CASE 1 Advising a patient against unnecessary investigations

CASE 2 Explanation of uncertainty of diagnosis

CASE 3 Discussion of the need to screen relatives for an inherited condition
CASE 4 Communicating news of a patient’s death to a spouse
CASE 5 Explanation to a patient of the need for investigations
Case 6 Explanation to a patient who is reluctant to receive treatment
Case 7 Lifestyle modification
Case 8 Possible cancer
case 9 Potentially lifethreatening illness
case 10 Sudden unexplained death
CASE 11 Intubation for ventilation
case 12 Patient refusing ventilation
case 13 Persuading a patient to accept HIV testing
Case 14 Talking to a distressed relative
Case 15 Explaining a medical error
Case 16 Breaking bad news
case 17 Cardiac arrest
Case 18 Stroke
Case 19 Congestive cardiac failure
Case 20 Lumbar back pain
Case21 Collapse during a restaurant meal
Case 22 percutaneous endoscopic gastrostomy (PEG)
Case 23 Fever, hypotension and confusion
Case 24 A swollen red foot
Case 25 Still feverish after 6 weeks
Case 26 Chronic fatigue
Case 27 Malaise, mouth ulcers and fever
Case 28 Don’t tell my wife
Case 29 Renal disease in pregnancy
Case 30 A new diagnosis of amyloidosis
Case 31 Is dialysis appropriate?
Case 32 Genetic implications

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Case 33 Explanation of the diagnosis of Alzheimer’s disease
Case 34 Prognosis after stroke
Case 35 Conversion disorder
Case 36 Explaining the diagnosis of multiple sclerosis
Case 37 Frequent falls
Case 38 Confusion
Case 39 Collapse
Case 40 Explaining an uncertain outcome
Case 41 The possibility of cancer
Case 42 No medical cause for hirsutism
Case 43 A short girl with no periods
Case 44 Simple obesity, not a problem with ‘the glands’
Case 45 I don’t want to take the tablets
Case 46 Limitation of management
Case 47 Limitation of investigation
Case 48 A patient who does not want to give a history
Case 49 Cold fingers and difficulty swallowing
Case 50 Back pain
Case 51 Widespread pain
Case 52 Explain a recommendation to start a disease-modifying antirheumatic drug
Case 53 Community-acquired pneumonia
Case 54 Acute pneumothorax
Case 55 Am I at risk of cancer?
Case 56 Consent for chemotherapy (1)
Case 57 Consent for chemotherapy (2)
Case 58 Don’t tell him the diagnosis

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 you are a junior doctor in a cardiology outpatient clinic.

Miss Jenny Pinto, aged 28 years, has been referred to the clinic for investigation of
palpitations.
She had previously not been worried about these symptoms, but recent knowledge of the
deaths of two relatives following sudden collapses has made her very concerned.
At her first appointment it became clear from her history that the palpitations were
consistent with ventricular ectopic beats.
Examination was normal, as was a routine 12-lead ECG.
Echocardiography showed her heart to be normal and a 24-hour ECG demonstrated
ectopic beats when she was symptomatic.
She is keen to have further investigations, but these would not be appropriate.
:

to reassure Miss Pinto that her condition is benign and explain that further investigations
are not necessary.

 What is the patient’s main concern?

 Why does she want further investigation?
 Does her desire stem from the actual symptoms or the perceived risk from the
condition in view of her family history?

 Reassure the patient that the diagnosis of ectopics is certain, as her symptoms have
been clearly correlated with ectopics on the 24-hour ECG.
 Additional reassurance is often provided when patients understand that most people
have ectopic beats at some stage every day, the majority of whom are unaware of
them.
 Some people have a lot more ectopics than others, but this does not signify anything
if the heart is normal.
 In this case we know from investigations that her heart is normal and further tests
will add nothing to this.
 It is important that the patient understands her symptoms are not being dismissed.
 An explanation that ectopic beats can be very debilitating in some people can
reassure.
 Further, knowing the symptom is benign often leads to a significant improvement in
the degree of intensity and awareness the patient feels.

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 in many cases they will just settle down without needing to do anything.
 Some people find that they are worse after alcohol or after drinks
containing caffeine.
 It might be worthwhile trying to reduce your intake of these to see
whether the symptoms improve.
 Other people find relaxation tricks such as taking a few deep breaths or
lying down can be helpful.

 there are drugs that can help suppress the symptoms, but these ectopic
beats are, essentially, a normal heart rhythm.
 We would not generally advise patients to take any medication unless
absolutely necessary, because you can end up with more symptoms from
the side effects of the medication than the actual palpitations
themselves.
 If you are desperate to take something\for these then beta-blockers may
help.
 I can explain how they work and what side effects they might cause.

 it is difficult to answer this question without further knowledge of exactly

what was responsible for the deaths of your two relatives.
 However, we have very carefully assessed your heart and can find no
problems that would give us cause for concern at all.
 I can certainly reassure you that the palpitations will not cause you to
die.

 of course you can.

 Either your GP or I can organise this for you, but I would emphasise that
all of the investigations have been reassuring and we know that these
ectopic beats, whilst unpleasant, are not in any way life-threatening, but
if you’d like to have a second opinion, then I can help arrange this.

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 : you are a junior doctor working on a general medical ward.

A 65-year-old man is admitted to your ward from the Emergency Department following an
unexplained syncope while shopping.
There have been no previous episodes and since his arrival on the ward he has been alert
and orientated with normal observations.
Physical examination and investigations including ECG, CXR and blood tests (including
troponin at12 hours after the collapse) have been normal.
His telemetry up to this point has shown no abnormalities.
The plan agreed after consultant review on the ward round is to discharge him home, with
arrangements for an outpatient 24-hour tape and echocardiogram.

:
to explain to his wife the uncertainty of the diagnosis and what the management plan is
likely to be.

 What is the wife’s current level of understanding of events?

 What are her concerns and expectations regarding her husband’s condition and
treatment?

 Firstly, establish that you have the patient’s consent to talk to his wife about his
condition.
 Explain that the cause of the collapse is uncertain, but initial assessment has so far
been reassuringly normal, as have the appropriate investigations.
 Reassure her that this is a common presentation and that the vast majority of
syncopal episodes have a benign cause.
 Explain that sometimes an exact diagnosis is not determined, and the importance of
investigations is to rule out the more serious causes for which there are effective
treatments rather than to pinpoint the specific cause.

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 at the moment it is not possible to give an exact cause, but the most
common cause of collapse is a simple faint.
 We will make a plan to do further tests, mainly to rule out other
causes.

 unfortunately there is no guarantee that the symptoms will not

reoccur, but the fact that he is well now, that there are no
abnormalities when we examine him, and that the initial tests, the
EGG (an electrical tracing of his heart), a CXR (a chest X-ray) and
blood tests, are all normal, makes it less likely that there is a serious
underlying cause.

 it’s very unlikely that they will show anything worrying, but to be on
the safe side we plan to organise for a 24-hour tape recording of his
heart beat to check that it doesn’t go too fast or too slow at any time,
and an echocardiogram– that’s a special scan – to look at the heart
in more detail than you can see on the CXR.
 We plan to do these with your husband as an outpatient.

 I’m afraid that we can’t do them right away.

 Your husband seems well now and when the consultant saw him
earlier on we agreed that we didn’t need to keep him in hospital and
would do the tests as an outpatient?.

 not at the moment.

 However, if he has no recurrence of his symptoms then he can
return to driving in 4 weeks (see Section 2.19).
 However, if there are any further symptoms then he should await
the results of his remaining investigations and clinic review before
recommencing driving.

 at this stage there is no evidence that a pacemaker would be

 helpful.
 The results of his tests will help decide whether this needs to be
considered in the future.

 as I’ve explained, we don’t think that this is likely or we wouldn’t be

suggesting that he goes home.
 If he does collapse, then– the same as if you or I were to collapse –
you would need to call the doctor or an ambulance.

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 you are a junior doctor in a cardiology outpatient clinic.

Mr Patrick McDonagh is a 37- year-old builder and father of three who was admitted on the
medical ward with a syncopal episode 2 months ago.
He has been previously fit and well.
Examination on admission revealed a normal pulse rate, but his BP was elevated
persistently at 160/95 mmHg.
There was a soft ejection systolic murmur over the left sternal edge.
His ECG was normal apart from large-voltage complexes consistent with left ventricular
hypertrophy.
He was discharged and prescribed atenolol for his hypertension, and arrangements were
also made for him to have a 24-hour ECG and an echocardiogram as an outpatient.
The 24-hour ECG was normal but the echocardiogram demonstrated severe hypertrophic
cardiomyopathy (HCM) with an outflow tract gradient of 50 mmHg, following which an
urgent appointment for the cardiac clinic has been made.
His GP has told him that the condition can affect the family, and he is concerned about
this.
HCM is typically an autosomal dominant disorder with very variable manifestations: some
people with the condition have no problems, but others die suddenly.
Further investigation, eg electrophysiological studies, will be advised.
to explain the diagnosis of HCM and the potential genetic implications of
the condition.

 Has the patient had any further symptoms since discharge?

 What does he understand about his condition and what are his main concerns
regarding his family?

 Establish that there are two main issues to be explored:

 firstly, the impact of HCM on the patient and the potential need for him to have
further investigations;
 secondly, the hereditary nature of the condition.
 It is important to understand precisely why the patient is concerned about the
impact of the diagnosis on his family.
 Is his main concern the impact of his health (or ill-health) on the family?
 Has he understood the genetic aspect of the condition?
 Or are both issues of concern to him? Both are very important, but an understanding
of the patient’s main concern will allow a more productive consultation.

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 that is really good news and an excellent sign, but it is important that
we do further tests of your heart as some patients with this condition
can have very serious problems later on.

 that’s not what I said, but a small number of patients with this
condition are at risk of dangerous heart rhythm problems and sudden
blackouts.
 The further tests will help us assess whether you are at risk of this.
 If you are, then there are a number of ways that we can reduce this risk

 I assume that none of your children have had any heart problems so
far? [Patient confirms that they have not.]
 But yes, this condition can be passed on to your children.

 because of the way it runs in the family the chances for each child are
about 50/50.
 So at some stage it will be important for you to have your children seen
by a specialist, when a simple test like an ultrasound scan of the heart
may allow the diagnosis to be made.
 However, it’s not always possible to say that a child definitely does not
have the condition.

 at the moment there is no single test that will give a definite diagnosis.
 There have been a lot of advances in the genetic testing of blood
samples that may allow us to get this answer in the future, and we can
refer you to a clinical geneticist who will be able to give you more
information on the inherited aspect of the condition.

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 you are a junior doctor on a coronary care unit.

Mr Smith, a 40-year-old man, is admitted from work with a large anterior myocardial
infarct, which is treated with thrombolysis. Unfortunately he arrests and, despite prolonged
attempts at resuscitation, he dies. His wife arrives 5 minutes after he dies.

to inform Mrs Smith that Mr Smith is dead

 What does the patient’s wife know already?

 She will be more prepared for bad news if she knows he is gravely ill than if she
doesn’t know why he is in hospital.
 Explaining an unexpected death is one of the most difficult communication tasks
that a medical professional has to perform:
 if it is done with compassion and sensitivity it can ease the inevitable distress that
family and friends will go through.

 Find a quiet room, if possible a relatives’ room, and ask the nurse looking after the
patient to accompany you.
 Leave your pager with someone else so that you are free of interruptions.
 There is no hiding from the fact that you must inform Mrs Smith that her husband
has had a heart attack and unfortunately has not survived.
 State that you and the team did what you could, and say how sorry the whole team
is.
 Demonstrate empathy: if it feels appropriate hold her hand or touch a non-
threatening area, such as the arm or the shoulder.
 Wait until asked to explain details, but keep it simple.
 Allow her to cry with dignity, such as by handing her some tissues.
 Do not be afraid of silence, but if this becomes uncomfortable it is often helpful to
make an open statement, such as ‘This must have come as a shock’.
 In finishing the discussion, explain that should further questions arise you will be
happy to answer them.
 Also say that you will have to notify the coroner, which is routine following any
unexpected death, and that the nursing staff will provide her with information about
practical matters such as death certification.

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 [After ascertaining that she knows that her husband was brought into
hospital as an emergency, but not that he has died; and speaking
quietly, slowly and deliberately to let the information sink in.] Your
husband was brought to the hospital as an emergency.
 He was very unwell: he had suffered a big heart attack.
 We gave him the best treatment we could – an injection of a drug
designed to open up the artery that had blocked off – but I’m afraid that
things did not go well.
 The damage to his heart was too great, it couldn’t beat properly and,
despite us doing everything we could, he passed away.

 yes. I’m very sorry, but I’m afraid he’s dead.

 I don’t know why it happened, but he had a big heart attack.

 This must mean that the blood vessels going to his heart muscle were
narrowed, and that one of them blocked off and gave him a heart
attack.

 you’re right, many people do survive heart attacks, but I’m afraid that
many also don’t.
 Sometimes the heart attack is so big that it damages too much of the
heart muscle for the heart to work at all; and sometimes the heart
attack affects the wiring mechanism that makes the heart beat in a
regular manner, so that instead of pumping in a normal way the heart
can’t pump at all.
 I’m sorry to say that both of these things happened in your husband’s
case.

 we did absolutely everything we could to restart his heart, but he had

suffered such a large heartattack that this wasn’t possible.
 We tried everything we could to resuscitate him, but I’m afraid that it
didn’t work.

 No – it was very quick and he was unconscious throughout, so he

wasn’t aware of what was going on and he would not have suffered.

 it is unlikely that he will have to have a post-mortem.

 We will need to inform the coroner, which is something that we have to
do after any unexpected death, and very occasionally they will insist on

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 a post-mortem.
 However, I think this is very unlikely in this case, because we know why
your husband died.
 If you would like further information about his health and how he died
then we can request a hospital post-mortem, but it may be difficult for
you to discuss this now.
 We can talk about this again later if you want to.

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 you are a junior doctor working on a cardiology ward.

Mr Hugh Jones, aged 23 years, has congenital heart disease.

He was admitted from clinic for further investigations into the cause of his breathlessness.
The view of the cardiac team is that it will not be possible to give best advice about
prognosis and treatment without information from a cardiac catheterisation study, but he
is refusing to consent.

to determine what concerns Mr Smith has and explain the purpose of further investigation.

 First find out what the patient knows about his condition: he may be concerned that
nothing can be done or be in denial about the seriousness of the problem.
 Then establish what he knows about cardiac catheterisation and his fears about the
procedure: some patients are worried about pain and discomfort, whereas others
worry about complications.
 Try and put any such fears in perspective.
 Explain any alternative investigative strategies that are available, but also why a
cardiac catheterisation study is needed to give him best advice about his condition.
 If possible offer him information booklets and if there is a specialist nurse available,
ask him or her to speak with the patient.

 Mr Smith does not have to undergo any investigation or treatment unless he agrees
to it.
 He will still receive care even if he does not undergo the investigations
recommended, but a proper investigation may improve the care that can be given to
him and thus alleviate some of his symptoms.

 I hear what you say, but you went to the doctor because your
breathing isn’t as good as it should be and it looks as though this is
due to a problem with your heart.

 I know that things aren’t terrible at the moment, but we have found
a problem with the heart that could be serious and which may get
worse.
 It may be that treatment now can improve things so that they don’t
get any worse, or the rate of any deterioration can be slowed down
so that you will feel well for longer.

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 no, I’m afraid that I can’t.
 Until we know exactly what the problem is, we won’t be able to tell
you.

 yes, we can and will do scans that will give us some information.
 However, cardiac catheterisation gives us the most important
information, such as the amount of oxygen in the chambers of the
heart, which we cannot get in any other way.
 We wouldn’t recommend this if there were better alternatives.

 the procedure may be uncomfortable while the local anaesthetic is

being given.
 This lasts a few minutes and after this it should not be
uncomfortable.
 It’s a bit like going to the dentist: the injection is unpleasant, but
then
 things go numb.

 that’s very unlikely indeed.

 This is a routine procedure, although as you can imagine any
procedure involving the heart carries a small risk, but it is very
small.
 The risk of death is 1 in 4,000, which means that 3,999 survive
out of 4,000 people undergoing the procedure.

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 you are a junior doctor in a medical outpatient clinic.
Mrs Jessica Yelland, aged 30 years, has been found to be significantly hypertensive when
she came to her GP’s family planning clinic.
Her BP has been measured on several occasions and found to be consistently in the region
of 180/100 mmHg.
It has been explained to her that she has high BP that requires investigation and
treatment,
but she feels well and only wants a prescription for the oral contraceptive pill, not any tests
or medication.
to inform Mrs Yelland why investigations and treatment are required.

 The key to a successful outpatient consultation will be to understand the reason why
the patient does not want further investigation or treatment.
 Does she feel that investigation and treatment are unnecessary because she feels
well?
 Is she afraid of what may be found?
 Is she concerned about the effects of treatment?

 It is very important to establish a rapport with this woman so that she will trust you
and thus hopefully follow the recommended management plan.
 Explain to her that hypertension is a common and often asymptomatic condition that
is frequently detected on routine screening, or incidentally as part of investigations
for other medical problems.
 It is important that she understands what hypertension is and why it should be
taken seriously, even in the absence of any complaints or limitations: the potential
harmful effects of longterm high BP must be explained.
 She will need reassurance and an explanation that investigations are necessary to
exclude a secondary cause of high BP, which might mean that the hypertension can
be cured and that she would not need longterm treatment.
 If no specific cause for hypertension is found, then simple changes to her lifestyle
may be adequate to treat her BP.
 But in some situations this is not enough and she may require medication.
 Your advice should be accompanied by provision of reading material and help with
associated programmes for smoking cessation, weight loss and dietary advice.
 But remember that most patients diagnosed wih hypertension perceive themselves as
being healthy and leading a normal lifestyle with no day-to-day limitations; hence
starting treatment and addressing lifestyle issues can be difficult and in some cases
unacceptable.

