1

Assessing confusion

Mrs Joy is an 84-year-old lady who has hypertension but was otherwise fit and well. She is
due to have an elective hip replacement tomorrow and has been admitted to the ward for
preassessment. The nurses have called you because they are concerned that this lady is
confused, and have spoken to her daughter, who tells them the patient is not normally
confused.

Assess this patient’s confusion and answer some questions from the examiner.

Click here

Please assess this patient’s confusion

Hello Mrs Joy, I am James one of the surgical trainees. How are you today?

I am ok, but don't really know where I am

Would you mind if I asked you some questions to test your memory?

Yes of course

How old are you?

What time is it to the nearest hour?
Can you remember this address? 24 West St. I will ask you this at the end
What year is it?
What is the name of this place?
What is my job? And what is the job of this person (e.g. a nurse)?
What is your date of birth?
When did WW2 end?
Who is the current prime minister?
Can you count backwards from 20-1?
What was that address I asked you to remember?
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Mrs Joy knows that her age is 84,

She doesn't know the hour, or remember the address
She thinks it is 2020
She believes she is in her house
She doesn't know what you or the nurse does
She correctly states her date of birth is 07/07/1928
She has forgotten when WW2 ended
Does not know the current prime minister
And fails to count backwards from 20

What is her ATMS?

Mrs Joy's AMTS is 2

What would you do next?

I would take a history from the patient, the notes, family members and her GP and perform a
thorough systemic examination.

My initial investigations would include a urine dip and MSU, blood tests including
inflammatory markers, haematinics and thyroid function tests.

Imaging should be arranged, firstly a chest X-ray and then a CT head if there are any
neurological signs, or after other investigations return as negative.

I would consider asking the medical registrar to see the patient to either take over care or give
appropriate advice.

Should the operation go ahead?

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No. The operation is non urgent, therefore it can be postponed until the cause of the
confusion has resolved. I would talk to my consultant and the anaesthetist in charge of the
case to inform them of the confusion and ask their advice before cancelling it

What is your differential diagnosis?

My main differential for this lady’s acute confusion is a urinary tract infection. Other causes
include other sources of infection, metabolic abnormalities such as renal or hepatic failure,
hypoglycaemia and hyperthyroidism, hypoxia, hyperthermia, vitamin deficiency such as
thiamine deficiency, medication such as steroids, opiates or other sedating medication, and
being in an unfamiliar environment on the background of dementia.

What the actress was told

Name: Wendy Smith

Attitude: Confused, pleasant

What you know: You think you are at home and the doctor has come to see you. You don’t
know why you would be in hospital as you feel very well. You sometimes have difficulty
walking because of pains in your hip, but it’s not bothering you at the moment. You have no
other medical problems that you know of, and you think you take no pills.

Responses: You know your date of birth, but are unable to answer any of the other memory
questions you are asked. You have no weakness in your arms or legs. If asked, say that you
think you have had pain when you last spent a penny (urinated).

When assessing a patient's confusion in the OSCE it is important to start like any
consultation, and ask an open question, allowing the actor to point you in the right direction.

The AMTS was introduced in 1972 as a tool to rapidly assess delirium or dementia in the
elderly. A score of < 6 suggests a significant cognitive deficit, although further tests are
needed to delineate the cause further.

The questions are:

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How old are you?

What time is it to the nearest hour?
Can you remember this address? 24 West St. I will ask you this at the end
What year is it?
What is the name of this place?
What is my job? And what is the job of this person (e.g. a nurse)?
What is your date of birth?
When did WW2 end?
Who is the current prime minister?
Can you count backwards from 20-1?
What was that address I asked you to remember?

To fully assess a confused patient you must take a history and collateral history, for instance
from her family, or the GP. You need to know her premorbid state, how rapidly she has
declined, and associated symptoms. A fully examination is necessary.

Tests to aid your diagnosis include a septic screen consisting of bedside observations,
inflammatory markers, urine dip and chest xray, and a confusion screen consisting of B12
and folate, thyroid function and a CT head.

Involving the medical team would be important if you felt that you couldn't find a simple
easily reversible cause.

The commonest differential for this lady’s acute confusion would be a urinary tract infection
however other causes include other sources of infection, metabolic abnormalities such as
renal or hepatic failure, hypoglycaemia and hyperthyroidism, hypoxia, hyperthermia, vitamin
deficiency such as thiamine deficiency, medication such as steroids, opiates or other sedating
medication, and being in an unfamiliar environment on the background of dementia.
5
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Breaking bad news

Mrs Balotelli has terminal lung cancer that has spread to brain and bone. After discussion in
the MDT it was decided that the only treatment option was palliative chemotherapy. Your
consultant Mrs Murphy a thoracic consultant surgeon has completed a Do Not Attempt
Resuscitation order due to likely futility of any attempt at CPR.

You are asked to speak to the patient’s family who is unaware of the diagnosis or the DNAR
order. You must give the diagnosis and inform her of the DNAR order and the reasons behind
it

Click here

I am Mrs Balotelli's daughter, thank you for coming to speak to me, how is she?

Hello, nice to meet you, I am Fay the surgical SHO. Can I start by finding out what you know
about your mother's condition?

know she is under investigation for a lump in the chest, which I realise might be cancer. I
pray it is not.

Otherwise she appears to be weaker than she used to be, and has lost weight but I am
unaware of any other problems.

Can you tell me what the diagnosis is? I have permission to hear it without my mother being
here, from her

I can tell you the diagnosis as your mother's scans were recently discussed in the
multidisciplinary meeting. Would you like me to arrange for anyone else to be present?

No, there isn't anyone really. Is it bad news?

Unfortunately it is bad news.

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You mother has lung cancer that has spread to her brain and to bone. There is nothing we can
do to cure her of this.

The patient's relative is visibly upset. In the OSCE how would you deal with this?

I would leave a silence, offer a tissue if needed, and wait for the relative to speak first.

Why can't you just chop out the lung cancer?

Unfortunately removing the lung tumour would not help as the cancer has moved to the brain
and bone, and the experts have agreed that she would not respond to chemotherapy or
radiotherapy

How would you inform the relative of the DNAR order?

Because her prognosis is so poor, we feel that we shouldn't be trying to do anything too
aggressive for her as it is likely to do more harm than good. In particular, if she stops
breathing, we feel that trying to resuscitate her would not be in her best interests. Because of
this, the consultant has signed a do not attempt resuscitation order.

What do you think about this?

I completely disagree with that and I want it changed. I want my mother to have all possible
treatment, I don't want her to die!
 8

I understand that. We don't want her to die either.

The decision to not resuscitate does not mean that we wont treat your mother. If she were to
suffer any complication such as an infection, that we were able to treat then we would, of
course, do so. It means that if her heart stops beating then we wouldn't try to restart it, as
doing so is very unlikely to work and he quality of life would be poor were she brought back.

Isn't it my legal right as her daughter to decide if my mum gets resuscitation or not?

In this case it is actually the doctors who legally have to decide what treatment is best. We
take into account her view, and the views of her relatives, but if we know that giving a
treatment is not going to work, then we have to judge that it is not in her best interests.

I understand. I know my mother, and she wouldn't have wanted the resuscitation if it wasn't
going to do her some good.

Thank you. I am always here if you want to talk to me again, just ask the nurse and she will
contact me

What the actress was told

Name: Francesca Balotelli

Attitude: Very anxious about your mother, and would like her to have maximal treatment, but
don’t want her to suffer.

What you know: Your mother is under investigation for a lump in the chest, which you
realize might be cancer, but have hope it is not. Otherwise she appears to you to be weaker
than she used to be, and has lost weight but you are unaware of any other problems. You had
an aunt who died of lung cancer last year, and are concerned that your mum will too unless
she receives surgery.

Responses to the candidate: Open with “How is she?” in an anxious manner. When told the
diagnosis, ask why can’t they just chop out the lung cancer? Understand if you are told that
removing the lung tumour would not help as the cancer has moved to the brain and bone, and
that the experts have said that she would not respond to chemo or radiotherapy If DNAR
order not mentioned, prompt with “what happens if she were to stop breathing?“ When told
about the DNAR order, indicate that you disagree and want it changed, as you want your
mother to receive all available treatment. If not mentioned, say surely it’s my legal right to
decide if my mum gets treated. Be angry until they explain that DNAR does not mean that
she will not be treated, and that complications such as infections etc will still be treated.
Understand if told that the DNAR order only applies if your mother’s heart stopped beating.
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Express that if it won’t cure her, then your mother wouldn’t have wanted to be treated. Thank
the doctor if appropriate.

How to score empathy points:

Remember to be natural and don’t use every suggestion here by rote each time. Be sensitive
to the situation and act appropriately.

Allow appropriate pauses.

Do not be afraid of silences.

Offer to return later if they would prefer.

Respect their point of view, and establish the reason for it if you disagree.

Offer to put them in touch with further support.

DNAR guidance from the joint statement from the British Medical Association, the
Resuscitation Council (UK) and the Royal College of Nursing October 2007

“Clinicians should ensure that those close to the patient, who have no legal authority,
understand that their role is to help inform the decision-making process, rather than being the
final decision-makers. Great care must be taken when people other than the patient make or
guide decisions that involve an element of quality-of-life assessment, because there is a risk
that health professionals or those close to the patient may see things from their own
perspective and allow their own views and wishes to influence their decision, rather than
those of the patient. These considerations should always be undertaken from the patient’s
perspective. The important factor is whether the patient would find the level of expected
recovery acceptable, taking into account the invasiveness of CPR and its low likelihood of
success, not whether it would be acceptable to the healthcare team or to those close to the
patient, nor what they would want if they were in the patient’s position. Doctors cannot be
required to give treatment contrary to their clinical judgement, but should be willing to
consider and discuss patients’ wishes to receive treatment, even if it offers only a very small
chance of success or benefit”
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Consent for colonoscopy

You have been asked by your consultant to consent Mr Mead, a 59 year old, for a
colonoscopy. When you read through the clinic notes, you see that he has been suffering with
PR bleeding and weight loss over the past 2 months.

Click here

Candidate:

Hello Mr Mead, I am Mr Roberts’ SHO and I have been asked to talk to you about an
investigation he would like to arrange for you. Can I just start by asking you what you
understand so far?

Actor:

Sure, no problem. From what I gather, Mr Roberts wants to use a camera to have a look into
my bowel to see where the bleeding’s coming from.

Yes that’s right. The camera test is called a colonoscopy.

It is a camera, known as an endoscope, which is inserted through the back passage and into
the large bowel. {You can draw a quick diagram to demonstrate this}. The camera then relays
the image onto a TV screen so we can have a look inside and see what may be causing your
symptoms. It is a very accurate way of looking at the lining of the bowel to see if there is any
disease.
We may also need to take some tissue samples from the lining of bowel to help us with our
diagnosis. Normally this doesn’t hurt.

