Ultimate Finals List - Communication & Ethics

Communications

• Apologise to woman to whose mum you had given ten times too much digoxin to and explain about PALS. Her mum now had slow heart beat. I said we would just monitor it as digoxin effect would wear off but think you were supposed to say something like atropine to counterbalance effects. // Explanation to a patient's daughter that she had been given 10 times dose of digoxin because you had not made decimal point clear on drug chart - ability to admit mistakes and comm skills // talk about effects of Digoxin, antidotes, what will happen to mother now (blood levels, cardiac monitoring), can see consultant if she wishes, incident form has been filled in and so situation will be investigated. She talks about wanting to make formal complaint, you have to tell her about, PALS, independent complaints advocacy service, procedure….generally be as informative and helpful as possible.

• METHOTREXATE overdose which I thought was really unfair as other people got insulin and warfarin. Never mind. We just had to explain it to the angry patient and say we were very sorry and talk about pals. // Given BNF, but looking at it with the patient I thought I’d freak her out more. That drug can cause most nasty side effects. Had to apologise, admit responsibility, explain the complaints procedure and produce a plan of action. // just apologise lots, refer to PALS, say you've filled out a serious incidents form and informed your consultant etc // 

• Angry patient. Came to pick up her mum after discharge for uncomplicated UTI over previous week. She arrived to find her mother sweaty and almost unconscious. Turns out you (student)are the doctor responsible for having mis-read her drug chart and given her the wrong kind of insulin lets call it 'X-tard' instead of her usual 'Y-tard'...Unfortunately - wouldn't you just believe it - 'X-tard' is stronger than 'Y-tard' ...oh dear... So you have to adopt a suitably remorseful, crestfalle manner and talk about how sorry you are, PALS and complaints procedures, incident forms... // Have to admit mistake and apologize and mention that a serious incident report form has filled in and it is being investigated and also provide information to patient about how to complain (PALS, writing to ward manager etc..)

• u prescribe penicillin on drug chart and on drug chart it says no allergies. but he is allergic to penicillin in the notes. so daughter is angry n I said it was my fault because I gave penicillin and im sorry etc PALS help and complain to trust complaints manager..speak to consultant and reassure her uve documented an incidents report form to ensure it doesn’t happen again...some people said it wasn’t their fault because they followed the drug chart n u didn’t fill in the drug chart...but don’t know..

• Woman whose husband died four hours ago and she wishes to talk to someone. Perfect station to end on. Lots of sympathy and suggestions for getting help from family / chaplain. Bit stumped really...

• Talk to wife of stroke patient who has died recently. Be sympathetic and state that nurse was with him when he died and he did not regain consciousness (as says in scenario). mention consultant will see her to discuss death certificate. There was a lot of spare time on this one.

• There was a gentleman actor who had come to the doctors as he felt he wasn't coping with a very difficult situation at home - his wife had cancer. Wasn't entirely sure what they wanted, think this was about listening, showing sympathy and offering some appropriate help. Again, the revision lecture was good // don't miss he was depressed

• My lead-in was 'take a history from this 69 year old lady with urinary diversion and recurrent UTI (Great, I thought - lucky Urinary Diversion Surgery is forms such a massive component of the medical degree...) For 6 months she had been receiving increasingly unpleasant UTI's with rigors fever etc. They were becoming more frequent and becoming less and less responsive to antibiotics. She also has severe osteoarthritis of the knee and needs replacement surgery but these problems are delaying her surgery. She had had her urostomy for 15 years post bladder cancer. Three stoma re-fashionings since October due to parastomal hernia problems. Also lurking away in her past was a nephrectomy following renal cancer, a recent cataract operation and depression secondary to the recent death of her husband but her three adult children all live locally and take good care of her. She started crying when I asked about her mood of late (having noted 'Fluoxetine' on the prescription she gave me when I was taking a drug history) - potential OSCE nightmare!! but in fact it was amazing how quickly you forget the OSCE and recognize that you're dealing with a real human and real human life. Luckily it brought the real human out in me and for those two minutes or so I forgot about the OSCE, the examiner and everything. The examiner mentioned being impressed at the end so it wasn't as big a disaster as I thought it was going to be.