14 | P a g e
 high blood pressure is a very common condition that can affect up to
20% of people.
 As in your case, high blood pressure is often discovered when someone
has their blood pressure measured for an entirely unrelated problem.
 The fact that it was discovered for that reason does not mean that
having high blood pressure is unimportant.

 over a period of many years high blood pressure can result in serious
damage to many important organs in the body.
 For example, if untreated it can lead to major heart problems and
strokes, and very rarely it can result in problems with the eyes that can
affect normal vision and in extreme cases may result in blindness.
 However, all these problems can be avoided by achieving good blood
pressure control.

 a good question, and I wish I could give you a good answer.

 For most patients we don’t know, but in some cases it can be caused by
problems with the kidneys or glands so we will recommend some tests –
blood tests and urine tests – to see if this might be the case for you.

 by examining you and doing tests.

 For instance, we can look in your eyes to see if it is having an effect on
the blood vessels at the back of the eye; we can do an ECG – an
electrical tracing of the heart – or an echocardiogram – a special scan of
the heart – and see if it is having an effect there; and we can do urine
and blood tests to check kidney function.

 the first thing is for us to look at your lifestyle to see whether we can
help you make it more healthy to bring your blood pressure down.
 Examples of things that can help are ensuring you take regular
exercise, stopping smoking and looking at your diet.
 But it is likely that tablets will also be needed.

 not everyone who is started on medication for blood pressure continues

with high blood pressure for the rest of their life.
 In some situations the changes to their lifestyle may mean that they do
not need to continue taking medication long term.
 The treatment is something that your doctor will want to review on a
regular basis.

 it might do, but a significant number of patients actually require a

combination of tablets.

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 We will start you off on one tablet and then review your blood pressure,
and only add in additional tablets if required.

 there are lots of different sorts of blood pressure pills, and we want to
make sure that we get one that suits you.
 If you do get side effects from the first one that we try, I’d like you to
tell me so that we can try and find one that suits you better.

 yes, as long as we can get your blood pressure under control.

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 you are a junior doctor in a general medical outpatient clinic.

A 52-year old builder who has smoked 10–20 cigarettes per day for many years is admitted
on a general medical take with 4 month’s history of exertional shortness of breath, which
has got significantly worse during the last few days.
He has no significant past medical history except for mild hypertension (150/95 mmHg),
for which he is reluctant to accept medication, and obesity (108 kg, BMI 36.5).
He has improved after treatment with oxygen, nebulised bronchodilators and antibiotics.
Spirometry on discharge confirms a moderate chronic obstructive pulmonary disease
(COPD).
explain to this reluctant patient that he should stop smoking and lose
weight.

 Why is the patient reluctant to give up smoking?

 Has he ever made an attempt to give up smoking?
 If he has, then how difficult was it?
 For how long did he manage to refrain from smoking, and why did his attempt to quit
fail?
 Has he tried to lose weight?
 If so, what lifestyle changes did he make in this respect and did he manage to lose
any weight (and why does he think that he was unsuccessful)?

 Introduce yourself appropriately.

 Explain the patient’s spirometry result and the cause of his breathing difficulty.
 Highlight why inhalers alone are not an effective way of treating his shortness of
breath in the long term.
 Explain the benefits of quitting smoking, its effect on spirometry and the price he will
have to pay if he continues to smoke (eg he is likely to have gradually decreasing
exercise capacity and need repeated hospital admissions).
 Focus on how smoking affects his health personally (COPD and hypertension) rather
than in a general way.
 Balance negative information about harm and risks with positive information about
the benefits of smoking cessation.
 Demonstrate active listening skills.
 Encourage open and nonthreatening discussion on how he sees his smoking.
 Make sure he does not feel pressured and avoid being judgemental.
 Back off if he appears annoyed. Stay positive and friendly.
 Show understanding of his fears about quitting.
 Keep avenues open for any changes in his mind.
 Praise him for his past achievements, however small they may seem.

17 | P a g e
 Explore options available to him to support him in his decision to quit (nicotine
replacement therapy, bupropion and smoking cessation clinics).

 Explain the BMI value, its implication and how obesity contributes to his breathing
problem.
 Show understanding regarding the difficulty that he might have experienced while
trying to lose weight.
 Suggest various strategies that may help him to lose weight(dietary change, physical
 activities, and drugs such as orlistat and sibutramine).
If something is difficult, like giving up smoking or losing weight, do not pretend to the patient
that it is or should be easy.

 changes related to smoking happen gradually over many years, and may
not cause any breathing problems until significant damage is done.
 Spirometry, the breathing test which you have had done, is the best way
of detecting changes in the lungs caused by cigarettes.
 One of the things measured – the amount that you can blow out in 1
second, called forced expiratory volume in 1 second (FEV1) – tells us how
narrow the airways are.
 If this reading, the FEV1, goes down to less than 80% of what it should
be for your age and height, then this indicates chronic obstructive
pulmonary disease.
 This is irreversible damage to the lung through smoking, and I’m afraid
that that is what you’vegot.
 It is not at all uncommon for smokers to first develop breathing
difficulties in the way that you have.

 lots of things affect whether or not you feel breathlessness, such as your
general level of fitness, weight, muscle strength, heart function and
tolerance of pain and breathlessness.
 With the same level of problems in their airways, one patient with COPD
may complain of extreme breathlessness whereas another gets mild or
even no symptoms.

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 it is true that damage due to smoking is irreversible, so if you give up you
won’t regain lost function.
 In fact your lung function will still continue to decline the same as
everyone else’s, but it will get worse at about the same rate as would be
expected in someone who didn’t smoke at all.
 However, if you keep on smoking it will get worse much faster.
 So, it is never too late to give up smoking.

 I agree that it may not be easy, but I am sure that you can do it.
 You have at least two reasons to lose weight.
 Your excessive weight will certainly make your shortness of breath worse,
and it may well be the cause of your raised blood pressure.
 As your body mass index is well over 30, you are also at high risk of
developing other serious medical conditions, particularly diabetes and
heart disease.
 Adietitian could help you to choose a diet that is best for you and you
could also consider joining a weightloss class where you could get advice
on both diet and exercise, and work along with other people with the
same problems to improve things

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 you are a junior doctor in a respiratory clinic.
This 48-year-old executive has had a CXR as part of his company’s health screening
programme (he has never had a CXR before).
It shows a pulmonary nodule in the right upper lobe.
He has been informed that he has a shadow in his lung.
:
discuss with him the implications of his undiagnosed abnormality and address his fears
that this may be lung cancer. You are not expected to examine the patient.

 What is the patient’s main worry?

 Is there any particular reason why the patient is worried?
In routine clinical practice patients will often not mention key reasons for their
concern, and in PACES the briefing notes for the surrogate will commonly say ‘Do not
mention this unless specifically asked’.
What further investigations are required?

 Introduce yourself to the patient and say why you have been asked to see him.
 Explain the proposed outline of your interview by telling him that you wish to go
through the history briefly to confirm the information that you have been given, that
you would then like to discuss the implications of the findings and finally address
any fears or concerns that he may have.
 Ask if the patient would like anyone else to be present during this discussion.
 Admit uncertainty: this might be something sinister, but it might not be.
 Emphasise that ‘something can always be done’, even if the diagnosis is serious.
Always adopt a non-judgemental attitude, eg if the patient says he will continue to
smoke 40 cigarettes a day despite being informed that there is a shadow in the lung.
Explain the medical benefits of changing behaviour but do not be judgemental, even
if the patient’s behaviour seems to have caused the illness.

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 it’s obviously a good thing that you feel well, and I agree that the
chances of something serious would be much higher if you felt ill.
 But, I’m afraid I can’t guarantee that the shadow on the lung isn’t
serious.

 there are a range of possibilities: sometimes shadows on the lung

can be caused by an infection, either recent or a long time ago,
sometimes they can be due to conditions that cause inflammation in
the lungs, and sometimes they are due to growths of various sorts

 I can’t tell you at the moment.

 I’m not hiding anything, I simply don’t know.
 It could be due to infection or to a benign growth of some sort, but
yes, I’m afraid that cancer is a possibility, and we need to find out if
that is the case as soon as possible.

 we need to do some more tests.

 In particular we need to organise a CT scan of your lungs and
probably a bronchoscopy, which means looking into the lungs with a
special telescope, as well.
 With one or other of these tests, depending exactly on where the
shadow is, we may need to perform a biopsy so that we can look at
the tissue under a microscope to see what the shadow is.
 We will also plan to do some more blood tests to check for evidence
of infection or inflammation.

 that very much depends on what we find.

 If it’s an infection, then antibiotics may be needed

 I honestly don’t know.

 There are several different sorts of lung cancer, and if it is one of
those it will also depend on how far it has spread.
 I don’t think we can really go into too much detail at the moment–
because we don’t know exactly what we’re dealing with here – but
some cases of lung cancer can be cured.

21 | P a g e
 you are the on-call medical junior doctor

Mrs Angela Warren is a 36-yearold single mother of two who has been brought to the
Emergency Department by ambulance.
She developed sudden-onset pleuritic chest pain and breathlessness at rest this evening.
On examination her pulse rate is 120 bpm regular and her respiratory rate is 24/minute,
but otherwise there are no abnormal findings.
Of her initial investigations the ECG shows sinus tachycardia, the CXR is clear and blood
tests are normal except for a raised D-dimer.
Arterial blood gases show a normal pH (7.44), normal PO2 (11.0 kPa) and reduced PCO2
(3.0 kPa).
The pain is easing, she reports feeling less short of breath and she wants to go home.

to explain to Mrs Warren that pulmonary embolism is a significant possibility and that she
should start treatment and be investigated as an inpatient.

 Explain the possibility of a potentially life-threatening problem.

 Find out why she is so keen to get home.
 In routine clinical practice patients will often not mention their reasons for wanting
to leave hospital unless specifically asked, and in PACES the briefing notes for the
surrogate will commonly indicate that they should do the same.

 The competent patient does have the right to refuse investigation and/or treatment.
 It is your responsibility to put her into such a position that she is able to make
decisions about her management from a well-informed standpoint.
Is she competent?
Does she understand the possible diagnosis and its potential implications?
She needs to know that she is at significant risk of deterioration, and even death,
from her (presumed) pulmonary embolism.

 Are there childcare issues(for example)?

 If there are, then offer to make an effort to help in sorting them out.
 It is unfortunately not uncommon for some doctors to ‘wash their hands’ of patients
seen to be‘refusing treatment’, but usually a compromise position can be reached
with good negotiation and the examiners will be looking for your ability to make a
workable plan in this scenario.

22 | P a g e
 Willingness to negotiate a reasonable compromise

 Negotiation may result in a treatment plan that is not necessarily ideal, but better
than nothing.
 For example, it may be agreed that the patient is given a dose of low-molecular-
weight heparin immediately, and that she returns in the morning for a ventilation–
perfusion scan and review.

 I’m obviously pleased that you’re feeling a bit better, but I’m afraid
that I can’t guarantee that there isn’t a serious problem here.
 One of the blood tests, the D-dimer, and one of the tests on the
blood from an artery indicate that there may be something serious
going on.

 it is possible that you have had a pulmonary embolus, which is a

blood clot in the blood supply to the lung.

 we’ll need to perform a scan that enables us to see the blood supply
and check if there are any blockages.

 if this is a clot, then usually the body slowly absorbs it over the next
week or so.
 But the main worry is that either this clot may extend and get bigger,
or that more clots may spread to the lung.
 If this happens then it can be very serious indeed: it can mean that
you can’t get enough oxygen into your blood, that the heart is
sometimes put under too much strain and cannot pump properly, and
in severe cases it may even stop completely.

 to help prevent this clot getting worse, or more clots from forming, we
need to put you on some blood-thinning medicine.
 Whilst we are getting the scan to confirm the diagnosis this will be in
the form of an injection under the skin.
 If the scan confirms a clot, you will then be put on blood-thinning
tablets for the next 6 months.

 is there some special reason that you want to go home?

 Is there a problem with looking after the children or something like
that, something that we might be able to arrange help for?

 I’m afraid that I don’t think that’s a good idea.

 I think that there’s a high chance that you’ve got clots of blood in the

23 | P a g e
 lungs, and from the tests we’ve done these seem to be affecting your
heart and your breathing.
 I think we should give you the treatment to thin the blood and get the
scan done in the morning.

 OK, as long as you understand that this condition can sometimes be

very serious, or even life-threatening, and that is the reason I would
strongly advise you to stay in hospital for now.
 But if you really insist on going home, then I can arrange for you to
have an injection of the blood-thinning treatment now before you go.
 If you do get worse at home, please call an ambulance and come
straight back to hospital.
 I’ll make a note in your medical records to say that this is what I’ve
advised.

24 | P a g e
 you are the medical junior doctor working on a general medical ward.
A 56-year-old woman admitted with an exacerbation of chronic obstructive pulmonary
disease (COPD) 5 days ago has died suddenly.
When seen on the ward round in the morning she seemed to have been gradually
improving, and certainly better than she was on admission.
She had been on a prophylactic dose of low-molecular-weight heparin, but the most likely
cause of death was probably massive pulmonary embolism.
Her husband has been called into the hospital by the senior sister on the ward.
He knows that his wife has died, but does not know the circumstances.

explain to the husband that his wife died suddenly, probably from a massive pulmonary
embolism, and that you will have to discuss the case with the coroner.

 The original reason for the patient’s admission and its management.
 What is the husband’s understanding of the cause or causes of his wife’s death?
 Explain to the husband that his wife was on proper treatment for COPD and that her
death was too sudden to be due to that condition, so it is most likely that she died
due to an underlying pulmonary embolism.
 Explain that there is an increased risk of thromboembolism in acutely ill medical
patients, and that a prophylactic dose of low molecular- weight heparin can reduce
this risk but not eliminate it altogether.

 The uncertainty regarding the cause of death, and that a definite cause of death can
only be established by a post-mortem.
 That you will not be able to issue a death certificate without discussion with the
coroner or the coroner’s officer, who may insist on a post-mortem examination.

 I would first of all like to say how sorry we all are here, especially as
her death was so sudden and unexpected.
 It was a shock to us all.
 As you know, she was admitted with exacerbation of her chronic
bronchitis and emphysema.
 She was on treatment for this, and when we saw her on the ward
round this morning she seemed to be improving.

25 | P a g e
 we don’t know for sure, but we think that she suffered from a massive
clot on the lung.
 This is the most likely thing to explain her sudden collapse and death.

 pulmonary embolism or clots in the lung are known to occur in people

who are confined to bed, and your wife had been in bed for much of the
last week or so.
 These clots can be prevented by injections of blood-thinning agents,
and we had been giving your wife these injections since her admission.

 I’m afraid that the injections aren’t 100% effective.

 Like all treatments they don’t always work: they cut down the chances
of having clots, but they don’t guarantee that you won’t.

 yes, that’s true.

 We think that a massive clot in the lungs is the most likely thing, but
we can’t prove it and it is possible that she had something else, like a
sudden heart attack

 because we are not absolutely sure why your wife died, I cannot issue a
death certificate.
 For this reason, and also because she died unexpectedly, I must speak
to the coroner’s office.
 It may be that they will decide that a post-mortem examination needs
to be done.

 I’m afraid that I can’t.

 I can only sign a death certificate if I know the cause of death and, as
we’ve discussed, I’m not absolutely sure here.
 This is why I must speak to the coroner’s office.

 I understand what you’re saying, but I am not able to issue a death

certificate because I do not know the cause of death.
 I have to refer the matter to the coroner.

 I can’t say for certain.

 I will explain what happened: that your wife came into hospital
because her chest was bad, that she was on treatment and seemed to

26 | P a g e
 be getting better, and then that she died suddenly and we think from a
clot of blood on the lungs.
 If the coroner is willing to accept that, then I will put it on the death
certificate.
 However, if the coroner says that he wants a post-mortem to try and
find out exactly what happened, then that’s his decision and we have
to accept it.

27 | P a g e
 you are the medical junior doctor working on a general medical ward.

Mr Ian Jones, a 74-year-old man with chronic obstructive pulmonary disease, is admitted
with an acute hypercapnic exacerbation precipitated by a chest infection.
He has previously been confined to his home because of exertional dyspnoea, despite the
use of domiciliary oxygen and nebulised bronchodilators.
Conventional medical therapy is being administered and adjuvant non-invasive ventilation
is being set up for him.
He still appears mentally alert.
The question of whether it would be appropriate to intubate him for ventilation is discussed
on the ward round.
The view of the medical team is that there would be no guarantee of success, and the
process may be unpleasant for the patient.
Moreover, even if intubation and ventilation were to be successful and the patient to
survive this episode, he is likely to be left with even greater respiratory disability than he
had prior to this illness.
There is no doubt that whatever is done his medium- to long-term outlook is very poor
indeed.

to approach him with the issue of whether or not he would want to be intubated for
ventilation in case the current therapeutic measures are unsuccessful in resolving his
ventilatory failure.

• What is the patient’s understanding of his medical condition and prognosis?

• What is the patient’s attitude to invasive procedures such as intubation and ventilation?
• What are the likely attitudes of his family members and carers?

 Is the patient competent to make an informed decision about endotracheal

intubation and ventilation?
 Does the patient have a realistic understanding of the advantages and disadvantages
of this treatment?
 Can he give you an account of them?
 Has the patient discussed these issues with anyone else or written a ‘living will’?

28 | P a g e
  hello Mr Jones, I just thought I’d come and have a chat while the
mask and equipment to help you with your breathing is being set
up.

 how much do you know about the sort of treatment you are
receiving?

 well, we are going to ask you to breathe through a mask that is

connected to a machine that will help you with your breathing.
 If you breathe normally then the flow of air coming from the
machine will help.

 good, but can we talk a bit further?

 As you know, your breathing is pretty bad just now, and while we
are hopeful that things will improve with this treatment we’re just
starting, it may be that they won’t.
 If that turns out to be the case, we have to consider carefully what
we should do.
 Is that something you’ve ever thought about or talked with anyone
about?

 some people with serious medical problems, such as your chest,

have thought about exactly what treatments they would want or not
want if things got really bad.
 Some people have talked with their family or friends about it, or
have written a ‘living will’. Is this something you’ve done?