Does that make sense so far?

Actor:

Yes it does, it doesn’t sound particularly pleasant! Will I be awake for the procedure?

Candidate:

I can appreciate that. No, you will be given sedation and analgesia.

Actor:

Are there any alternatives to having this done?

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Candidate:

Yes, a barium enema is an alternative, which involves the insertion of contrast solution into
the back passage and X rays are then taken. However, this does not provide as much detail as
an endoscopic investigation and we cannot take tissue samples for analysis.

Actor:

Oh right, I better have the colonoscopy then. Are there any risks?

Candidate:

No procedure is without risk. The risks are:

- Bleeding from the site of the tissue sampling. Usually this stops on its own and if it doesn’t
it can be treated with cauterisation or injection treatment. The risk is 1 in 200.
- The sedation can sometimes cause breathing or blood pressure problems so this is
monitored closely following the procedure.
- A more serious risk is perforation or a tear in the bowel lining which nearly always needs an
operation to repair. The risk is 1 in 1000.

Actor:

Can I eat and drink as normal beforehand?

Candidate:

So that we can have a good clear view of the bowel, you will need to be on a low fibre diet
and drink plenty of fluids 2 days prior to the procedure. The day before, you should have
clear fluids only including black tea/coffee with sugar, glucose drinks, clear soups.

You will also need to take a laxative which will explain when to take it on the label.

Actor:

Should I take my blood pressure tablets in the morning?

Candidate:

Yes, take your regular medications in the mornings.

Actor:
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What about my aspirin?

My GP gave it to me as a precaution because I have high blood pressure and my father died
of a heart attack.

Candidate:

Because of the risk of increased bleeding, you will have to stop your aspirin 7 days before the
procedure. You can restart it immediately after the procedure.

Do you have any other questions?

Actor:

Yes, just one more. How long will it take to get the results of the tissue sample?

Candidate:

The results of the tissue biopsy take 2 weeks. You will be seen in the outpatient clinic
following the procedure to discuss the findings of the investigation.

Actor:

Thank you.

You have been asked by your consultant to consent Mr Mead, a 59 year old, for a
colonoscopy. When you read through the clinic notes, you see that he has been suffering with
PR bleeding and weight loss over the past 2 months.

Click here

Key Information

-Introduce yourself and gain understanding of what the patient understands so far.

-Explain the procedure and tissue sampling. It is helpful to draw a diagram if you can do this
quickly.

-Explain that sedation and analgesia are administered.

-Explain alternatives and limitations – barium enema.

-Risks – Bleeding, infection, risks of sedation, perforation.

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-Explain bowel preparation methods.

-Inform them when to be NBM and to take their regular medications.

-Summarise if necessary and keep checking that they understand the information
-Offer information leaflet.

Consent Form 4

You are the CT1 in Orthopaedics. Mrs Audrey Dixon, an 89 year old lady has been admitted
with a fractured neck of femur. She has Alzheimer’s and cannot give consent for her
operation. The consultant on call has asked you to complete a consent form 4 and would also
like you to talk to the patient’s family.

Click here

Guidelines for speaking to relatives

• Where at all possible ensure you are in the appropriate environment. Most commonly a
relatives room or an office where you know you will not be disturbed is the most appropriate
place.

• Ensure that there are no distractions: you should leave your bleep with a colleague so that
you are not disturbed at a sensitive time

• You should always have another member of the MDT present with you, most commonly
another doctor or nurse who knows the patient

• Ensure that you know the patient’s history

• Ascertain how much the relative or patient knows

• Show empathy

• Pitch your information-giving and language at the correct level

• Provide information as to how the patient or relative can contact you if they have further
questions

Candidate:

Introduce yourself

If more than one family member is present and they do not volunteer the information , it is
always good practice to ask their relationship to the patient
 15

Actor:

“I am John Dixon, Audrey’s son. Thank you for coming to speak to me”

Candidate:

Start with an open-ended question

“Can I ask how much you know about the reason for your Mum’s admission to hospital?”

Actor:

“I know she fell over at the care home and has possibly broken her hip.”

Slight pause

“Is her hip broken”?

Candidate:

At this point you are breaking bad news so you should fire a warning shot first.

“Unfortunately it’s not good news”.

Slight pause...

“Your Mum has broken her hip”.

After telling a patient or relative any form of bad news it is essential to pause and allow a
period of silence. This will give them time to process what you have just said. Do not
continue with the conversation until the patient or relative is ready.

Actor:

Appears upset says:

“Thats really bad, is’nt it? Can you tell me more?”

Often, relatives will ask this, but you should be careful not to overload them with
information. Leave things open at the end of your conversation so they know they can come
back to you, or someone else, with their questions.

Candidate:
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Before discussing consent, it is well worth addressing the issue of why an operation is
required. In this case, we know that neck of femur patients have higher morbidity and
mortality from conservative management of their fracture (if fit enough for anaesthetic).

“It is a serious injury but we are able to fix her hip it with an operation”

Actor:

“Really?”

“That great, obviously my Mum cannot give permission but I am happy to give permission on
her behalf”.

Candidate:

“In this situation sir, where your Mum cannot give her own consent as an adult, it is the
responsibly of the doctors looking after her. We will of course be asking your....”

You are cut off by the actor....

Actor:

Becomes agitated.

“What do you mean”?

“She is my mother and I am not letting you lot operate on her without my permission. I know
my legal rights”!

Under these circumstances, an NHS consent form 4 is used to provide consent for the
operation. There is a section on this that encourages discussion with a relatives family but it
is not a legal requirement. Ultimately the decision rests with the clinician.

The following text has been quoted from the current NHS consent form 4

Section D Involvement of the patient’s family and others close to the patient

“The final responsibility for determining whether a procedure is in an incapacitated patient’s

best interests lies with the health professional performing the procedure. However, it is good
practice to consult with those close to the patient (eg spouse/partner, family and friends,
carer, supporter or advocate) unless you have good reason to believe that the patient would
not have wished particular individuals to be consulted, or unless the urgency of their situation
prevents this. “Best interests” go far wider than “best medical interests”, and include factors
such as the patient’s wishes and beliefs when competent, their current wishes, their general
well-being and their spiritual and religious welfare”.
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Source: Consent form 4 from the Department of Health website

Candidate:

“I understand your concern for you Mum and we want you to be a part of the consent
process. In this situation we use a consent form 4, which is used when a patient cannot
consent for an operation, as in your Mum’s case because of her Alzheimer’s disease. This
consent form is ultimately signed by the medical team but we like to discuss our plans with
any relatives and then they can sign the consent in agreement with the proposed operation”.

Although the relative (unless they have medical Lasting Power of Attorney) has no legal say
in the patient's care, it is worth involving them in the consent process and communicating the
surgical team's plans. The majority of complaints in this area arise from poor communication
with families.

Actor:

Appears more calm after you last statement.

“I understand. I am sorry for getting annoyed, I am just so worried about my Mum”

Candidate:

“I understand sir. We will look after her”.

“Do you have any questions”?

Make sure the relative knows who they can speak to about any further questions or issues. If
that is someone other than yourself, make sure they have the contact details.

Actor:

“Yes, when will my Mum have her operation”?

This is always a difficult question to answer, whether in an exam or on the ward! It can very
easily reignite a sensitive situation. You should have a model answer for this question.

Never commit to an exact time. By saying you will go and check with the team in theatre and
keep the relatives informed you are showing the examiner that you can think on your feet.
More importantly you are showing the relatives that you have you best interest of their loved
one at the forefront.

Candidate:

“The operation is planned for today. I will go and check with the team in theatre and let you
know”
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Actor:

“Thank you”.

Candidate:

Close the conversation by saying that you can be contacted by the nurses if there are any
other questions or concerns that arise and that you will keep Mr Dixon informed

Before closing the conversation ask Mr Dixon if he would like to go and see his mother.

Although this conversation may seem short, if you are delivery your statements at the right
pace and allowing appropriate silences then it should take 8 - 10 minutes.

Guidelines for talking to relatives:

• Where at all possible ensure you are in the appropriate environment. Most commonly a
relatives room or an office where you know you will not be disturbed is the most appropriate
place.

• Ensure you their are no distractions: You should leave you bleep with a colleague so that
you are disturbed at a sensitive time

• You should always have another member of the MDT present with you, most commonly
another doctor or nurse who knows the patient

• Ensure that you know the patients history

• Ascertain how much the relative or patient knows

• Show empathy

• Give a warning sign before you deliver the bad news

• Follow this by an appropriate pause. Do not be scared of silence

• Pitch your information giving at the correct level

• Provide information as to how the patient or relative can contact you if they have further
questions

An NHS consent form 4 is used when:

• “ the patient is unable to comprehend and retain information material to the decision;
and/or”

• the patient is unable to use and weigh this information in the decision-making process; or”
 19

• “the patient is unconscious”.

• It must also be documented on the consent form as to why the treatment cannot wait until
the patient recovers capacity.

Further to this you must declare on the consent form that:

• “To the best of my knowledge, the patient has not refused this procedure in a valid advance
directive. Where possible and appropriate, I have consulted with colleagues and those close
to the patient, and I believe the procedure to be in the patient’s best interests”.

Source: Consent form 4 from the Department of Health website

Discussion of Do Not Attempt Resuscitation (DNAR) orders

You are the CT1 in Ear, Nose and Throat. Mr Christopher Rogers, a 94 old gentleman has
just been admitted with supraglottitis. He has stridor and is working hard with regards to his
breathing.

After discussion with the anesthetic team, they feel that should Mr Rogers require intubation
his prognosis of being successfully extubated would be very poor. Mr Scott, your consultant
has said that a surgical tracheostomy would be very difficult due to Mr Roger’s severe
kyphosis. You have been asked to discuss Mr Rogers’ resuscitation status with his son who
has just arrived. Mr Rogers has had 3 previous myocardial infarctions, and suffers with
COPD and peripheral vascular disease.

Click here

Guidelines for breaking bad news:

• Appropriate environment. Most commonly a relatives room or an office where you know
you will not be disturbed is the most appropriate place.

• Ensure that there are no distractions: You should leave your bleep with a colleague so that
you are not disturbed at a sensitive time

• You should always have another member of the MDT present with you, most commonly
another doctor or nurse who knows the patient

• Ensure that you know the patient’s history

• Ascertain how much the relative or patient knows

• Show empathy
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• Give a warning sign or shot before you deliver the bad news and follow this by an
appropriate pause. Do not be scared of silence

• Try and pitch your language at the correct level, do not get too technical

Candidate:

Introduce yourself and allow any colleagues present with you to introduce themselves (it is
often a good idea to have a nurse with you).

If more than one family member is present and they do not volunteer the information, it is
always good to ask their relationship to the patient.

