MRCP PACES Communication Skills and History Taking Notes

Session One
MRCP-PACES
ETHICS & COMMUNICATION SKILLS
MRCP-PACES/Medical Ethics & Communication Skills/Dr Zein/2013

Copyright: KM-426122-613404
1. Ethical issues:
Respect for Patient Autonomy
Consent
Confidentiality/Disclosure/Public interest
Justice
2. Public protection:
a- Driving;
Epilepsy
Diabetes Mellitus
and TIA
and Heart disease
b- GU infections/Communicable diseases:
HIV
TB
HBV
3. Breaking Bad News
4. Medico legal issues:

Resuscitation/DNR
Advance directives
Brain death & persistent vegetative state
Coroner referral
Euthanasia
Postmortem examination
Organs donation
Religious bioethics
5. Counseling:
Multiple Sclerosis
IHD & Cardiac rehabilitation
Cystic Fibrosis
Huntingtons Disease
Rheumatoid Arthritis
Uncontrolled DM
Bronchial Asthma/COPD

6. Procedures:
Heart-Lung Transplant.
CABG
Pacemakers
Bronchoscopy
Endoscopy
7. Updated NICE Guidelines:
Beta-Interferon in MS
Infliximab (anti-TNF) in RA & CD

Layman English:
Feel edgy (an edge): Nervous

Invalid: Terminally ill
Low: Depressed
Give way: Collapse
Head piece: Brain
Fainting: Syncope
Giddiness: Vertigo
Fits/Shakes: Epilepsy/Convulsions
Ringing in ears: Tinnitus
Back passage: Anus
Bottom: Buttocks
Phlegm: Sputum
Tubes: Lungs
Puffed/Puffy: Breathless
Heart attack: MI
The Welfare: Social services
Get the sack: Lose job
Puffed up: Swollen
Tummy/belly: Stomach/bowel
Gullet: Oesophagus
Feels sick: Nauseated
Been sick: Vomited
Wind: Flatulence
- To belch: Send wind from stomach
- To part: ,, ,, anus
Toilets: Motions/stools
Water: Urine
Keep wanting to go: Frequency
To get up at night: Nocturia
A growth: A mass, cancer (also: the big C)
Lose: Menses
Pictures/Imaging: X-Rays
Temperature: Fever
Get back/Flare: Relapses
To be looking/to turn the corner: Improves
To be laid up: Confined to bed
To find ones legs: Start walks after illness
To have a bad turn: Becomes suddenly ill
To have a bug: To catch a virus/infection
To lose ones nature: Becomes impotent
To go steady: To have a regular partner
(Ref: English for Overseas Doctors)

The British Health System
Guidelines & Policies:

The General Medical Council (GMC)
The National Institute of Clinical Excellence (NICE)
The Scottish Intercollegiate Guidelines Network (SIGN)
The Royal Colleges
Hospitals (NHS): SHO, SpR, Consultants

The GPs
The Social Services System
The Home Health Care
Preventive Section, CICD
The Legal Advisor, the Coroner system, etc
Occupational health services & rehabilitation
The Nursing teams:
- Specialist nurses (diabetes, Asthma,)
- District nurses
- Teams (e.g. McMillan team)
- Nursing homes
Voluntary agencies
Support groups & Societies (MS)

Station 4: ETHICS and COMMUNICATION
Candidates Instructions:
o You will be given 5 minutes before entering the examination room to read a
scenario & to make your plan of action. On hearing the bell, enter the room
& begin the consultation.
o You will have 14 minutes to interview the patient/actor & one minute after
he/she leaves the room to organize your thoughts and to prepare yourself for
the discussion with the examiners.
o Dont re-take history from the patient and dont examine him/her.
In this section some scenarios will be presented & will be followed by a suggestion on how
to approach similar situations when you, hopefully face them in your actual examination.
This will be preceded by short talks emphasizing essential ethical & legal issues and some
important guidelines e.g. DVLA, INF in MS, End of life decisions etc.
A comprehensive knowledge of UK law is not required from overseas candidates; however,
they are expected to know in broad terms relevant ethical & legal principles.
Many candidates fail this section of the PACES examination not as a result of its difficulty,
but because they fail to prepare to it adequately. On the other hand, many of the successful
ones feel that with good preparation, success in this section is probably more predictable
than in any other section of this exam.
***The key sentence to success is Practice & practice till mastering

Station 4: ETHICS and COMMUNICATION
USEFUL HINTS
When given the scenario outside the examination rooms STUDY it carefully &
decide at first which ethical/communication principle is being tested.
Then on the provided paper write down the points that you would like to discuss
with the patient/actor & the plan of action needed to manage the given problem.
On entering the exam. room, start by greeting the examiners then sit facing the
patient, greet her/him & introduce self and explain role e.g. Hello Mrs. X. Im
doctor Y, the medical SHO who is looking after your husband. Then agree the
purpose of the interview We are here today to discuss the result of his bone
imaging. Is that right? Would you like to discuss any other issue?
Maintain good eye-to-eye contact with the patient & put him/her at ease.
Start the interview with open-ended questions e.g. what do you know about your
husbands condition? or I learned from your GPs letter that you have had a
seizure last weekend, can you tell me more about that?
Use close-ended questions as the interview progresses.
Provide clear & understandable explanations
Avoid using jargons
At the end of the interview:
- Agrees a clear course of action with the patient

- Summarizes
- Check understanding (e.g. what message you will take
home with
you? or what are you going to tell the other members of the
family?)
- Shake hands & say goodbye.

