history to suggest to the treating physician that the patient
was allergic to this medication, the act would not be considered negligent.
e Despite the adverse consequences, the physician acted like any other
reasonable physician would have acted under the same circumstances. On
the other hand, if the physician knew that there was a risk of the patient
having an allergic reaction to the antibiotic and prescribed it anyway
without considering more suitable alternatives, a case could be made for
medical negligence.
N.B : Approaching a case of medical negligence is different from approaching

a case of medical error:
> Inacase of medical negligence : You have to apologize , show empathy
and sympathy , admit the medical negligence and take actions for
investigations that mentioned in the scenario.
> Inacase of medical error : Your task is show your empathy and sympathy,
explain the whole condition and event to the patient or the relative,
Explaining that medical errors can happen in the medical field and no
medical negligence exist .
You don’t have to make these action of investigations.
Scenario: Mr.Gamal is 65 years old. He sought medical care today morning after complaining
of chest pain. ECG and cardiac enzymes done and revealed Anterolateral ST segment clevation
uM
PCT done for him in the best interest of his condition after discussion of risk versus benefits and
$e Sgned a consent. Unfortunately his condition was deteriorated after PCI And was transferred
@ the ICU, and had cardiac arrest, Resuscitation done for him but unfortunately he passed away.
Yeu xe SHO of cardiology department on call today. You have been asked to discuss this issue
wh Mr. Rami his son who just came asking for his father condition .
tetroduction:
Shake hands.
introduce yourself,
Confirm the son’s identity and ask if he is the next of kin.
Ask if he want any one of the family members o attend the meeting .
Ask the son : May I know how much do you know about your father condition ?
Explain to the son the condition of the father and break the news
gradually:
Your father sought medical care in our emergency department today moming complaining of
chest pain. Blood tests and heart tracing done for him and unfortunately, it revealed that he
had severe heart attack with extensive blockage of the blood supplies of his heart.
An urgent lifesaving procedure done for him in the best interest of his condition which is
called (Percutaneous Coronary Intervention).
It isa procedure done to dissolve the blood clot in the blood supplies of his heart.
Without this procedure, he was going to pass away.
The risk verus the benefits was explained to him in details. He agreed to do the procedure
and signed a consent for that.
Percutaneous coronary intervention procedure is like any other procedure, has its own
complications.
Unfortunately your father condition was deteriorated after this procedure, and was transferred
to Intensive care unit to be given the best care. Then, he had heart arrest . Maximum efforts
were done to resume his heart again. But unfortunately ... he passed away:® .
Stop for a while and let the son to express his feelings.
( Here, the son may show denial or anger)

Showing empathy and sympathy for the son:
¢ I'm really sorry for you.
My decp condolence to you.
| highly appreciate your feeling.
i know bow much theses news are hard for you.
Be sure that we did our best to save your father’s life .
Managing the medical errer:

The son angry:
-Did you kill my father doctor?
-Of course that happened because of some sort of medical negligence..
-How dear you to do such procedure without informing us?
I really appreciate your feeling again.

Be sure that we did our best effort to save your father’s life.
Your father presented with very advanced condition of heart attack.
Therefore, this procedure was done for him in the best interest of his condition (0 save his
life.
Without this procedure, your father would pass away at once,
¢ Your father was completely competent and had full mental capacity to made a decision .. All
the information of the procedure including the advantage and complications was explained to
him, and he agreed .. So the procedure was done urgently to save his heart and his life,
¢ Most probably, he passed away because advanced bicod clot in his heart> Moreover, any
procedure could have complications which are well known, Not all procedures have 100%
success rate.
* Does this make any sense for you ?
Show empathy and sympathy again:

e I'm sorry again Mr. Ramt -
¢ All the medical team members are feeling sorry for your loss.
« We tried our best to save his life . He is a loss for us too.
Social History:
May ! ask some social questions if you don’t mind?
® With whom your father was living? Are they doing well ? Any one of them needs social or
financial support?
c oncerns:
e Your concern is highty ica, I'm not defending my cillesene ban we 9 arescare
here as one team, and all of team members are responsible for your father's condition,
Se tear . 2
© Definitely this is your right, We will help you by referring you to the patient advice
liaison office, and we will follow up and appreciate the result of your complain, Any other
concem?
* The death certificate will be released by the coroner.

* We will contact him soon to release it, to avoid any delay of the funeral ceremony .
Summary : About the important points of the discussion and showing your empathy and
condenses again.
Help : Do you need anyone to drive you home?
N.B:
Approaching a case of medical negligence is different from approaching a case of medical error:
» Inacase of medical negligence: You have to apologize , show empathy and sympathy ,
admit the medical negligence and take actions that mentioned in the medical negligence
scenario before.
> Inacase of medical error: Your task is show your empathy and sympathy, explain the whele
condition and event fo the patient or the relative, explain that errors can happen in the
medical field and no medical negligence exists.
You don’t have to make any action of investigations for this incident.
Scenario; Mr Salem is 60 years old, He was admitted 3 days ago with a diagnosis of
urinary tract infection. He was given ceftriaxone 2 GM OD in the best interest of his
condition, Yesterday night, he started to develop bloody diarrhea. Stool workup revealed
a diagnosis of Pseudo membranous colitis as a side effect of ceftriaxone.
You are SHO of the medical department on call today. Mr. Ahmed his son asked to
discuss this incident with you.
Introduction:
¢ Shake hands.
© Introduce yourself.
Confirm the patient identity
Confirm he is next of kin of the patient.
Confirm if he had permission from his father for discussion.
Can T know how much do you know about your father’s condition?
(The son will tell you the story of antibiotic and diarrhea as a complication, He may
show his anger and satisfaction).

¢ [’m really sorry for what happened to your father.
¢ [highly appreciate your fecling.
e | understand your anger.
® Be sure that we are here to give your father the full care and the proper management,
Explanation of the father’s condition:

May i explain to you more about your father’s condition if you don't mind ?
¢ Your father was admitted three days ago because of infection of his water system.
e He was given antibiotic called Ceftriaxone in the best interest of his condition, which
is 2 broad spectrum antibiotic against a wide range of bugs.
e Without this antibiotic, your father condition might deteriorate and the infection
might spread and threaten his life,
Explanation of the side effect of the medication:

¢ Asany medication, ceftriaxone has its own side effects which are rare ,
¢ Unfortunately your father developed diarrhea secondary to a bug in his bowls called
clostridium difficile.
¢ This bug is normal habitant in the bowls, but sometimes can be harmful with some
types of antibiotics. !t is a rare side effect, but can happen some times.
sd
¢ We stopped the antibiotic at once and give another alternative to his infection and
started another antibiotic to his bowl infection. His condition is stabilized now.
Management plan for CDF infection:

* Isolation: So, as 2 management plan we are going to isolate your father in a special
room with special contact rules according to our policy to prevent his bowel infection
to spread to other patients in the hospital,
¢ So, don’t worry about this action, it is just infection control mules. Therefore, don’t be
bothered if we wear special gowns and gloves until his infection is cured.
¢ We started antibiotics for his bowel infection, which will be given per mouth for 10
days.

I'm really sorry again for this side effect of antibiotic. I highly appreciate your anger and
pain. Be sure that we will do our best to give him the proper care and management .
Social history:
¢ What is your lather doing for living? .. How much his illness impact his job and
usual daily activities? , Refer the patient to an occupational health worker if his job
is affected. Refer to a social worker if his social life is affected .
With whom he is living? Are they doing well ? Who is supporting you at home?
Does he smoke at all, drink alcohol?
Concerns ;Do you have any concerns?

would likeke to
to know the name of
kine
rescribed this antibiotic?
¢ | appreciate your concern, We are working here as one team. The all team
members are responsible for your father’s condition.
© This is completely your right. 1 will refer

you to the patient advice liaison
office for that, We will follow the result of your complaint, and be sure that
your father is going to receive the proper care regardless your complaint.
Make a summary: About the important points of the disease and management.
Check understanding: Check how much the patient got from the discussion ?
ner Emphasize again.
i'm going to give you some leaflets, brochures, websites to read more about the
antibiotic given to your father and incidence of side effects. I will, give you some
leaflets about the bowel infection he has as a result.
¢ 1 will give you the contact number of our department so that, you can contact us any
time if you have any worrics or queries.
Shake hands.
Notes on the case:

A side effect of a medication or a procedure is not a medical error or negligence.
A side effect of a medication is not uncommon,
Don’t mention name of any of the medical stuff to the patient. All the medical team is
responsible for the case,
¢ The patient has the right to complaint always; don’t persuade him not to complain.
Scenario: Mrs. Amira is 29 years old. She was admitted three days ago as a
case of pulmonary embolism. The hematology consultant prescribed warfarin
for her in the best interest of her condition.
She read about warfarin side effects on the internet, and she is very worried
about this drug.
You are SHO of the medical department. You are asked to discuss this issue
with Mrs. Amira,
Introduction
Shake hands.
Introduce yourself.
Ask the patient: Can i know how much do you know about your condition?
Ask how much information you got about warfarin?
Explain the condition of the patient simply without jargons:

¢ You have been admitted three days ago because of a blood clot in the
blood supplies of your lungs, which is a life threading condition.
Advantages of warfarin:
e That is why, the blood doctor prescribed to you warfarin as a blood thinner
medication in the best interest of your condition.
e¢ Warfarin works by thinning your blood to prevent further extension of the
clot and prevent another blood clot in the future.
¢ Warfarin is very important drug in your condition and you have to be
completely compliant on it to control your condition.
¢ On warfarin, your condition will be well controlled, and the chance of
further blood clots will be extremely rare, and you can live near normal life.
¢ Without warfarin, your condition may deteriorate and you may have
recurrent blood clots in the future which may threaten your life.
85
Disadvantages of warfarin:
e Like any other medication, warfarin has its own complications, like
increased blood thinning which may leas to bleeding from anybody orifice
or even bleeding in the brain .
e Outweighing the risk versus the benefits of warfarin, the benefits are
extremely more.
Explain how to overcome these complications:

¢ To overcome such complications, we are going to refer you to a special
clinic called (Coagulation clinic) with a special card containing your
warfarin dose and blood thinning value for regular follow up, and regular
checking of your blood thinning value to keep it within target range which
is (2-3).
« If we kept the range of blood thinning range within (2-3 ) the chance of
bleeding will be extremely low.
Special Advices:
New medications:
e Ifyou are going to receive any new medication, you have to inform you
blood physician as many medications may interact with warfarin and may
alter its efficacy.
Diet:
+ Some types of food may alter warfarin effect as well. So we will refer you
to a dietician to write the list of types of food you have to avoid.
Vigorous sports:
e You have to avoid vigorous sports like rugby and football to avoid head
trauma and bleeding under the skin and muscles.
Pregnancy:
e May i ask if you have a partner? Are you planning for pregnancy?
° Ifyou are planning for pregnancy any time, you have to inform your
women and blood doctor to make a MDT to give you the full care during
your pregnancy
e Warfarin can be harmful to the baby. Thus, during pregnancy it will be
exchanged with another thinner medication given under the skin which is
safe during pregnancy.
Social History:
* What are you doing for living?
¢ How much your illness may affect your work and social life? (Refer the
patient to an occupational health care worker if his work will be affected,
and to social worker if his social life will be affected)
With whom you are living? Are they doing well? Do they support you?
Do you smoke at all ? Do you drink alcohol? .
Smoking may change work of warfarin. So that, you are advised to stop
smoking. We can help you by referring you to the smoking cessation clinic.
Alcohol also may interact with warfarin and change its action.
Concerns:
ar) fs, a
aT
+ It varies from one patient to the other. This will decided by the blood
doctor according to the underlying causes and risk of recurrence (Provoked
versus unprovoked)
e Warfarin is prescribed by the blood consultant in the best interest of your

condition. Any other alternative can be discussed with him.
Make a summary: About the important points of the meeting

(Importance versus complication and how to overcome side effects ,
and special advices)
Check understanding: Can i ask how much you did get from our
discussion today?

¢ I'm going to give you some leaflets, brochures and websites to read more
about the warfarin.
* Iwill give you the contact number of our department to contact us any time
if you have any worries.
-Shake hands
Scenario: Mrs. Mona is 23 years old, was admitted three days ago with
history of recurrent loose motions for the last two months. Colonoscopy was
done for her, and a diagnosis of ulcerative colitis was confirmed, she was
prescribed Steroids by the gastroenterology consultant .
She read about steroids side effects on the intemet, and she is very worried
about this medication.
You are SHO of the Gastroenterology clinic, you are asked to discuss this
issue with Mrs. Mona.
Introduction:
Shake hands.
©
Introduce yourself.
@ -8:

@
Ask the patient: How much do you know about your condition.
@
Ask what information you read about Steroids?

Ss
Explain the condition of the patient simply without jargons:

e Ulcerative colitis is long standing soreness of the bowls due to disturbance of
your defensive system.
e tis along standing disease causing recurrent loose motions, tummy pain,
anemia, fatigue, electrolyte imbalance and loss of weight.
Advantage of Steroids:
® Steroids are prescribed to you in the best interest of your condition to adjust
your defensive system and control your condition.
e Steroid is very important drug in your condition, and you have to be
completely compliant on this medication to control your condition
and to avoid complications of the disease.
e You will receive steroids for a time will be decided by the bowl
physician until your condition is controlled.
Disadvantage of Steroid:
e Steroids like any other drug has its own complications , like weight gain ,
thin skin, linear rash, easy bleeding , abnormal hair growth , stomach
soreness , high glucose level, high blood pressure, fragile bones,
diminished defensive system, But ...
Explain how to overcome these complications:
But, most probably you are going to receive high doses during the flaring
up of the attacks for short time to decrease the course of the attack. You
may continue on small dose with less profile of side effects.
We are going to give you regular follow up to check for any side effect of
the drug to manage al once,
For stomach soreness , you will give you oral tablets to protect your
stomach.
We will check your glucose level and blood pressure and electrolytes
regularly for any disturbance.
For fragile bone we will give you calcium supplementation to preserve
your bone density.
And we will follow up any infection to be treated properly.
Outweighing the risk versus the benefits of steroids, the benefits are
extremely more.
Without Steroid, your condition will be deteriorated, and you may have a
lot of complications of the disease.
With steroids your condition will be controlled, and the chance for any
complication will be low, Is it ok with you?
Pregnancy: May | ask if you have a partner? Are you planning for
pregnancy? - If you are planning for pregnancy any time, you have to
form your women doctor and bowel doctor to make a MDT to give you
the full care and proper management during your pregnancy.
Social History:
What are you doing for living? How much your illness affects your work
and social life? (Refer the patient to an occupational health care worker if
her work will be affected , and to a social worker if her social life will be
affected)
With whom you are living? Are they doing well Who is supporting you at
home?
Do you smoke at all? Do you drink alcohol? .Drinking alcohol mat flare up
your condition. So , you are advised to follow the dietician
recommendations regarding alcohol.
ee ae concern, Steroid was prescribed iin the best interest of

your condition by the bowel consultant who is expert in such cases.
. ‘Tt varies from one patient to the other, This will be decided by the
bowel doctor according to the disease activity and control.
Make a summary: About the important points in the meeting.
meeting today?
Help:
¢ hope I covered all your worries about steroid therapy
e I’m going to give you some ieaflets and websites about steroids, to read more about it.
¢ I will give my contact number , If you have any worries or queries , please don't hesilate to
contact me,
~- Shake hands.
Scenario : Mr. Sami
is $3 years old known case of bronchial asthma
Me was admitted 3 days ago with SOB. Further investigations revealed heart failure. His
condition showed dramatic improvement with diuresis. Therefore, he is prepared for
Sscharge. One of junior doctors prescribed him Bisoprolol on discharge.
The pharmacist called the nurse and wamed her that bisoprolol is contraindicated in BA .
The patient heard that conversation and asked to meet you.
tetroduction:
Shake hands.
Introduce yourself.
Confirm Agenda of meeting (1 have been asked to discuss some issucs related to your
condition, Is it alright with you now?
* Ask how much the patient knows about your condition and concerns he has ?

You have been admitted 3 days ago because of shortness of breath. Further
investigation unfortunately revealed that you have heart failure causing salt and water
retention in the lungs and the whole body,
We started treatment at once with water medications to alleviate your symptoms. Your
condition showed dramatic improvement. Now you are candidate for discharge.
You have to continue on some medications in the long mun to control your heart failure
and to prevent further flaring up of heart failure.
importance of Bisoprolol :
One of these medications is Bisoprolo! . Bisoprolol is so crucial medicine in cases of
heart failure: It slows the heart rate and decreases the heart load of blood.
It is highly selective medication in small dose, acting mainly on the heart muscle with
minimal impact on the lung airways.
It decreases chances of flaring up of heart failure and readmission rate. Even it
decreases chances of death secondary to heart failure.
It could be contraindicated in cases of sever uncontrolled bronchial asthma. But it is
well tolerated in cases of mild to moderate BA with minimal effect on airways of the
tung .
Outweighing the risk versus the benefits of bisoprolol , the benefits are extremely
more. That is why bisoprolol is prescribed to you by our consultant in the best interest
of your condition. .. Does it make any sense for you?
Explanation of the situation of the pharmacist :
e Pharmacist is one of the medical team here in the hospital .
¢ Hes highly appreciated to review every prescribed medication for the safety of every
patient.
e Most probably, he is not aware about the whole condition and your status of heart failure,
That is why he called the nurse in charge regarding bisoprolol.
e Weare going to contact him for justification of bisoprolol in your condition,
Social history:
Can | ask some social questions if you don’t mind ?
e What you are doing for living? .. How much your symptoms may affect your job and
life?- 1 will refer you to the social worker if your social life would be affected and to
an occupational health care worker if your job could be affected,,
With whom you are living? Are they doing well? Who is supporting you at home?
Do you smoke at all ( If smoking ~ didn’t you think to give up smoking ? .
We can help you by referring you to the smoking cessation clinic . Smoking definitely
will worsen your heart fajfure and bronchial asthma - Do you drink alcohol ?- You are
advised to stop alcoho! intake as it worsen heart failure as well,
Concerns:
These is no alternative medication with no side effects
at all doctor?
¢ Bisoprolol is one of the best medications prescribed in your condition,
¢ — It was prescribed in the best interest of your case to control your heart failure with
significant decreased chances of readmission and deaths.
Make summary: About the important points of mecting..

e I'm going to give you some leaflets , brochures , websites to read more about the
disease and role of bisoprolol in both heart failure and bronchial asthma patients,
© Twill give you the contact number of our department to call us any time if you have
any worries Or queries,
N.B:
Your main task here is:
¢ Counseling for a medication ( Bisoprolol in heart failure here) .
© Importance of bisoprotol.
* Justification of the situation of the pharmacist.
% Ofcourse bisoprolol is prescribed by the junior doctor according to the
recommendation of the consultant, as junior doctors are not allowed to prescribe
medications by their own.
Scenario: Mr. Hend is 34 year old. She is known case of diabetes mellitus type! on insulin.
Her HBAIC in the last visit is 10.5. The diabetic nurse assume that her uncontrolled diabetes
is most probably due to non-compliance on insulin.
You are SHO of the diabetic clinic. You are asked to discuss this issue with her.
Introduction:
¢ Shake hands.
«Introduce yourself.
«Confirm the patient identity.
¢ Confirm agenda of meeting and take permission to start.
« Ask the patient: How much do you know about your condition?
Explanation of the result of HBAC(Avoid confrontation):

* The blood result of HBAIC. Which measures diabetes control in the last three months is not
as we hope. It was measured as 10,5, which is a high reading. Actually, We have to keep it
less than 6.5.
* That means that your diabetes is not controlled. This is due to non-adherence to diabetic
medications in most of the cases. What do think about that Mrs. Hend?
e Here the patient may deny non-compliance.
¢ Mrs. Hend , be sure that we are here not to judge you , we arc here to help you.
Exploration about reasons of noncompliance:

= Some people are not adherent on their medications because of forgetfulness, needle phobia,
bad experience , social or occupational issues.
* Can i know if you have any of these reasons?
Explanation about complications of uncontrolled diabetes:

Compliance on your medication is very important to control your DM and avoid short and
long term complications of high glucose level :
Short term complications:

> Short term complications of uncontrolled DM is loss of weight, increased thirsty and
increased water work frequency.
> Very high level of glucose can be serious and may result in diabetic coma, I'm sorry to tell
you that.
Long term complications:
> Long term complications of uncontrolled diabetes includes visual disturbance due to
impaction on the back of the eyes , pins and needles in the hands and feet due to impaction
on the nerve cables
> Deterioration of the kidney function, impaired healing of the wounds , easy infection due to
impaired defensive system and exposure to heart attacks in the future.
© But. If you are became completely compliant on your medications, your glucose level
would be well controlled, Therefore, you can avoid all of these complications and you
can live near normal life.
Offer solutions to the patient:

We can offer you some solutions to help your compliance:
e If you are not adherent because forgetfulness: We can help you by giving you reminder aid
device to remind you every time for your injection.
© Ifneedle phobia: We can refer you to the diabetic nurse can teach you or one of your family
members how to inject you in a perfect way.
¢ Other important options to heip adherence :
* Nowadays there are a lot of different advanced devices and equipment for treatment of DM.
* One of them is insulin pump to avoid repeated injection. I will refer you to the diabetic nurse
to explain to you the different devices. Then, you can choose the most suitable one for you .
fs it OK with you Mrs. Hend?
Life style modification:

Beside drug compliance, you have to make some life style modification to help your diabetes to
be controlled;
¢ Daily Exercise is very important for diabetes control. We can refer you to exercise
training program for more education about the best exercise regimen.
¢ Diet control is very crucial as well. We will refer you to a dietician for more
education about regular dict adjustment.
Social History:
© What are you doing for living? - How much your illness affect your job and usual daily
activities? Refer the patient to an occupational health worker if her job is affected. Refer to a
social worker if her social life is affected.
e Any history of low glucose level recording or loss of consciousness due to low glucose (Is
there is, advice the patient to stop driving and inform DVLA.
¢ With whom you are living? Arc they doing well? Who is supporting you at home?

ere sl
‘tlie
Nowadays there are a lot of different advanc

* One of them is insulin pump to avoid repeated injection. I will refer you to the diabetic nurse
to explain to you the different devices. Then, you can choose the most suitable one for you. Is
it ok with you?
eke 2 summary : About the important points in the meeting.
\Seck understanding : Can 1 know how much did you get from our discussion today?
Beis:
* Tm going to give you some leaflets , websites about DM and new devices and equipment
of treatment.
* fm going to give you my contact number, if you have any worries or queries please don't
hesitate to contact me any time.
~ Nice to meet you - Shake hands.
Notes on the case:
Ethical issues:
»* Autonomy — Maleficence — Non maleficence — Justice.
» Avoid confrontation and criticism for noncompliance.
* Offering solution in this case is so crucial such as proper teaching for needle injection and the
most important, insulin pump.
Scenario: Mr. Khan is 35 year old . He had been diagnosed to have lung
tuberculosis. Anti TB medications were started 4 months ago .
Today , during his follow up in the outpatient pulmonology clinic chest x
ray was repeated and showed deterioration of his lung condition.
The nurse in the clinic highly assumed that Mr.Khan is not compliant on his
medication.
You are SHO in the chest clinic today. You have been asked to discuss with
his the chest x ray findings and the possibility of noncompliance.
Introduction:
e Shake hands.
¢ Introduce yourself.
¢ Confirm agenda of meeting and take permission to start.
¢ Ask the patient: How much do you know about your condition and how do
you feel now?
Explanation of the result of x ray and possibility of noncompliance {Avoid

confrontation);
e Well Mr.Khan , The result of repeated chest x ray has been released and it is
not as we hope.
It revealed detcrioration of your lung condition than before.
In such cases, noncompliance is the main reason for deterioration of the
lung condition and delayed improvement . What do think about that?
e Mr. Khan, be sure we are here not to judge you , we are here to help
you.
Exploration about reasons of incompliance without criticism:

¢ Some people are not adherent on their medications because of forgetfulness,
bad taste, large numbers of tablets or side effects of medications.
e Can i know if you have any of these reasons?
Complications of noncompliance:
I would like to inform you about complications of noncompliance on Anti
tuberculosis medications:
¢ Noncompliance results in delayed improvement of your lung infection and
subsequent deterioration of your breathing, which may Icad to failure of
breathing and death . I’m sorry to tell you that , but I have to be honest with
you.
e These superbugs may spread to other organs like , the kidney , the bone and
the brain leading to deterioration of the general condition and difficulty of
management.
* Noncompliance also leads to development of resistant bugs , which may
need longer period for treatment.
Solutions to help compliance:

e If because of forgetfulness: We can help you by giving you reminder
aid device to remind you every time for your tablets.
* If because of large number of tablets: We can offer you combined
tablets called Refinah , which is a combination between Rifampicin
and Isoniazid .
¢ Direct observed therapy (DOT therapy): We have what is called
observed direct therapy, where there is TB team who can visit you at
home and give you the tablets under their observation 3 times per
week. What do you think about that?
Social Histery:
e@ What are you doing for living?- How much your illness affect your job
and usual daily activity? Refer the patient to an occupational health
worker if his job is affected, Refer to a social worker if his social life is
affected.
® With whom you are living? Are they doing well? Who is supporting
you at home?
> Advice the patient to stop smoking and help him by referring him to a
smoking cessation clinic , clarifying the risk of smoking on his lung
condition . Advice to stop alcohol as well.
C oncerns: Do you have any concerns?

SS the medi ications |
-mescications
Well, ‘A MDT fro the infectious discase hase aaa ine iesare eae to
assess you condition and to decide to continue the course of antibiotics or to
start from the start.
The MDT font Wie did tnfectioes disease consultant will decide according to
the presence of active bugs in your sputum analysis.
Check understanding: Can i know how much you did get from our
meeting today?
Hielp: I'm going to give you some leaflets and websites about Lung
tuberculosis and importance of adherence of medications
I'm going to give you the contact number of our department , if you have any
worries or queries please don't hesitate to contact us any time.
- Nice to meet you - Shake hands.
Notes on the case:
Ethical issues:
> Autonomy — Maleficence — Non maleficence — Justice - Honesty.
®» Avoid confrontation and criticism for noncompliance.
Legal issues :
>» The need for isolation if acid fast bacilli was positive in sputum.
> Isolation can be done at home if the circumstances at home are suitable for
isolation and the patient will be adherent to instructions of isolation.
Scenario : Mrs. Soha is 27 years old. She has been complaining of chest pain and shortness of
breath for the last two days. Ct angiography wad done foe her and 2 diagnosis of pulmonary
embolism had been confirmed. She is asking for discharge.
You are SHO on call today in the internal medicine department. You have been asked to discuss
this issue with her.
Introduction:
Shake hands.
Introduce yourself,
Confirm Agenda of mecting.
Ask May i how far do you know about your condition?

* The result of the scan has been released, and I’m sorry to tell you unfortunately it is not as we
hope .. Stop for a while.
* It revealed that you have a blood clot in the blood supplies of your lungs , a condition called
pulmonary embolism. .. Have you ever heard about this condition before?
* Is it serious condition Dr? It can be serious if untreated, but we are going to give you full
care and proper management.

* Pulmonary embolism is a blood clot in the blood supplies of the lungs. .
* Itisa result of thickening and stagnation of the blood in the blood conduits .
* This could be due to immobility, long journey, post-surgery or some medication like oral
contraceptive bills. Sometimes . it can happen without obvious cause.

* Symptoms of the disease vary from onc patient to the other according to the size and site of
the blood clot.
* It could be presented by chest pain, cough, coughing up blood, shortness of breath, racing of
heart beats and may be sever hypotension and shock in severe cases.
« I'm sorry to tell you that this condition is so serious and may be life threatening if untreated.
( Hard news)
* But fortunately treatment is available with very good outcome. (Reassurance)
(Always follow hard news by reassurance)
99
Treatment plan:
Admission: So that , you should be admitted for close observation and strict medical care
Anticoagulation: We are going to start a blood thinner medication fo thin your blood and
prevent further extension of the blood clot and. You will receive a blood thinner drug for few
months to prevent another blood clot in the future .
Referral to a MDT: We will refer you to a MDT including a blood doctor and a lung
doctor to assess your condition and decide the long term plan of proper blood thinner
medication.

How do feel now Mrs. Soha?
I'm really sorry for this bad news today.
I highly appreciate your feeling.
Be sure that we are going to give you the full care and the proper management
I want to reassure you that the outcome of the condition is very good on the blood thinner
medication.
(Use empathic eye contact, body language and voice tone)
Social history:
May | ask some social questions of you don’t mind?
e What do you do for living?.. How much your illness would affect your job and usual daily
activities? We will refer you to the occupational health care worker to give you medical
report for a sick leave,
With whom you are living at home? Are they doing well? Who is supporting you at home?
Do you smoke at all? Do you drink alcohol? - Smoking may aggravate blood clot in the
future, Thus you are advised strongly to give up smoking. We can help you by referring you
to the smoking cessation clinic.
Are you receiving any oral contraceptive bills? - OCP may trigger blood formation too, So
that
if you think any time to use contraception , please inform your blood doctor and women
doctor to give you the proper contraceptive method which is safe in your condition.
eee Do _—shave any concerns??
. - Your mans ‘highly pe ‘We a amie tbe maa serie tie now to solve this
problem. She will provide them with appropriate care during your admission. Is it ok with
you?
* I would like to clarify again that this condition is serious if not treated well. It could be life
threateningas well.
* Therefore, admission in the hospital is crucial to be under close observation and to receive
the proper medical treatment,
Af still insist.
I'm going to involve my consultant now to convince you more about admission.
You have the right to be discharged if you insist.
If you insist, you have to sign a form of discharge against medical advice.
We will be prescribed the blood thinner medication on discharge with follow up
appointment.
* You have the right to come back to the hospital any time if you changed your mind or felt
unwell.
Make a summary: About the important points of discussion and management plan.
Check understanding: Can I know how much you did get from our discussion today?
Help:
* I'm going to give you some leaflets and websites about blood clot in the lung and importance
of admission and close observation.
* Iwill give you the contact number of our department to contact us any time if you have any
worries or queries.
Notes on the case:

You have two tasks here:
* Breaking bad news of pulmonary embolism.
* Managing the concern of insistence on discharge:
» Your task is to convince the patient to be admitted.
> Solving the obstacles of admission like any social dilemma.
> Clarifying the complications of the disease and the risk of discharge
Ethical issues:
» Autonomy ~ Beneficence— Non maleficence- Justice - Honesty.
Legal issues:
> Signing a form of discharge against medical advice (DAMA form) after Solving the
obstacles against admission, like any social dilemma, and explanation of the complications
of the disease and the risk of discharge,
> The patient has the right to receive treatment on discharge and followup appointments.
> The patient has the right to seek medical care again if she if she changed
her mind or felt
unwell any time.
Scenario: Mrs. Liala is 23 years old. She was admitted two days ago with suicidal attempt
after intake of twenty tablets of paracetamol. Initial blood investigations done for she came back
as normal, She is asking for discharge.
You are SHO of the medical department on call today . The nurse in charge called you to talk
with Mr. Liala.
Introduction:
Shake hands,
e Introduce yourself.
e Confirm the patient identity.
e Confirm agenda of meeting and take permission to start.
( Lhave been called by the nurse in charge telling me that you are asking for discharge. Can
we talk about that if you don’t mind)
How do you feel now Mr. Laila?
Can i know how much do you know about your condition?
Circumstances of the suicidal attempt:

To assess the patient liability for further suicidal attempts in the future: May I know what
happened exactly?
What happened before?
vee
Do you have History of similar attempt in the past ?