Actor:

“I am Oliver Rogers, Christopher’s eldest son. Thank you for coming to speak to me”

Candidate:

A diagnosis of supraglottitis in any patient is serious but more so in an elderly patient with
pre existing cardiac and respiratory disease.

You are breaking bad news so you should fire a warning shot first.

“I afraid it is serious”..

“We know that your Dad has supraglottitis. This is most commonly caused by an infection
that leads to swelling around the voice box / airway and that is why his breathing has been
noisy and difficult for him. Unfortunately at present his breathing is not responding to
treatment and he is getting very tired”.

After telling a patient or relative any form of bad news it is essential to pause and allow a
period of silence. This will give them time to process what you have just said and will also
allow you time to gauge their feelings and reaction. Do not continue with the conversation
until the patient or relative is ready.

Actor:

In a slightly broken voice:

“Is my Dad going to die”?

Candidate:

“I am afraid he might die”

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Pause to gauge the relative's response, and allow them to speak if they wish, before
continuing.

”If the infection does not respond to treatment then he may die as the swelling around his
voice box will prevent him breathing”. We are giving all the treatment we can at present”.

Pause...

“However, if you dad’s breathing stops we feel that resuscitation would be very traumatic for
him and if he survived his quality of life would be poor. Due to this we would like put a do
not resuscitate order in place. Do you know what that means?”

Actor:

Actor becomes agitated by your last statement.

“So if he stops breathing your not going to do anything?”

This is a common question during discussion about DNARs, so be prepared for it.

Candidate:

Remain calm and composed

“I stress that we are providing all active treatment that we can at present to prevent your
Dad’s breathing stopping. But if the infection gets worse his breathing may stop. In that
instance we could try to get it started again, but this would be through very aggressive
treatment and your Dad’s quality of life following this would be very poor, especially in view
of his heart and lung disease. Therefore, if your Dad’s breathing stops we would prefer to
make him as comfortable as possible."

It is important to stress that a DNAR form, is not a 'Do Not Treat' order.

Actor:

Appears more calm after you last statement.

“I understand, but it’s very hard to hear these things about your own Dad”

Pause...

“But he has said before that if he did stop breathing he wouldn't want anyone to revive him”.

Remember, unless a relative has Lasting Power of Attorney (medically, not financially) then
legally their word has no weight. It is, however, extremely important to involve them in any
decision regarding a DNAR and take the time to explain the rationale behind it. Thanks to
 22

hospital-based TV shows, cardiovascular resuscitation has become somewhat glorified, and it

can sometimes be difficult to explain that despite best efforts, very few attempts are
successful, and often those that are result in much poorer quality of life for the patient.

Candidate:

Confirm that Mr Roger’s son understands and is happy with the DNAR order.

Ask if there are any other questions.

Follow this up by saying that you can be contacted by the nurses if there are any other
questions or concerns that arise.

Before closing the conversation ask Mr Rogers’ son if he would like to go and see his Dad.

Although this conversation may seem short, if you are delivery your statements at the right
pace and allowing appropriate silences then it should take 8 - 10 minutes.

hen breaking bad news you should have the following points in your mind:

• Appropriate environment. Most commonly a relatives room or an office where you know
you will not be disturbed is the most appropriate place.

• Ensure there are no distractions: you should leave your bleep with a colleague so that you
are not disturbed at a sensitive time

• You should always have another member of the MDT present with you, most commonly
another doctor or nurse who knows the patient

• Ensure that you know the patient’s history

• Ascertain how much the relative or patient knows

• Show empathy

• Give a warning sign or shot before you deliver bad news and follow this by an appropriate
pause. Do not be scared of silence

• Pitch your information giving at the correct level

Decisions relating to cardiopulmonary resuscitation. A joint statement from the British

Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing.
October 2007

http://www.resus.org.uk/pages/dnar.pdf
Main messages:
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• “Decisions about CPR must be made on the basis of an individual assessment of each
patient’s case”.
• “Advance care planning, including making decisions about CPR, is an important part of
good clinical care for those at risk of cardiorespiratory arrest”.
• “Communication and the provision of information are essential parts of good quality care”.
• “It is not necessary to initiate discussion about CPR with a patient if there is no reason to
believe that he patient is likely to suffer a cardiorespiratory arrest”.
• “Where no explicit decision has been made in advance there should be an initial
presumption in favour of CPR”.
• “If CPR would not re-start the heart and breathing, it should not be attempted”.
• “Where the expected benefit of attempted CPR may be outweighed by the burdens, the
patient’s informed views are of paramount importance. If the patient lacks capacity those
close to the patient should be involved in discussions to explore the patient’s wishes, feelings,
beliefs and values”.
• “If a patient with capacity refuses CPR, or a patient lacking capacity has a valid and
applicable advance decision refusing CPR, this should be respected”.
• “A Do Not Attempt Resuscitation (DNAR) decision does not override clinical judgement in
the unlikely event of a reversible cause of the patient’s respiratory or cardiac arrest that does
not match the circumstances envisaged”.
• “DNAR decisions apply only to CPR and not to any other aspects of treatment”.

Explaining a procedure

Mr Sreedharan is a 70-year-old man who is due to undergo a colonoscopy. He had noticed a

change in bowel habit and weight loss over the past year, and has had the colonoscopy
arranged by his GP. He has some questions about the procedure

Discuss the procedure with Mr Sreedharan and answer the questions he has.

Click here

How would you open the consultation?

I would introduce myself and start with an open question for instance

Hello I am Jamie the surgical SHO, I understand you have come for a colonoscopy and have
some questions about the procedure. Can I start by asking what you know about the
procedure please?

Hi Jamie, nice to meet you, I'm Aditya.

I'm actually a bit confused as to why I am here for the colonoscopy. I know my GP arranged
it but I don't really know why. Could you explain?
 24

Of course, but, could I start by finding out if you have had any symptoms related to your
bowels recently?

Yes I have, I first noticed a change in my bowel habit about a year ago, but only recently
went to the GP because I realised my trousers had became loose making me realise that I had
lost weight. The GP arranged a blood test and this colonoscopy. I don't really know what a
colonoscopy is, would you mind explaining it to me?

Of course. A colonoscopy is a camera test, where a thin camera is used to look at the insides
of your bowel. It involves having a camera about as wide as a 2 pence piece inserted in your
back passage to have a look at the large intestine. The pictures generated will appear on a
screen.

Before hand you shouldn’t have any food for 6 hours, but can drink clear liquid. You will be
given laxatives to clear your bowels out to allow us to see clearly. You will be awake for the
procedure but receive sedation medication which means you will not mind the procedure too
much, and won’t remember it clearly. It also means you will be drowsy after the procedure
and can’t drive so it is important to arrange transport home afterwards.

During the procedure you may feel as if you are passing wind as air is passed into the bowel,
you shouldn’t feel embarrassed. The operator may ask you to move around onto your side or
back at certain times. Take your time as you do this. They may take a tissue sample or
remove small growths for testing if they see them. This will not hurt.

Why do I need a colonoscopy?

The reason for a colonoscopy is because a change in your bowel habit can sometimes mean
there is something happening on the inside of your bowel. We need to find out about this as
early as possible as the earlier we find out someone has a medical problem the earlier it can
be treated

What could be happening inside my bowel to cause my symptoms?

The sort of things we are looking for include inflammation and abnormal growths. If we see
evidence of this we take a sample so that we can analyse further and decide on further
management.

By growths do you mean cancer?

A growth can represent cancer yes, and this is one of the things we are hoping to rule out. A
growth can also represent a benign tumour, which once removed shouldn't cause you any
more problems, or be a precancerous lump, meaning that it will one day turn into cancer. The
 25

colonoscopy allows us to find this information out, and treat the precancerous lumps before
they turn into a cancer.

What happens if something is found, will I be told what it is straight away?

It normally takes a while for the histology, which involves looking at cells under a
microscope, to return. Once it does we will discuss the results with a multidisciplinary team
of experts so that the best management can be decided on. We will then contact you to
arrange a time to come back in to receive the results, This will usually be within two weeks
of the procedure.

When this happens it is a good idea to ask a close friend or relative to come in with you.

The good news is that you are in good hands and having the investigation that you need to
find out the cause for your symptoms.

What are the risks for this procedure?

The most serious risk in a colonoscopy is damage to the bowel wall. This occurs very rarely;
you should see a doctor if you experience any abdominal pain, a fever, shortness of breath,
vomiting or significant amount of blood in your stool afterwards, although if a biopsy is
taken, a small amount of blood is normal.

You may also feel bloated and have wind-pains, which should disappear within 24 hours.
Occasionally, the colonoscopy will have to be repeated.

The surgeon performing the procedure will go through the risks in more detail for you later.

How long does a colonoscopy last?

The procedure itself will last around 20-30 minutes, with time around it to explain the
procedure, gain consent, and position you.

What foods should I avoid after the procedure or can I eat normally?

You can eat normally after the procedure

hat is the Dukes classification of colon cancer?

 26

The Duke's classification is a system used to stage colon cancer based on level of invasion. It
has been replaced in clinical practice by the TNM staging system

What the actor was told

Name: Aditya Sreedharan

Attitude: Confused as to why you need the colonoscopy as your GP arranged it without fully
explaining the reasons for it.

What you know: You have had a change in your bowel habit, which you first noticed about a
year ago, but only recently presented to your GP when your trousers became loose and you
realised that you had lost weight. The GP arranged a blood test and this colonoscopy which
you understand to mean that the specialist doctors will look at the insides of your bowel. You
don’t know what the procedure involves or why it is being done

Responses: You should start by asking politely for an explanation of the procedure before
moving on to ask why the procedure is being done. Look and sound confused if medical
jargon is used. Understand when simple terms or a diagram is drawn for you. When the
doctor mentions why you are having it, if the word cancer is used straight away, then appear
shocked and upset saying no one had told you that was a possibility. If they use terms like a
mass/lump etc, push them to what that means, and ask directly could this be cancer? Ask
about the risks of the procedure and the other questions on the mark scheme

This station is testing how well you can communicate the need for a procedure and what the
procedure involves.

Start by washing your hands and introducing yourself.

Find out it they’ve had a colonoscopy before and what they know about the procedure.

When explaining a colonoscopy, it is important to break the explanation down:

“It is a camera test to look at the insides of your bowel. It involves having a camera about as
wide as a 2 pence piece inserted in your back passage to have a look at the large intestine.
 27

The pictures generated will appear on a screen. Before hand you shouldn’t have any food for
6 hours, but can drink clear liquid. You will be given laxatives to clear your bowels out to
allow us to see clearly. You will be awake for the procedure but receive sedation medication
which means you will not mind the procedure too much, and won’t remember it clearly. It
also means you will be drowsy after the procedure and can’t drive so it is important to
arrange transport home afterwards. During the procedure you may feel as if you are passing
wind as air is passed into the bowel, you shouldn’t feel embarrassed. The operator may ask
you to move around onto your side or back at certain times. Take your time as you do this.
They may take a tissue sample or remove small growths for testing if they see them. This will
not hurt.
The reason for a colonoscopy is because a change in your bowel habit can sometimes mean
there is something happening on the inside of your bowel. We need to find out about this as
early as possible as the earlier we find out someone has a medical problem the earlier it can
be treated.“

You should briefly explain the risks and state that they will be discussed more thoroughly
with the patient during the consent process.