PRINCIPLES OF MEDICAL ETHICS
The 4 Principles of Medical Ethics

1. Respect for Patient Autonomy
2. Beneficence
3. Non-maleficence
4. Justice
1. Respecting the patients Autonomy: (wishes & self-rule)

Autonomy: means self rule i.e.(the capacity to think, decide & act freely and
independently). It is the patients right to be involved in any decision about his health.
This requires that the health professionals help patients in making their own decisions and
respect & follow these decisions. Respect of autonomy implies that doctors treat competent
patients in accordance with their informed choices, even if these conflict with the doctors
beliefs.
2. Beneficence: (doing good to & promoting of what is best for the patient.)
This entails doing what is best for the patient.
In most situations 1&2 lead to the same conclusions, however, the two principles conflict
when a competent pt. chose a course of action that is not in his/her best interests.
* If such a conflict arises (Autonomy vs. Beneficence):
1. Make sure that the patient is competent
2. Explain the possible consequences of his choice (e.g. refusal of treatment)
3. Suggest discussing others (a friend, family member, etc) & a senior colleague
4. Respect the patient's autonomy
3. Non-maleficence: (do no harm, need to avoid harm)

With regard to treatment & procedures, the potential goods & harms and their possibilities
must be weighed up to decide what, overall, is in the patient s best interest.
* *These two last principles imply that:
1. Treatment must be thought likely to be successful OR that,
2. Potential benefits overweight potential risks.
4. Justice: (fairness in provision of health care)

Refers to the duty of the doctor to the whole society.
A. Patients with similar situation should get accessibility to similar health care.
B. When determining what level of care should be available to one set of patients, we
should take into account the effect of such use of resources on other patients (i.e. we
must try to distribute limited resources fairly). Using these resources to aggressively
treat a terminally ill patient is potentially depriving others of the treatment.

*Sometimes the patient's autonomy conflicts with the "Public Interest". In such a
case the latter must be respected; as your role for the whole society is more superior
to respecting the patient's autonomy.
CONSENTING PATIENTS
Types of Consent:
1. Expressed: Written or verbal agreement for the procedure
2. Implied: e.g. the patients action in response to a request for exam.
3. Statuary: When the law requites a particular consent e.g. IVF
Elements of valid consent:

VALID CONSENT =
Understanding (Competent patient + Appropriate Information)
+ Voluntary decision (i.e. without coercion)
True informed consent requires that the patient does not merely passively assents to the
doctors decision, but specifically authorizes the doctor to initiate the medical plan.
Information to be provided to the patient:

Diagnosis/Prognosis
Uncertainty about the diagnosis/need for further investigations
Purpose, details & expected outcome of procedures
Likely benefits & probability of success
Possible side-effects & complications
Techniques:
- Use illustrations, written or visual aids for explanation
- Allow a relative/a friend to attend if the patient agrees
- Involve other staff e.g. a nurse
- Give a balanced view
- Allow sufficient time for reflection & decision-making
Consent in English law:

What is Competence (Capacity)?
A competent patient must fulfill the following requirements & demonstrate them repeatedly
and consistently:
Understands a simple explanation of his/her medical condition, treatment and

expected outcome.
Is able to reason about specific goals of treatment & choose to act on the best of
such reasoning.
Communicates his/her choice & the reason for this choice.
Understands the consequences of such choice.

N.B. - A patient should not be regarded as incompetent merely because he makes
a decision that is against his best interest.
- Competence is function specific
Consent contd
(1) Competent patient:

A. A competent patient may refuse any, even life-saving treatment.
Anything done without the patients consent, even touching, is battery (for which
damage may be awarded). In contrast to negligence, the patient doesnt need to
prove that he/she has suffered harm as a result of the battery for damages to be
awarded.
B. The patient should be given information about the nature of the procedure or other
medical interventions (otherwise battery), common & rare side-effects, benefits &
reasonable alternatives (otherwise negligence: failure to give appropriate
information to the patient before choosing to accept/refuse a treatment or a
diagnostic test.
(2) Incompetent patient:

Possible approaches:
A. Doctors should act in the best interests of patients.
Relatives & friends may be approached as a source of information to judge the
patients best interests, but cant give or withhold consent (i.e. there is no proxy
consent for an incompetent adult patient).
NB: Tutor dative (Partnership giving)
B. Substituted judgment: What treatment option would the patient choose if he
become competent?
To answer this question, Consider:
- The patients previously expressed preference
- His general values & backgrounds
- The doctors experience with other patients
C. Advance Directives:
Should be respected after ensuring that the patient was competent & had all the
relevant information and that he had considered the clinical situation that has arisen.
D. Involve hospitals legal adviser/apply to the Court if:
There are differences of opinions/controversy in therapy.
Examination/testing & treatment without consent:
1. For life-saving procedures when the patient is unconscious/incompetent to indicate

his/her wishes.
2. Where a patient is incapable of giving consent as a result of a mental illness, the
treatment should be based on the patients best interest" principle.

3. Where a minor (<18 years of age) is a ward of Court & the Court decides that a
specific treatment should be given in the childs best interest.
SESSION TWO

Useful Skills in Breaking Bad News
BBN Step-by-step:
(1)Preparation:
Before talking to the patient / relative:
- Have all the facts available; ensure privacy, uninterrupted interview, etc
- Make sure that support is available from an experienced nurse, a relative / friend
or an appropriate religious support
- Find out with whom you are going to speak/Any relatives around?
(2) Check awareness:

Establish the patient/relatives current knowledge e.g. Have you any thoughts of what
might be causing your / her pain or problem? --- What you understand from all the tests
that were carried out? --- Have you any idea of whats going wrong with you?
This will help to judge the gap between the persons perception & the reality.
Is more information wanted & how much?
Would you like me to explain a bit more? Do you like to know everything?
Dont force information into the patient.
(3) Give a warning shot:

I am afraid that it looks rather more serious
Then pause to allow the pt to prepare for the news. The pt will then ask for clarification
or re-maintain an eye contact when ready to listen to more.
Then give further details, to narrow the gap step-by-step. Avoid information overload
& the use of jargons. Speak out slowly & clearly.
(3)Pausing & acknowledging distress:

Dont be afraid of silence.
Allow time for the bad news to be absorbed & the response to occur.
Wait for a signal that the pt. is ready to re-engage in the conversation.
Actively acknowledge distress I can see that what you have heard has made you
very upset
(4) Encourage ventilation of feelings:

This is the key phase in items of pt satisfaction with the interview. It also gives you the
chance to show empathy.