Did you write any suicidal notes?
What happened during?
How many tablets did you take?
vvve
Did you take any other tablets or alcohol?

Did you lock the door form inside?
What happened after?
VVV*°
Did you call for help? Did you feel any regret?
Do you still have any suicidal thoughts?
Is life still precious for you?
why the patient want to go home and fry to solve her troubles:
May i ask why do you want to go home ?
Patient: The nurse stuff has bad attitude here doctor,
I'm sorry for that. I’m going to talk to the nurse in charge in this regards , and i promise they
will improve their attitude .
Patient: They banned me from smoking doctor?

You: Didn’t you think about giving up smoking before, we can help you by referring you to
smoking cessation clinic to help you giving up if you don’t mind., Is it Ok with you?
2
Patient: The food quality is so bad here doctor?
You: I'm sorry for that. I'm going
to talk to the chief in charge,
and i promiseto improve the
food quality and provide you with the of food you like. Is it ok for you?
The patient still insists

to go home.
Explain complications of paracetamel overdose:

* Paracetamol overdose may be asymptomatic with normal blood tests in the first two or three
days.
* But it may carry high risk later on in the form of :
> Deteriorationof liver function, and may be liver failure in the late stages. This could be
followed by deep coma, And in advanced stage liver transplant may be needed,
> Deterioration of kidney function, and may be kidney failure in late stages.
> Blood thinning and exposure to casy bleeding duc to decrease level of clotting factors.
7 Increase blood acidity, and deterioration of whole the functions of the body organs. It could
be like threating later on.
importance of admission and risk of discharge:

* That why , you should be admitted under our observation for at least five for regular
checking of your liver function and kidney function
* The admission is in the best interest of your condition until confirming that your condition
is stable, and you are completely free from any complications mentioned before.
* Ifyou developed any complications any time while being away from hospital, your like
could be threatened.
Patient: Thank you doctor. | feel ok now. I just want to go home?

(The surrogate task here is to insist to go home
You: I'm going to involve my consultant soon to convince you more,

and a psychiatrist to assess your condition before discharge .. Is Ok with you?
(Avoid confrontation).
Social history:
* What
are you doing for living? Does your mood affect your job and your social life?
~- Refer
the patient to an occupational health care worker if her job is affected and to a social worker
if her social life is affected.
* With whom you are living? Are they doing well? Who is supporting you at home? Do have
any social troubles? We have a social worker here, who can talk with you and help you if you
have any social dilemma.
* Do you smoke at all? Drink alcohol?
at if T inst to go home doctor’

+ For yourx aly, I'm going to inform my consultant and a psychiatrist to assess your
condition. And accordingly, we are going to make our plan.
eo A Pcie not ri mad come only. HHe isis maaniging people with low mood as well.
We hope he can help you regarding your bad mood.
Make summary: About the important points in the meeting
Check understanding: Can I know how much you did get from our discussion today?
Help:
¢ I'm going to give you some leaflets and procure about paracetamol over dose to be aware
about its complications.
¢ I’m going to give you the contact number of our department to contact us if you still have an
worries or querics. .
~ Shake hands
Notes
on the case:
¢ The surrogate task here is to insist for discharge.

Your task is to convince the surrogate kindly to stay for further investigations, and
observation. You have to explore the reasons for asking for discharge, trying to solve any
dilemma for her, clarifying the risk of early discharge.
¢ The legal issue here is : This lady is not allowed to go home before assessment by a
psychiatrist
Avoid confrontation with the patient, and try to convince her kindly without judgment,
If the psychiatrist sees that she still has suicidal thought. Therefore, she isnot allowed to go
or sign against medical advice. And if she insists for discharge, she has to be kept under the
mental act.
¢ The patient could be detained in section 5(4) or section 5(2),
Section 5(4) gives nurses the ability to detain someone in hospital for up to six hours until
y
to be assessed by a doctor.
Section 5(2) gives doctors the ability to detain someone in hospital for up to 72 hours,
Vv
during which time you should receive an assessment that decides if further detention under
the Mental Health Act is necessary.
Scenario: Mrs. Lila is 55 years old known case of diabetes and hypertension.
She had been complaining of severe headache sisnce yesterday night. CT brain
done for her and a diagnosis of subarachnoid hemorrhage was confirmed.
You are SHO of the neurology department on call today. You have been asked
to discuss the result and further concerns to her.
Introduction:
Shake hands.
Introduce yourself.
May I know how much do you know about your condition?

« The result of your imaging has been released, and unfortunately it is not as
we hope.. Stop for a while.
* Itrevealed that you have some sort of bleeding in the brain called
Subarachnoid hemorrhage.. Stop for a while ( let the patient to express his
feelings and thoughts) .

e I’m really sorry for that.
* | understand how much these news could be hard for you.
¢ Ihighly appreciate your feelings.

Do you want to explain to you more about this condition Mrs. Lila?
¢ Itis bleeding in one of the brain cavities. This could happen due to
trauma, high blood pressure or rupture of some abnormal balloon
dilatation of one of the blood supplies of the brain.
105
¢ The symptoms may vary from mild to serious symptoms.
e Itcan be presented in different symptoms like headache, visual disturbance,
feeling sick, getting sick, and can be presented in serious symptoms like
altered conscious level , deep coma and seizures
e [I’m sorry to tell you that it is a serious condition and can be life threatening
if untreated.
Management plan:
¢ Management plan will includes urgent referral toa MDT team from a nerve
doctor, a brain surgeon , a social worker and an occupational health worker
to give you the proper care and management plan.
e Anurgent meeting will be done between the nerve doctor and brain surgeon
to decide for you the proper plan of management in the best interest of your
condition.
In most cases, medical treatment is the treatment of the choice.
You have to be admitted under closed observation to follow any further
complications.

e I'm really sorry again Mrs.Lila.
e [know how much these news are hard for you.
e Be sure that we are going to do our best to give you the proper care,
Social history:
e What are you doing for living? .. How much your illness could impact your
job and usual daily activity? .. Refer the patient to occupational health
worker if job could be affected. Refer to social worker if his social life cold
be affected.
e With whom you are living? Are they doing well? Who is supporting you at
home?
Do you smoke, drink alcohol ?
Concerns:
Do you have any concerns?
I want to go home doctor
Patient : I want to go home , just give me medications and I’m going to receive
them at home.
You : Can | know why do you want to go home ?
(Solve any dilemma the patient has)
Patient : | have some social commitments , as my children at home and no one
will take care of them.
You : I’m going to contact the social worker who can manage this problem and
will provide them with the full care during your admission.
Risks of discharge:
¢ I’m sorry to tell you again this condition is so serious, and can be life
threatening if untreated properly.
¢ Admission is crucial in your case to receive the appropriate treatment to
prevent further complications of bleeding, and to be under our close
observation for any further complications.
¢ This condition may be complicated by serious events like seizures) , deep
come , and I’m sorry to tell you that it may threaten your life.
If the patient insist

Ok I'm going to involve the nerve consultant right now to assess your condition
before discharge.. Is that ok for you?
Summary: About important points of the disease and management plan.
Check understanding: How much did you get from our meeting today?

* I'm going to give you some leaflets, brochures and websites to read more
about the disease .
¢ | will give you the contact number of our department to call us any time if
you have any worries.
~- Shake hands.
N.B: Mental capacity

* We have a legal issue here: This patient may lacks mental capacity to make
a decision of discharge against medical advice. Subarachnoid hemorrhage
may affect the mental status of the patient. Therefore, if the patient insists to
be discharged against medical advice, she should be assessed by a
neurologist to assess her Mini mental score before discharge.
* IfMMS conformed that the patient has lack of capacity , then she has th be
admitted under the mental act.
* Your task is to convince the patient for admission by solving any social
commitments and clarification of the risks and complications of the disease.
¢ Avoid confrontation.
Scenario: Mr. Salem is 65 years old. He was admitted two days ago as a case of
community acquired pneumonia with CURB 65 score of 5, There was no bed available in
the hospital at that time. Therefore, he was admitted in the surgical ward.
His line was dislodged and he missed one dose of antibiotics.
Late night, his condition was deteriorated, and he was transferred to ICU - Unfortunately,
he had cardiac arrest. Trials of resuscitation failed and he passed away.
Task: You are SHO of the medical department on call today . You have been asked to
discuss this issue with Mr. Ahmed his son.
Introduction:
Shake hands.
6
Introduce yourself.
CEs: ea
Confirm the son identity,

CC
Confirm agenda of meeting.

Ask how much he knows about his father's condition?

e Mr. Ahmed, as you know your father was admitted 2 days ago because of a severe and
serious lung infection .He presented with symptoms and signs of very advanced lung
infection which carries high risk of death in such patients,
¢ Unfortunately, there was no bed available in the intensive care unit at that time which
was the best place for managing his condition.
¢ That is why; he was admitted in the surgical word. We started antibiotics in the best
interest of his condition. The line was dislodged because a technical problem and he
missed one dose of antibiotic.
¢ Late night. bis condition was severely deteriorated and he was transferred to the
intensive care unit urgently.
© Later on, his heart stopped beating, We tried our best to resuscitate him but
unfortunately, our trials had been failed and I’m sorry to tell you that -.. he passed
away.