“Risks include damage to the bowel wall which occurs very rarely and you should see a
doctor if you experience abdominal pain, fever, shortness of breath, vomiting or significant
amount of blood in your stool; however if a biopsy is taken, a small amount of blood is
normal. You may feel bloated and have wind-pains, which should disappear within 24 hours.
Occasionally, the colonoscopy may have to be repeated. The surgeon performing the
procedure will go through the risks in more detail for you later.

If asked is it cancer, explain that among other things the test is being done to rule out a
cancer. Carefully explain that the procedure following the test, including that the histology
takes a while to return, that the case will be discussed in a multidisciplinary team of experts,
and that he will be contacted to arrange a time to receive the diagnosis. Suggest that when
this happens, a close friend or relative can come in with him. Reassure him that he is in good
hands and having the investigation that he requires

When explaining procedures, use of a diagram can help patient understanding, and there will
usually be a pen and paper available to you; if not you can ask the examiner for this.

Remember to use the 4 key communication techniques to maximise your marks

Establish a rapport by asking an open question - this allows them to talk and set the scene for
you and points to where the marks are going to be

Split longer answers into 3 parts - this gives your answer a beginning, middle and end,
keeping the examiners attention by sign posting what you are saying, and prevents you from
waffling

Actively listen, by leaning in when the patient is talking, using active encouragement, eg "I
understand..." and leaving appropriate pauses to allow them to express their feelings -
feelings that will undoubtedly be on the mark scheme!
 28

Summarise the consultation, keeping things brief and asking them if there is anything else
they would like to ask - allowing you to sweep up any remaining marks that you have missed
to this point
29
 30

Haematuria

You are the CT1 in Mr Howard’s urology clinic. Mr Jones is a 61 year old man who has been
referred to clinic with haematuria. You have been asked by your consultant to take a history,
present your findings to him and he will then ask you some questions about the case

Click here

Candidate:

Hello, my name is Tom Robinson, I am a core surgical trainee working for Mr Howard. How
can I help you today?

Actor:

Well, the main reason I am here is because I’ve noticed my urine becoming redder over the
last month.

Candidate:

Okay. Tell me a bit more about this reddening of your urine.

Actor:

I’ve noticed that when I go to the bathroom, my urine comes out very red. It doesn’t hurt, but
it’s quite scary.

Candidate:

Is it painful when you pass urine?

Actor:

No

Candidate:

Have you had anything like this before?

Actor:
 31

No

Candidate:

Do you have any other problems with your waterworks?

Actor:

I have had to get up in the middle of the night to go to the bathroom in the last year which is
unusual for me. I’d just put it down to age really.

Candidate:

Have you had any unintentional weight-loss recently?

Actor:

Yes actually. I’ve lost about a stone in the last few months.

Candidate:

Do you have any other medical conditions?

Actor:

No

Candidate:

Do you take any regular medications?

Actor:

No

Candidate:

Do you have any allergies?

Actor:
 32

No

Candidate:

What is your occupation?

Actor:

Well, I’m retired now but I used to work in the rubber dye industry.

Candidate:

Do you smoke?

Actor:

Yes. A bit too much probably. I smoke about 2 packs a day, and have done for 20 years.

Candidate:

Are there any medical problems which seem to run in the family?

Actor:

Well, my dad had COPD and my mum died of lung cancer when she was 75.

Candidate:

I’m sorry to hear that. Do you suffer from any other problems at the moment, for example do
you get breathless easily, suffer from chest pains, dizziness, constipation?

Actor:

No

Candidate:

What do you feel may be causing your symptoms?

Actor:
 33

Well, to be honest doctor I’m worried it might be cancer.

Candidate:

Why do you think it might be cancer?

Actor:

My mate had the same problem a few years ago and was diagnosed with cancer. Do you think
it could be?

Candidate:

It is one of many possibilities, but I really cannot say anything for definite until we have run a
few more tests.

Is there anything else that you would like to ask me?

Actor:

No, thank you doctor

Examiner:

I’m going to stop you there. Please present your history.

Candidate:

I saw Mr Jones in the urology clinic today. He is a 61 year old smoker who previously
worked in the rubber dye industry. He presents with a one month history of painless
haematuria with associated weight loss of one stone over the last 3 months, and nocturia. He
is otherwise fit and well, takes no medications, has no allergies, and has a family history
significant for lung cancer and COPD. He is concerned about the possibility of having cancer

What is your differential diagnosis?

The most important diagnoses to exclude are bladder cancer and renal cell carcinoma. Given
his age, smoking history, occupational history, and recent weight loss these would be at the
top of my differential.

Other diagnoses to be considered include infection, stones, or trauma of the kidneys, ureters,
bladder, prostate or urethra.
 34

What else would you like to do to narrow down your differential?

I would like to perform a full examination of the patient looking particularly for abdominal
masses and evidence of metastatic disease.

Further, I would like to perform simple bedside investigations including urine dipstick to
confirm haematuria, assess for presence of infection, and send a sample off for cytology.

I would want to take bloods including FBC looking for anaemia, U&Es looking for renal
dysfunction, clotting screen, and PSA to assess for prostate cancer. This could followed up
with imaging including cystoscopy, USS or CT.

Let’s say now that we are several months down the line and we have diagnosed transitional
cell carcinoma of the bladder. What treatment strategies are available?

The patient would be managed in a multidisciplinary setting with the input of specialist
urology surgeons, pathologists, radiologists, oncologists, and specialist nurses.

The type of treatment would depend upon the stage and grade of tumour, patient factors, and
the latest evidence base available.

Treatment can include non-surgical options e.g. chemotherapy, radiotherapy, and surgical
options e.g. transurethral resection of bladder tumour, radical cystectomy.

• Painless frank haematuria should be considered to be cancer until proven otherwise.

• Key aspects of the history include exposure to carcinogens e.g. smoking, rubber dye.

• The patient will often have an idea of cancer in their mind.

• Keep in mind the other causes of haematuria as there are simple tests for many of them e.g.
dipstix for UTI.

• The management of a patient with cancer always starts with the multidisciplinary team.
 35

Hidden diagnosis

You are asked by the nurses to talk to Mr Barry Jones, the son of Jennifer Jones a patient
under your care. Mrs Jones is a 78-year-old lady who was admitted following a fall. She had
a CT head yesterday which shows a right-sided lesion suggestive of a malignant tumour. The
patient has not yet been told the news.

Click here

The patient’s son would like to speak to you about his mother’s condition and recent scan.
She has given you permission to discuss anything about her including the results of the scan
with her son.

How would you open the consultation?

After introducing my self I would start with an open question, to find out what the relative
knows already.

"Hello, I am James the surgical doctor looking after your mum. I understand you wanted to
talk to me about your mother's care. Can I ask what you know so far?"

"Thank you for taking care of Mum. I know she came in because of a fall, but has made a
good recovery back to normal. She had a scan yesterday, and I wanted you to discuss them
 36

with me first, as she is doing we and I don't want her upset if there is anything bad on it.
Mum has given you permission to tell me the results first"

How would you respond?

I would suggest it would be better if we all discussed the results of the scan together so that
we can talk about what we are going to do next.

He replies angrily that his mother has asked him to find out the results first, and explicitly
given you permission to tell him the results.

What would you do?

I would apologise and check with the patient that she wants me to give her son the
information before I speak to her.

If the patient wants me to tell her son first, and he is insisting on this I would give him the
results without his mother present, but explain that it is important for us all to discuss the
results together soon afterwards.

How would you approach giving the results, presuming you had confirmed with your
consultant that you should do so in the manner the relative has asked for?

I would give a warning shot, by saying that the scan has shown something abnormal. I would
follow this up by suggesting that we can't be sure what the abnormal lesion is, but that there
is a possibility that it could be a tumour.
 37

Following the silence the station might go as follows

"Do you mean this could be cancer?"

There is a possibility it could be cancer, however we wont know until we discuss the scan at
the multidisciplinary team meeting with the radiologists and oncologists, and decide what the
next step is going to be

"What happens next"

Once we have discussed your mothers case, we will consider whether she needs a biopsy, to
allow us to diagnose exactly what the lesion is. After this we will be able to give you more
information about her management options.

"I'd like you not to tell her about this yet, as she's happy at the moment, and I don't want this
news to upset her"

I understand that you want to protect your mother. However I think it is important that she
know's everything that we do so that she is able to understand what is going to happen next.

She should be allowed to decide on what investigations and treatment she will accept, and to
do so, she needs to be fully informed and involved in all discussions.

Normally patients are much happier when they know the reason for their symptoms than if
they are kept in the dark. Therefore I have to give her the same information that I have given
you.

I hope you understand?

 38

The relative eventually agrees that you will tell his mother.

How would you close the consultation?

I would summarise our discussion and arrange a time in the next few hours when I can return
and talk to the patient with her son present. I would also offer to bring a senior along with me
if they wished to ask further questions regarding future management

What the actor was told

Name: Barry Jones

Attitude: Concerned about your mother

What you know: Your mother has been complaining about left sided weakness for a few
weeks now, and now she has had a fall, you are concerned that she may have had a stroke or
even worse brain cancer. You are very close to your mother and don’t feel that she should be
told if the diagnosis is a bad one. You would like to know the results of the scan and for the
doctor to agree to not tell your mother as you think she would react very badly, and as she is
doing so well, you don’t feel she would want to know what the diagnosis was anyway.

Ask the candidate to promise to withhold information from your mother. Become initially
cross if they say they have to inform your mother, and then become placated if they give an
explanation making you realize that it is better for your mother to know.

When speaking to a relative it is essential to ensure you have consent from the patient for the
discussion. In this case it is made explicit in the scenario.

Start by washing your hands and introducing yourself. Find out what they know by asking an
open question. “Can I ask what you know so far?”

Actively listen to the relative’s answer.

When breaking bad news, it is important to first give a warning shot “I’m afraid the news
isn’t good. Unfortunately you are right that there is something happening in your mother’s
head. The CT scan that we performed shows a mass in the brain.”

If appropriate after giving this information you can pause and leave a silence to allow the
information to sink in.
 39

The treatment pathway for a possible brain tumour is the same as for any other cancer. It
involves obtaining a tissue diagnosis and discussion in an MDT where a decision over the
best course of action will be made.

If at any point in the OSCE you are asked for information that you don’t know the answer
for, you should explain that you will arrange for one of your senior colleagues to come and
give the information rather than make anything up.