• Talk to a son about his father being diagnosed with Alzheimers. All the medical information is given it was just to see how you communicate and show empathy // how long before the patient will no longer be able to take care of himself, are there drugs available etc. All the information you need to tell the son will be given to you so its not about testing your knowledge at all // Explaining Parkinson’s to a son (all information given, testing communications skills)

Ethics

• Ethics also straightforward, dying man, wanted LPAs explained and if the Dr could commit euthanasia and how to go about writing an advance decision. Just go to the revision lecture, straightforward. // assisted suicide scenario and discussion. one doctor wants to help, the other refuses - what is the basis of their decision? // Case of man who is going to die who wants to know about options for his care. Wants to know if you can kill him with opioid (nope) and then about advance decisions and lasting power of attorney. // Ethics – counsel daughter re father who wants to be left to die i.e. DNR. Q from daughter who had clearly been to ethics school. Is he competent? If not who makes decisions? Can I? Discuss AD / AS. All in revision session. // Patient has mets liver ca. He refuses chemo but daughter wants him to have it. Assess competence. Also he wants you to end his life - refuse!! He's worried about dying in pain. Explain PCA and role of palliative care team. Give lots of counselling, reassure. Advise him to talk to his daughter and you will be willing to meet // man with cancer, 6 months to live wants help to die, say NO. Then he asks if you can give him morphine to relieve his pain, you say YES, but may kill him. Then he asks about advanced decisions, advanced statements and lasting power of attorney. Easy stuff, use the revision handouts.

• Man with HIV doesn’t use condoms, talk about confidentiality. I just asked him what he thought, he said I wasn’t allowed to tell anyone right? I talked on about how I’d have to tell the partner as she was at risk of getting aids, discussed his reasons for not wanting to tell her himself, explained I’d try to persuade him and wouldn’t tell her before alerting him I was about to, arranged a meeting with a counsellor to discuss the best way to tell partner of HIV status. Bit short on time here. // I also mentioned offering anonymous counselling to the wife, using condoms and ensuring he had time to think about what we'd discussed and setting a time to meet a week later.

• Epileptic telling her doc she was still driving. Legal issues etc. Will tell the DVLA if she doesn’t.

• Regarding breast cancer treatment of 49 year old woman with Down syndrome. Sister and consultant favoured palliation, while registrar favoured discussing intensive potentially curative treatment with her. Asked about mental capacity act (i.e. give patient best chance to demonstrate competence, if they are not competent act in their best wishes, choosing option least restrictive of their freedoms), the criteria of competence (can retain information, can understand proposed treatment, weight up pros and cons, communicate their wishes), case law: Tony Bland.

• Talk to daughter of competent 80 year old with an aortic aneurysm. Healthcare professional daughter had been present at ultrasound scan. Mother just gone to toilet and daughter wanted to know if it was an aneurysm she saw - 4cm diameter, which you were told in scenario was not large enough to merit operating on. Some students didn't tell her anything at all owing to confidentiality wanted written permission from her mum. I told her that surgery would not be required. Then she asked me not to mention anything to her mum as she would worry. I said this would not be possible, but said we would be sensitive to her concerns // Not sure if this station was meant to have you say “confidential – need permission from mum to discuss it” or if there was implied consent to talk as she had been in all the scans. If you spoke to her (as I did) she asked you not to tell her mother the diagnosis so as not to upset her (and you were meant to say you would find out the level she wanted to know but that you needed to tell her etc.. Lots of people did not realise this was a law station) // it was your job to assert that it was up to the patient how much information she wanted and that the team would be having full discussions with the patient as they were her choices to make

• Ethics - Again this was very fair, given a case of a woman who was making an unwise decision not to have ehr leg cut off even though it was gangrenous! Basically about competence. Its all in the lecture handout. // ethics - discussion around consent (woman with critical ischaemia refusing amputation), had to discuss the differing views of 2 doctors

• Ethics - longstanding MS, didn't want to go in to hospital for treatment when she had a heart attack, and pointed to a living will when the gp on call came to see her, he agreed to treat her as best he could at home. the next day her own gp said he thought it was ridiculous and told her she should go to hospital just for some investigations but that she wouldn't be admitted (he was fibbing) and so she agreed to go on that basis. she was then admitted. Qs - what makes consent valid, and was the consent valid in this case, when do you not need consent, what does the law say about competence, what is a living will and is it relevant in this case, which doctor do you think was acting most in line with current law/guidelines, what is the essence of their disagreement fact or value? what positions are each adopting, in your opinion could the other gp ever be right? Examples from your own clinical experience where you might be worried about the validity of consent. // I was also asked about paternalistic ideas and patient autonomy and my own experience of patients not being fully informed/consented and the reasons why a doctor might do this and the consequences of unethical practice.