(5) Reactions to the bad news:
Crying:
Avoid looking embarrassed & let the pt know that this is understandable & normal
behavior, also avoid speaking whilst the patient is recovering his composure.
Have tissues available
Anger:
Anger is from the bad news & is not against you.
Remain objective, stay calm & dont get defensive.
Denial/disbelief:
A useful coping mechanism. e.g. Are you sure that he is dead?
Could there have been some mistake e.g. identification?
Are you sure that these reports are mine?"
Firmly, but gently, reassure the person.
Quilt: e.g. I should have made him come to the hospital earlier!
(6) Discussing prognosis:

(Key advice: Be honest & realistic- Avoid giving specific time frames.)
**Commonly asked Qs about death & dying:
Am I going to die?
I am afraid that your cancer is so advanced, that it is likely to shorten your life
How long have I got?

A useful framework is I can not tell exactly. It may be months rather than years, but it is
unlikely to be a few weeks
A better approach might be: Different cancers behave differently in different people & it
isnt possible to predict exactly how they behave in each individual
+ Encourage hope: Let us look foreword e.g. symptom control, a birthday, X-mas etc

Collusion with relatives:
Dont tell him doctor, the news will kill him."
When requested by relatives not to tell the patient:

1) Acknowledge their concerns & stress. Explain that you will handle the matter
sensitively.
2) Outline the ethical position often helps. e.g. Your husband(the pt.) has the right to
know if he wants, but I will not force the information on him.
3) Stress that it is best to be open now about the situation rather than risking the
distrust of the patient if he found out at a later stage.
Then explain that telling him about the bad news is not all bad He might have things to
do, specific people to be around, some wills to tell, planning for the journey, etc
(6) Identifying other concerns:

- Elicit all the pts main concerns (e.g. pain relief chemotherapy, surgery etc.)
before giving advice or further information.
- Reassurance can be given that every effort will be made to help the patient
e.g. giving the best possible care, helping pain relief etc.
- Dont give a false reassurance about the future.
- Foster hope but dont allow misunderstanding treatment for cure.
(7) Summarizes,
& Check understanding frequently:
e.g. What message you are taking home with you?
What you are going to tell the other members of the family?
(8) Ensure continuity of care/support:
Support: e.g. We will do our best to make you/him as comfortable as possible

Explain the potential treatment available & share with him/her the management
plan e.g. radiotherapy for bone metastasis, feeding etc
Offer availability
(Document in the patients medical records)

Useful Strategies in BBN:
Always respect the patient autonomy. Dont discuss his condition with relatives
without his consent.
Honesty is the best policy.
Dont tell the pt more than he/she wants to know
Never give a specific time period
Dont take all the hope away; find some reason to be optimistic e.g. encourages
the pt to look foreword to a particular event such as a birthday, a period of
remission or pain-free death. However, you should never give a false hope.
Pitfalls in Breaking Bad News:

BBN without exploring the patient's willingness to know them
Being unsure of the information to give to the patient
BBN too early without preparing the patient by a reasonable "warning shot"
Delaying the bad news in a fear of the patient reactions
Getting shaky or hesitant when asked direct Qs by the patient like "Is it cancer?" Or
"Is she going to die?"
Remember to break the BN at an appropriate time & to leave adequate amount of
time to deal with the patient's reactions, other concerns, or discussing other relevant
issues e.g. DNR, Postmortem, etc

Session Three

Counseling for an HIV testing
Objectives of Pretest discussion:
1. To clarify why the patient have to be tested & what are his expectations
2. To provide information on technical aspects of the test
3. To provide information on possible implications of the test
4. To educate about risks of transmission & risk reduction
Consenting for HIV testing:

- In most cases informed consent is sought. Written consent is only required from
blood donors and for life insurance.
- Implied consent can be assumed when an individual is requesting to be tested.
- When testing a seriously ill patient in order to make a diagnosis, the doctor should
act in the patients best interest. Informed consent should normally be obtained.
Pretest Counseling:
Pretest discussion checklist

Introduce yourself & clearly identify your role
Assess risk factors & explore HIV/AIDS
Explain the test procedures
Discuss potential advantages/disadvantages
Discuss coping with the test results
Identify personal, social & medical support systems
Discuss how to protect sexual partner(s) in the meantime (safer sex and/or
safer drug use)
If a female, discuss pregnancy & fertility
Check who the patient like to tell & who has already been told
Technical aspects of the HIV test:
A simple, clear & jargon-free explanation of the test should be given to the patient. Written
materials should be available as some individuals may like to defer the test.
Examples of information that patients need to be told:
- It is a simple blood test & its result will be available the same day.
- It reflects the HIV status in the previous three months (explain in a simple language

the window period). A single test at 3 months will diagnose the majority of patients.
- Explain that if the test is positive, a confirmatory test will be required on another
blood sample in the same day.
- If someone is labeled as HIV positive, this means he is confirmed positive.
Advantages and Disadvantages of HIV testing
Benefits (Advantages) of HIV testing
(1) Individual health benefits:

1. Early diagnosis & institution of anti-retroviral therapy
Risks
2. Prophylaxis against opportunistic (disadvantages)
infections e.g. PCP of HIV testing
1. False positive/negative
3. Screening/prophylaxis against TB, STD, etc results
4. Appropriate vaccinations 2. Psychological reactions
3. Possible loss of jobs
5. Institution of other health measures
4. and
6. Better motivation for safer sex Consequent
drugs useproblems with mortgage
7. 5. Difficulties in getting life insurance
(2) Public Benefits: 6. Social relationship prospects
7. Breach
1. Reduction of high risk behaviors of confidentiality
& attitudes
2. Monitoring of HIV epidemiology
3. Improvement of the general awareness of HIV
4. Overall reduction of the prevalence of HIV/AIDS

HIV: Introduction to discussion
- A discussion of diagnostic possibilities & results of investigations to date may help.

- Check awareness of: - Nature of the test
- Difference between HIV and AIDS
- Risk factors/risk reduction methods
- If there is evidence of HIV, the patient should be told of this.
- Ask him/her if there are any thoughts as to what the illness might be?
- Enquire about risk factors in an indirect way e.g. marital status, sexual activities,
partner(s)/, exposure to high risk behaviors, PH/ STD, travel abroad,
drug use, blood transfusion etc
- Ask about any previous test or recent blood donation.
- Ask if he would like to have an HIV test performed?
Educate:
- Methods of transmission, risk factors & how to reduce them.
- That every day social & domestic activities are safe.
- That the patient will have continued medical care regardless of the test result.
- Discuss advantages & disadvantages of testing and how he/she will cope with result.
- Inform of the availability of social & psychological support.
Confidentiality:
- Patients can be reassured that their HIV results will only be seen for Medical reasons
by doctors& nurses involved in their care.
- Samples may be labeled High Risk & phrases like Low T4 Count or Retroviral
Illness may be used.
- Reassure the patient that the front of the notes will not be changed to identify the
infection. (See section 2of NHS Venereal Disease Regulation 1974)
- It is important to discuss with patient who they want to made aware of their illness
e.g. a partner, family doctor etc
- As a general rule, information is best disclosed on A Need to Know only.

HIV: Giving the result
If the result is POSITIVE:
o BBN: --- Shock, anger denial etc ----- EMPATHY

o IS IT HIV OR AIDS?
o Plan of action:
o What is the next step?
o Who will be looking after the patient?
o What further tests need to be done?
o Any therapeutic measures/interventions?
o With whom the patient wishes to share the information?
o Educate: safer sex, injecting practices etc
o Be ready to answer the patients questions & queries,
e.g. How long have I been infected? In this case the patient
wanted to discuss who else might have been infected
o Give written information
o Provide the patient with a list of voluntary agencies, support groups,
and social work facilities.
If the result is NEGATIVE:
o Advice to repeat the test after 3 months (The Window Period)

o Asserting safer sexual or injecting practices (Risk Reduction)
o Clearly emphasizes to the patient that a negative test does not mean that he/she is
immune against HIV infection unless the present practice is modified.
Needle-stick injuries: (See attachment)

Session Four

End of Life Decisions & Terminal Care
Discussing Resuscitation Status & DNR with patients and relatives
Justifications for making Do- Not- Resuscitate (DNR) decisions:

1. When a fully-informed competent patient asks not to be resuscitated
2. A poor quality of life following a successful CPR is anticipated
3. Futility: the chances of the patient surviving CPR are so low that it can be regarded
futile. This is a clinical decision, which doesnt need involvement of the patient, &
there is no obligation to attempt CPR in such cases. Examples: disseminating
malignancies, septicaemia, severe HF etc
A DNR decision isnt necessary to discuss with patients:

1. If the patient is incompetent
2. If the decision was made on grounds of futility
3. If a competent patient indicates that he/she doesnt wish to discuss it
4. This may also be justified in competent patients, without obtaining consent, if
decision is based on basis of poor quality of life.
Discussing DNR decision with patients & relatives:

1. Competent patients:
- The discussion should aim at determining the patients views of his/her quality
of life.
- Relatives should only be involved in discussion with the patients consent.
- Relatives may be discussed if the decision is made on Poor quality of life
Basis & the patient don't like to discuss the issue.
2. Incompetent patients:
- The doctor should decide on the Best interest of the patient.
- Relatives & friends can be discussed for the purpose of getting a better idea of
the patients wishes and also to determine whether there is an Advance Directive
(Living will)
What facts need to be told to the patient?

- The patient should be fully informed about the diagnosis & prognosis
- That CPR is usually unsuccessful.
- About 10 20% survive to leave the hospital & for one year afterwards
- The possibility of survival with a neurological damage should be pointed out.
However, these are relatively uncommon; 1 2% survives in a Permanent
Vegetative State (PVS)
- Elderly patients with chronic illnesses have < 5% chance of survival to
discharge.
- Ascertain that the patient understand that if they have a cardio-respiratory arrest &
they dont have CPR, they will almost certainly die.
- That a DNR is a Consultant decision.

Session Five

Sudden Death of a family member
(A special form of breaking bad news that requires great empathy)
(A) The interview with the relative; Breaking the bad news:
Preparation:
- Check your facts about the deceased per son, his illness, etc.
- Put him at ease.
- Make sure that support is available (an experienced nurse/other health
professional, a relative/friend, religious support, etc).
(1) Introduce your self, explain role & identify the relative.
Also check whether other relatives are around / need to attend the interview.
(2) Establish his current information/knowledge of the situation:
(3) Give a warning shot:
(4) Wait for his response, then BBN:

- Dont wait too long as this will aggravate the agony.
- Be ready to confirm direct questions e.g. Is he dead?
- If there is no direct question: Use a clear & simple language to give
a brief description of the illness and explain that treatment/resuscitation
hasnt been successful & the patient has died.
(5) Give relatives the chance to ventilate.