When asked to keep the CT results a secret you should be empathetic to the sons concerns,
and ask whether his mother has previously stated a wish not to be told of any serious
diagnosis, or whether she has an advanced directive stating this. If not, you need to explain
why it is important that the patient is told of her CT result. This is so that she is aware of
treatment options, and of what will happen over the next couple of weeks. She should be
allowed to decide on what investigations and treatment she will accept, and to do so, she
needs to be fully informed and involved in all discussions. Reassure the son that normally
patients are much happier when they know the reason for their symptoms than if they are kept
in the dark.

Remember to use the 4 key communication techniques to maximise your marks

Establish rapport by asking an open question - this allows them to talk and set the scene for
you and points to where the marks are going to be

Split longer answers into 3 parts - this gives your answer a beginning, middle and end,
keeping the examiners attention by sign posting what you are saying, and prevents you from
waffling

Actively listen, by leaning in when the patient is talking, using active encouragement, eg "I
understand..." and leaving appropriate pauses to allow them to express their feelings -
feelings that will undoubtedly be on the mark scheme!

Summarise the consultation, keeping things brief and asking them if there is anything else
they would like to ask - allowing you to sweep up any remaining marks that you have missed
to this point. Arrange a time in the next few hours when you can come back and talk to the
patient with her son present.
40
 41

Jehovah’s Witness

Mr Ungwe is a 67-year-old man who is due to have a craniotomy for a removal of a highly
vascular brain tumour. Normally this would require 4 units of blood to be crossmatched;
however Mr Ungwe is a Jehovah’s witness and he has previously stated that does not want a
blood transfusion.

Talk to Mr Ungwe about the operation with particular attention on the possibility of a blood
transfusion.

Click here

Please explain the operation Mr Ungwe is going to have including the possibility of a
transfusion, using the information you have

Hello Mr Ungwe, I am Rosa one of the surgical SHOs, I wanted to discuss the operation
you're due to have if that's ok?

Can I start by finding out what you know?

He responds, "I know I am going to have an operation to take out a brain tumour. If it goes
well, please God, I will be cured. I understand there are risks"

Yes. We are planing an operation to take the tumour out of your head. It is a risky operation
mainly because the tumour can bleed a lot. Therefore I wanted to get your permission to
crossmatch and store some blood so that it is available if the need arose.

Would that be okay?

 42

He refuses as he is a Jehovah's witness and believes it is wrong to receive a blood transfusion.

He asks you, "What are the risks if I don't?"

The tumour is a vascular tumour, which means that it can bleed a lot. We will do our best to
avoid this but bleeding can be unavoidable sometimes. The risks if we can't stop the bleeding
are that we have to abandon the operation before the tumour is completely removed. It could
also cause a serious stroke, and there is an increased risk that you could die.

He understands this but still refuses a blood transfusion.

How would you check the patient has capacity to make this decision?

I would ask them to relay the information and the risks of refusing a transfusion back to me.

Patient's have capacity to refuse treatment even life saving treatment if they can understand,
retain and weigh up the information, and are able to communicate their decision by any
means

Who would you inform of this decision?

I would discuss the refusal of a blood transfusion with the consultant neurosurgeon,
anaesthetist, and liase with theatre staff

Should the operation be considered safe without a transfusion what precautions can be taken
to reduce the risk?
 43

Preoperatively, I would check the baseline Hb; if low it may be worth postponing the
operation and establishing a higher baseline Hb. I would discuss the case with a
haematologist and consider erythropoietin to increase the preoperative Hb. I would consider
starting IV fluids to ensure good hydration in the run up to the operation.

Intraoperatively, a quick operation by an experienced consultant is preferable, with focus on

haemostasis. We could use a cell salvager to allow blood lost to be replaced in an autologous
transfusion. Good communication between the anaesthetic and surgical team is important to
ensure that blood loss is anticipated and treated quickly with fluid replacement.

Postopratively, I would ensure adequate hydration, recheck the Hb immediately after the
operation, then again in the evening and morning after. I would hand this patient to the on
call surgical team and clearly document the refusal of transfusion under any circumstances in
the notes.

How would you close the consultation?

I would close by summarising our discussion and documenting it in the notes.

For instance

We have been through some of the risks of the operation, and discussed why we would
recommend that you have blood available for a transfusion. You have decided to refuse a
transfusion, even in the event that it is needed to save your life. As you understand all of the
risks, we will respect your decision and I will make sure everyone involved in your care is
aware of it.

I have told you that we will take extra precautions to minimise the risk of significant blood
loss, and you are happy with these precautions.

Do you have any further questions?

 44

What the actor is told

Name: Ken Ungwe

Attitude: Adamant that you will not have a blood transfusion as you are a Jehovah’s witness
and you believe that doing so is a sin.

What you know: You have a brain tumour that is operable, but the operation is risky. You
have been told by the house officer that you may need a transfusion as the tumour can bleed a
lot. You have told them you don’t want a transfusion, and if necessary to cancel the
operation. A senior house officer has come to you to discuss your options.

Responses: You get angry if the candidate insists that you must have blood available for the
operation, but otherwise are pleasant and inquisitive. When it is established that you will not
have a transfusion, you should ask, “what are the alternatives to a transfusion?” You may
prompt if they don’t mention preoperative measures, intraoperative measures and
postoperative measures. If not mentioned you should ask, “is there a risk I could die?”

In any refusal of treatment station, it is important to empathise with the patient to understand
why they are refusing the treatment. In the case of a Jehovah’s witness, it is important not to
assume refusal of blood products. Instead you should explain why a transfusion could
become necessary and why it is advisable. Explain to them the risks of the procedure,
including heavy bleeding. It is important to emphasise that by refusing a blood transfusion
there is an increased risk to their life in the event of a haemorrhage.

Establish capacity to make a decision by checking they understand this.

A patient has capacity if they can

Understand the information relevant to the decision

Retain the information relevant to the decision
Use or weigh the information
Communicate the decision (by any means)

Once established it is important to respect patient autonomy by allowing their decision to

stand, whatever that decision is.

Assuming the operation is in their best interests and the risk of haemorrhage doesn’t out
weigh the benefit the operation will provide, there are other alternatives to a blood
transfusion.
 45

Preoperatively, it is important to check baseline Hb; if low it may be worth postponing the
operation and establishing a higher baseline Hb. Discuss the case with a haematologist and
consider erythropoietin to increase the preoperative Hb. Good hydration is important in the
run up to the operation, so consider starting IV fluids

Intraoperatively, measures can be taken to reduce the risk. A quick operation by an

experienced consultant is preferable, with excellent haemostasis an imperative. Use of the
cell salvager will allow blood lost to be replaced in an autologous transfusion. In addition for
some certain operations (e.g. when treating epistaxis) transexamic acid can be used to reduce
heavy bleeding.

Postopratively, you should ensure adequate hydration, recheck the Hb immediately after the
operation, then again in the evening and morning after. It is important to let the on call
surgical team know about this patient and the refusal of a transfusion, with clear
documentation in the notes.

Remember to use the 4 key communication techniques to maximise your marks

Establish a rapport by asking an open question - this allows them to talk and set the scene for
you and points to where the marks are going to be

Split longer answers into 3 parts - this gives your answer a beginning, middle and end,
keeping the examiners attention by sign posting what you are saying, and prevents you from
waffling

Actively listen, by leaning in when the patient is talking, using active encouragement, eg "I
understand..." and leaving appropriate pauses to allow them to express their feelings -
feelings that will undoubtedly be on the mark scheme!

Summarise the consultation, keeping things brief and asking them if there is anything else
they would like to ask - allowing you to sweep up any remaining marks that you have missed
to this point
46
 47

Leg pain, claudication

You are the CT2 in Mr Harrison’s vascular clinic. You have been asked to see Mr Walters
who is a 55 year old man with lower leg pain. Your consultant wants to you take a history
from him, and then come and present the findings to him. You will be asked a series of
questions about the case.

Click here

Candidate:

Hello, I am Joseph Sabaya. I am a core surgical trainee working for Mr Harrison. How can I
help you?

Actor:

I have had these pains in my legs for the last 6 months. It is really bothering me. I can’t sleep.

Candidate:

Tell me a bit more about these pains, when do you get them?

Actor:

Well, they come when I’m walking, particularly in the calves.

Candidate:

Tell me a bit more about these pains, when do you get them?

Actor:

Well, they come when I’m walking, particularly in the calves.

Candidate:

How far can you walk before having to stop because of the pain?

Actor:
 48

About 100 meters.

Candidate:

Has it suddenly become worse or has it gradually worsened over the months?

Actor:

It has gradually worsened over the months.

Candidate:

Do you get any pain at rest?

Actor:

No. Only when I’m asleep at night, otherwise rest seems to relieve the pain.

Candidate:

Do you suffer from any other medical problems, for example diabetes?

Actor:

Yes, I have type two diabetes mellitus and am taking metformin.

Candidate:

Have you or anyone in your family ever suffered from a heart attack or stroke or had
problems with pains in the legs?

Actor:

My father died of a heart attack aged 60, and my mother died of a stroke aged 70.

Candidate:

Do you smoke?

Actor:
 49

Yes, about 3 packets a day for as long as I can remember.

Candidate:

Do you take any other medications?

Actor:

No

Candidate:

Do you have any allergies?

Actor:

No

Candidate:

Aside from the leg pains, is there anything else causing you trouble at the moment, for
example do you get chest pains or short of breath?

Actor:

No

Candidate:

Thank you. Is there is anything you would like to ask me?

Actor:

No, thank you doctor.

Examiner:

Please present your findings.

Candidate:
 50

I saw Mr Walters in the vascular clinic today. He is a 61 year old overweight smoker with
lower leg pains for the last 6 months, limiting his exercise tolerance to 100 metres and
causing him pain at night in his feet which resolves with resting his feet over the bed. He
does not suffer from rest pain. He suffers from type two diabetes mellitus and takes
metformin for this. Otherwise he is fit and well. He has a positive family history for vascular
disease (mother had a stroke, father had a heart attack).

What is your differential diagnosis?

The history is consistent with chronic arterial ischaemia causing vascular claudication,
however other diagnoses should be considered including deep venous thrombosis and spinal
claudication.

How would you distinguish clinically between spinal claudication and vascular claudication?

Spinal claudication is due to lumbar spinal canal stenosis, and patients suffer from
paraesthesia predominantly in a poorly localised distribution compared to the severe pain
localised to the calves and feet in vascular claudication.

What is critical ischaemia?

This is ischaemia severe enough to threaten the limb, and is clinically defined by rest pain,
and ankle brachial pressure index (ABPI) measurement less than 0.5.

How does the acutely ischaemic leg present?

The clinical signs and symptoms consist of pain, pallor, pulselessness, paraesthesia, paralysis
and perishing cold (“the six Ps”).