Doctor:  if things get worse, we need to think about whether it would be the
right thing to take you to the intensive care unit.
 There they could put you to sleep, place a tube into your throat and
connect you up to a breathing machine, called a ventilator, that will
do all the breathing for you.
 How do you feel about that?

 the idea would be to help you with your breathing while we try to
overcome the infection in your chest, but the treatment has its own
set of risks.
 This includes chest infections that can be very difficult to treat, and
there is a strong possibility that you may not be able to come off the
breathing machine easily.
 In that case – if you were going to need the breathing machine for a
long time – we would have to make a hole in your neck [show
visually], pop a tube down into your wind-pipe and use this to

29 | P a g e
 connect you to the breathing machine.

 I’m afraid that this can’t be guaranteed.

 Your chest is very bad and whatever we do it isn’t going to get
completely better.
 I’m afraid that it’s likely that every episode of infection such as this
is going to make things a bit worse, even if you do get over it.

 this isn’t the sort of situation where there’s a ‘right’ and a ‘wrong’
thing to do.
 Some people will decide that they want to try the ventilator if things
get really bad, but they have to recognise that this can be very
difficult for them and might not work out.
 Other people decide that they want to be kept comfortable if they get
into that sort of situation.
 Whatever decision is made, we will look after you as well as we can.

30 | P a g e
you are the medical junior doctor on call and you are asked by the nurses to speak to the
daughter of a patient who was admitted on acute medical take a few nights ago.

Mrs Natalie Cooper, aged74 years, has presented with type II respiratory failure secondary
to an exacerbation of severe chronic obstructive pulmonary disease that normally limits her
exercise tolerance to approximately 50 metres at best.
She is well known to the respiratory team because of her recurrent hospital admissions,
but on this occasion she has failed to respond to maximal medical treatment that has
included a trial of non-invasive ventilation.
During previous admissions the question of escalation of treatment has been discussed
with her, and she has consistently said that she would not want to be intubated and
ventilated in the event of deterioration.
The respiratory team think that this is a reasonable decision for her to have made, that she
is competent to make it and this has been recorded in her notes.

explain to the daughter that her mother does not want mechanical ventilation and that her
views must be respected.

 What is the daughter’s understanding of her mother’s condition?

 Explain the details: a life-threatening flare-up, a poor response to medical therapy
including a trial of non-invasive ventilation, and the progressive character of her
underlying lung disease and its complications.
 What is the daughter’s understanding of her mother’s wishes?
 The impossibility of predicting the outcome of this situation accurately.

 Demonstrate an understanding of the daughter’s wishes, in particular if she wants to

do everything to keep her mother alive.
 Ensure that the daughter understands that her mother’s decision against
mechanical ventilation in the future was her own, and was made on the basis of a
full understanding of her condition and the probable consequences of not proceeding
to mechanical ventilation.
 Explain that patients have a legal right to decline specific treatment, including
treatment that is life prolonging.
 Demonstrate sympathy with the daughter’s difficulty in accepting her mother’s
decision.
 Reassure her that every effort will be made to keep her mother comfortable in the
event that she deteriorates and is dying.

31 | P a g e
 you are right, your mother is probably too ill now to make any
valid judgements.
 However, she has discussed this with the chest team before when
she was well.
 At that time she was fully competent to make decisions on what
treatment she would wish to receive in the future, and this has
been recorded in her notes.

 your mother was aware that she has a chronic lung condition,
which is progressing, and that her lung reserves are low.
 She knew that at some point she might end up in a ‘do-or-die’
situation, because of a flare-up or deterioration, and the possible
ways of treating this, with their advantages and disadvantages,
were discussed.
 She made a conscious decision that if such circumstances arose
she did not wish to be put on a life-support machine.
 She, along with any other patient who can understand the
implications of their decisions, has the legal right to decide what
kind of medical treatment to choose or refuse.

 I fully understand what you say, as you obviously would like your
mother to receive all available treatment so that she can live for as
long as possible.
 But your mother took the decision not to be put on a mechanical
breathing machine(a ventilator), and this has been recorded in her
notes.
 She has not changed her decision since she’s been on the ward so
we therefore have to respect her wishes.
 I am afraid that no one has a legal right to accept or decline
treatment on her behalf and that includes the closest family,
however distressing this may be.
 I fully understand that it’s very difficult for you.

 no, it’s not absolutely definite.

 At the moment she is very ill and we fear that she is going to die,
but it’s not 100% certain.
 Patients do sometimes come back from situations as bad as this,
but we don’t think that’s likely, although I’d be delighted to be

32 | P a g e
 wrong.

 again, I’m afraid that’s not certain.

 The machine would help the breathing in the short term, but there
can be problems.
 It can sometimes be very difficult indeed to get someone off the
machine and this can lead to a variety of complications.
 So no, it’s not certain she’d live if she went onto the breathing
machine.

 I suspect that your mother was concerned that she might become
incapacitated and unable to make decisions on her own behalf.
 She has been on maximal medication for her chronic lung
condition for some time now, and I think that she felt tired of
fighting for breath and, more importantly, that the prospect of
losing her independence was unacceptable to her.
 She must have felt that enough was enough.
 It was very brave of her to make up-front planning: making a
decision not to pursue life-prolonging treatment is obviously not
an easy one and she probably wanted to protect her loved ones
from the responsibility of being involved.
 Our duty is to respect her values and wishes.

 I honestly think that even if your mother could be pulled through

this flare-up, she might have a significantly worse quality of life.
 There is also a significant chance that she might end up on a
ventilator permanently in order to go on living, and she probably
would not wish to face this.
 This is not only my opinion, but also the view of other doctors who
look after her.
 I have to say that I support your mother’s decision and would also
feel the same if it were my own mother.
 At the same time I fully understand how difficult it is for you to
accept this, and I can assure you that the doctors and nurses will
work together to ensure that your mother does not suffer, and that
she continues to receive all the treatments needed to relieve her
symptoms.

33 | P a g e
 you are a medical trainee working in a general medical outpatient clinic.

John Ward is a 21-year-old university student who has visited East Africa.
Lately, he has complained of increasing lethargy and difficulty concentrating, has lost one
stone (6.35 kg) in weight over the last 2 months and has developed swellings in the neck,
armpit and groin area.
At night-time his temperature has gone up to 39.7°C, when he would sweat profusely.
The warden of his hall of residence noticed that he was unwell and sent him home, telling
him that he should see his GP.
The family GP took a very detailed history covering all physical and social aspects of
John’s life.
He examined him and confirmed generalised lymphadenopathy, also finding
oropharyngeal candidiasis, and organised blood tests that showed elevated
immunoglobulins and haemoglobin 9.6 g/dL(normal range 12–16.5), platelets 87 × 109/L
(normal range 150–400), neutrophils1.8 × 109/L (normal range 2–7) and lymphocytes
0.02 × 109/L(normal range 1–3).
John was referred to the medical clinic where you discussed the differential diagnosis of
lymphoma and HIV.
You recommended an HIV test after a thorough explanation of the possibility of HIV and
the development of AIDS.
John refused to discuss this, saying that ‘he was worried about obtaining a mortgage in
the future’.
He asked if he could have his immediate symptoms treated.
You gave him a prescription for high-dose fluconazole tablets and some paracetamol to
bring his temperature down, and gave him an appointment at clinic in seven days time, to
which he has now returned.
to convince the patient to allow you to test him for HIV.

• The differential diagnosis.

• The patient’s understanding of and fears about HIV.
• Issues about insurance.

• That best treatment cannot be provided without a definite diagnosis.

• Does he have recognised risk factors for HIV infection, or is there another explanation?
• Does he realise that there is effective treatment for HIV-positive people?
• That applications for life insurance require any significant illness to be disclosed.

34 | P a g e
 I could, but this would be just treating the symptoms and not the
disease.
 If we do that, then whatever is causing the problem will simply get
worse and it’s very likely that you will develop other infections,
more serious than thrush, and these could make you very ill
indeed.

 no, that’s not true nowadays.

 It is right that in the early days of HIV there was no effective
treatment, but we now have combinations of drugs that can
prevent or slow progression of the disease, so it’s very worthwhile
finding out whether or not it’s the problem.

 I think we need to establish the diagnosis first, and then – if you

are HIV positive – you need to think about informing him.

 again this depends on whether or not you are HIV positive, but if
you are, then there are a number of issues: your partners may
already be infected, and my advice would be that they should see
someone appropriate to discuss this.
 Also, you will need to adopt the appropriate sexual precautions to
prevent infectivity because, as you may be aware, having
unprotected sex knowing that you could be HIV positive is a legal
issue

 you are right, it might be.

 But because, as you recognise, you are at risk of HIV, it makes
sense to check this possibility rather than get a lymph node
biopsy in the first place.

 yes, that’s possible.

 However, this sort of generalised gland swelling is more likely to
be a feature of the HIV reaction at an early phase.

 your lymphocyte count and blood picture is very suggestive of HIV

infection in a homosexual person.

35 | P a g e
 occasionally drugs will suppress your bone marrow, but with all
drugs it’s a matter of balancing benefits and risks.
 At present the HIV – if that’s what it is – is damaging your blood,
so it is important to control the infection to minimise this damage.

 you are right that this can cause difficulties, but I’m afraid that
the fact of the matter is that you’ve almost certainly got a serious
medical condition – HIV or lymphoma I think.
 Any substantial insurance that you take out will require you to
declare if you have any serious medical problems, so I don’t think
that the issue can really be avoided by simply not having the test.

36 | P a g e
 : you are the junior doctor on call at the weekend covering a general medical ward.

Mr Sutton is a 64-year-old man who has been admitted for investigation of anaemia, back
pain and weight loss.
He becomes confused and disruptive, is found to be hypercalcaemic (serum calcium 3.21
mmol/L, normal range 2.1–2.6) and the medical team have started appropriate treatment
for this (intravenous saline and intravenous bisphosphonate).
Mrs Sutton has come to visit her husband, is distressed about his deterioration and feels
that his medical team is missing something.
Her mother had myeloma and a back pain similar to her husband.
She tells the nurses that she wants to speak to a doctor, and they call you.
Before you see Mrs Sutton you review the notes and see that Mr Sutton has had a CXR
and barium meal, which are normal; that his haematinics are normal; that a spinal X-ray
showed a lytic lesion, but protein electrophoresis was normal.
Although you cannot find any record of a test for Bence Jones protein being performed,
you recall that 15% of myeloma cases are Bence Jones positive but without a serum
monoclonal band.
: to reassure Mrs Sutton that her husband is receiving appropriate
treatment.

• That you are sympathetic to Mrs Sutton’s worries.

• That investigations into Mr Sutton’s condition are proceeding, but a diagnosis is still not
clear.
• That hypercalcaemia is the probable cause of his confusion, and that treatment for this
has been started.
• That a definitive management plan cannot be made until the diagnosis is established.
• That you will make sure that Mr Sutton’s regular medical team knows about his wife’s
concerns.

• What are Mrs Sutton’s main concerns?

37 | P a g e
 the nurses told me that you’d like to talk about your husband, Mr
Sutton

 yes, I agree that he’s confused.

 That’s almost certainly because he has high calcium in his blood.
 He’s been put on treatment with the drip for that, but it often takes a
while before things improve.

 it is often difficult and unsafe to attempt to scan patients who are

acutely confused, and I don’t think that this is necessary at the
moment.
 I think we know the cause of your husband’s confusion – the high
level of calcium in the blood – and I expect that things will improve as
this comes down with the treatment.
 But if it doesn’t, then we can review the situation.

 we’re not sure at the moment.

 There are a number of conditions that can do this.
 Have the regular doctors on the ward had a chance to talk to you
about the possibilities?

 I don’t know for certain, but it is possible.

 I’ve looked in the notes and it’s true that the immunoglobulins in his
blood are normal, and they are usually abnormal when someone’s got
myeloma.
 But this isn’t always the case and I think we need to see the result of
a special urine test before we can say that we are certain.

 I don’t know, but I will discuss it with them.

 I can understand your concerns and frustrations.

38 | P a g e
 You need to speak to the consultant in charge of your husband’s case
and take these concerns up with them.
 I will let the nurse in charge of the ward know that you want to do
this and she should be able to tell you the best way of making
contact.

 I think that this is very unlikely, but discussions about difficult cases
occur all the time between teams of doctors and this is how problems
are solved.

 it’s far too early to be able to say anything like this.

 We need to be sure of the diagnosis before we can say what might, or
might not, happen in the future.

 I think that’s right.

 It’s certainly not a condition that we can guarantee to cure, but there
are treatments that can help substantially.
 Some patients with myeloma can have many years of good-quality
life, even if the disease does eventually come back.

39 | P a g e
 you are the medical junior doctor working over the weekend to cover a
gastroenterology ward.

Mr Alistair Bates, a 66-year-old man with well-known alcoholassociated cirrhosis, portal

hypertension and angina, is admitted with haematemesis.
He is not severely shocked, and after receiving 500 mL of plasma expander and 500 mL of
0.9% saline intravenously his pulse and BP are satisfactory, but because his haemoglobin
is 9.1 g/dL (normal range 12–16.5) a decision is made to give him a blood transfusion.
Within half an hour of commencing the transfusion he develops chest pain and becomes
profoundly hypotensive.
There is concern that he might be bleeding and that this might be precipitating ischaemic
cardiac pain, so his transfusion is speeded up and the haematology laboratory is phoned
to ask for more blood.
A urinary catheter is inserted and the urine passed is red.
By this time Mr Bates is unresponsive to pain and arrangements are made for his urgent
transfer to the intensive care unit (ICU).
The fact that Mr Bates had collapsed following transfusion and that he had haematuria
clearly suggests a transfusion reaction.
In discussion with the biomedical scientist in the haematology laboratory it rapidly
becomes apparent that a Mr Alan Bateman had also been admitted through the
Emergency Department at the same time as Mr Alistair Bates– your patient – and that
blood had also been cross-matched for this patient.
A repeat sampling from Mr Bates is immediately organised: this reveals that he is group O
Rhesus (D) positive with a strong Coombs’ test, which is at variance with his first sample
that was group A Rhesus (D) positive.
The blood for transfusion had been issued on the basis of the first sample.
The other patient with a similar name is also re-bled:
Mr Bateman’s first sample grouped O Rhesus (D) positive, but repeat testing reveals he is
group A Rhesus (D) positive.
Clearly there had been a transposition of samples during the admission of the two men in
the Emergency Department leading to a haemolytic transfusion reaction for Mr Alistair
Bates.
Group O blood (correct) is now issued for him as he is transferred to the ICU for further
management.
You discuss the case with the on-call gastroenterology SpR, who knows Mr Bates well.
He tells you that Mr Bates has had several admissions over the last6 months with
gastrointestinal bleeding (always from varices) and/or ascites, and that his prognosis from
the point of view of his liver is extremely poor.
He does not think that attempts should be made to resuscitate him in the event of cardiac
arrest.
you are asked by the senior nurse on the ward to talk to Mr Bates’s wife,
and explain what has happened and why he is to be transferred to the ITU.

40 | P a g e
 The wife’s understanding of her husband’s medical condition and prognosis.
 The blood transfusion error that has led to a serious transfusion reaction.
 The possibility of a fatal outcome.
 Does Mr Bates’s wife know her husband’s views about attempts to resuscitate him in
the event of cardiac arrest?
 And what are her views?

 Mr Bates has a very poor prognosis because of his liver disease.

 A transfusion reaction has occurred, with immediately life-threatening consequences.
 It is not clear who is to blame for the transfusion error at this point, but the issue
will not be ignored.
 That an attempt to resuscitate Mr Bates in the event of him having a cardiac arrest is
extremely unlikely to be successful.

 he has had a serious bleed from his stomach, and I’m afraid that he
has reacted to the blood transfusion.
 His blood pressure is very low, which is why his brain is not working
properly at the moment.

 I’m afraid that there seems to have been a mix-up with the blood
samples and the blood he received has resulted in him becoming
seriously ill with a transfusion reaction.

 the sort of reaction that he’s got happens when the body recognises
that the transfused blood is the wrong sort.
 It destroys the transfused cells, which release substances that can
damage the body.

 I’m not hiding anything when I say that I’m not exactly sure how this
mistake has happened, but there seems to have been a mix-up
between two patients’ blood samples.
 We are investigating this, and when we have found out what
happened we will let you know.
 We will not sweep things under the carpet.
 The consultant in charge will speak to you but he is not here at the
moment.

41 | P a g e
 However, I think the ICU staff may be able to help with your concerns
until the consultant in charge can speak to you.

 I am sure that the consultant in charge will speak to you, but she is
not here at the moment.
 The most important thing to do now is to get Mr Bates to the ICU, but
before we finish I will take your contact details and pass them on to
the consultant.

 I’m afraid that he might.

 His liver disease is very bad indeed and, as I’ve said, the transfusion
reaction is a very serious thing in itself.
 Have any of the gastroenterologists, the doctors who look after him
regularly, had a chance to talk to you about his liver?

 yes, that’s right.

 As you know he’s been in and out of hospital several times recently,
sometimes with bleeding and sometimes with swelling due to fluid in
the abdomen.
 All of which means that the liver is in very bad shape.
 So, if we put the transfusion problem to one side for the moment,
even without this I’m sorry to say that his outlook isn’t good at all.
 I spoke to one of the team of doctors that know him a few minutes
ago, and he said he thought he was unlikely to live for more than a
few months.

 we are trying to get his blood pressure up, but if we are unsuccessful
then I’m afraid that his heart could stop.
 Did your husband ever talk with you about what he would want done
in this situation?

 that’s a difficult question.

 If there’s a problem that can be made better, then it’s clearly right to
try and do everything that you can to keep someone alive – to give
them the ‘kiss of life’ and that sort of thing.
 But when there are problems that cannot be improved – like your
husband’s liver – then it’s very unlikely indeed that things like that
would work; and I think, and the doctor from the team that knows
him also thinks, that we should make sure that he’s comfortable.

42 | P a g e
 you are a junior doctor working on a haematology ward.

A 24-year-old shop assistant presents with a 6-week history of increasing tiredness.