Express empathy & give more details when needed.
- Insure & show continued care and support to the family.
E.g. Offer transport to home, give details of contact with the
department for more explanation etc.
- Allow accessability to the deceased body, it is important for some people
to see and hold their dead loves ones & to keep a lock of their hair.
- Provide clear explanation of any visible injuries
(9) Always Summarize & check understanding.

(B) A Request for Organ Donation:
A. Many relatives ask about organ donation.

B. Otherwise you can sensitively & at the suitable time,
bring the issue for discussion. This can be addressed in
many ways; one approach is to ask whether the deceased
had expressed any wishes/advanced directive in this
regard (check also if he has a donor card). You can also
invite the discussion by telling other peoples
experiences e.g. Some people in a situation similar to
yours like to make good to their loved ones by donating
their organs to some patient who are in desperate need
of them. His internal organs can be used for other
patients who need them to maintain their lives
Re. Corneal Donation:

The eyes must be removed within 6 hours if the corneas are to be donated.
Contact the eye hospital.
If death has to be reported to Coroner, his/her permission must be obtained
before organs are donated.
(C) Requesting permission for a Postmortem Examination:
-Approach in a sensitive & understanding manner that allows relatives to make

well- informed decisions.
- Explain the specific reason for the PM request & the benefits of PM exam.
- The request should be made in a way that doesnt put pressure on relatives.
- Relatives should be given enough time to think about the issue & to discuss
with other members of the family if they wish to do so.
- Try to explore relatives misconceptions regarding PM & to find out the
reasons for refusal and then to clarify them(refer to information box ).
- Relatives should be informed of the PM results as soon as possible.
- Clinicians should be:
- Able to anticipate & cope with the concerns and reactions of relatives at
the time of bereavement.
- Aware of the possible cultural/religious impacts related to death, funeral
arrangements & attitude towards PM.
- Aware of the administrative procedures.
- Able to explain the difference between medico legal & academic PM.
(NB. In non-medico legal PM consent is required from the next of kin).
- Able to consider possible alternatives in case of PM refusal
E.g. limited PM, laproscopic/endoscopic exam. etc
- Be aware of deaths reportable to the Coroner!

Reasons for consent for a Postmortem examination:
1- To establish the precise cause of death
2- To confirm the diagnosis
3- To help others / medical researches etc
4- To respect the wishes of the deceased / family
5- Organ donation
Reasons for refusal of Postmortem:

1- Concerns about disfigurement of the deceased
2- Interference with funeral arrangements
3- Lack of information about the reason for PM
4- Religious / Cultural (e.g. Muslims, Jews, Afro-
Caribbeans, Christian Scientists)
5- Respect for the deceased & their wishes
6- Too upset to consider it
7- A desire to finish things as soon as possible
8- Objection from other family members
Deaths reportable to the Coroner:

1- The deceased wasnt seen by a doctor within 14 days prior to death
2- If the death:
A. Is of suspicious circumstances, there is a history of violence or may be
linked with an accident
B. May be linked with an abortion
C. Is related to a medical procedure or treatment
D. Had occurred during an operation or before full recovery from anesthesia (or
in any way related to anesthesia)
E. Is due to lack of medical care
F. Is due to industrial disease or in any way related to the deceased
employment.
G. Occurred during or shortly after detention in police or prison custody.
3. The actions of the deceased may have contributed to his death.

COUNSELING RELATIVES FOR A POSTMORTEM EXAMINATION
If a relative is concerned about PM examination:

Speak to the relative aiming at: exploring their main concerns about PM, improving
their understanding & give justifications and benefits of PM exam. e.g.
- The PM may provide useful information that was not available when the deceased was
alive.
- The PM results may assist relatives overcoming their grieving reaction. It may lead to
peace of mind by knowing the cause of death & that the appropriate care was given.
- The PM can be beneficial, not only to medical profession, but also to the family & the
society in general (give examples)
- Medical profession can gain vital feedback about accuracy of diagnosis, effects
of treatments, etc.
(1) Reassurance re. disfigurement:

The PM exam. is similar to a surgical operation & is carried out by
medically-qualified pathologists.
The outward appearance of the deceased would not be altered in ant way
& no external markers would be visible apart from incision scar.
(2) Reassurance re. possible interference with funeral arrangements:

PM exam. will only need a short time to perform.
In urgent cases, the PM can be expedited.
The mortuary staff can liaise with the funeral director to release the body
in a reasonable time.

THE BENEFITS OF PM
A. For the relatives:

Knowledge of the precise cause of death / Confirmation of the diagnosis.
Reassurance & peace of mind. Alleviation of guilt by reassurance that death
was inevitable & that all the needed care was provided.
Identification of possible hereditary conditions.
Helping others e.g. organ donation.
Assistance in advances in medical knowledge.
Insurance & compensation claims.
B. For the medical profession:

To establish the precise cause of death.
Gives a feedback about the accuracy of the clinical diagnosis.
Aids in medical audit & risk management.
Enables researches & advancement in knowledge.
Improves accuracy of epidemiological statistics.
C. For the society:

Improvement of accuracy of epidemiological statistics.
Organ donation.
Identification & prevention of environmental and occupational hazards /
infectious diseases & epidemics.
Improvement of medical knowledge.