This comes on suddenly, often in the presence of atrial fibrillation, absence of previous
vascular disease, and the presence of normal pulses in the other foot.

• This is a history of chronic vascular ischaemia of the lower limb.

• Other “mimics” include spinal claudication and deep venous thrombosis.

• Acute vascular limb ischaemia is a vascular emergency and must be recognised and dealt
with promptly.

• Critial limb ischaemia requires relatively urgent intervention, therefore it is important to

specifically ask about rest pain, and exercise tolerance.
 51

• Most patients with chronic vascular claudication will have a personal and/or family history
and/or risk factors for vascular disease.

Liverpool Care Pathway

You are the CT1 on call. Overnight a patient with end stage pancreatic cancer was admitted.
Mr Peter Smith is well known to your consultant and on the post take ward round you release
that Mr Smith is dying. Your consultant asks you to do everything you can to make him
comfortable and speak to Mr Smith’s wife about the Liverpool Care Pathway (LCP).

This station should be treated as a combination of breaking bad news and information giving.
You have to tell the Mrs Smith that her husband is dying, then discuss and provide
information on the Liverpool Care Pathway.

Although the LCP has been in the media recently in a particularly negative light, and has
been withdrawn from circulation in some trusts, this station contains a number of tricky
aspects of communication that are vital to practice in similar situations.

Click here

Guidelines for breaking bad news:

• Appropriate environment. Most commonly a relatives room or an office where you know
you will not be disturbed is the most appropriate place.

• Ensure that there are no distractions: You should leave your bleep with a colleague so that
you are not disturbed at a sensitive time

• You should always have another member of the MDT present with you, most commonly
another doctor or nurse who knows the patient
 52

• Ensure that you know the patient’s history

• Ascertain how much the relative or patient knows

• Show empathy

• Give a warning sign or shot before you deliver the bad news and follow this by an
appropriate pause. Do not be scared of silence

• Try and pitch your language at the correct level, do not get too technical

Mrs Smith has arrived and you are going to talk to her...

Candidate:

Introduce yourself and allow any colleagues present with you to introduce themselves

Actor:

“I am Jackie Smith, Peter’s wife. Thank you for coming to speak to me”

Candidate:

Start with an open-ended question

“Can I ask how much you know about your husband’s current condition?”

It is vital to know how much the relative does or does not know, so even though you may feel
the urge, do not rush into breaking bad news.

Actor:

“I know that he has terminal pancreatic cancer. He has been getting weaker and weaker over
the past few weeks and his pain is getting unbearable”

There is a pause and Mrs Smith becomes upset whilst asking:

“Is Peter dying”?

Candidate:

You are breaking bad news so you should fire a warning shot first.

“I am afraid it is not good news”.

Pause...
 53

“Unfortunately, your husband is dying”.

After telling a patient or relative any form of bad news it is essential to pause and allow a
period of silence. This will give them time to process what you have just said. Do not
continue with the conversation until the patient or relative is ready.

Actor:

“I was expecting this but not so quick. Will he pass away today”?

It is impossible to tell how someone will react to this information. Try practicing with a
fellow candidate a variety of reactions from sadness to anger and see how you get on: the
actors in the exam can act all of them!

Candidate:

“It’s very hard to say how long, but in that time we want to make your husband as
comfortable as possible. To do this we are guided by the Liverpool Care Pathway”

Before you can ask do you know what that means, the actor becomes angry.

Voice raised

“Oh no, not that pathway, I read about it in the newspaper. You just let people starve and
ignore them to speed up their death! Under no circumstances is Peter to be put on that !”

Unfortunately this is a common reaction: while placing a patient on the LPC is a clinical
decision, it is vital to communicate the rationale for this to the family.

Candidate:

Remain calm and composed

“I understand your concerns and under no circumstance would we starve or ignore Mr Smith.
There has been a lot of publicity about the Liverpool Care Pathway recently and not all good.
Can I explain exactly what the pathway is”?

Actor:

With reservation...

“Ok, tell me”.

Candidate:
 54

“The Liverpool Care Pathway or LCP as some people call it is a pathway used to give dignity
in the dying. We would not withhold food or fluids unless from your husband. At all times
we will make your husband as comfortable as possible by providing pain relief, anti-sickness
medications and we will not be using deep sedation. We will provide regular mouth care and
change his position in bed to make him as comfortable as possible as long as it is not too
distressing. We will not be carrying out any routine tests as they can also be distressing and
do not give us any added information, but we will regularly review Mr Smith’s condition. I
would like to stress that we will provide the best care possible for your husband and you can
spend as much time on the ward with your husband as you wish”.

Actor:

Appears more calm after you last statement.

“That is very different from the newspapers”

Candidate:

“I agree”.

Pause and then ask:

“Are you happy Mrs Smith for use the LCP?”

"Do you have ay further questions?"

Actor:

Yes, I am. Thank you for explaining it so clearly”.

"I have one question. I would like a Catholic priest to come and see my husband. Is that
possible?”

Candidate:

The LCP does not restrict any religious beliefs

“That is not a problem. We will arrange for that”.

Close the conversation by saying that you can be contacted by the nurses if there are any
other questions or concerns that arise.

Then ask Mrs Smith if she would like to go and see her husband.
 55

Although this conversation may seem short, if you are delivery your statements at the right
pace and allowing appropriate silences then it should take 8 - 10 minutes.

When breaking bad news you should have the following points in your mind:

• Appropriate environment. Most commonly a relatives room or an office where you know
you will not be disturbed is the most appropriate place.

• Ensure that there are no distractions: you should leave your bleep with a colleague so that
you are not disturbed at a sensitive time

• You should always have another member of the MDT present with you, most commonly
another doctor or nurse who knows the patient

• Ensure that you know the patient’s history

• Ascertain how much the relative or patient knows

• Show empathy

• Give a warning sign or shot before you deliver bad news and follow this by an appropriate
pause. Do not be scared of silence

• Pitch your information-giving at the correct level

• Provide information as to how the patient or relative can contact you if they have further
questions

The Liverpool Care Pathway was developed in the late 1990s for the care of terminally ill
cancer patients. Since then the scope of the LCP has been extended to include all patients
deemed dying.
• The LCP has been recognised nationally and internationally as a good model to support the
dignity of a dying patient. It is supported by the GMC and NICE.
• The LCP is built around maintaining the highest possible dignity of the dying patient
• The LCP should be used when there is no further treatment that a patient can have and it is
recognised that they are in the last days or hours of their life
• The LCP does not hasten death. It is not euthanasia
• The LCP does not stop a patient from having oral intake or artificial hydration
• The LCP does not use deep, prolonged sedation
• The LCP does not interfere with a patients religious beliefs
• The LCP should be regularly reviewed (every 4 hours)
• Through the pathway good communication is essential with the patient, relatives and
amongst the MDT

We would recommend that you look at a copy of the LCP at your place of work.

Source:
Marie Curie Cancer Care website http://www.liv.ac.uk/mcpcil/liverpool-care-pathway/
 56

Making a referral

Mr Choi is a 56-year-old gentleman who presented with symptoms of a ruptured appendix.

He is unwell and will need an emergency laparotomy, which has been arranged. His past
medical history includes chronic renal failure, an MI two years ago, and hypertension.

You have 10 minutes to prepare after which you should discuss this patient with the ITU
registrar on call to get advice on management and arrange an HDU bed postop.

Click here

There is a 10 minute preparation station

Please review the patient's notes

Clinical assessment
 57

Clinical assessment
 58

Clinical assessment
 59

Drug chart
 60

Observation chart

Blood results
 61

ABG

Please refer this patient to the ITU registrar on call to get advice on management and arrange
an HDU bed postoperatively

Hello, my name is Mr Jones. I am the surgical SHO working for Mr Hendry the colorectal
consultant at the Newcastle Royal Infirmary. I am calling to speak to the ITU registrar to ask
advice on an unwell patient who has been today admitted and is going to require a
laparotomy. I would also like to arrange an HDU bed postoperatively. Could I check who I
am speaking to, please?

Hello, I'm Dr Patel the ITU registrar. Could you tell me more about the patient please? I have
to see an unwell patient in HDU in around 10 minutes so please could you keep the story to
the point

Mr Choi is a 59 year old with a background of chronic renal failure, an MI and hypertension,
who presented with a perforated appendix and has gone into acute renal failure, with
 62

hyperkalaemia. His bloods tests show an potassium of 6.1, an creatinine of 240 up from a
baseline of 175.

His ABG shows a metabolic acidosis, with a high lactate and high negative base excess.

Please could I have some advice on optimisation before theatre and would it be possible to
arrange an HDU bed?

What medication is the patient on?

They are on Bisoprolol, Ramipril, Simvastatin, Paracetamol and we have just started IV
coamoxiclav on microbiology advice.

Next question

Why do you think the lactate is high?

The most likely cause is sepsis secondary to perforation of the appendix

During the hypoperfusion of tissues, reduced oxygenation results in anaerobic respiration

producing lactic acid as the end point, and utilising it for energy production.

What is sepsis?

Sepsis is the presence of clinical signs of SIRS, the systemic inflammatory response
syndrome criteria, associated with infection either suspected or confirmed by culture or Gram
stain.

The SIRS criteria are:

Temp > 38 or < 36
HR > 90
RR > 20 or PaCO2 < 4.3
WCC > 12 or < 4

What does the chest X-ray show?

 63

We haven't arranged one yet, but I will do so as soon as I get off the phone.

Why do you think the patient is in renal failure?

The most likely mechanism is pre-renal failure secondary to sepsis. He has a background of
chronic renal failure making him more susceptible to an acute insult.

How do you think we should optimise this patient for theatre?

The patient is already on IV antibiotics. We should commence IV fluids to prehydrate him, as

he appears septic and under filled, although in light of their his MI I would be careful not to
overload him.

I would withhold his beta blocker and ACE inhibitor until his blood pressure improves.

He may warrant closer monitoring, with arterial and central venous monitoring, as his high
potassium, sepsis, and renal failure suggest he could deteriorate rapidly.

Do they meet the criteria for HDU admission?

Yes they do, as they require support for a single failing organ system, they don't require
advanced respiratory support and there is a reversible cause.
 64

Dr Patel tells you he will come and review the patient before theatre, and asks you to liaise
with the anaesthetic registrar who is running the emergency list.

He will arrange an HDU bed for your patient post op.

What the ITU registrar was told

Name: Dr Patel - you are acting as the ITU registrar.

Attitude: You are quite busy, but able to listen to the history and advise on management,

What you know: There is one HDU bed available and a neurosurgical registrar who has
requested a bed for a subarachnoid haemorrhage has just phoned you. The patient is currently
GCS 14, and is coming over to have an external ventricular drain inserted for hydrocephalus.
The reason for their HDU admission is that they require observation in the event of
deterioration.