She has also had several episodes of cystitis and more recently has noticed that she has
started to bruise more easily.
Her FBC is as follows: haemoglobin 7.8 g/dL (normal range 12–16.5), white blood cell
count 5.1 × 109/L (normal range 4–11), neutrophils 0.2 × 109/L (normal range 2–7) and
platelets 18 ×109/L (normal range 150–400).
Bone-marrow aspirate confirms the diagnosis of acute myeloid leukaemia and cytogenetic
analysis reveals a normal female karyotype in all metaphases examined.
The case is discussed at the multidisciplinary team meeting and it is agreed that with
current combination chemotherapy (which should last about 6 months) the patient has
an approximately 90% chance of going into remission, with a 5% risk of death during
treatment, a 5% risk of refractory disease, a 50% chance of relapse in the next 5 years
and a 40% survival at 5 years.
In the case of refractory or relapsed disease, two out of three patients respond to
alternative treatment and 5-year survival is about 30%.
Failure to respond to treatment in instances of relapsed or refractory disease implies
incurable leukaemia.
Without treatment this woman would die in a matter of weeks.

you must explain the diagnosis, treatment options and prognosis to this woman and her
husband.

 Find out what the patient believes is going on.

 Describe the outcome of the disease if it is not treated.
 Describe the treatment options(including the option of no treatment) and the
prognosis for each of the treatment approaches– in this case her condition is
potentially curable.
 Be honest about the side effects and risks of treatment, but emphasise that there is
a whole system in place to provide her with 24-hour support both when in hospital
and when at home.

 The diagnosis is not in doubt: the patient has leukaemia, which is a cancer of the
blood.
 You must use the word ‘cancer’: it is the only word that you are sure everyone
understands in the same way.
 Do not use words like ‘tumour’, ‘growth’, ‘neoplasm’ and ‘lesion’ when talking about
cancerous diseases because these can be ambiguous and confusing.
 That you and your colleagues will do everything possible to cure the leukaemia,
although a cure cannot be guaranteed.
Also that you will support the patient and her family throughout the process of
treatment and recovery.

43 | P a g e
 That if there is no curative option, every effort will be made to control the disease for
as long as possible and that any symptoms the illness might cause will be dealt with
actively.
 Reinforce that there are extremely effective treatments for the control of all symptoms
and that you are determined that at no point during the illness should your patient
suffer.
 That you will always tell the patient the truth, whether it is good news or bad.
 Encourage the patient to ask questions and reaffirm your intention to be open and
honest with your answers.
 It is uncommon today for relatives to ask for the patient to be kept ignorant of the
facts of the illness.
 If the patient is to give informed consent to further treatment, then she has to be
fully aware of the diagnosis.
 Chemotherapy is potentially lethal, and informed consent must be obtained.
 Gentle persuasion and logical reasoning help most relatives see that this is correct.
Occasionally, where it is clear that the patient is going to die rapidly, it may be more
appropriate to keep them comfortable and spare them the details.
 However, if the patient demands information you must be honest with them: relatives
have no legal right to withhold information in the UK.

44 | P a g e
 yes, leukaemia is a form of cancer.
 It is cancer of the blood.

 no, I’m afraid that it couldn’t.

 I’d like to tell you something different, but I wouldn’t be being
honest if I did.
 You’ve got leukaemia.

 this form of leukaemia is curable in some people but not in

others.
 We can make the leukaemia go away in nine out of ten people
like you with our current treatments– we call that remission –
and after treatment the disease never comes back in about
half of these patients.
 However, in others it does, which we call relapse.
 In a few people the leukaemia doesn’t respond well to
treatment at all, but we will do everything we can to make
your leukaemia go away and stay away.

 it involves having injections of drugs and taking tablets,

which we call chemotherapy.

 you’re right that there can be side effects such as sickness.

 We will explain to you what these might be, and also tell you
about the treatments that can prevent them or make them
less severe.
 We won’t give you any treatments without explaining to you
what they’re supposed to do, and what effects they might
have on you.

 remember that most people like you do respond to treatment.

 However, if the first course of treatment doesn’t work, we
would have to change tack and use a different combination of
drugs to try to make the leukaemia go away.
 Many people who do not respond to the first set of drugs do
respond to this different combination.
 That said, if you didn’t respond to the second course of
treatment then I think we’d have to accept that no drugs
available would be able to cure your leukaemia, and our
emphasis would switch to dealing with the symptoms that it
caused.

45 | P a g e
 unlike many other cancers, if people like you relapse with
leukaemia there are still treatments available that can cure
the disease.
 It is harder to cure the disease second time around, but it is
still possible.
 We could talk more about treatment options at that stage if it
were to happen.

 many women treated with this type of chemotherapy do go on

to have children.
 Fertility may be reduced after chemotherapy, and if you did
have problems in getting pregnant in the future then there are
a number of investigations we would want to do at that stage
to see if we could identify and treat the cause.
 While you are on chemotherapy you must not get pregnant,
as the chemotherapy would harm the developing child.
 Also, you must not assume the chemotherapy will stop you
getting pregnant, so you must use contraception such as
condoms.
 If you think you might be pregnant at any stage during
treatment, then you should let us know immediately.
 Most doctors recommend waiting 2 years after finishing
treatment before trying to get pregnant.
 But after you have recovered from chemotherapy and it has
left your system, then we don’t think there is an increased
risk of cancer or of an abnormality in children whose parents
have previously received treatment for cancer.

 no, we don’t have to make a decision this minute.

 But we can’t wait too long, because without treatment the
disease will get worse and I’m sorry to say that it will probably
kill you within a few weeks.
 I’d suggest that you think things over, and I’ll come back later
on today or tomorrow morning to discuss your decision.
 I’ll also ask one of the specialist nurses to come and talk to
you: they’ll be able to give you more information about how
the treatments are given and the support that is available for
you and your family.

46 | P a g e
 you are a junior doctor on the cardiac arrest team.
A 75-year-old man, Mr Tony Foster, has suffered a cardiac arrest on the ward.
He was admitted 3 days previously with an inferior myocardial infarction.
Unfortunately resuscitation attempts have been futile.

the nurses have asked you to speak to Mr Foster’s wife and explain that her husband has
died.

 It is vital to find out what the wife knows already: she may have just arrived
spontaneously without any warning of what has been going on; alternatively the
nursing staff may have phoned to explain that her husband is very poorly and that
she should come to the hospital immediately.

 Get the setting right:

o ideally you need a quiet room adjacent to the ward where you are not going to
be interrupted.
o Ensure that you have left your bleep (and mobile phone) with a colleague.
o Take one of the senior ward nurses as support (both for the family and
yourself).
o The room should ideally have a supply of tissues and a telephone.
 Introductions:
o ensure you have introduced yourself and what you do; also introduce any
nursing or other hospital staff who are with you.
o Ensure you have the correct family and know precisely who you are speaking
to: many of us have had the misfortune to break news to a daughter thinking it
was the patient’s wife, or vice versa.
o Be explicit about what has happened: that the patient’s heart stopped
suddenly; that the cardiac arrest team was called; that attempts were made to
resuscitate the patient; but that these were unsuccessful and that
unfortunately Mr Foster has died.
 It is important to listen:
o give his wife time to understand and to ask questions.

 as a result of the heart attack, your husband’s heart had become

weaker.
 Just after a heart attack the heart is irritable and the normal pattern
of the heartbeat can be disrupted, which can lead it to stop pumping
blood properly to the brain and other organs.

 as soon as the team on the ward recognised that his heart had
stopped, they called the cardiac arrest team.
 He was given oxygen and heart massage – pressing up and down on

47 | P a g e
 the chest to keep the blood moving in the body – and he was
defibrillated which is a special electric shock to try to get the heart
beating steadily again.
 He was also given various drugs to try to help, but I’m afraid that
these didn’t work.
 The damage to his heart was obviously too great.

 no: patients become unconscious very quickly as soon as this

happens.
 During the resuscitation attempts he showed no signs of life and will
not have felt any pain.

 yes, I know, but in real life the heartbeat only returns in about 30% of
people who have a cardiac arrest in hospital, and only around half of
those survive to reach hospital discharge.
 I agree that things go well on the television more often, but
unfortunately the figures are much lower in real life.

Further comments Which deaths require reporting to the coroner (procurator fiscal
in Scotland)?
1. Cause of death is unknown.
2. Deceased was not seen by the certifying doctor either after death or within the 14
days before death.
3. Death was violent, unnatural or suspicious.
4. Death may be due to an accident(whenever that occurred).
5. Death may be due to self-neglect or neglect by others.
6. Death may be due to an industrial disease or related to the person’s employment.
7. Death may be due to an abortion.
8. Death occurred during an operation or before recovery from the effects of
anaesthetic.
9. Suicide.
10. Death occurred during or shortly after detention in police or prison custody.
Who should be notified following a cardiac arrest?
• The coroner may be required to be notified (see above).
• The patient’s GP.
• The consultant responsible for the management of the patient should be notified as soon
as possible.
Who fills in the death certificate?
• Part 1 should be completed by one of the medical team caring for the patient. It should
include the date of death and details as to the presumed cause. It has sections detailing
whether information is available (or may become available later) from a postmortem
and whether the coroner has been informed.
• Part 2 is completed by a medical practitioner with at least 5 years of experience.

Following the Shipman enquiry, the person completing part 2 will contact not only the
person completing part 1 but also one of the nursing staff or another medical practitioner
involved in the case to ensure there were no suspicious circumstances.

48 | P a g e
 you are a junior medical doctor on-call for the wards.

An 80-year-old man, Mr Anand Patel, has been admitted to hospital with a dense left
hemispheric stroke resulting in aphasia and a right hemiparesis.
He has a background history of prostatic carcinoma, left ventricular failure, atrial
fibrillation and chronic obstructive pulmonary disease.
His Glasgow Coma Scale score has fallen to 7 (E2, M4, V1), which is presumed to be due
to an extension of his stroke.
The consultant has reviewed the patient and feels that intensive care unit (ICU) care is
inappropriate and that the patient should not be resuscitated in the event of
cardiopulmonary arrest.
you are asked to explain to the family what has happened and why it would
be inappropriate to attempt resuscitation in the event of cardiopulmonary arrest.

 What preparations should you make before speaking to the family?

 Obtain as much information as possible about the patient’s comorbidities and
functional level before his stroke: in PACES scrutinise the scenario very carefully for
details; in routine clinical practice look through the notes and speak to any staff
present who may be able to give you useful information.
 This is essential, not only to inform appropriate decision-making, but also in
discussing the issue with the family.
 They are much more likely to accept advice from a doctor who clearly knows the
patient, Mr Patel, rather than one who seems to regard him as ‘just another old man
who’s had a big stroke’.
 The scenario states that ICU care is not appropriate, but if that is so then what care
is to be given?
 If the patient were to develop a chest infection, are you are going to try a course of
antibiotics or is only comfort care indicated?
 These issues may be spelled out in a PACES scenario, but in routine clinical practice
it is very important to establish and agree amongst the medical and nursing team
exactly what treatments will and will not be given before embarking on discussions
with a patient’s relatives.
 What do the family know already and what are their expectations?
 They may have expected Mr Patel to make a full recovery with supportive care.

 Get the setting right: ideally you need a quiet room adjacent to the ward where you
are not going to be interrupted. Ensure that you have left your bleep (and mobile
phone) with a colleague.
 Take one of the senior ward nurses as support (both for the family and yourself). The
room should ideally have a supply of tissues and a telephone.
 Introductions: ensure you have introduced yourself and what you do; introduce any
nursing or other hospital staff who are with you.
 Ensure you have the correct family and know precisely who you are speaking to.

49 | P a g e
 Be explicit about what has happened: the patient has had a severe stroke that has
resulted in paralysis and loss of speech, and despite supportive measures his
condition has deteriorated and he is now semi-conscious.
 Be explicit about your management plan: you are going to ensure that he is
comfortable, with enough analgesia (if required) and fluids to ensure that he will not
be distressed. The priority is to maintain his comfort and dignity.
 Be explicit about the limits of care that will be given: that increasing the level of care
is felt
 to be futile, and that ventilation or cardiopulmonary resuscitation would not alter the
outcome(families are often very relieved that their loved one will not be put through
distressing ‘treatments’ for no effect).
 Listen: give the family time to understand and to ask questions.

 as a result of the stroke, he has very severe weakness of the right side
of his body and he has lost his speech.
 After a stroke as big as this the brain sometimes becomes progressively
more
 swollen, which makes things worse, and the patient becomes more
deeply unconscious

 I’m sorry to have to say this, but I don’t think he is.

 He’s had a very big stroke and things seem to be getting worse.
 I’d be delighted to be wrong, but I don’t think he’s going to recover.
 I’m afraid that I think he’s going to die.

 no, I don’t think he is.

 I think he is too deeply unconscious to be aware of what’s happening
or to be in any pain.
 Our priority is to make sure that he is comfortable, and if we thought
he was in pain or was distressed, we would give him painkillers to
prevent him from being in any pain or discomfort.

 the most important thing is that we make sure that he’s not in any
pain or distress.
 You are right that sometimes doing cardiac massage – CPR – and
putting people onto breathing machines can be helpful.
 However, doing this is only kind and sensible if you have a condition
that you can reverse with treatment and in this case I’m afraid that the
effects of the stroke are not going to be reversible.
 Ventilation and CPR would not have any effect on his underlying
condition.
 We will ensure that he is comfortable and not in any pain.

50 | P a g e
 you are a junior doctor working as evening cover on a general medical ward.
Mr Harold Wilson is 89 years old.
He had a stroke 5 years ago and is a diabetic on insulin.
He lives at home with his son, but has been house-bound since his stroke.
He was admitted 5 days ago with congestive cardiac failure.
Medical therapy has been instituted, including oxygen, diuretics, fluids and vasodilators.
There has been no response to treatment.
He has become increasingly short of breath
and is hypoxic despite oxygen.
He has not passed urine for4 hours.
His Glasgow Coma Scale score is currently 8.
He was reviewed by the consultant on the ward round who decided that he should be
managed conservatively and not resuscitated in the event of cardiac arrest.
His son was involved in the decision.
It is now 9 p.m. and Mr Wilson’s daughter has arrived: she feels that her father should be
on the intensive care unit (ICU).

to explain to the daughter that transferring her father to the ICU would not be
appropriate.

 What does the daughter believe is likely to happen to her father?

 Why does she want him transferred to the ICU?

 What does she know about her father’s condition and his previous state of health?
She does not live with him and may not be aware of these things.
 Explain what treatment has been given: he has been treated actively but has
deteriorated despite this.
 Be explicit about the prognosis: her father is dying and there is no treatment that will
prevent this. Futile treatments (such as resuscitation or transfer to ICU) will not be
given.
 Explain the management plan: her father will be given treatments to alleviate his
symptoms and to ensure that he is comfortable and dignified (some people may be
worried that a ‘Do not resuscitate’ order means that no treatment will be given).

51 | P a g e
 I’m sorry to have to tell you that your father is dying.
 He has been given treatment for his heart with oxygen, diuretics –
drugs to get fluid out of the body – and other drugs to help the heart
beat more strongly, but despite all of these the situation is
deteriorating.
 Your father’s heart, lungs, kidneys and brain are all failing.
 There is no treatment that will reverse this, on the ICU or anywhere
else; nothing that will alter the final outcome.

 we can try to make his breathing easier for him, we can make sure
that he is comfortable and dignified, and we will ensure that he is not
in any pain.

 no, that’s not true.

 We have spoken about things with your brother, and he does agree
with our plan for treatment.
 But decisions about treatment are made us, by the medical team, and
not by your brother or anyone else.
 We have made what we think is the right plan.

 yes, I can arrange that.

 The consultant saw your father earlier today on the ward round.
 She is aware of your father’s condition, and the plan that I have
outlined to you is the one that she made.
 However, she is not in the hospital at the moment.
 If you would like to speak to someone right away, then I can find out
if the on-call registrar is available to answer any questions you may
have that I cannot answer, or if one of the doctors on the ICU could
speak to you, but I’m sure that they will tell you what I’ve already said.
I’m very sorry.
 I’d like to be able to say something different, but your father is dying
and we must make sure he’s comfortable.

52 | P a g e
 you are a junior doctor on the medical assessment unit.
You have taken a history and examined a 40-year-old man Mr Chris Pitman, who called
999 with severe lumbar back pain.
He is usually fit and well but has a 2-day history of pain
radiating down his left leg.,
There are no red flags in the history or on examination. Examination confirms a diagnosis
of mechanical back pain. You have prescribed appropriate analgesia. On review, his pain
has settled and you want to discharge him to the care of his GP. He is insistent that he
needs X-rays prior to discharge.
to explain to the patient that no further investigation is needed at this
stage and that he can be discharged back to his GPfor follow-up with referral to
physiotherapy if required.

 What is the patient’s main worry?

 Why does he want further investigation?

 The history and examination have given reassuring results: the pain is not sinister;
he does not have cancer of the spine (or any similar problem).
 Further tests are not indicated at this stage.
 There are simple strategies for coping with the pain.
 What to do if the pain fails to settle.

53 | P a g e
 no, I’m afraid that unfortunately I can’t guarantee that.
 The prognosis for mechanical back pain is good, with 90% of sufferers
recovering by 6 weeks, but recurrence is common

 I’m afraid that an X-ray will not be helpful here.

 As I’ve said, I don’t think that there is a sinister problem: I don’t think
that you have cancer of the spine or anything like that.
 But even if you did, then it’s extremely unlikely that a simple X-ray
would show anything.
 You’d need other special scans.

 no, I don’t think so.

 The chances of them showing anything would be extremely small and
they are not without risks: some of these scans would expose you to
radiation.
 However, if the pain continues beyond 6 weeks then the matter
should be reconsidered.
 It is important that you arrange to see your GP when you get home,
so that he or she can review your symptoms and see if anything
further needs to be done at that time

 yes, there is.

 I can give you some strong painkillers, some antiinflammatories and
some tablets to help muscle spasm.
 All of these can help and it is advisable for you to stay as active as
possible.
 Even simple exercises can help.
 Your family doctor could organise a referral to a physiotherapist if
things don’t settle down quickly

54 | P a g e
 you are a junior doctor working on a general medical ward.