Session Six

COUNSELLING
Guidelines for Giving Information to a Patient
(1) Check how much information to give.

E.g. test result, diagnosis, management plan, advice on life style, etc
Would you like to know the result of your bone scan? Do you want
to discuss any thing else? Then explain accordingly.
(2) Summarizes the patients problems.

E.g. You have told me that your Asthma isnt as well controlled as it
used to be. Is thats right?
(3) Check the patients Understanding of his condition.

E.g. Have any thoughts of what might be the cause of this problem?
(4) Outline the Structure of the interview.

E.g. Now we are going to discuss several things: 1st: what I think is
wrong with you. 2nd: what further tests we need to do, and lastly: what
treatment Im going to give you. Is thats ok?
(5) Use appropriate language:

- Describe and explain each piece of information
- Give the most important information first.
- Use short sentences.
- Be specific.
- Avoid medical jargons
(6) Use drawings when appropriate.
(7) Explore the patients views:

E.g. Perhaps you could tell me what you think about that
(8) Negotiate management.

If necessary, help the patient in making his decision
(9) Check understanding:

E.g. Well, Mr. James, I seem to have given you lots of information.
Would you like to just go over what we have said?
(10) Summarizes.
MULTIPLE SCLEROSIS

What should the patient be told?
- Ask the patient if he/she have Any thoughts about what might be wrong with you?
Any particular condition worries you?
- BBN step-by-step
- Educate: what is MS
- Check understanding What are you going to tell your family?
- Consequences:
Difficult to get life insurance or promotion at work
Alteration of life style
Psychological & emotional burden
- Positive aspects of diagnosis:

NOT a brain tumour & NOT a mental disease
Benefits of early diagnosis & treatment with Interferon beta & copolymer
- Early follow-up appointment:

To give the patient the chance of asking questions in a calmer state of mind.
- Provide support & information:
Written information, videos
Specialist nurse
Social worker
Occupational therapist for self-support measures
Local MS society- shouldnt be rushed as an early visit may be depressing for a
newly-diagnosed patient
What information to give?

MS is a chronic disease affecting 1:1000 of UK population
Cause is NOT known
At present NO medical cure, but there are treatments which can help many
symptoms
Course: -Variable & is very difficult to predict.
- Different in each individual
- Initially may be relapsing & remitting with full recovery between the
attacks. Length of relapses (flares) is 24 hrs.-12 months. Rate of relapses
is around 1:100/year. Relapses are more common in the first 5 years &
particularly the first year.
- May become progressive at any time, secondary progression affects 40%
patients by 10 years & 60% by 15 years. Progression is not inevitable.
- Primary progression from the onset occurs in 10-20% cases.
- There is a clear relationship between progression & late age of onset
- Foster hope by giving examples of good predictive features applicable to
the patient.

Employment:
Different studies:
- In the first 5 years: up to 50% were in full work & 70% capable of some work
- By 15 years: 10-25% were in full work & 40% of long-term survivals are capable of
some useful activity. Spastic paraparesis is the major cause of loss of work. More
patients could work from home.
Life expectancy:
- Is strongly predicted by the degree of the disability.

- Death isnt directly caused by MS but results from infective complications
- Life expectancy was found to be only 6-7 years less than population without MS for the
ages 20-50 & this is even less after the age of 50.
- Many individuals have normal life expectancy.
Pregnancy:
- Fertility isnt reduced

- No increased risk of abortion or stillbirth
- No specific complications of labour
- No contra-indications to breast feeding
- There is slight risk of relapse during the first 3 months after delivery.
Genetics:
MS doesnt occur more common in relatives than in general population. The risk of a child
being affected is 1-4%.
Self-help measures:
- No specific diet alters the course of MS.
- Symptoms may be aggravated or induced with exertion. Advice to avoid excessive
fatigue, but otherwise to continue normal activities.

HUNTINGTONS DISEASE
- Progressive chorea & dementia in middle life are the hallmark

- Onset: 30-50 years. Prevalence is 1:20000 . AD with full penetrance.
- Mutation in the short arm of Ch 4 with variable expression of CAG- repeat in exon1. This
results in translation of an extended glutamine sequence in huntingtin; the protein product
of the gene.
Pathology:
- Cerebral atrophy with marked loss of neurons in the CN&P.
- Changes in neurotransmitters
Course:
- Progressive illness & death occurs between 10-20 years of onset.
- NOT a cancer & NOT a psychiatric disorder
- Initial symptoms: personality or behavioral changes, uncontrolled aggression or sexual
behavior. Serious depression is common & suicide is a risk.
Later- rigidity & akinesia - bed ridden & emaciated - death
- NO cure.
- NO treatment to arrest the disease although phenothiazines(e.g. sulpiride) may reduce
chorea. Tetrabenzine helps to control movements.
- Chronicity & disability - psychological impact on family: Consider residential care
- Supporting the family is essential.
Family Screening:
- Children of patients have 1:2 chance of having the disease & their children have 1:4 risk
- Using molecular genetics. Blood DNA samples are required from as much family
members as possible.
- Mutation analysis (accurate &specific) is available for pre-symptomatic testing of family
members.
Centers performing these tests have a common nationally agreed protocol for counseling.
- Pre-natal diagnosis is possible.