* |'m really sorry for these bad news Mr. Ahmed,
eee

Be sure that we tried our best to save your father’s life,
108
¢ My deep Condolences for you.
*Here, the son may be anxious. And may rise up an issue of neglicance
because of surgical ward admission , line dislodgment and missing one dose
of antibiotic.
Explain the leading cause of death:

e lappreciate your feeling and concer.
¢ As told you before, your father presented to us with a very advanced and severe
lung infection which carry a high score of death in these patients.
¢ Your father presented with a score of 5 out of 6. This score carry a death rate 15- 40%
in such patients.
¢ Mostly Probably, his severe infection is the main leading cause of death , not missing
one dose of antibiotics.
« However...
Actions will be taken for the incidence of missing antibiotic dose:

However, we are going to investigate that seriously:
* Weare going to write incident report,
Consultant and nurse in charge will be informed.
We will discuss this issue in the next morbidity and mortality meeting
We will refer this incident to the risk management team to be investigated seriously.
Social history:
¢ May I ask some social questions if you don’t mind?
® With whom your father was living? Is there anyone of the family who need any
social or financial support ?

-Why not admitted in the intensive care unit from the beginning doctor?
¢ Unfortunately, there was no bed available at that time. Referring a patient in such
serious condition to another hospital would be risky. Although , we are going to
check that out to know what was going on.
- I would like to do 2 complaint

doctor?
¢ Definitely this is your right, we are going to help you by referring you to the patient
advice liaison office and follow up your complaint.
Make a summary: About the important points of the meeting
Check understanding: May I know if you absorbed all the information in our
meeting today?
109
¢ Weare going to finish the death certificate soon not to delay any funeral ceremonies.
« Anyone will drive you home?
-Shake hands.
Notes about the case:

Your task here is;
e Breaking bad news
¢ Managing possible medical negligence with actions mentioned in the scenario,
clarifying that missing one dose of antibiotic is not the leading cause of death.
° Such cases need showing empathy and sympathy.
© Ifthe son asked to complain , this is his right .
Scenario: Ms. Sara is 27 years old, a nurse in your medical unit. When she tried to havea
eod sampic from one patient who is known case of HIV she had a needie stick injury. She is
wary anxious since that event and want to discuss with you this issue.
‘You are SHO of the medical department on call today, you have been asked to discuss with
be this issue.
tnatroduction:
* Shake hands.
Introduce yourself.
Confirm the patient identity,
Ask the patient: May i know what happened exactly ?
Ask about the Circumstances of needle stick injury:

* What happened before? Did you wear gloves? How many?
* What happened during? Was it wide or narrow bored needle? Was it deep or superficial
injury?
* What happencd after? Did you squeeze the site of injury? Did you wash your hands with
soap and alcohol?
* Did you receive immunization for Hepatitis B before?
Reassurance:
* I'mreally sorry for what happened to you today.
* Needle stick injury may carry a risk of HIV, HCV and HBV as well.
* Buti want to reassure you that the chance of HIV infection after needle stick injury is only
0.3% , For HCY is 3% and for HBC 30%,
* A large number of medical stuff had history of needle stick injury with very limited reported
cases of infection,
Explain the plan of care:

What we are going to do is to
* Write incident report.
* Give you prophylaxis treatment soon.
* Check your blood for HCV, HBY, and for HIV now and after 3 months.
* A signed consent will be required for agreement to do HIV test ., The result will be released
after 24 to 48 h and will be completely confidential, and will be released only to you , not by
email or telephone.
¢ Weare going to refer you to a MDT from an infectious disease doctor, an occupational
health care worker to give you the proper plan of care and follow up.
e Ifyou have any symptoms of fever, skin rash , lumps or bumps, or loss of weight you have
to seek medical care at once (Seroconversion symptoms)
* HIV is different from AIDS. AIDS is HIV plus superimposed illness or infection
Explain the Results of the test:

The test may has false negative and false positive results,
-If the test is positive: It means that you have HIV infection. You may have anxiety and
mood changes. You may lose your future insurance, bur prior insurance will be preserved.
But the advantage is that we will start early treatment to avoid complications. You may need
some life style and job modification.
¢ If the test is negative: You may have some relief. It has to be repeated within 3 months to
be sure you are completely free from the virus.
Modification of life style:

Until confirming that you are completely free from the virus you have to make some life style
modification:
e Atwork you have to avoid sharing in procedures and direct contact with the patients, I'm
going to involve occupational health care worker to provide you with an office work.
e You have to avoid transfusion of blood during that time, you have to keep your personal
instruments like razors, mouth brushes for only your personal use.
¢ Do you have a partner? Are you pregnant or planning for pregnancy soon? You have to make
safe sex until confirming that you are completely virus free,
Showing empathy and sympathy and Reassure again:

« I’mreally sorry again for what happened today
¢ [highly appreciate your feeling.
¢ | want to reassure you again that the chance of catching infection of HIV is extremely low
after a needle stick injury.
Social History:
My L ask some social questions if you don't mind.
¢ With whom you are living? Are they doing well ? Who is supporting your at home?
¢ Do you smoke? Drink alcohol?
If the test is positive, it means that you have HIV infection.

* You may have anxiety and mood changes, so that we will refer to a psychiatrist for
counseling to stabilize your mood.
* We will refer you toa MDT form infectious disease and occupational health care worker
to give you the plan of management.
* Your job would be changed with another office job away from direct contact with the
patients.
* You have to inform your partner at that time.
* You may nced some life style and job modification.
Make summary: About important the points in the meeting.
Check understanding: May i know how much did you get from our discussion today?
Help:
« Iwill give you some leaflets and websites about needle stick injury.
* I'm going to give you the contact number of infectious discase department, if you have any
worries or queries, please don't hesitate to contact us.
* Anyone to drive you home?
~ Shake hands.
Scenario: Mr. Oliver is 57 years old. He has been complaining of productive
cough and shortness of breath for the last 2 months, He sought medical care
with his GP 2 months ago , who treated his as viral infection and gave him
antipyretic and cough medications.
His symptoms are sustained since that time. Recently, chest X ray was done for
him and revealed left upper lobe mass.
Further CT chest abdomen and pelvis with contrast revealed lung cancer with
metastasis to the liver and bone.
You are SHO of the outpatient chest clinic. You have been asked to discuss the
results with Mr. Oliver.
Introduction:
e Shake hands.
e Introduce yourself.
¢ Confirm Agenda of meeting.
eee
How much do you know about your condition ?


¢ The results of blood investigation and imaging have been released, and 'm
sorry to tell you that they not as we hope .. Stop for a while.
They reveal that you have cancer in your lungs.( With sad voice tone)
I’m sorry to tell you that it seems to be advanced and spread to other
organs like liver and bone .. Stop for a while ( Let the patient to express his
feelings and thoughts)
Patient is very angry for delayed diagnosis:

Patient: How can doctor , | sought medical care with my GP two month ago and
he just gave me some medications and didn’t asked for further investigations. |
think if | was diagnosed earlier | could start the treatment early , and I might be
completely cured.
* I’mreally sorry for these bad news today Mr. Oliver.
* lhighly appreciate your feelings.
* lunderstand how much these news are hard for you.
* But be sure that we are going to give you the full care and support as much
as we can.
* Give a tissue if he started to cry.
Managing the dilemma of delayed diagnosis:

* Many diseases could mimic each other, and may be presented with similar
symptoms.
* lassume that mostly you presented at that time with mild symptoms and
without alarming symptoms which indicate further investigations.
Majority of patients with cancer are diagnosed lately with advanced stage .
* I'mnot defending my colleague, but im trying to explain that situation
which we are facing a lot in our medical field .
* However, we are going to check your file and to call your GP to find out the
whole situation.
* I promise you if we found out any negligence we are going to investigate
seriously.. It that ok with you?
* Letus look to the future and find out what to do as a proper care and
management plan .. Is that ok with you?
Explaining the management plan:

* Referral to a MDT: So what we are going to do is to refer you toa MDT
team including a cancer doctor, Macmillan nurse, a psychiatrist , and a
social worker to give you the proper care and management plan.
* Hint about available options of treatment: Some treatment are
available for cancer like cycles of chemotherapy and radiation. The
treatment plan will be discussed in details with the cancer doctor.

I'm really sorry again for these bad information today . | highly appreciate your
anger and pain , We will do our best to support you and give you the proper
care and management .
Social history:
sie Steeneo!
ii RSE: StL STE Tat Ba : I a
e What are you doing for living? (Job is very important in a case of lung
cancer, as it may be implicated. Therefor . you have to counsel the patient
for disablement compensation)
e How much your illness impact your job and usual daily activity? .. Refer
the patient to an occupational health worker if his job is affected. Refer to a
social worker if his social life is affected .
e With whom you are living? Are they doing well? Who is supporting you at
home?
Do you smoke at all, drink alcohol?
Concerns :Do you have any concerns ?

- There is no hope doctor ?
e I’msorry to tell you that your condition is advanced .
e But, we are going to give you all the social, psychological and medical
support and to keep you comfortable all the time.
¢ Avoid giving no hope or false hope. (Don’t reply: There is hope or there
is hope)
“TV wantto complain
My GP doctor ?
e This is your right, and I will refer you to the patient advice liaison
office for that. We will follow the result of your complain , and be
sure that you are going to receive the proper care regardless your
compliant,
-I want to change my GP doctor?

e You have the full right for that. We can contact the authorized medical
office for that.
Make summary: About the important points of the meeting,
Check understanding: Check how much the patient got from the
discussion?

e I'm going to give you some leaflets, brochures, websites to read more
about the disease.
e Iwill give you the contact number of our department to contact us any
time if you have any worries or queries.
-Shake hands.
B.D : You have two tasks here:
Counseling for breaking bad news.
Dealing with an angry patient due to a delayed diagnosis.
Delayed diagnosis is not considered as a medical error or negligence.