You have admitted a 19-year-old female student following a severe anaphylactic reaction
to peanuts
Following emergency treatment she is well.
She has no significant past medical history and lives in a university flat with two fellow
students, one female and one male.

to explain to the patient the diagnosis of nut allergy as the cause of her
anaphylaxis, and avoidance measures and the use of self injectable
adrenaline/epinephrine (eg EpiPen).
There is no specialist allergy service in your hospital, but one of the pharmacists would
be able to show the patient how to use EpiPen and you would be able to make an
outpatient referral to the regional allergy service.

 It will obviously be appropriate to ask the patient if she has any particular concerns
and to address these, but the most important issue that must be tackled is to find
out what she understands about her anaphylactic reaction.
 Understanding is important if she is to feel confident about minimising future risk.
 Lifestyle issues will be important.
 She will need to know how to minimise the risk of ingesting ‘hidden’ sources of
peanut if eating out.
 She will need to read food labels if buying preprepared food.
 Does she have a partner, flatmates or family? They could be important allies in
avoiding peanuts and may be able to assist in an emergency, if given the appropriate
information.

 After an appropriate introduction, let the patient know that the purpose of your
interview is to discuss what happened so that the chance of it happening in future is
minimised.
 Say that you will also discuss simple but effective treatment that she can give herself
in case of emergency.
 You must try to give her confidence in her ability to manage the situation.
Explain how to avoid future reactions
 Emphasise that she should continue to live a normal life, but that she must take
appropriate precautions.
 Discuss potentially difficult or risky situations: parties, restaurants and choosing
peanut-free food when shopping.
 Allow her time to express her concerns.

Discuss self-management of anaphylaxis

55 | P a g e
 Discuss the need to carry two self-injectable epinephrine devices at all times, the
recognition of anaphylaxis and measures which should be taken if it happens again.
 Be aware that she may be afraid of using injectable epinephrine and encourage her
to discuss this.
 Encourage her to discuss her peanut allergy with her friends, who may be trained in
the use of the epinephrine if appropriate, but you should ensure that she gains the
confidence to self-inject in an emergency: her friends will not always be with her.

 that’s a good question, and I’m afraid that I don’t have a good answer.
 All I can say is that this often happens: for some reason we don’t
know, people can become allergic to peanuts, and to other things,
and their body starts to react in this dangerous way if they are
exposed to them.

 that’s another good question and at the moment I can’t be sure.

 Sometimes people who react to peanuts also react to other nuts, so
my advice for now is that it’s very important that you avoid all nuts.
 But I will, with your agreement, refer you to the regional allergy
service as an outpatient.
 They will do various tests to find out whether it’s just peanuts that
you’re allergic to, or other nuts as well.

 it’s natural to feel that way at first, but you can overcome your fear.
 You will feel safer knowing that you know what to do in an
emergency.
 One of the pharmacists in the hospital can show you how to use a
device that does all the work for you: you don’t actually see the needle
and you can practice using a ‘trainer’ pen, which doesn’t actually
inject you.
 We could also show your flatmates how to use it too, if you wanted
that and they were willing to learn.

 the epinephrine is only for severe reactions like the one you had
today.
 If you think you may be having an allergic reaction, you should take
epinephrine if you feel any throat tightness, wheezing or faintness.

 I can understand why you are worried about that, but you can
minimise the chances by taking simple measures.
 Most restaurants are aware of the difficulties faced by people with

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 allergies: some have allergy information on the menus.
 However, you should always ask the waiter to specifically check with
the cook in the kitchen if what you’re thinking of ordering contains
any nuts at all.

 there is no need to cancel your holiday, but be cautious about

unfamiliar foods that may contain nuts and always check in
restaurants, as I’ve said before.
 Make sure that you carry your epinephrine with you and, to avoid
difficulties on the plane and at customs, it would be wise to carry a
doctor’s letter explaining what it is and why you need it.
 I can write one of these for you.

 in any situation where you need to use the epinephrine, an

ambulance should also be called.
 The aim of the epinephrine is to give time for the ambulance to get to
you.
 The epinephrine will work, but if the effect is insufficient or if your
symptoms start to come back, you should use your second
epinephrine syringe.
 By that time medical help is likely to be there.

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 you are a junior doctor working on a medical ward.

Miss Fiona Davies is the daughter of one of your patients.

She is concerned about the current condition of her father, Mr Harry Davies, a 72-year-old
man with a history of hypertension and mild short-term memory problems who was
admitted 2 weeks ago with a stroke that has left him with a marked left-sided weakness
and poor swallowing.
Over the past week there have been no signs of improvement in his swallowing when
assessed by the speech and language therapists.
Plans for his long-term care are in progress and early indications are that he will require
full care in a nursing home setting.
He has been receiving nutrition via a nasogastric tube, but this has been intermittent as he
has not tolerated it well and the tube has become dislodged on several occasions.
Plans for his feeding have been discussed and the multidisciplinary team have considered
that a percutaneous endoscopic gastrostomy (PEG) would be appropriate.
The medical team think that Mr Davies is able to consent to the procedure.
Miss Davies has come to the ward by appointment to discuss long-term feeding issues.

to explain to Miss Davies what options there are for feeding her father and the
recommendation that he has a PEG.
Key issues to explore
 Begin by establishing what the daughter’s main concerns are.
 Things that she might want to discuss include different options for maintaining
hydration and feeding, her father’s capacity to understand and consent to an
intervention such as a PEG, and long-term plans for care in the event of his
condition deteriorating.
Key points to establish
 That you will listen to any of the daughter’s concerns, but that providing artificial
hydration and nutrition is a medical intervention and the decision about whether to
do so is a medical one, informed by the multidisciplinary team.

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 That the view of the medical team is that her father has the capacity to make a
decision about his feeding.
 That any decision made will be reviewed if there is any change in her father’s
condition.

 this is something that we have considered.

 We always prefer a patient to drink and eat normally if they can, but
I’m afraid that the stroke has damaged the nerves that control his
swallowing.
 This means that when he tries to eat or drink he coughs and splutters,
and some of the food or drink goes down the wrong way and is in
danger of landing up in the lungs.
 If this happens he will get pneumonia, from which he’d be unlikely to
recover.

 I understand what you’re saying.

 A PEG tube does sound rather alarming, but it sounds worse than it
is.
 We’ve already tried feeding him with a tube through the nose into the
stomach – a nasogastric tube – and he found that very irritating and
kept dislodging it: many people do.
 A PEG tube obviously doesn’t go through the nose, but straight
through the abdominal wall and into the stomach, so patients find it
much less irritating.

 I agree that it can be difficult to know exactly what a patient

understands sometimes.
 However, we have talked to your father about the reasons for
recommending that he has a PEG on several occasions, and we think
that he understands the issues: he knows that he needs to have food
and drink, he knows that he can’t eat and drink normally, and he
know that the tube through the nose is uncomfortable and keeps
falling out.
 We’ve explained to him how a PEG tube is put in, and the problems
that can sometimes arise.

 a PEG is inserted in the endoscopy department using a special

telescope that is passed through the mouth into the stomach.
 The patient is given a sedative injection if they need one, and local

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 anaesthetic is used in the throat and stomach wall.
 When the telescope is in the stomach its light can be seen through the
skin.
 A small needle and guidewire are then put through the skin into the
stomach from the
 outside, which the telescope can catch and which is then used to pull
the PEG tube into position .

 I don’t know, but it’s possible that he will.

 Some patients with swallowing difficulties caused by a stroke can
improve as time goes on.
 Sometimes they improve to the point of not needing the PEG any
more, in which case it can be removed very simply by pulling it out.

 in most cases the business of putting in a PEG is very straightforward,

but you are right in thinking that this isn’t always the case.
 The risks are related to having the telescope inserted into the stomach
and to the procedure itself: in a very few cases it isn’t possible to put
in a PEG; some patients experience bleeding from the stomach
afterwards, but this is usually very minor and settles on its own; and
sometimes the PEG tube falls out of the stomach into the stomach
cavity which can cause irritation.
 But 18 or 19 out of 20 people have a PEG put in without any
problems.

 yes, we try to do all the feeding overnight so that the day is freed up
for other things such as physiotherapy.

 not when it is not being used.

 When your father is not attached to the feeding bag and tube, the PEG
tube lies close to the skin and is not usually visible under clothes.

 if we cannot give him adequate nourishment and hydration, he will

deteriorate and would find activities such as physiotherapy more
difficult.
 We think that other methods of trying to give him food and drink will
be less effective and have more problems than a PEG.

Any form of artificial feeding is a therapeutic intervention and informed consent from the patient or
carers with legal authority must be sought.

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The question of artificial nutrition in a patient in a persistent vegetative state was
considered by the High Court in 1993, and four principles were established:

 the best interests of the patient is to be the guiding principle;

 artificial nutrition is considered a medical intervention;
 withholding and withdrawing artificial nutrition are equivalent acts;
 it is not unlawful to withhold or withdraw artificial nutrition.

Anorexia nervosa is considered a psychiatric condition and a patient may be detained and
treated (eg artificially fed) under the terms of the Mental Health Act.

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 you are a junior doctor working on a medical admissions unit.

You have admitted a 20-year-old female university student who presents with a 12-hour
history of fever, chills and generalised aches and pains.
On arrival she is extremely ill: confused, breathless, tachycardic and hypotensive (80/50
mmHg).
You suspect that she has toxic shock syndrome or septicaemia.
Initial resuscitation is underway and arrangements are being made for her transfer to the
intensive care unit.
The patient’s mother has been phoned by the warden from the university hall of residence
where her daughter lives.
She has driven from her home town 80 miles away in a state of distress and has arrived
on the medical admissions unit.
to explain the situation to the patient’s mother.

 The daughter is clearly very unwell with a life-threatening illness.

 The mother will undoubtedly want an explanation of the possible causes of the
illness and your proposed investigation and management plan, but it will be
important to find out if she has other concerns, eg about the possibility of spread of
infection.

• Likely diagnosis is toxic shock syndrome/septic shock.

• A clear plan for investigation and management is in place.
• Prognosis must be guarded as she is likely to develop multisystem disease.
• Risk to others is very unlikely unless she has meningococcal septicaemia, where
prophylaxis would be offered to close personal contacts.

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 at the moment we don’t know why this has happened.
 It looks as though it is the result of an extremely serious infection and
we are organising tests to try and find out the cause of the problem.
 However, we have already started treatment because she is too ill for
us to wait for all the results to come back.

 from what we know, she was perfectly well until about12 hours ago.
 This is a condition that can occur without warning in a previously
healthy person, and can develop extremely rapidly.

 I’m not hiding anything when I say that I don’t know.

 I’m afraid that your daughter is seriously ill, and there is a chance that
she may die from her illness.
 We are treating the infection with antibiotics and helping to support
her vital organs – giving fluids into the veins and giving oxygen; if she
needs help with breathing we will put her on a breathing machine, a
ventilator, and if the kidneys need help we will use a kidney machine,
a haemofilter.
 We will know more when we see how she responds to treatment over
the next few hours.

 yes, I’m afraid that’s still possible.

 Many of the serious complications of this condition are due to the
effects of bacterial toxins on vital organs, and killing bacteria will not
destroy all the toxins immediately.
 Much of the tissue damage has already occurred and cannot be
prevented by antibiotics at this stage.

 no, unless the tests show that she has one special form of infection,
with a bug called a meningococcus, the risk to others is extremely
small and antibiotics are not necessary for anyone else.

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 you are a junior doctor working on a general medical ward.

A 54-year-old patient of Indian origin is under your care.

He has been admitted with cellulitis around a penetrating diabetic foot ulcer on his right
heel.
Deep wound swabs have grown meticillin-resistant Staphylococcus aureus (MRSA).
He is currently being kept in a side room; staff are wearing aprons and gloves when they
see him; he is being treated with intravenous vancomycin; and he is awaiting further
investigation to rule out underlying osteomyelitis.
If he does have osteomyelitis, it is likely he will require a belowknee amputation.
The patient asks you to speak to his wife, who speaks reasonable English.

to explain the diagnosis of MRSA and its implications to the patient’s wife.

As always you will start off by finding out what the patient’s wife knows already, in
particular:
• how much she knows about the problem with her husband’s foot and the possible
consequences of the ulcer;
• her understanding of MRSA.

• The diagnosis is known and the patient is on the correct treatment.

• Further investigations to exclude complications are pending.
• The possible best- and worse-case outcomes (such as the possible need for amputation).
• The nature and implications of MRSA infection.

 I’m afraid that I don’t know.

 Your husband has a serious infection in his foot, which we must
treat properly.
 If we don’t, it could get very bad indeed.
 The infection could spread throughout his body.

 I hear what you say.

 If it’s at all possible we will try to make sure that he’s able to go,
even if only for a few hours or half a day.
 But I’m not hiding anything when I say that I can’t promise: if he’s
not well enough, then it would be very unwise for him to go.

 it’s the name of the bacteria, the bug, that’s in his wound.
 It’s a common sort of bug – Staphylococcus aureus, that’s what the

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 SA stands for– to cause wound infections, but I’m afraid that the one
he’s got is resistant to some of the standard antibiotics: the M
stands for meticillin, that’s one of the antibiotics, and the R stands
for resistant.
 This is why we have to keep him in the side room and wear aprons
and gloves when we see him – to try and stop it being spread to
other patients.

 I cannot say for sure.

 It’s likely that he became colonised with the bug, the MRSA, during
a previous hospital visit, but there are strains of MRSA in the
community as well.
 People can carry the staphylococcal bacteria, including MRSA, on
their skin or in their throat or nose without having any symptoms.
 The infection is only serious if it invades the body tissues or
complicates surgery.

 I don’t know.
 It is possible that other members of the family are also carrying
MRSA, but it is unlikely to be a problem for them unless they have
open wounds that become infected.
 If anyone at home has a possible infection that is worrying them,
then they should arrange to see their GP.

 I’m not sure.

 If the infection is only in the skin and soft tissues, then they should
be able to.
 But if the bone is infected, and we’re organising X-rays and scans to
check for this, then I’m afraid that they might not.

 at the moment, we’re hoping that the antibiotics will deal with
things.
 But if it doesn’t look as though they’re going to, then we would plan
to discuss the situation with our surgical colleagues.
 Sometimes it is necessary to operate to remove dead tissue and
sometimes it is even necessary to amputate the foot.
 I’m not saying that we will definitely need to do so in your
husband’s case – as I said, we’re hoping the antibiotics will cure the
problem – but sometimes amputation is the only way to get rid of the
infection.

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 you are a junior doctor working on a general medical ward.

A 49 year-old male teacher has been admitted for investigation of a 6-week history of
malaise and fever.
He has been in hospital for 4 days and a diagnosis has not been made.
A wide range of tests have been normal or negative, including a urine dipstick, FBC,
electrolytes, renal and bone function tests, serum immunoglobulins, autoimmune/
vasculitic screen and CXR.
Cultures of urine and blood have produced no growth after 2 days, but longer cultures are
awaited.
Liver blood tests show slight elevation of alanine aminotransferase; inflammatory markers
show markedly elevated C-reactive protein.
The results of other tests, eg viral serology, are awaited.
Other tests, eg echocardiogram and CT scans of the chest/abdomen/pelvis, are planned.
The patient is not acutely very ill, but he is frustrated and angry about the lack of
progress and has been shouting at the nurses.
He wants to be started on treatment.
The nurse in charge of the ward asks you to speak to him.
to explain the situation to the patient; in particular that it is necessary to
establish a diagnosis before treatment can be given.

 The patient will almost certainly be concerned about the fact that he is unwell and
the doctors have not been able to work out why.
 But does he have any other concerns?
 Is he worried about anything in particular?
 It is unlikely that the patient’s frustration and anger will be relieved unless such
issues are explored and dealt with.

 The complexity of differential diagnosis.

 Reassurance that the investigations are progressing in a logical fashion.
 Reassurance that as soon as definitive results are known they will be discussed with
the patient and specific therapy commenced.
 That problems can be incurred by premature treatment, specifically the difficulty of
further investigation should there be a failure to respond to initial treatment.
 Explanation that empiric therapy would be instituted should patient deteriorate.

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 I’m sorry it’s taking a long time.
 I can understand why you’re frustrated, but it’s not obvious what the
problem is.
 You’ve had a range of tests – blood tests, urine tests and an X-ray of
the chest – and they haven’t given us the answer.
 There’s clearly something going on.
 One of the tests shows there’s a high level of inflammation in the
blood and another that the liver isn’t working completely normally,
but we don’t yet know what the cause of the problem is.

 yes, the fever will make you feel unwell.

 We can give you a fan and medication to help that: paracetamol is
very good.
 But the fever is not dangerous in itself: it is a sign that there’s
something going on in your body that we need to get to the bottom of.

 because we don’t know what’s wrong.

 There are a number of possible diagnoses that all require different
treatments, and it is possible that we could make things worse if we
gave a ‘best guess’ treatment that was actually wrong.
 This might mask further progression of your illness or interfere with
further investigation, making it more difficult or impossible to get the
right diagnosis in the end.

 yes, if that was the case we would make the best guess that we could
and start you on treatment straight away.
 But as I said, this would have the risk of making it more difficult to
get the right diagnosis and it wouldn’t be the right thing to do at the
moment.

 I’m not hiding anything when I say I don’t know, but it is possible.
 Some cancers can cause fever and some of the tests we are planning
are designed to check this out.

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 you are a junior doctor working in a general medical outpatient clinic.

A 29-year-old man has been referred to the general medical outpatient clinic because of
severe fatigue, which he has had for several months.
He dates the onset to a viral illness he had last winter and feels he has an ongoing
infection to explain his persistent symptoms.
He does not have any symptoms to suggest that depression is the primary process.
Following his first clinic attendance a standard range of tests are performed:
FBC, inflammatory markers, electrolytes, glucose, renal/liver/ bone function tests,
autoimmune/ vasculitic screen, thyroid function tests, serology for Epstein–Barr virus
and cytomegalovirus, CXR and a short Synacthen test.
All are normal or negative.
He now returns for a second clinic appointment.
At the meeting with the consultant before the clinic it is agreed that the diagnosis is
chronic fatigue syndrome, that no further investigations are required, that he should be
encouraged to take gentle daily exercise, gradually building up over time, and that referral
for cognitive behavioural therapy could be considered (although this is not likely to be
readily or rapidly available).

to explain the diagnosis and treatment of chronic fatigue syndrome to the patient.