MRCP-PACES
Station 2: HISTORY TAKING

(SHOULD BE PROBLEM-FOCUSED & WELL STRUCTURED WITH
SPECIAL CONSIDERATION TO SOCIAL CIRCUMSTANCES)
THE 3 MAIN TASKS:
1. OPENING THE ENCOUNTER:
- Greet by name
- Introduce, explain role
- Agrees the agenda
- Explain note-taking
2. MAIN DISCUSSION
- Gathering information
- The main skillful task to promote disclosure
- ICE (Ideas, Concerns & Expectations)
3. CLOSURE:
- Encourage the patient to ask questions & express Ideas,

Concerns & Expectations (ICE)
- Counsel on health promotion
- Agree a mutually satisfactory plan and follow up.
- Check understanding & Correct when necessary.
- Goodbye & Offer availability.

MRCP-PACES
A. Opening the encounter:
Engagement (Starting the interview):

- Great by name
- Introduce yourself & Explain your role
- Build good rapport
- Agrees the agenda
- Explain note-taking
B. Gathering the information:
Presenting Complaint (PC):

- Elicit the main presenting problem(s).
- Any other problem?
HPC:
- Full detailed h/o each complaint from onset to date.
- Clarify each problem before moving to the next.
- Appropriately use open & close-ended questions.
- Nature: e.g." Would you tell me more about the problem/symptom"
- Onset: "When it started?"
- Duration: "How long it lasted?"
- Pattern: - Continuous/Intermittent
- Episodic (frequency, severity & duration of each episode)
- Course to date:(static, progressive, or improving)
- Precipitating/Relieving factors.
- Associated symptoms.
- Patient's view/perception of his/her problem: "Any thoughts of what
might be causing this problem?"
- "Do you want to add anything which I might forget to ask about?"
- Effect of symptom/problem on quality of life?
- Summarize.
PMH:
- Open Q: "What about your health otherwise?"
- Similar problem?
- Specific: DM, HTN, HD, BA, etc
- Hospitalizations & Operations
FH:
- Open Q: "What about the health of your family?"
- All 1st degree health (parents, siblings, children)
- If any death: Age & cause of death.
- Specific: DM, HTN, HD, BA, etc

DH:
- Ask about the drug's list.
- Enquire about each drug:
- Dose, frequency, duration
- Does it help?
- Compliance.
- SE: "Have you experienced any problem with this drug?"
- Any recent change in medications?
ROS (Review of systems):

- Always ask about: general wellbeing, fever, appetite, wt
loss/gain, rashes,
- Briefly enquire about each body system.
- Then ask in more depth about affected system.
SOCIAL Hist. (SH):

1. Occupation: Present & previous" What do you do for living?" If unemployed,
ask about pensions.
2. Marital status: ?partner(s), sexual life/orientation
3. Smoking.
4. ALCOHOL: Detailed: quantity, type, and frequency. CAGE
5. Finance: income support, invalidity benefits, other allowances & adequacy
of these.
6. Availability of Support: Practical & emotional: Home help, district nurse,
social worker, occupational therapy, etc
7. Impact of problem: Ability to work, coping with daily activities, mood,
personal relations, etc
8. House: flats, steps, modifications
9. Activities of daily living: ?Coping, help
10. Hobbies? animals, sports
11. Travel:
12. Diet.
13. Immunization & prophylaxis.

Alcohol history:
- Drinking habits: What type? How much? How frequent?
For how long?
- Quantity:
1 UNIT alcohol = 1/2 Pint of beer = 1 glass of wine = 1 measure of spirit
- CAGE test:
C: Have you ever felt the need to Cut down on drinking?
A: ,, ,, ,, ,, Annoyed by criticism on drinking?
G: ,, ,, ,, had Guilty feeling about drinking?
E: ,, ,, ,, taken alcohol the first thing in the morning?
(Eye opener)
Drugs:
- What about recreational drugs?
- Have you ever injected drugs? Shared needled?
- Marijuana "pot"
- Cocaine "coke"
- Heroin, others
- Are you using them now? How often?
Smoking:
- Do you smoke? Have you ever smoked?
- Type, amount, for how long?
- Did you ever try to quit?

3. Closure:
Check Understanding:
"It seems we discussed many issues, and I need to make sure that we have
the same understanding, so:
- What message you take home with you?
- What you will tell to a family member(s) if they asked?"
Agrees a clear "Plan of action":

Investigations, management, hospitalization, etc
Dispose Appropriately:
In the closing portion of the interview, you may:
- Inform the patient of your opinion about the illness
(diagnosis, management, prognosis)
- Encourage the patient to ask Qs & to express concerns
- Negotiate a mutually satisfactory plan
- Counsel about health promotion
- Offer advice including follow-up
- Any Qs?
- Offer availability
- Thank & say goodbye

COMMUNICATION SKILLS
Useful Skills to promote disclosure
Eye contact:
Established at the onset of the interview & maintained at reasonable intervals throughout
the consultation. Re-establish when the patient mention important piece of information.
Acknowledging & exploring verbal cues:

By that you reflect that you are interested in the patient problem.
Non-verbal cues:
Pick, address, explore & acknowledge them.
e.g. "You looks anxious, can u bear to say why?"
Open-directive Qs:
You can gather lot of information by using open-ended Qs.
These are the type of Qs their answers are not yes & no.
e.g." Can u tell me more about your bowel problem?"
Closed-ended Qs:
These are used when a specific piece of information is needed.
e.g. "Does the pain go anywhere else?"
Control & Sensitive redirection:

Gently control the interview. If the patient raised a relevant issue while you are discussing
another important one, you can suggest postponing the issue till u finish with the first one.
However, if the issue raised is not important or irrelevant, you can suggest leaving it for
another session.
Negotiation:
Always negotiate your plans with the patient & try to reach an agreement. However, if you
failed to do so, the priority is for the patient's agenda.
Precision:
e.g. " You say u have been suffering dizziness. Can u describe exactly what happens
when u experience this?"
Empathy:
Use I & you.
e.g." I could imagine how that experience had affected you"
"I understand your concerns about your job"
"I can see that it is hard for you to care for your dad & the 2 kids"