• Ethics and Law - scenario. 92 year old man with dementia and depression stabs himself at nursing home. Taken to hospital and given (expensive) surgery. Patient continues to decare that he wants to die (stabbing himself with needles etc at hospital). Some doctors say he should be left to die, others say the (now necessary further) surgery should continue. Asked questions about withdrawing care vs withdrawing support, circumstances where treating a patient against their will is legal. Competence and its assessment. We were asked what issues are at stake (I think he meant values versus facts etc) // Ethics and Law - patient in a nursing home has dementia and depression. He tries to kill himself by slitting himself with a knife one night from the kitchen of the nursing home. When he is first bought into A&E he is resuscitated and undergoes a very expensive surgery to stop the bleeding. His sister arrives later and says that he's been depressed for years, ever since his wife died and no longer wishes to live and shouldn't be kept alive. The consultant and registrar have a disagreement about what should be done in his treatment. The first question I was asked was how the law applies in this situation - very vague so you just have to pick an avenue and go with it. Asked lots of questions, about consent and competence, what to do if a patient is non-competent, lasting power of attorney and whether it is written down and needs to be witnessed, who makes the decision in this case, should money ever be a consideration in such cases

• Ethics - Patient who had metastatic renal cell Ca, signed a DNR when competent, gets infection, doctor gives ABx, does not improve, debate as to whether 2nd round of Abx should be given. Family says yes. Consultant decides they should, Registrar disagrees. Questions about why they disagree and whether DNR is relevant to the Abx treatment etc.

• Scenario about consultant telling poor prognosis of an elderly patient to her daughter first and the 2 of them deciding it is better NOT to tell the patient. GP tells daughter that is not on, and tells the patient. Questions on confidentiality: law? GMC guidelines? Who acted correctly and why? Why did the 2 doctors differ in their actions. disagreements about facts or disagreements about values? Examples of cases of breach of confidentiality that I have witnessed in everyday clinical practice.

• Ethics - Giving drugs with a therapeutic benefit that might shorten life

• Ethics and Law – Shown case: patient refuses treatment but sons want father treated and say that he is depressed. One doctor wants to treat, the other doesn’t. Talk about Mental Capacity Act and values of each of the doctors.

Explaining Procedures

• Explain endoscopy for dysphagia, presumed oesophageal ca, answer concerns

• Hernia - explanation to patient of hernia operation- will be done under local anaesthesia. Good to know some stats beforehand e.g. 2% recurrence risk. Have to mention risks such as testicular ischaemia, haemorrhage etc. Advise not to drive until comfortable with emergency stop (can be 1 month), advise re time off work (can be 2 weeks, depends on job and how well they recover) // Answering Pts questions about a inguinal hernia repair - local anaesthetic or general anaesthetic is better, Man asks questions about returning to work, how painful it will be, whether it will ever come back what the operation involves etc // When discussing his concerns about the operation it became apparent that he was worried he would be able to see everything that was going on if he opts for an LA and was also concerned that an inguinal hernia could mean he has cancer/a higher risk of cancer. You needed to talk to him about these concerns. // wanted to know lots about the mesh we'd use (infection risks?was it permanent? and other things i cant remember), if he would have stitches and if/when he had to have them taken out // Overall comment: This station said it tested consultation skills, and asked candidates to answer questions specifically that he had. It helped having gone over 'explaining a hernia op' the day before with a friend, but still i was not expecting the questions to be as specific as some of them were. Where i didnt know the answer, i said I'd have to double check with a senior to avoid giving him the wrong information and I'd get back to him as soon as possible with the answer. I didn’t want to risk giving patients the wrong information as we were told always to be safe by being honest with what we dont know. The questions about mesh complications threw me a little because all i could really think of at the time were the general ones that come with any procedure eg infection. It may be a good idea for future candidates to go over all the common ops that patients have and go through explaining what the procedure involves/what happens pre and post op including drinking/eating/work/driving/sex if appropriate for operation, day case vs admitted to hospital for days, main complications /risks. // Most students forgot to ask about occupation and recreational activities. (patient was a solicitor but did weight training, so tell him to stop the latter)

• Communication skills - tell bloke about two different operations for hip osteoarthritis. Lots of information on sheet for me to read so I just handed it to him and we went through it together. Arrange follow up appt etc. Hard to know how it was going, but I just answered concerns etc.