Responses: Open by saying that you have to see an unwell patient in HDU in around 10
minutes so please could they keep the story to the point. Be friendly if they summarise the
story telling you from the start that they want advice and to arrange a bed. Otherwise,
interrupt and ask them what exactly they want from you. Ask them for the clinical picture, for
the blood tests, the comparison to the previous tests and the ABGs. Go through their
medications. Ask what the bowel sounds are – (doesn’t have that information available). Ask
what the chest X-ray shows (hasn’t had one). Advise them to arrange a portable chest X-ray
when they get of the phone. Ask what management has been initiated. What is her premorbid
status? Ask if this patient meets the criteria for HDU admission. Suggest that they prehydrate
this patient before theatre and that they inform the on call anaesthetist that will be doing the
case. Hold off the beta-blocker and the ACEI. You will come see the patient and liaise with
the on call anaesthetist and the neurosurgeon regarding the last bed.

It is important in the preparation station to get a feel quickly for what the most important
information is. Make notes as if you were the one receiving the referral. Make sure you check
the date and time of the investigations and circle all the abnormal results.
 65

Open by introducing yourself and the reason for your call, asking if you are speaking to the
ITU registrar.

For instance:

“My name is Dr Jones. I am the surgical SHO working for Mr Jones the colorectal consultant
at the Newcastle Royal Infirmary. I am calling to speak to the ITU registrar to ask advice on
an unwell patient who has been today admitted and is going to require a laparotomy. I would
also like to arrange an HDU bed postoperatively. Could I check who I am speaking to?”

When you are asked for the information, give it concisely. A good technique is to start, “Mr
Jones is a 56 year old with a background of X, who presented with a perforated appendix and
has gone into acute renal failure, with hyperkalaemia. His bloods tests show … (here give the
abnormal ones only, the SpR can ask you if there are any further results he wants) and his
ABG shows a metabolic acidosis, with a high lactate, and a potassium of Y”

Do not ever lie in a station (or in real life…). If you don’t have the information, apologise,
admit you don’t know and indicate that you will find out as soon as you get off the telephone.
If the SpR insists you find this information out first, you should apologise again for not
having it available but suggest that you go through the information that you do have first so
that if anything else is missing, or if urgent action needs to be undertaken it can be.

HDU admission criteria:

Patient’s requiring support for a single failing organ system

Patient does not require advanced respiratory support
Patient’s requiring more detailed monitoring than can be provided on the ward
Post operative patients who require post op monitoring for more than a few hours
Patients being stepped down from ITU

ITU admission criteria:

Patients requiring or likely to require advanced respiratory support – intubation and

mechanical ventilation
Patients requiring the support of two or more organ systems
Patients with a severe chronic impairment of one or more organ system who now require
support for an acute reversible failure of another organ system
A reversible disease process

HDU is categorized as level 2 care, and ITU as level 3 care.

Level 0 Ward
Level 1 Ward with critical care team input
Level 2 HDU – for detailed observation, a single organ failure or following major surgery
Level 3 ITU – for support of two or more failing organs, or patients requiring ventilation
66
 67

Consent for oesophago-gastro-duodenoscopy (OGD)

You have been asked by your consultant to consent Mr Jarvis, a 64 year old, for an OGD.
When you read through the clinic notes, you see that he has been suffering with dysphagia
and indigestion for the past 4 weeks.

Click here

Candidate:

Hello Mr Jarvis, I am Mr Smith’s SHO and I have been asked to talk to you about an
investigation he would like to arrange for you. Can I just start by asking you what you
understand so far?

Actor:

Sure no problem. From what I gather, Mr Smith wants to put a camera down to have a look to
see why I’m having all these problems with my swallowing and heartburn.

Candidate:

Yes that’s right. The camera test is called an oesophago-gastro-duodenoscopy, which is

shortened to OGD.
It is a camera, known as an endoscope, which is inserted through the mouth, down the food
pipe, into the stomach and along to the first part of the small bowel. {You can draw a quick
diagram to demonstrate this}
The camera then relays the image onto a TV screen so we can have a look inside and see
what may be causing your symptoms. We may also need to take some tissue samples from
the lining of your digestive tract to help us with our diagnosis. Typically, this doesn’t hurt.

Does that make sense so far?

Actor:

Yes it does, it doesn’t sound very nice though! Will I be awake for the procedure?

Candidate:

Yes I can appreciate that. There are two options. You can either have local anaesthetic
sprayed into your throat to numb the area or you can be sedated (that is, not asleep but you
won't remember). The benefit of having local anaesthetic spray means that you can go home
straight after the procedure and you can drive. You would just need to avoid hot drinks until
the numbness has worn off in around 30-60 minutes. If you have sedation, you will need
someone to accompany you home and stay with you until the next day. You cannot drive for
 68

24 hours. You will likely be able to go home the same day if you are well and have managed
something to eat and drink.

Actor:

I see. I think I would prefer to be sedated. Are there any alternatives to having this done?

Candidate:

Yes. You can have a barium swallow/meal X ray, which involves drinking a contrast solution
and then having sequential X rays. This is not as informative as an OGD and we wouldn’t be
able to take tissue samples to help with the diagnosis with this investigation.

Actor:

Oh right, I think the OGD sounds like the better option.

You have been asked by your consultant to consent Mr Jarvis, a 64 year old, for an OGD.
When you read through the clinic notes, you see that he has been suffering with dysphagia
and indigestion for the past 4 weeks.

Click here

Candidate:

Unfortunately, no procedure is without risk. The possible risks involved with this procedure
are:

- Bleeding from the site of tissue sampling.

- Infection, such as a chest infection if some fluid passes into the lungs.
- There is also a risk of damage to the teeth from the endoscope.
- A slightly more serious risk is a perforation or tear of the lining of the digestive tract which
may need an operation to repair. The risk of this is 1 in 1000.

It is normal to expect a sore throat for a few days afterwards.

Actor:

What about eating around the time of the OGD?

Candidate:

If your appointment is in the morning, take no food or drinks after midnight.

If your appointment is in the afternoon, you may have a light breakfast no later than 8am, but
 69

no food or drinks after that.

Small amounts of water are ok to take up to two hours before the procedure.

Actor:

Should I taKe my blood pressure tablets in the morning?

Candidate:

Yes, take your regular medications in the morning.

Have you got any more questions?

Actor:

Yes, how long will it take to get the results of the tissue sample?

Candidate:

It takes 2 weeks to get the results of the tissue biopsy. You will be seen in the outpatient
clinic following the procedure to discuss the findings of the investigation.

Actor:

Thank you, I think that is everything.

-Introduce yourself and gain understanding of what the patient understands so far.

-Explain the OGD procedure and tissue sampling. It is helpful to draw a diagram if you can
do this quickly.

-Explain that it can be done under local anaesthesia or sedation.

-Explain alternatives – barium swallow/meal Xray.

-Expect a sore throat afterwards.

-Risks – Bleeding, infection, damage to teeth, perforation.

-Inform them when to be NBM and to take their regular medications.

-Summarise if necessary and keep checking that they understand the information.

-Offer information leaflet.

 70

Radiology request

You are the core surgical trainee in General Surgery on call. You have been asked by your
registrar to organise a CT scan of the abdomen and pelvis TONIGHT for a 51 year old man
with severe left iliac fossa pain, localised peritonitis and raised inflammatory markers. He is
otherwise fit and well. His observations show a sinus tachycardia and raised temperature of
38.9 degrees. You have to discuss the request with the radiology registrar on call.

Click here

Candidate:

Hello. My name is Dr Thompson. I am the general surgical core surgical trainee on call. Am I
speaking to the radiology registrar on call?

Actor:

Yes. How can I help you?

Candidate:

I would like to arrange an urgent CT of the abdomen & pelvis of a 51 year old man who was
admitted to the surgical assessment unit yesterday evening with acute left iliac fossa pain, and
localised peritonitis, please.

Actor:

Okay. Put a request in and I’ll arrange it for the morning.

Candidate:

Actually, I would really like the CT to happen tonight, if possible. I am concerned that he
may have a collection or localised perforation of the bowel given his worsening clinical
examination findings.

Actor:

If you’re worried about perforation shouldn’t you be taking him to theatre rather than wasting
time with a CT scan? We are extremely busy at the moment and this doesn’t sound like it is
going to change your management

Candidate:
 71

I appreciate that you are busy. My registrar has examined the patient and feels that a CT scan
is the best first course of action. He has been on treatment for diverticulitis for 24 hours and
is getting worse. He is very keen that we get this done this evening to guide us.

Actor:

Okay, what are you going to do this evening if it does show a perforation?

Candidate:

I will review the scan with my registrar and consultant. If it shows a significant perforation
we may have to take him to theatre tonight. It may also guide us to an alternative diagnosis.

Actor:

Okay. What is his renal function?

Candidate:

I do not have the renal function results to hand. I will check his renal function as soon as I am
off the phone and call you back with the results.

Actor:

Does he have any co-morbidities which might put him in a high risk group for contrast?

Candidate:

He doesn’t have any risk factors for renal impairment, and he is not allergic to contrast.

Actor:

Okay. Give me his details and put a request through on the computer system. I will contact
the radiographers to see if we can get it done soon.

• These scenarios typically start with a preparation station to familiarise yourself with the
patient’s history and examination findings based upon a set of case notes.

• Ordering imaging out of hours can be a challenge as there are fewer resources available.

• It is important to be clear about what you want in terms of imaging and urgency, with a
clear rationale.
 72

• You may be challenged more than you would be during normal working hours, particularly
as a junior doctor, but it is important to stay calm and focus on the clinical issues.

• It is important not to make things up – this will reflect very badly in the exam scenario.

Self discharge

You are the on call surgical registrar. Please talk to Mr Donald, find out why he wants to go
home, and explain why he must stay in.

Click here

James Donald is a 27-year-old man who presented with right iliac fossa pain. History,
examination and investigation including US and bloods point to a possible but not definite
appendicitis
 73

Mr Jones the colorectal surgeon has reviewed him and decided that he wants to observe the
patient in hospital for the next 24 hours, with a view to a laparoscopic appendicectomy in the
morning if he fails to improve and an emergency appendicectomy overnight if he
deteriorates.

The patient is feeling a little better, and although he still has some pain, it is bearable and he
has asked to speak to you about letting him go home.

What would you do before speaking to him?

I would review the notes and investigation results and speak to the consultant involved as it
may be that the patient is safe to be discharged.

After speaking with the consultant, he tells you that this patient should stay in as his life is at
risk if he does not.
 74

The patient asks to be medically discharged regardless as he lives near the hospital, “its
probably nothing” and his young family is at home. Your wife will be able to look after you
and bring you back in if you feel any worse, and you don’t mind coming back in in the
morning to see the consultant again.

How would you respond?

I would spend some time establishing why the patient wants to be discharged. If there is
something I can change to make him agree to stay, I would make it happen if possible.