Educational guesses:
Share them with the patient.
e.g. "When we are talking I got the feeling that your diabetes had affected your job & that u
looks rather worried of loosing it"
Facilitation & Silence:

Facilitation: by nodding or by saying" yes, I see, go on, uh-huh, or what else" & by looking
attentively to the patient.
Never get panic because of silence. This important for both of you & the patient to
organize thoughts and to think of "what is next?"
Repetition:
Used to foster elaboration.
You can repeat the patient's last sentence e.g." chest pain?"
Clarification:
You have to clarify any information you are not clear about.
e.g." I'm not sure I understand. Would u explain it again?"
"Do u mean?"
"Could you explain to me what you u mean by light-headed?"
Encouragement & Support:

- Fine. That's great. You're doing fine, carry on.
- You have put great effort to help your sick mum.
- I'm happy that you're working hard to control your BP.

MRCP-PACES
SUGGESTED STRATIGY
In the 5 mins before entering the examination room, make your plan in the
provided sheet of paper:
1. OPENING
- Introduce yourself, Role
- Privacy
- Agenda
- Any relative to attend
- Explain note taking
2. MAIN DISCUSSION
- PC
- HPC
- ROS
- PMH
- FH
- DH
- SH
3. CLOSUING
- Agreeing a plan of action
- Checking understanding
- Disposal
PAIN: SOCRATES
Site
Onset
Character
Radiation
Association
Time (duration)
Exacerbating/Relieving
Severity

MRCP-PACES
The Most Common Case Histories
o Abdominal pain
o (IBD)
o Jaundice/CLD/PBC
o Malabsorption/ Diarrohea - Coeliac
o Headache
o Epilepsy
o TIA (funny turns)/CVA
o IHD/CAD/CHF
o SOB/Palpitations(PAF)
o BA/COPD
o Pulmonary fibrosis
o Bronchiectasis/CF
o DM
o Goitre/thyroid disease
o Pyrexia/Diaaohea following foreign travel
o Arthritis/RA, SLE
o HBV/HIV
o Leukemia/Lymphoma


MRCP PACES Communication Skills and History Taking Notes

Caricato da

Informazioni sul documento

Titolo originale

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

MRCP PACES Communication Skills and History Taking Notes

Caricato da

Copyright:

Formati disponibili

Session One

MRCP-PACES/Medical Ethics & Communication Skills/Dr Zein/2013

3. Breaking Bad News

4. Medico legal issues:

MRCP-PACES/Medical Ethics & Communication Skills/Dr Zein/2013

7. Updated NICE Guidelines:

MRCP-PACES/Medical Ethics & Communication Skills/Dr Zein/2013

Feel edgy (an edge): Nervous

(Ref: English for Overseas Doctors)

MRCP-PACES/Medical Ethics & Communication Skills/Dr Zein/2013

Guidelines & Policies:

Hospitals (NHS): SHO, SpR, Consultants

MRCP-PACES/Medical Ethics & Communication Skills/Dr Zein/2013

***The key sentence to success is Practice & practice till mastering

MRCP-PACES/Medical Ethics & Communication Skills/Dr Zein/2013

Use close-ended questions as the interview progresses.

Provide clear & understandable explanations

Avoid using jargons

At the end of the interview:

- Agrees a clear course of action with the patient

MRCP-PACES/Medical Ethics & Communication Skills/Dr Zein/2013

The 4 Principles of Medical Ethics

1. Respecting the patients Autonomy: (wishes & self-rule)

3. Non-maleficence: (do no harm, need to avoid harm)

4. Justice: (fairness in provision of health care)

MRCP-PACES/Medical Ethics & Communication Skills/Dr Zein/2013

Elements of valid consent:

Information to be provided to the patient:

Consent in English law:

Understands a simple explanation of his/her medical condition, treatment and

MRCP-PACES/Medical Ethics & Communication Skills/Dr Zein/2013

(1) Competent patient:

(2) Incompetent patient:

Examination/testing & treatment without consent:

1. For life-saving procedures when the patient is unconscious/incompetent to indicate

MRCP-PACES/Medical Ethics & Communication Skills/Dr Zein/2013

MRCP-PACES/Medical Ethics & Communication Skills/Dr Zein/2013

(2) Check awareness:

(3) Give a warning shot:

(3)Pausing & acknowledging distress:

(4) Encourage ventilation of feelings:

MRCP-PACES/Medical Ethics & Communication Skills/Dr Zein/2013

(6) Discussing prognosis:

How long have I got?

MRCP-PACES/Medical Ethics & Communication Skills/Dr Zein/2013

When requested by relatives not to tell the patient:

(6) Identifying other concerns:

(8) Ensure continuity of care/support:

Support: e.g. We will do our best to make you/him as comfortable as possible

(Document in the patients medical records)

MRCP-PACES/Medical Ethics & Communication Skills/Dr Zein/2013

Pitfalls in Breaking Bad News:

MRCP-PACES/Medical Ethics & Communication Skills/Dr Zein/2013

MRCP-PACES/Medical Ethics & Communication Skills/Dr Zein/2013

Objectives of Pretest discussion:

Consenting for HIV testing:

Pretest discussion checklist

MRCP-PACES/Medical Ethics & Communication Skills/Dr Zein/2013

Advantages and Disadvantages of HIV testing

Benefits (Advantages) of HIV testing

(1) Individual health benefits:

MRCP-PACES/Medical Ethics & Communication Skills/Dr Zein/2013

- A discussion of diagnostic possibilities & results of investigations to date may help.