 The patient is likely to have very clear-cut ideas about the cause of his problems,
which need to be explored before the discussion can move on.
 Why is he convinced that an ongoing infection is responsible?

 You can find no serious progressive disease.

 This does not mean that you do not believe the patient’s symptoms.
 Chronic fatigue syndrome is real.
 There is no specific drug therapy but there are treatment options, including graded
exercise and cognitive therapy.

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 I haven’t said that there isn’t anything wrong with you.
 I know that chronic fatigue syndrome is a real illness that causes
very real symptoms and problems for people who’ve got it.
 What we have been able to establish, and this is good news, is that
there is no serious infection, cancer or anything like that to explain
your symptoms.

 no, I haven’t said that.

 People with any severe illness are prone to get depressed, which can
be a natural reaction in this situation.
 But I don’t think that chronic fatigue syndrome is all due to
depression or all in the mind, although sometimes depression can
make it worse.

 yes, a doctor can always do more tests, but that wouldn’t be the
right thing to do here and we don’t plan to do any more.
 We would only do more tests if the situation were to change in some
way that made us think we should check something else out.
 But we have all discussed things, and we don’t think that any more
tests are necessary at the moment.

 yes, you can.

 Your GP could refer you to someone else and, if it was helpful, we
could give your GP advice as to who they might refer you to.
 But I would be concerned that this might delay you getting started
on appropriate treatment.

 chronic fatigue syndrome is not an easy thing to treat – I won’t

pretend that it is – but there are two treatments that are known to
be effective.
 The first is graded exercise, where you aim to gradually improve
your energy levels by increasing daily activities in a planned fashion.
 The second is cognitive behavioural therapy, where you explore
reasons and triggers for your illness with a therapist and determine
appropriate responses to those triggers.
 Either we or your GP could make a referral for you to visit someone
who can help you with cognitive behavioural therapy, but it isn’t
always easy to get access to this treatment.

 I am afraid that there aren’t any vitamins or medications that help

this condition.
 Antidepressants are sometimes used if we feel that there is
coexistent depression, and they may help if someone has a sleep
disorder.

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 you are a junior doctor working on a general medical ward.

A 54-year-old gay man is admitted on the medical take complaining of malaise, rash,
mouth ulcers and pyrexia.
You suspect HIV infection and want to encourage him to take the test but he is reluctant.

explore the reasons for the man’s reluctance to test for HIV and explain why you think he
should agree to be tested.

 Why is he reluctant to test?

 You will begin by asking him open-ended questions, but if the reasons are not
forthcoming you will need to probe regarding common reasons for reluctance,
including:
o fears about confidentiality;
o misconceptions about the prognosis of HIV;
o concern that he may lose his mortgage/insurance as a result of being found
HIV-positive, or even through the act of testing for HIV.
 It will also be appropriate to discuss the following.
 What will he feel like if he fails to test but subsequently develops a severe illness?
 What about his partners?
Shouldn’t they be given the information that they may be at high risk of HIV?

• Reassure the patient about confidentiality: you have a duty of care which includes
confidentiality.
• Explain that with modern antiretroviral therapy (see Section 2.11) the prognosis of HIV is
very good and management has become that of a chronic condition in which patients
mostly feel very well. People now rarely die of AIDS in the UK.
• Taking an HIV test will not affect any current insurance or mortgage, even if the test is
positive.
• His partners may be asymptomatic and yet still could be HIV-positive and therefore are
best told of any risk.

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 I am pleased to say that that’s not true: there are several good
reasons why you should know the diagnosis.
 If you have HIV, we can do tests to see how badly your immune
system has been affected: the CD4 count.
 If the count is low you would need to go on treatment, and modern
treatment is very safe and effective.
 Even if you don’t need treatment, we can monitor your health with
regular blood tests and start treatment when the time is right; this
would stop you becoming ill.
 If managed in this way, most patients in the UK with HIV infection
will live for many decades and possibly have a near-normal lifespan
if they get the right treatment.

 no, I don’t think so.

 As the disease progresses it damages the immune system more
and more, and if it becomes so badly damaged that the person
becomes ill with a very severe infection or cancer it may be too late
to save their life.
 For HIV treatment to work properly, so that people with the disease
can live for a long time, it is best to start it before they become
seriously ill.

 I can understand why you are worried about this, but all
healthcare workers are bound by a duty of confidentiality.
 If any healthcare worker is discovered to have breached
confidentiality without good reason they will be punished, and they
may lose their job.
 HIV units are especially aware about maintaining confidentiality,
but it is often in the patient’s best interest that other people are
told.
 For instance telling the GP means that someone doesn’t get the
wrong treatment if the GP is aware of that person’s HIV status.
 Many people also find that it is good to tell close friends and join
community HIV support groups as they can help the person talk
through the problems they face, but this would be your decision.

 if your partner was my patient, then I would have a clear duty of

care to him and would have to tell him; but he is not my patient, so
I don’t have to tell him.
 However, in some circumstances doctors are allowed to break
confidentiality, for instance if they think that a patient is putting
the lives of other people at risk.

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  If you are HIV positive, and we don’t know if you are yet, then I
would strongly advise that you do tell your partner.
 I could help you do this if that would be helpful, because if he is
positive then he would benefit from being diagnosed and monitored
or treated in the same way that I think you would.
 I am sure that you wouldn’t want to be responsible for denying him
the opportunity to make his own decisions about this, would you? I
must also say to you that if you have unprotected sex with your
partner and he finds out about the HIV later from someone else,
then he could have you prosecuted for endangering his health.
 People have been sent to prison for this.

 any existing insurance and mortgage policies will not be affected

and will continue in the normal way.
 If you are positive you are right that you will find it more difficult to
get insurance, but there are companies that will offer insurance to
people with HIV, especially as the prognosis has improved so
much.
 If you test HIV-negative, then this won’t affect any current
insurance policies either and a negative test also won’t have any
effect on your future insurance chances.
 The insurance companies now accept an HIV test as being a
‘routine’ test and are more interested in your future risks based on
the information you give them on the application form.

HIV testing
• In the mentally competent this must always be performed with consent.
• Testing without consent is only acceptable if the patient is not competent and the
test is in their best interests.
• Pre- and post-test discussion should be available.

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 you are a junior doctor working in a medical outpatient clinic.

A 38-year-old man is referred to the outpatient clinic because of weight loss.

On examination he has oral candida.
After appropriate discussion he consents to testing for HIV.
The result is positive.
He returns to the clinic and accepts advice that he should start antiretroviral therapy,
but is not willing to accept that his wife should be told about the diagnosis.
to explain to the man why his wife should be told.

 The man has just tested positive for HIV and a common reaction is to want no one
else to know.
 The discussion is likely to be difficult, but important things to find out include the
following.
o What does he understand about how HIV is transmitted,
o how it can be treated
o what the prognosis is with treatment?
o His views about informing his wife and others may be based on significant
misconceptions.
o What are his fears about revealing the diagnosis to his wife?
o What would he feel like if his wife became ill and this could have been
prevented if she had been told about the HIV?
o What happens if his wife finds out through other means?
What will that do to their relationship?
o Does he have children?
o If his wife is also positive then they are also at risk and need to be tested.
o Does he have other sexual partners who may also be at risk?

 Make it clear that his care is your main priority and that your aim is to help him to
understand HIV and what options will be open to him.
 Facts regarding the transmission of HIV and its prognosis with appropriate
monitoring and treatment.
 Reassure him about confidentiality: you have a duty of care to him which includes
confidentiality.
 However, if his wife is also your patient, then inform him that you have a duty of care
to her and that if he doesn’t tell her then you will do so.
 If his wife is not your patient, then your duty to her is less clear-cut, but you should
inform him that if he has unprotected sex with her and she finds out about the HIV
later from someone else then she could have him prosecuted for endangering her
health, and that people have been sent to prison for this.

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 I’m afraid we can’t be sure of that.
 People with HIV can remain healthy for many years, so you can’t
tell just by looking at them and so she might be positive.
 If she is, then we would advise her about the proper tests and
treatment that would prevent her becoming ill in the future.
 If she is negative, then we can do our best to make sure that she
and any children you may have in the future will remain negative.

 I’m afraid that can’t be guaranteed.

 You may have been HIV positive for many years and your wife
could have become infected at any time during this period.
 You are right that condoms are very good protection against HIV if
used properly, but they sometimes break or come off, and if your
wife is HIV-negative now she would be at risk of catching the
infection each time this happens.
 This risk can be greatly reduced by giving immediate treatment
called postexposure prophylaxis if a condom fails, but if she doesn’t
know about the HIV then she wouldn’t know to take this treatment.

 if she attends the clinic and is my patient, then I will have to tell
her because I know she is at risk of catching the infection and my
duty as a doctor is to protect my patients from harm.
 But I would prefer that you tell her as that shows your trust in
her.
 If she is not my patient, the rules of confidentiality mean that I
don’t have to find her and tell her if you refuse permission, but I
cannot lie if she or her GP ask me directly.
 I certainly would feel unhappy that she hasn’t been told: it is best
for everyone if she is told, and there are many people who are
experienced in HIV who can help you do this.
 Also, I have to tell you that if you have unprotected sex with her
and she finds out about the HIV later from someone else, then she
could have you prosecuted for endangering her health and people
have been sent to prison for this.

 transmission of HIV between couples is variable and depends on

many factors.
 We very frequently find couples where one partner is positive and
the other negative after many years together, so you can’t assume
that your partner is positive.
 Furthermore, if she is negative now, then she can still catch the
infection from you in the future.

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 You are potentially putting her at risk if you have unprotected sex
with her now that you know you are positive, and there is a
growing number of people who have been prosecuted and sent to
prison for having unprotected sex when they knew they were
HIVpositive and their partner was at risk of catching the infection.
 It is therefore best to tell her before putting her at risk and before
she finds out some other way: for instance, if she becomes
pregnant then she will be offered an HIV test and might find out
that way.

 your children cannot catch HIV from you unless you were to bleed
heavily and they were to be covered in your blood.
 Things such as kissing or sharing a toothbrush are not a risk, but
if your wife is HIV-positive then your children might have caught it
from her at birth or from breast-feeding if she wasn’t tested for HIV
when she was pregnant.
 Children who are HIV positive can sometimes remain well for
many years, but then eventually can become very ill or die unless
diagnosed early and given the right treatment.
 If you tell your wife about your condition, you can then find out if
your children need a test according to her result.

 it is a legal responsibility for the doctor to put the accurate cause of

death on the death certificate, so if you die of HIV then this has to
be mentioned on the death certificate.
 The person registering your death, who is normally one of your
close family members, will see this.
 Although my duty of confidentiality to you continues after death,
under these circumstances it is likely that I will meet your wife and
I would have to tell her that she is at risk of being infected, even if I
can’t tell her your medical history without your previous consent.

 no, we can’t do that.

 We cannot do any test without informed consent, which means
that we would have to tell your wife she is having an HIV test.

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 you are a junior doctor in a nephrology outpatient clinic.

Mrs Jean Booth is a 27-year-old woman who is known to have reflux nephropathy with
moderate renal impairment.
She is hypertensive and taking lisinopril 10 mg daily.
She attends the nephrology clinic every 6 months for review.
Her routine pre-clinic investigations demonstrate proteinuria (1.2 g per 24 hours) and
creatinine196 mol/L (estimated glomerular filtration rate 28 mL/min).
Her BP is 156/90 mmHg.
She tells you that she is planning to start a family.
This is something that she has said before and a previous letter in the notes from the
renal consultant to the patient’s GP has documented that there would be considerable
risks: at least a 50% chance of significant rapid deterioration in the patient’s renal
function and at least a 50% chance of fetal loss.

to explain the implications of pregnancy with regard to the patient’s renal condition.

 What is her understanding of the risks of pregnancy to her own health.

 What does she think the chances are of her having a healthy baby?
 What does she understand about the risks to pregnancy caused by her medication?

 Pregnancy poses a very significant risk to her own health.

 There is a high chance that pregnancy will not be successful.
 Angiotensin-converting enzyme inhibitors (lisinopril) are contraindicated in
pregnancy.
 That you will try to give her the best care, whatever she decides about pregnancy.

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 it’s obviously good that you feel well, but I am afraid that this does
not mean that there aren’t any problems.
 Kidney disease does not make people feel ill until it is very bad
indeed; but the fact that your blood pressure is high, that you have
protein in the urine and the blood test showing that kidney
function is about 30% of normal all mean that the risks of
pregnancy would be very high.

 I mean that there’s at least a 50% chance that the stress of

pregnancy would make your kidneys get significantly worse, and at
least a 50% chance that the pregnancy would not go well, so you
would not end up with a healthy baby.

 no, we’re trying to give you the proper facts.

 I’d like to be able to tell you that there aren’t any problems, but
that wouldn’t be true.
 The risks of pregnancy for you are much higher than they are for a
woman who doesn’t have kidney problems, and it’s important that
you understand this.

 we would try and look after you as well as we can.

 We would want to see you in clinic as soon as you knew you were
pregnant, and we would monitor your blood pressure and kidney
function very carefully.
 And if things were going wrong, we would talk to you about it.

 we should try and get better control of your blood pressure and we
should change the blood pressure tablet, because lisinopril – the
one you’re taking at the moment – can cause problems in
pregnancy.

 it’s not inevitable, but it is possible that they might.

 If this was a concern, then the baby could have scans done to see.

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 you are a junior doctor working on a renal ward.

Mr Stephen Foster is an anxious 45-year-old man who was admitted for investigation of
nephrotic syndrome (oedema, proteinuria of 16 g per 24 hours and serum albumin 15
g/L).
His plasma creatinine is normal.
He has a history of long-standing ankylosing spondylitis and the renal biopsy showed
deposits of AA amyloid.
His case was discussed on the renal ward round.
Treatment of his ankylosing spondylitis may reduce inflammation and thereby his
tendency to form amyloid, but this is unlikely to have a dramatic effect and it is expected
(1) that he will require continued symptomatic treatment for his oedema and proteinuria;
(2) that his renal function is likely to deteriorate with time, even to the point where he
requires dialysis, but this is not predictable; and
(3) that his amyloid may cause problems with function of other organs in the future, but
this also is not predictable.
to explain the diagnosis of amyloidosis to the patient and discuss what this
means for his future.

 What is his understanding of the situation?

 The link between ankylosing spondylitis and amyloidosis.

 The multisystem and progressive nature of amyloidosis.
 That control of the underlying inflammatory disease can halt/slow progression of
amyloidosis.
 That symptomatic treatments can help his renal symptoms.

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 it’s quite a rare problem so that isn’t very surprising.
 When we get infection or inflammation in the body, the body makes
special proteins to try and fight the infection or inflammation, which
is a good thing.
 But if the inflammation goes on for a very long time, as in your case
with the ankylosing spondylitis, the body finds it difficult to get rid
of the proteins designed to fight inflammation and they get deposited
in the tissues.
 In your case at the moment this is happening in the kidneys, and
once the proteins are there it’s very hard for the body to dissolve or
break them up.

 at the moment your kidneys are actually doing their main job of
removing waste from the blood normally.
 The problem is that they are ‘leaky’, so some of the protein in your
blood is being lost into the urine.
 When this happens the kidneys try to make up for it by hanging
onto more salt and water than usual, which is why your ankles are
swollen.
 We can help the ankle swelling with diuretics, ‘water tablets’, and we
can reduce the amount of protein leaking with a particular sort of
blood pressure tablet, an angiotensin-converting enzyme inhibitor.

 no, I’m afraid that it’s extremely unlikely that it will be possible to
get rid of it.
 But if the inflammation caused by the ankylosing spondylitis can be
reduced, then the rate at which it increases can be slowed down and
it may even improve a little.
 I am not an expert in this area, but we will discuss things with our
colleagues in the rheumatology department and see if they can
recommend any treatments to do this.
 This is something I am sure you’ll want to talk about with them in
clinic.

 there is a chance that over time the kidneys will work less well and
stop cleaning the blood properly, so we will keep an eye on this with
blood tests in the clinic.
 If the kidneys do fail because of amyloid, this will not happen
suddenly; it will be a gradual process over many months and years,
and we will let you know what is happening so that we can plan
treatment.
 It may be that you will need dialysis – that’s treatment to do the
work of the kidneys – in the future.
 You might not, but it is a possibility.

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 you are right that amyloid can cause trouble in other places,
especially the bowel and liver.
 But these are less affected than the kidney and I’m pleased to say
that, although some other kinds of amyloid do affect the heart, the
kind that you have almost never causes heart trouble.

 you’re right to think that this is a serious condition, and some

people with amyloid do die earlier than they would have done
otherwise.
 But at the moment the problem you have is not life threatening and
many people with this problem will not get worse for years and
years.

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 you are a junior doctor working on a renal ward.

A 78-year-old retired lecturer was found to have metastatic carcinoma 3 months

previously.
No primary site has been identified and previously he declined further investigation and
treatment.
He has been more short of breath for the last week and confused for about 2 days.
He has chronic renal failure, cause unknown.
Previous imaging has shown that both of his kidneys are of reduced size and his serum
creatinine was 300 μmol/L 2 months ago.
He is brought to the emergency department by his son who was visiting him.
His BP is 70/50 mmHg.
Blood tests show creatinine 670 μmol/L, urea 38 mmol/L and potassium 7.2 mmol/L.
You are called to give advice on the management of his renal failure.
You discuss this with the renal consultant who is on call and she says that dialysis would
not be appropriate and that he should be managed conservatively.

to explain the management plan to the patient’s son, who is upset.

What is the son’s understanding of his father’s condition?

Does he know about the diagnosis of malignancy, and does he know that his father
declined further investigation and treatment?

 The background of malignancy.