I would explain why going home is not medically advisable and stress that the consultant, the
expert in this field, wants him observed overnight. This means there is a real possibility that
he could get worse. I would stress that if he goes home he could become seriously unwell and
even die.

He still wishes to go home, can you keep him in hospital against his wishes?

If he has capacity to make a decision then I can't prevent him from going home even if the
decision does not seem to be a sensible one. He will have to self-discharge.

ow would you assess his capacity?

I would ask him to repeat what I have told him back to me to check capacity to make this
decision.

If he can understand the risks associated with him going home, retain that information, weigh
it up and communicate his decision back to me then he has capacity to make the decision.
 75

He demonstrates his capacity to make this decision. What must you do now?

As I cannot discharge him medically, I would explain that he needs to self-discharge,

explaining that he is responsible for the consequences of the decision.

He must sign a legal document that states that the clinical scenario was explained, continued
admission was medically advised, the potential consequences of self-discharge have been
explained and he takes responsibility for any adverse outcomes.

The patient asks: "Can I have some pain killers to take home with me?"

As he is self-discharging, I cannot officially give him any to take home medication (TTOs),
however I would advise him to buy appropriate analgesia from a chemist.

He agrees and signs the self discharge document.

What advice would you give him?

Once it is established that he will self-discharge, I would give him information on what
symptoms to look out for and what to do if the symptoms return or worsen, suggesting that he
should attend A&E and ask them to contact the me or surgical SHO directly.

I would also arrange for the patient to be seen by the team as a ward attender or outpatient if
he is able to return the next day.

Who would you inform of the patient's decision?

 76

I would inform the consultant in question, the consultant on call if different and the bed
manager.

How would you close the consultation?

I would close the consultation by summarising what we have discussed. For instance:

"Mr Donald, you have decided to self discharge and signed the appropriate documentation,
therefore I am going to sum up what we have been through. You know you could have
appendicitis, and that the medical advice is to keep you in hospital. You understand the risks
of not being in hospital, which include becoming more unwell and possibly even dying. You
have accepted responsibility for those risks. We have discussed what signs to look out for,
and that you will return to hospital if you feel more unwell. Our door is always open. You
will return tomorrow to see the consultant in the morning.

Could you repeat that back to me so I can check I have got it right, and please ask any
questions you have"

What the actor was told in this station.

Your name is James Donald a 27-year-old who has come to hospital with abdominal pain,
which the doctors say might be appendicitis. You are feeling a bit better now than when you
presented 8 hours ago, the morphine has helped your pain, you have had all the investigations
and you understand that the consultant feels you don’t need an emergency operation but
wants to watch you overnight. You are otherwise fit and well, and are not confused.

You have decided that you don’t want to stay in hospital as “its probably nothing” and your
young family is at home. Your wife will be able to look after you and bring you back in if
you feel any worse, and you don’t mind coming back in in the morning to see the consultant
again.

You are aware that your life is at risk if you go home, but feel that this risk is small, you also
understand that you should come back in immediately if you feel worse.

You ask the candidate to discharge you and prescribe some painkillers

You get frustrated if the candidate insists that you should stay in and angry if they tell you are
not allowed to leave. If this happens you should ask, “don’t I have the right to decide what I
should do? Can’t I discharge myself?”
 77

If the candidate explains that he cannot discharge you as he does not feel it is safe to do so,
but that if you understand the risks you can self discharge signing a form saying it is against
medical advise you are appeased. Tell them that you do understand the risks, but you want to
self discharge and will sign the form

They are not able to convince you to stay no matter what they tell you

Repeat wish for painkillers if necessary.

Self discharge is a common scenario you will have experienced in the hospital itself. In the
OSCE it is more formalised and you need to display a range of different communication
skills to score full marks - and remember these marks are as valuable as the marks for
anatomy, so spend time practicing!

It is important to spend sometime establishing why he wants to be discharged. If there is

something you can change to make him agree to stay, you need to find out about it and if
possible make it happen.

You then need to explain why going home is not medically advisable. Stress that the
consultant wants him observed which means there is a serious possibility that he could get
worse. You must stress that if he goes home he could become seriously unwell and even die.

Ask him to repeat what you have told him back to you to check capacity to make this
decision. Remember that if he can understand the risks associated with him going home,
retain that information weigh it up and communicate his decision back to you then regardless
of whether it is a sensible decision, you must accept it.

As you cannot discharge him medically, you should explain that he needs to self-discharge,
explaining that he is responsible for the consequences of the decision.

He must sign a legal document that states that the clinical scenario was explained, continued
admission was medically advised, the potential consequences of self-discharge have been
explained and the patient takes responsibility for adverse outcomes.

As he is self-discharging, you cannot give him any take home medication; however you can
advise him to buy analgesia from a chemist.
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Once it is established that he will self-discharge, you should give him information on what to
look out for and what to do if the symptoms return or worsen, suggesting that he should
attend A&E and ask them to contact the surgical SHO directly.

You can arrange for the patient to be seen if he is able to return the next day.

You must inform the consultant and bed manager as soon as possible about the outcome of
the consultation.

Remember to display appropriate body language throughout the scenario. This is best done
by forgetting that this is an actor, and imagine instead that this is a real patient who is under
your care. The much used mark scheme phrase "ideas, concerns and expectations" wants you
to find out what the patient thinks about the current issue, what is worrying them and what
they want from you. Covering these issues is a good way to demonstrate your empathy in the
communication station and score the communication marks in other stations.

Summarise the discussion and check their understanding to close the consultation.
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Telephone referral

You are the surgical SHO at a DGH. Mrs Franklin is a 50-year-old lady who had a
laparoscopic cholecystectomy 4 days ago. She has been complaining of abdominal pain since
the operation and you have noticed bile in her abdominal drain.

Your consultant has asked you to refer her to Prof Adli at the Royal Free Hospital in London.
Spend 10 minutes reviewing the notes, and then you will be asked to phone him and refer the
patient.

Click here

There is a 10 minute preparation station

You are given a set of notes to flick through

Clinical assessment
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Clinical assessment
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Clinical Assessment
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Bloods
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Operation Note
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The patient is sent for a scan.

Here is image that is seen.

Please call Prof Adli at the Royal Free Hospital in London and ask him for advice and refer
the patient to him for ongoing care.
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Hello, my name is Sandra, I am the surgical SHO working for Mr Jameesh at the Crawfields
Hospital. I am calling to speak to Prof Adli, the hepatobiliary consultant to ask advice on a
patient who has a bile leak day 4 post-laparoscopic cholecystectomy. Could I check that I am
speaking to Prof Adli, please?

Yes, I am Professor Adli, how can I help?

Mrs Smith is a 50-year-old previously fit and well lady who underwent a laparoscopic
cholesystectomy 4 days ago. She has been complaining of abdominal pain since, and today
we have noticed bile in the drain. Clinically she is slightly jaundiced, and on examination she
is not peritonitic but has generalized abdominal pain; she is also tachycardic and pyrexic.

Her bloods from 2 days ago show a slightly raised bilirubin, ALP and CRP. Full blood count
and U+Es were normal.

So far we have started fluid resuscitation and antibiotics and arranged for an ultrasound.

We suspect that she has a bile leak, and I was hoping to refer her for transfer to your
specialist care for definitive treatment, if possible.

Why do you think her CRP is up? Is there an infection?

As the CRP is an acute phase protein, it is likely to be raised due to the operation. The trend
is showing it to be decreasing, and in this patient the pattern of symptoms fits with a bile leak.

When were those bloods taken?

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Unfortunately the last set of bloods were taken 2 days ago. I apologise that I don't have a
more recent set available, but I'll make sure they are sent as soon as I am off the phone

What does the Ultrasound scan show?

The ultrasound scan shows a bile leak (black arrow).

What do you think the diagnosis is and what investigation do you think this patient needs?

We suspect this patient has had a bile leak; therefore she needs an ERCP to identify the
location of injury and the presence of any retained stones.

What does ERCP stand for and what does it involve?

ERCP stands for Endoscopic Retrograde CholangioPancreatography. It is an X-ray

examination of the common bile duct and the pancreatic duct.

It involves an operator passes a flexible telescope down the oesophagus into the duodenum.
Dye is injected through the ampulla of Vater to allow the bile ducts, pancreatic duct,
gallbladder and hepatic ducts to be visualised when an X-ray is taken. A bile leak will be
shown by extravasation of dye into the abdomen.
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How is this managed?

First the patient is stabilized, fluids and antibiotics commenced

Referral to a tertiary hepatobiliary centre is appropriate

Definitive management is either by stent placement or operative management which aims to

restore biliary continuity via a bilioenteric anastomosis such as a Roux-en-Y
choledochoduodenostomy.

There are no beds available at this hospital at the moment. How do you think we should
proceed?
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I will alert the bed managers in both hospitals of the urgency of the transfer and ask if they
have any way of creating a bed for this patient, for instance, by facilitating the discharge or
repatriation of a patient.

What the Professor was told:

Name: Prof Adli, eminent hepatobiliary professor.

Attitude: You are friendly, but like the message to be to the point.

What you know: Nothing about this patient

Responses: Once the introductions have been made, let the candidate give you the
information at their own pace. Ask them for any details that they have failed to tell you eg
"When were those bloods done?", "2 days ago and no blood since?!"

Turn the station into a viva once the information has been accurately presented to you. Ask
the set questions on the mark scheme

It is important in the preparation station to get a feel quickly for what the most important
information is. Make notes as if you were the one receiving the referral. Make sure you check
the date and time of the investigations and circle all the abnormal results.

Referral to a Professor might appear daunting, but you should follow the same process as you
do for any referral

Open by introducing yourself and the reason for your call, asking if you are speaking to Prof
Adli.

For instance:

“My name is X, I am the surgical SHO working for X at the X Hospital. I am calling to speak
to Prof Adli, the hepatobiliary consultant to ask advice on a patient who has a bile leak day 4
post-laparoscopic cholecystectomy. Could I check that I am speaking to Prof Adli?”

Give the key clinical history succinctly:

‘Mrs Franklin is a 50-year-old previously fit and well lady who underwent a laparoscopic
cholesystectomy 4 days ago. She has been complaining of abdominal pain since, and today
we have noticed bile in the drain. Clinically she is not periotonic but has generalized
abdominal pain; she is tachycardic, but otherwise stable.
Her bloods show….
So far we have ….
I was hoping to refer her for transfer to your specialist care.’

Notice that the blood tests results were 2 days old, which the prof will undoubtedly pick you
up on. Apologise and assure him you will send a set of bloods today.
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You should thank the professor for accepting the patient once a bed does become available
and indicate that you will facilitate this process.

To find a bed in a hospital, it is important to make the bed manager in both hospitals aware of
the urgency of the transfer. They may be able to hasten the transfer out or discharge of
another patient to accommodate your patient.

Remember to summarise the plan, and thank the Professor for his advice
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