We
can deal with it as a matter of uncertainty.
Scenario:
Mrs, Mona is 55 years old was admitted 2 days ago after extensive ischemic stroke with
left sided weakness. 24 hours after admission, her condition was deteriorated and went
into coma, Repeated CT brain didn’t reveal any interval changes.
Since day one of admission, she received aspirin in the best interest of her condition and
pantoprazole for peptic ulcer protection. .
Her daughter Mrs. Lila is very anxious because of deterioration of her mother’s condition.
She is very angry because of Aspirin therapy, as her mother had history of upper GIT
bleeding 2 years ago as a result of aspinn.
You are SHO of medical department on call today . You have been asked to discuss this
issue with Mrs, Lila.
Introduction:
Shake hands,
Introduce yourself.
Confirm the daughter identity.
Confirm he is the next of kin of Mr.Mona.
Ask if she need any one of the family members to attend the meeting.
Ask the daughter: Can I know how much do you know about your mother condition
and any concerns you have?
The daughter: My mother was admitted 2 days ago because of stroke. She had left
sided weakness but was conscious and communicating well , Yesterday her condition
was severely deteriorated and nol communicating with us and went into coma.
Of note, she received aspirin. She had allergy for Aspirin as she developed gut bleeding
after she received aspirin 2 years ago . I informed the treating team about that incident
before.
I think Aspirin is the main cause of her deterioration.
(The surrogate may express her anger and start to cry}

I'm really sorry for your mother.
[highly appreciate your feeling
Be sure we are going to do our best to give her the proper care.
Give a tissue to the surrogate if started crying.
Explanation of the condition of the mother:
Can i explain to you more about your mother’s condition?
* Your mother is admitted due to extensive stroke in her brain and presented with left
sided body weakness.
* This is a blood clot in one of the blood supplies of the brain causing extensive
damage of a large arca of the brain.
* Unfortunately her condition was deteriorated with altered conscious level. We
repeated imaging again, which didn’t reveal any interval changes,
e Her deteriorated condition is duc to the extensive stroke she had, not related to
aspirin therapy.
Explanation of the importance of aspirin:

* Aspirin was prescribed to your mother in the best interest of her condition as a
thinner drug to thin her blood. Therefore, it can decrease chances of blood clots in
the future significantly.
* Oldhistory of gut bleeding after Aspirin doesn’t mean that she is allergic to aspirin,
This could be a side effect of this medication. However , she is receiving other
medication called pantoprazole to protect her stomach.
* Outweighing the risks versus the benefits of aspirin in your mother’s condition, the
benefits are extremely more.
Daughter: How would you know she is not bleeding doctor?

We didn’t notice any bleeding per her motions or dropping of her blood count,
Be sure we are going to observe closely for any biceding to stop aspirin.
Management plan:
* We have a MDT taking care of your mother and giving her the full care. Now ,She is
under our close observation .
* Besure we are doing our best to your mother and following the best interest in her
condition...
Social History:
My Lask you some social questions if you don’t mind?
¢ With whom your mother is living? Are they doing well ? Any one of them needs any
support?
Concerns: Do you have any concems ?

Do you think I have to call my brother to see my mother as he is living in another city?
* J think it is wise to inform him about his mother’s condition as she is deteriorating
¢ Wecan reply and queries he has by phone if he wants.
Make summary: About important the points in the meeting.

Check understanding: May I know how much did you get from our discussion
today?
Help:
¢ I will give you some brochures, leaflets and websites about stroke and importanceof
aspirin therapy to be more aware.
e I'm going to give you the contact number of our department, If you have any worries
or queries , please don't hesitate to contact us .. Anyone to drive you home?
- Shake hands.
N.B:
e In this case , there is a misunderstanding that the patient has history of allergy to
aspirin , as she had history of bleeding due to aspirin before.
¢ Your task is to explain the condition of the paticnt, and importance of aspirin
clarifying that previous history of bleeding from aspirin doesn’t mean allergy and is
not a contraindication for aspirin theray.
Scenario: Mrs. Gchan is 25 years old, her father had been diagnosed as
huntington disease two weeks ago. She read on the internet that it has strong
familial predisposition. She is very anxious since that time. She is coming to
discuss Genetic test for huntington disease.
You are SHO of the Neurology clinic, you are asked to discuss this issue
with Mrs. Gehan.
Introduction:
Shake hands.
Introduce yourself.
Ask if she want her husband to attend this meeting.(Ask only for husband)
(For confidentiality)
Ask the patient: How much do you know about Huntington disease?
How much do you know about the test?
Did anyone pressurize you to do the test?
Explain Huntington disease simply without jargons:

May i explain to you more about (Huntington discasc)?
¢ itis a progressive condition causing gradual impairment of the cognitive
and abnormal jerky movements all over the body.
¢ [tis a familial condition which runs in families. Unfortunately the chance of
every one of the offspring to have the disease is 50%.
¢ Unfortunately The disease in the next generation is coming in earlier age,
and with more severe symptoms (Anticipation and Expansion)
¢ Wecannot guarantee when the symptoms will appear exactly, it varies from
one to the other.
Explain the test:

Genetic test is a simple blood test.
The result will be released within 24 or 48 h.
You will be the only one to receive the result. It is not released by email or
telephone (Confidentiality).
This test may have false positive or false negative results.
seme test is positive:
Positive test will have some disadvantages: You may have a bad mood and
anxiety. Moreover, you may lose your future insurance, but prior insurance
will be preserved.
* Advantages: We will refer you early to a MDT to give you regular follow
up and management plan.
if the test is negative:

* Disadvantages: It may be false negative and may be repeated to confirm the
result.
* Advantages: You will feel comfortable, and continue your life without
stress
Consent:
e Ifyou agree to do the test, you have to sign a consent in which all the
information of the test is mentioned.
e lf you changed your mind and asked to withdraw any time, you have
completely the right for that .
e You can have some time to think about it. You can bring your husband next
time to share the information and decision with you. We are not in hurry.
Postponing the test will not alter the outcome of the disease.
Social History:
May | ask some social questions if you don't mind?
What are you doing for living?
With whom you are living? Are they doing well? Are you supported at
home?
e Do you have any sisters or brothers? Are they doing well? you can bring
them too for another meeting to discuss about genetic screening test.
Do you smoke at all? Do you drink alcohol?
Concerns: Do youhave any concerns?

If i have
the disease do
e Tl appreciate your concern, we cannot guarantee when the: symptoms
will appear exactly, it varies from one to the other,
e If} you are confirmed to nye the disease, I'm sorry to> tell: you that every
one of your children have chance of 50% to have the disease.
refer you to a MDT involving the women doctor and genetic doctor to help
you in this issue to make the best of your interest. .
Check understanding : May I know how much did you get from
our meeting today?
Help: I'm going to give you some brochures, leaflets and websites about
genetic test of Huntington,
1 will give the contact number of our department. If you still have any
worries or queries, please don't hesitate to contact me
- Shake hands.
Notes on the case:

Ethical issues:
« Autonomy — Beneficence- Non maleficence — Justice — Honesty
* Confidentiality:
> No one is allowed to attend the discussion without allowance of the person.
>» The result is not released by mails or telephones. Only the patient has the
right to receive the results.
* Be sure the patient is not pressurized to do the test.
Legal issues :
e Consent: She has to sign a consent in which all the information of the test is
mentioned.
¢ Ifshe changed her mind and asked to withdraw any time, she has the rig ht
for that .
** The approach of counseling for genetic test of Huntington is different from

the approach for counseling for newly diagnosed Huntington.
* Counseling for newly diagnosed Huntington is counseling for a chronic
iliness
a)
Scenario: Mrs. Mona is 40 years old. She has been complaining of
recurrent headache, chest pain and abdominal pain for the last 10 years.
All blood tests done for here were completely normal. The consultant made
decision that no more investigations are needed for her .
You are SHO of the medical Outpatient clinic. You are asked to discuss
this issue with her.
Introduction:
Shake hands.
Introduce yourself.
Ask the patient: How much do you know about your condition?
Do you have any expectations for results of the blood test done for you?
Inform the patient about the result:

e Mrs. Mona i have good news for you. The results of the blood tests done
for you all are normal .. What do you think about that?
The surrogate will express her anger:

e Patient; What do mean doctor? Do you mean I’m medically free? Do you
mean I’m malingering? Do you want me to go back to my husband telling
him all blood test are normal and I’m such a big liar?
¢ Let the surrogate to express her anger without interruption and keep calm
until she finish her anger..
Managing anger of the surrogate and admit her suffering:

e [really appreciate your fecling and anger.
e [don’t mean you are malingering at all.
¢ | admit you are suffering, and you have something wrong we have to
manage.
¢ Weare here to give you the full help and care, is that ok with you ?
Explaining the condition of the patient:
Do you want me to explain to you more about your condition if you don’t
mind?
Your symptoms mostly due to stress and being overwhelmed with
responsibilities.
When someone is under mental stress, he may express this with physical
symptoms like headache, chest pain, tummy pain , loose motions and
fatigue.
So we admit you are suffering and needs medical support and care.
Be sure we are here to help you as much as we can, and do our best to
manage your condition.
Detailed Social history:

May i ask you some social questions if you don’t mind?
What are you doing for living? Any stress or troubles at work? How much
your symptoms affect your job and usual daily activities?
With whom do you live? What your husband is doing for living?
Does he support you at home? Does he stay away from the house for long
time?
Do you have children? Are they doing well? What about their school
performance?
What about your family, dad , mom , brothers and sisters? Are they doing
well?
Do you think you need any social or occupational support? We can help you
in this issue. We have expert teams to manage any social troubles.
Any troubles with your neighbors?
Do you smoke at all? Do you drink alcohol?
Do you think you are under stress or overwhelmed all the time?
Management plan:
So what are going to do is to refer you to a MDT from a social worker and a
psychologist to give you the proper care and support.
The social worker is to discuss with you any social troubles and try to
manage them.
The psychologist is to share a talking therapy with you to understand the
reasons of your symptoms. He may prescribe some medications which may
improve your mood and relieve your symptoms.
125
Concerns: May | ask if you have any concerns?
Not at all. Psychologist is not for mad people only. a lot of people are seeking
medical care with psychologist for mental support and relief when they are
under a lot of stress.
I have long standing headache doctor;

i want to do Im:
e Actually your headache is one of the symptoms secondary to stress.
e We don’t have any indication to do imaging for the brain in the time being.
e You are going to have all complications of exposure to radiation
without benefits.
I wantto be sure that my brain is ok and I don't have something

¢ Our consultant decided that no need for more investigations in your
condition, this decision is taken in the best interest of your condition.
® Imaging has some side effects like exposure to radiation.. and no need to
expose you to radiation without clear indication .
Make a Summary: About the important points in the meeting.

Check understanding: | hope you absorbed all the information in
our meeting today.
Help: I'm going to give you the contact number of our department. If you
still have any worries or queri, please don't hesitate to contact us.
- Shake hands.
Notes on the case:
This case is one of the tricky cases in the exam.