 The patient’s wishes are more important than anyone else’s:
 he is confused now, but when competent to make decisions he declined intervention.
 The patient is dying and heroic medical interventions would not change that, as well
as being contrary to his wishes.
 That you will ensure that the patient is not distressed, and will look after him until
he dies.

 it’s difficult to be sure what has caused the recent deterioration, but
it’s quite clear that his kidneys, which weren’t working normally
before, have got worse – he has advanced kidney failure.
 The kidneys control the levels of salts in the blood and also remove
toxins and the level of toxins and salts in your father’s blood are now
very abnormal.
 They are at a level that might be responsible for his confusion, and
also the fact that the heart is not pumping properly.
 I’m afraid I think he is dying.

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 you are right, it can be.
 We can do the job of the kidneys with a dialysis machine, and this is
something we do for lots of people every day.
 However, dialysis treatment tends to lower the blood pressure, and his
blood pressure is already very low.
 He would not be strong enough for the treatment, and if we tried to
give it I think he might die more quickly.
 I think we ought to concentrate on making him as comfortable as
possible.

 yes, there are obviously a lot of tests we could do, but I don’t think
they’d do any good.
 We know that your father has got widespread cancer, which we cannot
cure.
 Furthermore, a few months ago he was quite clear that he didn’t want
more tests and treatments, and it’s important that we all respect that
view.
 We cannot make him better, and it would be wrong to put him through
lots of tests that won’t alter anything when he’s dying.
 We must make sure that he is as comfortable as possible.

 I understand why you find that difficult, but people are very different
and he has a cancer which he knew we couldn’t cure.
 Perhaps that’s why he was so clear that he did not want more tests
and treatments.
 Even people who are well in other ways often find some of the tests and
treatments we do very draining.

 I think whatever we do he is going to pass away quite soon, and it’s

likely to be within the next few hours.

 no, I don’t think so.

 The toxins in the blood affect the brain, which is why he is confused.
 As they build up he is likely to become sleepy, but if he seems to be
distressed in any way, we can give him some medicine to make him
more comfortable.
 If his heart stops, we won’t go jumping up and down on him to try and
resuscitate him, we will let him die peacefully.

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 you are a junior doctor in the neurology outpatient clinic.

Mr David Johnson, aged54 years, is referred to the neurology clinic because of

behavioural change and increasing cognitive difficulties.
His son, who attends with him, has also noticed that his father has become increasingly
‘fidgety’.
Mr Johnson has no significant past medical history, but an extended family history, given
by the son, reveals that Mr Johnson’s mother (the son’s grandmother) died in middle age
with dementia, but this is something that ‘the family don’t talk about’.
It is difficult to be sure how much Mr Johnson understands, but he tells you that you
should ‘talk about anything you want with my son’.
He has also said the same thing to his GP, who arranged for the son to attend the clinic
with his father.
The view of the neurological team is that the most likely diagnosis is Huntington’s chorea,
which could be confirmed by genetic testing.
to discuss the implications of genetic testing for Huntington’s disease with
Mr Johnson’s son.

• The son’s knowledge of the disease and the diagnostic testing available.
• ‘If you have Huntington’s disease, would you like to know’?
• Why test when the disease is incurable?

• The fact that any test results will have widespread implications for other family members,
including the son himself.
• That testing may or may not clarify matters, but if the results are negative the problem
will not be cured and so further investigations may be needed.
• That there is no treatment for Huntington’s disease.
• Although it is difficult to produce‘black and white’ rules in an area where much is grey,
most physicians with experience of Huntington’s disease feel that it is inadvisable to test in
the following circumstances: children under18 years; for insurance purposes;
if the patient is reluctant; and if the result automatically reveals someone else (ie a parent)
to have the disease without their consent.
• After any test, follow-up will be required whatever the result.

• Depression may follow a positive or negative result (‘survivor guilt’).

• Suicide after a positive result has occurred, but this is no more common than for
any other disease or chronic disability.

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 yes, I can make a referral to the regional specialist clinical genetics
service, where you and your father would be able to receive further
counselling regarding the test.

 because of all the things that the test might mean, I feel it is
important for you to have pretest counselling.
 This is provided by the regional specialist clinical genetics service.
 I will refer your father and you to them.

 Huntington’s is a genetic disease, which means that it runs in the

family.
 If your father has Huntington’s – and we don’t know that at the
moment – but if he does, then there is a 50% chance that he will
have passed it on to each of his children.
 I’m afraid that means there’s a one-in-two chance that you will have
it, and also a one-in-two chance that any of your brothers and
sisters will have it.

 I’m afraid that there is no specific treatment for Huntington’s.

 There are things that can be done to help the symptoms, for
instance drugs can sometimes help the distressing movements, but
there isn’t any treatment that will deal with the underlying disease.

 no, the timing can be variable and the onset of the disease could
only be established by examining you neurologically.

 no, you don’t.

 As you can see it’s a difficult issue, which is why I think that talking
to someone in the clinical genetics service is necessary rather than
just racing into the test.
 Some people decide that they want to know, and some people decide
that they don’t.
 There isn’t a right and a wrong answer to the question.

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 you are the neurology junior doctor working in a general neurology outpatient
clinic.

Mr Harry Wilson is a 69-year-old man who has come to clinic with his wife and one of his
sons.
He saw your colleague 2 months ago for investigation of memory difficulties.
His symptoms have been coming on for several years and his wife initially took no notice
of his memory lapses.
Recently he has become disinterested in all activities, but his wife does not feel that he is
depressed.
His wife tells you that he is a shadow of his former self and can sit alone in a chair for
hours without initiating conversation or activity.
He recently had to be brought home by a friend after he was found wandering back and
forward in front of his local shops.
They have two sons in their forties.
The results of the blood tests, including thyroid function, erythrocyte sedimentation rate,
syphilis serology and B12 were normal.
His CT scan demonstrated some mild generalised atrophy, but there was no evidence of
hydrocephalus, subdural haematoma, focal cortical atrophy or infarcts.
His electroencephalogram demonstrated some diffuse slow waves but no overt epileptiform
activity.
The diagnosis is probable Alzheimer’s disease.
His wife is finding it very frustrating as her husband does not appear to be aware of most
of his problems.
She would like to know what has caused his memory problems, and their son is anxious
that it may affect him: ‘Is it mad cow disease?’ At the neurological meeting some of these
issues have been discussed recently: the risk of inheriting late-onset Alzheimer’s disease
is not high, perhaps two to three times the risk of it occurring in a member of the general
population with no family history.
to explain to the patient and his wife and son the diagnosis of probable
Alzheimer’s disease, its prognosis and treatment, as well as discussing the probability of
inheriting late-onset dementia.

 A common problem with patients who have Alzheimer’s disease is that they often
have little insight into how they have been affected.
 This can cause significant problems, especially with frustration, within the family.
 The prognosis of the condition.
The issue of symptomatic treatment with anticholinesterase inhibitors.
 Risk of family members developing the disease.

 The diagnosis and prognosis of Alzheimer’s disease.

 Possible treatment symptomatic options.
 Genetic risks in first-degree relatives.
 Future care involving the Alzheimer’s Society, the patient’s GP and social services in
conjunction with regular outpatient follow-up.

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 the diagnosis is almost certainly a form of dementia called
Alzheimer’s disease, although doctors can never be100% certain in
life of the diagnosis.
 Other treatable causes of dementia have been excluded with the
tests that have been done, and any other diagnoses would be
degenerative brain conditions similar to Alzheimer’s.

 I’m afraid it means that the brain gradually deteriorates, and we

don’t have any treatments that will stop this happening.

 I can’t give you a definite answer, not because I’m hiding, but
because I don’t know.
 However, he is not imminently in danger of dying, but I’m afraid that
his ability to do things for himself will slowly get worse and he is
likely to need more and more care in the next few years.

 your father has what we call late-onset Alzheimer’s disease, so the

risk of you developing Alzheimer’s is higher than in the general
population, perhaps two to three times more likely.

 no, there aren’t any tests that will detect whether people are going to
get late-onset Alzheimer’s.
 It may be that such tests will become available in the future, but
unless there’s some sort of treatment that can be offered it will
require very careful thought as to whether you, or anyone else,
would want to be tested.

 I’m afraid that there is currently no cure for Alzheimer’s.

 But there is a group of drugs, called the anticholinesterase
inhibitors, that are relatively new and may have a mild symptomatic
benefit in some patients by increasing one of the chemicals in the
brain that is low in those with Alzheimer’s.
 However, it is not known if these drugs alter the long-term outlook.
 If your husband did want to try them, he would be monitored with
memory tests every 3–6 months initially.
 If there was ongoing deterioration, then the drug would probably not
be of benefit and would probably be stopped.

 no, there are no more specific tests that would be helpful.

 Neuropsychometry is a more formal and accurate way of assessing
the degree and types of thinking problems your husband has, and it
may be useful in monitoring progression of the disease and response
to treatment; but there aren’t any other critical tests that need to be

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 done.

 some patients and their carers find contact with the Alzheimer’s
Society helpful.
 I will write to your GP outlining our conversation and send you a
copy of the letter.
 Your GP will be able to initiate contact with social services, nurses
and other health professionals as and when they are needed.

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 you are the medical junior doctor working on a care of the elderly ward.

Mr John Smith, a 78-year-old man, was admitted to your ward yesterday following
sudden onset of right-sided weakness and speech difficulties.
He is also unable to swallow safely.
There has been no change in his condition over the last 24 hours: he has no movement in
his right arm or leg, he cannot speak and he does not respond to simple commands.
A CT brain scan has shown a large left-sided middle cerebral artery infarct.
His prognosis is very poor.

to explain to Mr Smith’s wife that he has had a large stroke and may not
survive; and also that if he does survive, there is a high chance of severe disability.

What does the patient’s wife know already about her husband’s condition?
 What are her expectations?
 What does Mrs Smith already know and, in particular, what does she understand by
the term ‘stroke’?

 That you would normally obtain permission from a patient to speak to the relatives,
but this is not possible due to communication difficulties.
 That Mr Smith is very unwell having suffered a large stroke; that there is a large
amount of damage seen on the brain scan, and that it is not possible to reverse this
damage; that everything that can be done for Mr Smith is being done and that he is
quite comfortable; that he could die from this illness and that the first few days are
particularly unpredictable; and that even if Mr Smith does not die as a result of the
stroke it is very possible that he will have some long-term disability as a result, but
that the nature and extent of this cannot be determined at this early stage.
 That Mrs Smith is introduced to key members of the stroke team and encouraged to
ask as many questions as she wishes.

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 there are lots of reasons why people have a stroke, especially as they get
older.
 Your husband’s scan shows a type of stroke caused by a blood clot
rather than a bleed, but we don’t know exactly what caused this.
 At the moment we need to focus our attention on looking after him, but
if he shows signs of recovery then he will have more tests to see if we
can find the cause.

 no, that wouldn’t help.

 We very rarely operate on patients who have had a stroke, unless the
scan shows us that the brain is under a lot of pressure.
 We didn’t see this on your husband’s scan so an operation would not
help him.
 In fact it would almost certainly make things worse.

 no, I’m afraid not.

 You are right that there are drugs available which can dissolve blood
clots – they’re often used for patients who have had heart attacks – but
using them for people who have had strokes is not at all straightforward
because they can cause severe bleeding in the brain that makes things
worse.
 They are sometimes used, but only in people with some sorts of stroke
and who have got to hospital very quickly.
 In your husband’s case I’m afraid they wouldn’t help – they wouldn’t do
any good and the risk of bleeding on his brain would be very high.

 I’m not hiding anything when I say I don’t know.

 As you know he’s had a big stroke, but I don’t know whether or not it’s
going to kill him.
 We have to take things hour by hour and day by day at the moment, but
if there’s any change in his condition then, assuming it’s what you
would like, we will let you know immediately.

 again, I’m afraid that I can’t give you a definite answer as to what will
happen but the stroke is on the left side of his brain, which controls the
right side of his body and his speech.
 At the moment he is unable to move his arm and leg and he cannot
speak.
 The extent to which these functions will recover is unpredictable, but if
he stabilises and shows progress over the next few days then our team
of physiotherapists, speech and language therapists and occupational
therapists will make some assessments.
 They will then devise treatment plans with the aim of recovering as

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 much function as possible. If he does survive, the rehabilitation
programme will last
 many months and he still may require help to look after himself.
 There is a high chance that he will need to use a wheelchair, at least in
the early stages and perhaps in the long term, and he may also have
persistent problems with understanding and speech.

 your husband is in a stable condition for now, but he could become

worse at any time.
 This can happen suddenly and he could deteriorate very quickly and
even die.
 I would suggest that you should speak to your son and ensure that he
understands this.
 He can then make a decision based on this information as to whether or
not to return.

Despite recent advances in the management of acute stroke, the prognosis remains
poor, with up to 20% of patients dying within 30 days of the onset of the stroke.
It is important when breaking the news of a large stroke to relatives that you are
realistic about the chances of survival and full recovery.

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 you are the neurology junior doctor working on the neurology ward.

Miss Kate Beaumont was originally referred to the epilepsy clinic with a 2-year history of
frequent episodes of apparent loss of consciousness.
She is taking antiepileptic medication.
These attacks were recently witnessed on the neurology ward while she was undergoing
videoelectroencephalogram(EEG) telemetry.
The episodes do not have an epileptic basis on either clinical or EEG grounds.
Other investigations have also been normal, and a diagnosis of non-epileptic attack
disorder has been made.
The neurology team have agreed that no further investigations are required.
Miss Beaumont wishes to know what the cause of her attacks is and how you are going to
treat them.
to explain to Miss Beaumont that the attacks are not due to epilepsy but
have a psychological basis and are best managed with help from the neuropsychiatry
team.

 What does the patient think is the cause of her attacks?

 What were the possible triggers more than 2 years ago that led to the attacks
emerging?
 Is there any relevant past psychological history, eg depression, anxiety or self-harm?

Appropriate tests have given reassuring results and further tests are not indicated.
 The episodes will not improve with antiepileptic medication, which should be
gradually withdrawn.
 The most appropriate therapy is psychological, and this is usually successful in
reducing the attack frequency or stopping the attacks altogether.

 The patient is not considered to be ‘putting it on’ or ‘faking illness’.

 The patient has little control over the nature of the episodes.

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 no, not at all.
 The attacks that you have are real, disabling and outside your
conscious control: they could be thought of as involuntary
episodes of ‘switching off’ or going into a ‘trance’.
 For example, we have all had times when we do not hear our
name being called when we are engrossed in a book or film, or
remembering nothing of a familiar journey home.
 We can all therefore be unaware or have no memory of episodes
that we have experienced.

 we don’t fully understand what causes this disorder, but

twothirds of people with it have suffered some sort of traumatic
experience in the past.
 This may be important for us to talk about further.
 We can’t explain the link for certain, but it may be that when
people are exposed to repeated frightening incidents they learn to
switch off.
 Initially this is a helpful thing for them to do; it protects them
emotionally at the time.
 But it may come back later in life as these attacks, so it may be
that your attacks are brought on by stress.
 However, sometimes people are initially unable to identify the
triggers of their attacks; and when they are found they often turn
out to be fleeting stressful or unpleasant thoughts that you may
barely be aware of, and which have little to do with your
circumstances at the time of the attack.

 as you probably know, there are always more tests that doctors
can do, but I don’t think that any more tests would be helpful for
you.
 You’ve had thorough tests done, including monitoring of the brain
waves when you’ve been having an attack, and we’ve discussed
the results with everyone in the neurology team.
 We think we should move on from doing tests to focus on how we
can try and treat the problem.

 in some patients clarification of the cause of the attacks and

withdrawal of antiepileptic medication is enough for the episodes
to stop or greatly improve.
 If your attacks do not improve, then it is likely that we will need to
refer you to another part of our team, the neuropsychiatrists, with
whom we work very closely.
 They will need to see you and talk more about the cause of your
attacks.
 Usually they suggest some form of counselling or therapy
involving changing your body’s response to a certain trigger or

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 experience.

 there is no evidence that the attacks that you have cause you any
harm, other than minor injuries that you may already have
experienced such as biting your tongue or friction burns from the
carpet.
 It is theoretically possible to be hurt more seriously if an attack
occurs at the roadside or on the stairs, but this is extremely
unusual and it’s very rare for patients with this sort of problem to
come to serious harm because of them.

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 you are the neurology junior doctor in an outpatient clinic.

Miss Marlene Cox is a 34-year old woman who is coming back to the neurology clinic for
the results of her recent scans.
She was initially referred by her GP with numbness and tingling in the legs, and she has a
past history of episodes of blurred vision 6 months ago.
An MRI scan of her brain and spinal cord has shown several high-signal white matter
lesions in both cerebral hemispheres and a high-signal lesion at the level of C4 typical of
demyelination.
Visual evoked potentials and the results of a lumbar puncture are all consistent with this
diagnosis.
No further investigations are required.
She needs referral to the specialist multiple sclerosis (MS) service for discussion of further
management.
to explain to Miss Cox that the most likely diagnosis is MS.

 What does the patient know/fear about MS?

 The prognosis and treatment options.

 That the most likely diagnosis is MS.

 That there is no definitive test to make a diagnosis of MS, but that the combination
of typical symptoms and results from various tests help to make the diagnosis.
 That MS can manifest in many different ways and is not always disabling.
 Often patients with MS seen in the media are those with more severe disability.
 There are many thousands of patients with MS who live relatively normal lives, hold
down jobs and raise families.
 That there are now several treatments available: these cannot cure the condition but
can help to keep patients as healthy as possible for as long as possible.
 That the patient has the contact details of someone she can call when she leaves the
clinic (the MS specialist nurse if possible).

 there isn’t one single test that can ever prove the diagnosis of MS, but
the problems that you’ve had – with the vision and now with the legs
– coupled with the test results, the scans, the vision tests and the
lumbar puncture all point to MS.
 I wouldn’t be telling you the truth if I said anything different.

 I’m not hiding anything when I say that I don’t know whether or not

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 you will need to use a wheelchair in the future, but hopefully you will
stay as well as
 you are now for a long time.
 As you know some patients with MS do deteriorate, but very many
don’t.
 However, it tends to be the ones with severe disease that you see in
the papers or on the television.
 We will make sure we see you regularly so that you will be able to
report any changes in your condition to us.