In this case let the patient to express her feelings and anger without
interruption.
* Appreciate the feeling of the patient a lot and show a lot of empathy and
sympathy.
* Admit for her that you know she is suffering a lot and admit that she need
medical care.
* Inform her what could be the reasons of her condition without
confrontation.
* Try to explore her detailed social history to pick up any underlying stressful
social life she might has.
What are the somatoform disorders?

The somatoform disorders are the extreme end of the scale of somatization. So,
the physical symptoms persist long-term, or are severe but no physical disease
can fully explain the symptoms. Somatoform disorders include:
e Somatization disorder
¢ Hypochondriasis
¢ Conversion disorder
e Body dysmorphic disorder
¢ Pain disorder
People with somatoform disorders usually disagree that their symptoms are
due to mental factors. They are convinced that the cause of their symptoms is a
physical problem.
Somatization disorder
People with this disorder have many physical symptoms from
different parts of the body - for example:
¢ Headache
Feeling sick (nauseated)
Tummy (abdominal) pain
Bowel problems
Period problems
Tiredness
Sexual problems
‘v7i
The main symptoms may vary at different times. Affected people tend to be
emotional about their symptoms. So they may describe their symptoms as
‘terrible’, ‘unbearable’, etc and symptoms can greatly affect day-to-day life.
The disorder persists long-term although the symptoms may wax and wane in
severity.
The cause is not known. It may have something to do with an unconscious

desire for help, attention or care. It runs in some families, The disorder
usually first develops between the ages of 18 and 30. More women than men
are affected.
It is difficult for a doctor to diagnose somatization disorder, This is because it
is difficult to be sure that there is no physical cause for the symptoms. So,
people with this disorder tend to be referred to various specialists, and have
many tests and investigations. However, no physical disease is found to
account for the symptoms.
Hypochondriasis
This is a disorder where people fear that minor symptoms may be due to a
serious disease. For example, that a minor headache may be caused by a brain
tumor, or a mild rash is the start of skin cancer. Even normal bodily sensations
such as ‘tummy rumbling’ may be thought of as a symptom of serious illness.
People with this disorder have many such fears and spend a lot of time
thinking about their symptoms.
This disorder is similar to somatization disorder. The difference is that

people with hypochondriasis may accept the symptoms are minor but believe
or fear they are caused by some serious disease. Reassurance by a doctor
does not usually help, as people with hypochondriasis fear that the doctor has
just not found the serious disease.
Conversion disorder
Conversion disorder is a condition where a person has symptoms which suggest
a serious disease of the brain or nerves (a neurological disease). For example,
blindness (severe sight impairment), deafness, weakness, paralysis or numbness
of the arms or legs. The symptoms usually develop quickly in response to a
stressful situation. You unconsciously convert your mental stress into a
physical symptom.
Conversion disorder tends to occur between the ages of 18 and 30, Symptoms
often last no longer than a few weeks but persist long-term in some people. In
many cases there is only ever one episode and no treatment is needed once
symptoms have gone. Some people have repeated episodes of conversion
disorder from time to time.
srs:
Body dysmorphic disorder
Body dysmorphic disorder is a condition where a person spends a lot of time
worried and concerned about their appearance. A person with this disorder
may focus on an apparent physical defect that other people cannot see. Or,
they might have a mild physical defect but the concern about it is out of
proportion to the defect.
For example, a person may think that he or she has a skin blemish or an odd-
shaped nose. However, no one else can see the defect, or the blemish would
be considered trivia! by most people. The person becomes preoccupied with
the imagined defect, or slight defect. For example, they may spend a lot of
time looking in the mirror at the apparent defect. They may wear
camouflaging make-up to hide the defect. The thought of the defect is very
distressing for people with this condition.
Some people with body dysmorphic disorder consult a cosmetic surgeon to
have the imagined or trivial defect corrected.
Pain disorder
Pain disorder is a condition where a person has a persistent pain
that cannot be attributed to a physical disorder.
What is the treatment for somatoform disorders?

Treatment is often difficult, as people with somatization disorders commonly
do not accept that their symptoms are duc to mental (psychological) factors.
They may become angry with their doctors who cannot find the cause for
their symptoms. Another difficulty is that people with somatization disorder,
like everyone else, will develop physical diseases at some point. So, every
new symptom is a challenge to a doctor to know how far to investigate.
e Cognitive behavioral therapy

e Antidepressant and Anoxylitics
Scenario: Mr. Sameh is 55 years old He is known case of diabetes, hypertension and
heavy smoker.
He was admitted three days ago as a case of ST segment elevation MI.
PCI done for him in the best interest of his condition. His condition is stabilized with
uneventful recovery. Now he is fit for discharge. He was prescribed aspirin , plavix ,
concor , ramipril and simvastatin on discharge.
You are SHO of the cardiology department on call today, You have been asked to
discuss with him further plan of management after discharge.
Introduction:
Shake hands.
Introduce yourself.
ees

Ask how much the patient knows about your condition ?

° You have been admitted with a heart attack, A blockage of the blood supplies of the
heart which was a life threatening condition.
A procedure called percutaneous coronary intervention was done to you in the best
interest of your condition to release the obstruction and save your life,
Your condition is stabilized now. And a decision of discharge has been taken in the
best interest of your condition.
But still there is a risk of recurrence of heart attacks in the future.
Therefore, long term plan of management after discharge is so crucial to decrease the
chances of recurrence of heart attacks,
Compliance on medications:
You are prescribed four important medications to reduce incidence of heart attacks in the
future:
Aspirin and Clopidogrel: They reduce the stickiness of blood, which reduces the
risk of blood clots.
Concor: This slows the heart rate and reduces the risk of abnormal heart rhythms.
Ramipril; This reduces the risk of developing hear failure and further heart attack.
Simvustatin: This reduces the cholesterol level and thus heart attacks.
Heart rehabilitation program:
We are going to refer you to a cardiac rehabilitation program in the outpatient clinic.
This program includes: Nurses, physiotherapists and other health professionals.
They aim to provide advice and help on exercise, dict, stress and getting back to work
and normal life following a heart attack.
It is also useful to mix with others who are going through the same experience.
Life style modification:
Smoking:
Giving up smoking is the single most effective way to reduce your risk of having a
further heart attack,
Your risk of a further heart attack is roughly halved (compared to the risk if you
continue to smoke).
We can help you in this issue by referring you a smoking cessations clinic.
Alcohol:
Alcohol intake should be justified. So it is advised not to exceed the recommended
amount of alcohol. You are advised not to drink more than 4 unites per day , and 3
unitesper days (For females), and have at least two alcohol-freedays a week.
We are going to refer you to dictician, he will guide you how to drink in healthy way.
Diet:
Your diet has to be balanced avoiding fatty and salty food , rich in fruits and
vegetables
The dietician will discuss with you the healthy diet in details.
“we activity and exercise

¢ Regular exercise isa major way to reduce the risk of having a further heart attack.
You should try to be physically active- for example, take the stairs whenever
possible, walk to the shops, and wash your car,,
Afier about 6-8 weeks, you can build up to at least 20-30 minutes
of moderate
exercise on most days (at least five days per week).
Weight:
« (ifoverweight); Losing weight will improve your diabetes and hypertension, and
reduce your risk ofa further heart attack as well.
Diabetes and Blood pressure control:

¢ Diabetes and hypertension contro] is essential in your condition to reduce chances of
heart attacks. Therefore compliance on their medications is mandatory.
Driving and flying:

¢ You should not drive for at least four weeks after a heart attack.
e You can usually fly as a passenger within two to three weeks of 2 heart attack, as long
as you have no complications.
¢ You have to inform DVLA and insurance company about your condition
Sex:
¢ Another sensitive issuc. Regarding sex, it is probably best avoided for a few weeks.
e The heart doctor will assess your condition later, and will give you the appropriate
advice,
Social history:
¢ What are you doing for living? - We will provide you with medical report and
proper sick leave until your condition is fit enough for working,
With whom you are living? Are they doing well? Who is supporting you at home?
e Are you financially supported?.
Concerns :Do you have any concems ?

- How can I know that I have heart attack doctor?
e Ifyou felt any chest pain, racing of heart beats or shortness of breath any time , you
have to seck help and medical care at once.
Check understanding: Did you get all the information in our meeting today.
Help: I'm going to give you some Icaflets, brochures, websites fo read more about the
heart attacks and, modification of your life style and methods to prevent further attacks,
e | will give you the contact number of our department to contact us any time if you
have any worries or queries. - Shake Hands
Scenario: Mr. Hassan is 60 years old. He was admitted 3 days back because of
community acquired pneumonia. He feels better now and asking for discharge.
Repeated chest X ray is much better The treating team assessed his condition and see
that he can be discharged as his clinical condition showed significant improvement and
he can continue his antibiotic course at home.
Mr.s Nada, his daughter assume that her father is not fit for discharge yet.
You are SHO on call today, you have been asked to discuss this issue with Mr. Nada.
introduction:
Shake hands.
Introduce yourself.
Confirm the daughter's identity.
Confirm if she is the next of kin.
Confirm if her father gave her permission for discussion.
Confirm agenda of meeting (We are together today to discuss some issucs related to
your fathers condition and any concerns you have)
¢ How much do you know about your father’s condition?

e Your father was admitted three days ago because of bug infection of his lungs.
* We stated a course of antibiotics in the best interest of his condition. His clinical
condition showed significant clinical improvement with improving repeated blood
markers and imaging.
¢ You father asked for discharge as he felt better. He was assessed again by our
consultant The treating team assumed that your father is fit for discharge in the best
interest of his condition , and to complete his course of antibiotics in the form of oral
tablets at home.
Argument of the Daughter:

Doctor , I assume that my father is not fit for discharge yet . He still needs medical care.
May L ask please if you have any concems against discharge other than his general
condition?
es)
Solving any concern against discharge:
You:
° May Lask please if you have any concerns against discharge other than his general
condition?
* Can I ask with whom your father is living and who is supporting your father at home?
(Maybe she is refusing discharge because of social issues)
Daughter:
My father is living alone doctor, and no one will give him the full care during his illness.
You:
| highly appreciate your concern. We can contact our social worker to arrange with home
health care unite , so that they can provide your father with 24hours home health care
nursery to give your father medications at time and the full medical care . 1s that ok with
you?
Explanation of complication of hospital stay without need:

¢ The medical team thinks that your father is not going to get benefit any more by
staying in the hospital.
¢ Unnecessary stay in the hospital may be complicated by hospital acquired infection ,
which can be difficult to be treated .
¢ Unjustified stay in the hospital may predispose elderly patients to bad mood
depression.
© Be sure that this decision was taken in the best interest of your father’s condition.
Social history:
e What is your father is doing for living? . How much his illness affect his job and
usual daily activity? .. Refer the patient to an occupational health care worker if his
job is affected. Refer the patient to a social worker if his social life is affected,
¢ With whom your father is living? Are they doing well ? Who is supporting him at
home? (You asked before)
e Is your father financially supported?
* Does he smoke? Drink alcohol?
Concerns: Do you have any concerms?
Summary: About important points of the disease and management plan.
Check understanding: May I know how much did you get from our meeting today?
er
Help: Emphasize again, i will give you the contact number of our department to contact
me any time if you have any worries or queries.
~ Shake hands.
Notes on the case:

¢ The decision of discharge is a decision of the medical team in the best interest of the
patient condition. It is not the decision of the patient or the relative.
¢ Ifthe patient is not fit for discharge, He has to be counseled for risks of discharge and
to convince him to stay in the hospital to receive the proper care.
e In this case, the patient asked for discharge. But the decision was made by the
medical team after assessment of his clinical status.
¢ Preparing the patient for discharge and solving any social dilemmas against discharge
is so crucial. (For example if the patient is living alone and no one give him the
medical care at home)
e Involve the social worker for any social dilemma which may delay discharge.
* Avoid confrontation with the daughter . Just try to convince her in diplomatic way as
mentioned in the scenario.
Scenario: Mr.Kamel is 78 years old. He is known case of advanced dementia,
hypertension and diabetes. He was admitted today morning with community
acquired pneumonia.
The medical registrar on call decided to start antibiotics according to the local
policy of the hospital.
His son Mr,Amr is refusing to start antibiotic for his father, and asked to give
herbal medication instead.
You are registrar on call today, you have been asked to discuss this issue with
Mr.Amr.
Introduction:
Shake hands.
Introduce yourself.
Confirm the Son’s identity.
Confirm he is next of kin of the Mr. Kamel.
Ask if he want anyone else from the family to attend the discussion.
How much do you know about your father’s condition?

e May i explain to you more about your father’s condition if you don’t mind?
e Your father has been admitted today morning due to bug infection in his
lungs. This infection is serious and may have bad outcome if not treated.
e So that, the treating team decided to start antibiotics in the best interest of
your father’s condition.
Importance of Antibiotics:
e Antibiotics are crucial in the condition of your father to cure his bug
infection.
e Without antibiotics, his condition could deteriorate, and even his lung
infection might threaten his life.
Argument of the son:

¢ Thank you for your explanation doctor. But , i don’t want my father to
receive any antibiotics , as i read about a lot of side effects of these
medications .I have bad experience with theses antibiotics , one of them
136
occurred to my uncle recently, which was secondary infection of the gut
with a bug called clostridium difficile, which was so serious actually .
* So that, | assume to start with herpetic medications as I have a good
experience previously with this type of natural medications,
Advantages of Antibiotics:
* | appreciate your suggestion, but the antibiotics we are going to give to
your father is evidence based on many studies. Safety of these medications
is approved by food and drug administration agency.
Antibiotics like any other medications may have some rare side effects.
But, outweighing the risk versus the benefits of antibiotics, the benefits are
extremely more.
Disadvantages of herbal medications:

* On the other side, safety of herpetic medications is not approved, and they
might have serious side effects which could be difficult to be treated.
* These side effects even may threaten his life.
The son still argues:

* Thank you doctor for your clarifications. But still I insist not to give
antibiotics to my father and to start with herpetic medications instead.
Advanced directive and living will:

You:
* May [ask please if your father has any advanced directive, living well or
power of attorney?
Son:
* No doctor.
Tou:
* Well, therefore the treating team has the right to give your father
antibiotics in the best interest of his condition as long as he lacks mental
capacity and doesn’t has advanced directive , living well or power of
attorney .
* I'm going to involve my consultant and our legal counselor aw well to
meet you for any further discussion if you wish. Is that ok with you?
Social history:
@ With whom your father is living? Are they doing well? Who is supporting
him at home?
@ |s your father financially supported?
®@ Does he need any social or medical support at home?
Concerns ‘Do you have any concerns ?

What if I refused antibiotic therapy completely doctor, are you going to give
against my desire?
e Incase of lackof mental capacity and judgment to make a decisions, And
with absence of advanced directive , living well or power of attorney .
Hence the treatment plan has to be taken by the treating team in the best
interest of the patient condition.
® We can involve our consultant and legal counselor if you still reluctant.
Summary: About important points of the discussion.
discussion today?
Help:
e Emphasize again . I'm going to give you some leaflets , brochures ,and
websites about antibiotics prescribed to your father and serious complications
of herbal medications as well,
¢ | will give you the contact number of our department to contact us any time
if you have any worries or queries
~ Shake hands.
Notes on the case:

Legal issues:
« As the patient has lack of capacity (advanced dementia her) and there is no
advanced directive, living will or power of attorney. Therefore, the decision
of the management plan should be taken by the treating team in the best
interest of the patient condition,
e You can involve our consultant and legal counselor if he still reluctant.
Ethical issues:
¢ Autonomy, Beneficence, Non maleficence, Justice, Honesty
« Avoid confrontation with the son: You can involve the consultant and legal
counselor if he still reluctant.

Rokh 2e ST4 PDF

Uploaded by

Copyright:

Available Formats

You might also like

Rokh 2e ST4 PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Rokh 2e ST4 PDF

Uploaded by

Copyright:

Available Formats

Station 4

Ethical and legal issues in COMMUNICATION SKINS ........-escecceecessrseesceeeseereesesteeree 4

- Communication Scheme <e

~ Counseling for chronic disease (Pheachromcytoma) .........c...-c:ccsesseeescecceeceee 9

~ Counseling for chronic disease (Multiple Sclerosis) ..........cccccsescccsecseeceeneseesenee 12

- Counseling for chronic disease (Adult polycystic kidney disease)... 16

- Counseling for chronic illness (Celiac Disease) .........---ccessessecoensnsreesenreesssennsea 20

- Counseling for chronic disease (AddiSOM dis@aSe).........scasssrseneecceeeeererstacecenes 23

- Counseling for chronic illness (Epilepsy) 26

- Breaking bad news (Advanced cancer for palliative care).........-ccscesceceeeeeenees 29

~ Breaking bad news (Meningitis) ........ccscccseressserneesseseesseresseesctsescareeesseenesasereeens 33

- Counseling for chronic disease (Ulcerative Colitis) ........cssseecsssssreseerneenecereree 36

~ Counseling for chronic illness (Hereditary Obstructive Cardiomyopathy) ........ 39

- Breaking bad news {Mesothelioma with metastasis}

- Breaking bad news (Hodgkin Lymphoma for Hickman line)............s0-scceeneeeee 48

- Breaking bad news (Guillain Barre SyNGrome) ............:sscsssseseseerceeceecrsnacentiaess 56

~ Counseling for DNR GecisiOn .........:sssscesssscsssssesorsssceseresessssnsnseseorenseseessassansensvsees 59

- Counseling for Brain stem death and organ donation ...............ccs:ecsssseseneeeeees 63

~ Breaking bad news (Advanced COPD — Not to ventilate) 0.0... cceseerereenseeeeee 66

- Counseling for a procedure (SLE for Renal biopsy) ....-.....:ccscssessersserseeeceeeeneene 69

- Counseling for a procedure (Gastrostomy tube).........cccccssesscececcecssessenesesenerees 72

- Medical negligence(Angry son - Father developed Allergy for codeine)........... 75

- Medical error (Complication of a procedure) Patient died

- Angry son (Side effect of a Medication) oo... cccseeeseesseseesseessecseeesnecseessersecees 82

- Counseling for side effects Of Warfarin............cccsccseccsseeeesseccseessseceeeeeennsaeesenee 85

- Counseling for side effects of Steroid therapy ........-..sceccssssssceescssesernreerssesceneess 88

- Counseling for a medication (Bisoprolol for heart failure in BA patient).......... 91

- Drug noncompliance (Diabetic patient on Insullin)................:cssssssesesesseeeeeeeees 93

~ Drug Non-compliance (Anti TB medications) ......:ccccceescccsesseeeereererseseeeeseeeee 36

- Pulmonary embolism asking for discharge.............:ccscssessessssesseceeseeserssessenesnesee 99

- Patient with Suicidal Attempt Asking For Discharge ...........cccsssssserseeeerereeeeee 102

- Breaking bad news Possible medical negligence............csssseessccecesesssensasessesseee 108

- Counseling for Genetic test (Huntington dis@ase)......ccccecesseseeeesseeesssceseeees 121

~ Somatoform Disorder... = is 124

= POST MU COUNSE NING eetewsissiserduearcousswssxenaisiosscarconnsanes

- Patient with pneumonia (Daughter refusing discharge) ...........:..scccessssseeeeees 133

SRETUSAL OG CP CEr TION On secesensane cops agnncmacsecasconconeasmnsticrterssite

- Microcytic Anemia in Young Female ..........0ccccccccccceessesseescccssesseseeeessceecsensees 147

SCTAPONIC DIGIT Ted vin caressaazesas-apycenoeo

- Jaundice........ suaca eas sk pavo speRMa Manieanpesritean 157

- Chronic Cough and Wheezy CheSt ........-..eescsssssesessssossorctssssssssterrsseretesseaseaaseasens 163

~ Chronic cough and hyponatremia ...........cccccessssssscrverseresssssccssetrerereneseaseasseenesses 169

= Periodic ParalySis......c.cscssccreesssesenesesses aanieagcueSeraeas iy .178

- Abnormal sensation in both Lower limbs............cccccceccecssssssessssceeeesecssesecceereesees 183

Golden points in communication

discussion with the surrogate.

Avoid jargons absolutely. Try to be fluent in your discussion.

Don’t push a lot of detailed suffocated information

To do good for the patient.

Not to harm the patient.

Be honest when explaining the disease, but follow it with reassurance.

In case of cancer with metastasis:

Other Ethical issues according to the case:

Respecting the privacy of the patient,

Lasting power of attorney:

Treating life threatening condition:

Discharge against medical advice (DAMA) :

after discussion of the risks of discharge.