 I’m afraid that there isn’t any treatment that has a magical effect in
MS, but there are some treatments that can possibly help in some
cases.
 I’m not an expert on this, but I want to suggest that I will make an
appointment for you to see someone from the MS specialist service so
that they can discuss things with you.

 you should still see your GP as the first port of call if you are worried
about any new symptoms, because not everything you experience will
necessarily be caused by MS.
 Also, you can always contact the MS specialist nurse to discuss new
symptoms or problems with medication.
 You may also find it helpful to keep a diary of symptoms so that when
you come to clinic you are able to report any changes.

 that’s very unlikely.

 We don’t know exactly what causes MS.
 There is a lot of research being done that is trying to establish what
factors can increase the risk of developing the condition, but it is not
a genetic condition that is inherited from parents.
 So although there is a slightly higher risk that children with an
affected parent will develop the condition, the risk is still very small
indeed.

Beware of making a diagnosis of MS in patients who have had only one episode of central nervous system
demyelination.
This is referred to as a ‘clinically isolated syndrome’ and the patient may not ever have any further symptoms.
Making a diagnosis of MS has many implications for the patient medically, socially and psychologically.

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 you are a junior doctor working on a general medical ward.

Mrs Elizabeth Dunn is aged 74 years and has been admitted after a fall.
Her daughter asks to speak to you.
She has heard that the occupational therapist is taking her mother on a home visit
tomorrow.
Mrs Dunn’s daughter, who lives 50 miles away and rarely sees her mother, does not think
she should go home, but should be discharged to a residential home.
Mrs Dunn was admitted after a trip at home, following which she sustained bruising to her
arms and face.
She had no postural drop in blood pressure, a 12-lead ECG showed sinus rhythm and she
has not fallen while on the ward.
She has been started on prophylaxis against osteoporosis.
She has no mental health issues, wants to go home and it is the view of the
multidisciplinary team that it is reasonable for her to do so.
She gives you permission to talk to her daughter.

to explain to Mrs Dunn’s daughter that Mrs Dunn wants to go home and has the right to
make her own decisions.

 The patient’s autonomy.

 The patient’s right to choose where she goes on discharge.
 The patient’s capacity to choose where she goes on discharge.
 The patient’s safety.

 That Mrs Dunn is happy for you to discuss her discharge plans with her daughter:
introduce the session by explaining that you have specifically sought permission
from Mrs Dunn to talk to her daughter.
 This sometimes comes as a surprise:
families may infantilise older members and need reminding gently that they have the
same rights to confidentiality as other adults.
 The daughter’s understanding of the situation.
 That Mrs Dunn has the capacity to decide to go home: capacity is situation specific,
i.e she may be able to go home safely but may not have the capacity to change her
will.
 That ‘safety’ cannot mean absence of any risk.

 we have looked into the reasons why your mother fell and we think
that she tripped.
 We have checked out her heart with an ECG – an electrical

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 recording – and everything seems to be in order.
 Furthermore, there is nothing to suggest that she had a fit or
anything like that.
 But I am afraid that I cannot give you a guarantee that she won’t
fall again: there will always be some risk, but admitting her to a
residential home would not stop her from falling.
 The aim of the home visit is to assess her home for hazards and
find out what care package, if any, she needs to support her, and
to make arrangements to keep her as safe as possible.

 I can understand why you are worried about this.

 I agree that she is at risk, as is pretty well every old person, of
breaking her hip.
 To cut down the risk we can assess her home to try and deal with
things that might trip her up, and we can provide aids like walking
sticks and a frame if that would be helpful.
 Also, we have started her on some tablets to treat thinning of the
bones, so that they’ll be stronger if she does have a fall.

 she is not confused at the moment.

 She is able to retain information and is able to weigh up risks
about her discharge.
 Why don’t you arrange to go on the home visit with your mother
and the occupational therapist? Then you can see what she is able
to do safely and say what you are concerned she will have difficulty
with.
 After that you could discuss the amount of care that would make
you feel confident with the social worker and your mother.
 If Mrs Dunn’s daughter is still not happy, offer to arrange a
meeting with your consultant.

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 you are a junior doctor working on a medicine for the elderly ward.

You have been looking after Mrs James for over 2 weeks.
She is 84 years old and was originally admitted via the Emergency Department with
cellulitis.
Her physical state has improved markedly since admission: she is no longer febrile and her
white cell count and C-reactive protein are returning to normal.
When she first came in she was extremely muddled, had an Abbreviated Mental Test Score
of 2/10 and called out constantly.
She has gradually settled and is walking short distances now using her rollator frame with
the physiotherapist.
However, she still gets restless in the evenings and found it difficult to make a cup of tea
with the occupational therapist.
Before admission she had a carer every morning and was apparently just managing.
She is now feeling better and is very keen to go home.
She is missing her cat greatly.
Her daughter, who lives a couple of hours’ drive away, has come to see her.
She is upset when the nurse tells her that a home visit is being organised in the hope that
it will be possible to discharge her mother home soon.
She feels that it would be more sensible for her mother to move into a residential home,
especially as the nurse has said she is still muddled.
She demands to speak to a doctor.

to meet the daughter on the ward and discuss planning for her mother’s discharge home.

• The patient’s autonomy: frail older people still have rights despite cognitive impairment.
• The patient’s right to choose where she goes on discharge.
• The patient’s capacity to choose where she goes on discharge, which in this case is
reduced.
• The patient’s safety: a patient can fall and break a hip in a hospital or care home as well
as at home.

 Ask the daughter in detail about how her mother was coping prior to admission.
 She may have nonspecific concerns and be anxious (and often guilty) that she can do
little of practical help as she lives at a distance.
 If she has specific worries, then make a list as you need to address each one, eg if
she fears her mother might leave the gas hob on, then the gas can be turned off and
carers can provide hot meals with a thermos flask for hot drinks between their visits.
 Explain why Mrs James was admitted and that, although there is a degree of
dementia, she is less confused now.
 If her daughter knows nothing about dementia, give a brief explanation and a source
for more information(eg Alzheimer’s Disease Society).
 Explain that her mother will have a full multidisciplinary assessment and that an
appropriate care package will be arranged before she is discharged.
 Say that as her mother only had care once a day before admission, you anticipate
that with more care she should do well at home.

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 Explain the drawback of residential care: institutionalisation often leads to rapid
decline in early-to-moderate dementia.
 Also, it will be difficult to find a home that will accept the cat, a key component of
Mrs James’ quality of life, and this may affect her longevity.

 I can understand why you think that, but because of her dementia she
is likely to find it difficult to adjust to a new environment.
 She may become more muddled and likely to fall.
 She really misses her cat and is determined to go home, and although
we accept that she is not fully able to weigh all the risks involved we
have to try to respect your mother’s strongly held wishes.

 the score tells us that her memory and orientation are not perfect, but
what really matters is how much she can do towards looking after
herself.
 She is walking steadily with her frame, but did find it difficult to make
a hot drink in the kitchen here.
 That is why the occupational therapist is planning on taking her on a
visit home.
 The therapist will put her through her paces in a familiar environment
to assess how much regular care she needs.
 I know it’s a long journey, but do you want to take part in the visit to
see how she manages for yourself ?
 Would you like me to ask the occupational therapist to contact you?

 that is the purpose of the home visit.

 The occupational therapist will take her home to see how she
manages: whether she can get into the house, how she can move
around inside it, whether she can get herself into and out of bed,
whether she can use the toilet and whether she can use the kettle and
the cooker – all the basic things that someone needs to be able to do to
look after themselves.
 If she can’t do any of these things, then help would need to be
provided to enable her to get home.
 Without the help, she would not be able to go.

 of course you know her best and I know this is a difficult situation,
but we cannot force her to go into a home against her will.
 Can I fix an appointment for you to see her consultant?

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 you are a junior doctor working on a medicine for the elderly ward.
Mr Davis was admitted to your ward 10 days ago with a dense right hemiparesis, right
homonymous hemianopia and a degree of receptive and expressive dysphasia.
He is 94 years old, but prior to this stroke was living independently at home.
Initially he was treated with intravenous benzylpenicillin, ciprofloxacin and metronidazole
for 7 days for aspiration pneumonia.
He is still on intravenous fluids and has remained drowsy since admission, but he had
been more alert for the last couple of days.
Today his chest sounds worse, his oxygen saturations have dropped and his score on the
Glasgow Coma Scale has fallen again.
The view of the medical and nursing team is that he should be kept comfortable.
His daughter and grand-daughter are upset about his deterioration and the nurse in
charge of the ward asks you to speak to them.
to meet the family on the ward and discuss their concerns.

 This is a major stroke in a very old man.

 Although he was previously fit for his age, his homeostatic reserve will now be
limited: whatever you do he is very likely to die, and you want him to have a dignified
death that is not prolonged by pointless medical intervention.
 Key ethical aspects are beneficence, non-maleficence and justice.
 Ethical aspects that many doctors still avoid are the actual cost of his treatment if it
is futile and the opportunity cost, eg if he is put in intensive care, this may deny the
bed to another.

 The names of the daughter and grand-daughter: much confusion and many
complaints arise when the notes record ‘discussed with daughter’, and it is only
discovered later that there are three daughters with very different views.
 Establish the background: as always, encourage the daughter and grand-daughter to
talk first.
 This may provide an easier route to delivering your bad news and you will be able to
assess the appropriate level of complexity for your replies.
 For example, ask how Mr Davis was coping before admission: even though he was
independent, he might have been struggling with developing dementia, failing vision
or a recent bereavement.
 Ask what his views were (‘He was such an independent, outdoor man’).
 Ask what their experience on the ward has been so far.
 If they have a major concern, however unlikely, about the care (eg ‘He has caught
pneumonia from the man next to him’), they will not be interested in what you have
to say until this is addressed.
 Mr Davis is dying and no treatment will prevent this.
 Aggressive medical attempts to prolong life would be futile and wrong, and you
intend Mr Davis’ comfort to be the priority.

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  I’m afraid you are right.
 As you know it was a very big stroke and almost straight away he
developed a chest infection.
 We have treated that and his chest improved, but he is certainly very
chesty again today.
 He may be getting another infection, or because he cannot move his
legs he may have developed a clot in the leg veins which has gone to
the lungs.

 that’s what I wanted to talk to you about.

 Even when your granddad was getting over the first infection there
wasn’t much sign of improvement in his stroke, so there is obviously a
lot of damage to his brain.
 It’s disappointing that he has got another problem with his chest so
quickly, but I think this is telling us just how seriously ill he is.

Doctor:  treatment with antibiotics usually works only along with other
measures such as physiotherapy to clear the chest.
 This would not be very effective because your father cannot work with
the therapist and having physiotherapy – shaking his chest and
sucking out his throat – would almost certainly be uncomfortable or
distressing for him, particularly as we cannot explain to him what we
are trying to do.
 It is also getting difficult to find a vein for his drip and that is quite
uncomfortable for him as well.

 the only way of being sure of that would be to send your father down
to the X-ray department for a special scan, but his is too poorly for
that at the moment and there wouldn’t be any point.
 If it was a clot, we would not be able to treat it: the treatment for a clot
on the lung is to thin the blood and this would probably cause
bleeding into the brain which would make things even worse.

 I’m sorry, but I think you are right that he is probably going to die.
 If that is going to happen, I don’t think there is anything we can do to
change it and we don’t want to make things more uncomfortable for
him.
 But we certainly do not want him to suffer: we will move him into a
side room so that you and the rest of the family can come and go as
you wish.
 The nurses know him well now and they will carry on with his mouth
care so that he doesn’t feel dry and thirsty.

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 They will also turn him regularly on his special mattress.
 If he seems to be in discomfort or any distress, we can give him a little
diamorphine to make sure he is comfortable.
 Just occasionally patients surprise us and rally, so we won’t be doing
anything that we can’t change.
 But I think we need to make him comfortable now and see how he
goes.
 Offer tissues, cups of tea, a visit from the chaplain, a chance to pop
back to see the patient later and beds in the hostel if the family are
not local.
 If things are not going well, do what you should in real life: offer a
senior opinion and propose arrangements to ensure this happens.

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 you are a junior doctor on the admitting medical team.

Mrs Agnes Smith, a 72-year-old woman, previously well apart from mild hypertension, has
been admitted comatose to the Emergency Department.
A CT scan of her head has shown no abnormality, but her serum sodium is 112 mmol/L.
This is almost certainly caused by the thiazide diuretic that she takes for her high BP,
although other possible causes have not been excluded, and is the only obvious cause for
her coma.
The management plan is to give her a controlled infusion of hypertonic saline, with
frequent monitoring of the serum sodium concentration until this is corrected into the
mildly hyponatraemic range.
Her son arrives and is very worried about his mother’s condition.
The staff nurse asks you to explain the situation to him.
to explain the management plan and the uncertainty of the prognosis to Mrs
Smith’s son.

 Although the son will understandably be concerned for the health of his mother, are
there any specific worries or questions that he would like you to address?
 Is there a hidden agenda or worry?
 For example, is he concerned that she has been confused or depressed and may have
accidentally or deliberately taken an overdose of tablets that has contributed to her
condition?
 Is he the next of kin, and are there other close relatives or friends who would be
appropriate to speak to?

 Outline the basis and prognosis of his mother’s condition by explaining the following
in simple language.
o Cause of the problem: a ‘low level of salt (or sodium) in the blood’, which can
have many causes; and that the low salt level can itself cause loss of
consciousness, but that you are also excluding other causes of coma.
o Treatment: that the low salt level can be corrected with a drip and by
restricting water intake.
o Outlook: uncertain. The very low level of sodium can cause irreversible brain
damage or death, and the longer-term outlook depends on the underlying
cause of the condition

 I’m not hiding anything when I say I don’t know.

 Unfortunately it is very early days and I cannot give a guarantee that she
will get better.
 We’re trying to rule out other causes, but we think the reason for her

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 being unconscious is the very low level of salt in her blood and we’re
trying to correct this.
 However, this has to be done slowly and carefully: doing it too rapidly
can itself cause or worsen damage to the brain.

 I’m afraid that I don’t know.

 As you can see, she is unconscious now, which means that her brain has
been badly affected by the problem.
 It is possible for people to make a complete recovery from this situation,
but that isn’t certain.
 She could die, or could be left with some permanent brain damage.
 I’m afraid that we just can’t tell at the moment.

 Again we’re not 100% sure.

 The most likely reason for it is a reaction to a tablet that she was taking
for her high blood pressure, but there are other causes that we need to
check for.
 It’s not a common problem, but sometimes some sorts of infection or
some sorts of cancer can cause it.

 As I’ve said before, we’re not absolutely sure what’s causing the problem.
 The most likely thing is a reaction to one of her tablets, so I think that
cancer is unlikely, but at the moment I can’t rule it out and it is one of
the things we need to consider.
 Is there something that makes you suspect that your mother may have
cancer?

 The tablet that she was on is one of the drugs that is most widely used to
treat high blood pressure, and it normally doesn’t cause any serious side
effects at all.
 However, very rarely it can cause the salt in the blood to drop very low,
and that’s what we think is most likely to have happened in your
mother’s case.

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 you are the admitting doctor working on an acute medical ward.

Mrs Harriet Claremont, a 64- year-old woman, has presented with with severe but non-
specific lethargy and fatigue, and is found to have a serum calcium of 3.2 mmol/L.
The initial history and examination fail to provide a clear diagnosis for this.
There are no features to suggest malignancy, but the possibility cannot be excluded.
The patient’s daughter visits the ward wanting to discuss the possible causes of her
mother’s condition with you, and Mrs Claremont gives you permission to talk with her.
She is particularly worried because of the recent demise of her aunt (the patient’s sister)
from lung cancer.
to explain what is meant by hypercalcaemia, and to discuss likely
investigation and possible diagnoses.

 What does the daughter already know, and what are her main concerns?
 Ask her to tell you about these before embarking on explanations.

Explain the following in simple terms:

• the diagnosis and possible causes of hypercalcaemia;
• that the underlying diagnosis is not certain and that it will not be possible to give a
reliable prognosis until it is, but there is a range of possibilities from the benign to the
malignant.

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 There is an abnormally high level of calcium in the blood, which can
cause the tiredness and fatigue that your mother is suffering from.

 I don’t know at the moment, but there are many possible causes that
we need to check for.
 One of the most common is overactivity of the glands which normally
control the blood calcium level, called parathyroid glands, and this is
usually caused by a small benign tumour that can be removed with a
simple operation.
 But there are some more worrying possible causes, including some
types of cancer.

 No, I’m not sure that it is.

 As I’ve said, it’s certainly a possibility that we need to look for, but I’m
not hiding anything when I say that we don’t know what the cause of
the problem is at the moment.
 It could turn out to be a cancer, but it could turn out to be something
much more straightforward.

 I won’t force any information on her that she doesn’t want to know,
but I won’t keep things from her if she does want to talk about them.

 I hear what you say and I understand it.

 As I’ve said, I won’t force anything on to her that she doesn’t want to
hear, but I will ask her if she’s got any questions about things, and if
she has I will answer them as simply, honestly and kindly as I can.
 But if she doesn’t ask, then I certainly won’t force information on her.

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 you are a junior doctor working in the Endocrine Outpatient Clinic.

Miss Irene Harris has come back to the clinic to discuss the results of investigations for
hirsutism.
She is 21 years old and has been troubled by mild to moderate hirsutism since menarche:
she has been bleaching or shaving her upper lip weekly and waxing her abdomen and
thighs monthly.
She has regular periods.
Her blood tests, including luteinising hormone, follicle-stimulating hormone and
testosterone, are all normal.

to explain to the patient that she has idiopathic hirsutism, and that
treatment options include cosmetic hair removal and various tablets, eg Dianette (an oral
contraceptive pill, with limited efficacy for hirsutism, that typically reduces hair growth by
one-third).

 What is the patient’s main worry?

 Ask her if she is concerned that she has a serious underlying disorder, in which case
the diagnosis will be a relief, or if she simply wants you to give her a tablet to make
things better for her forthcoming summer holiday, in which case she is likely to be
disappointed!
 Does she have other concerns?
 For example, is she worried about fertility? This is unlikely to be a problem in view of
her regular periods and normal blood tests.

 Explain the following in simple terms.

 Reassure her that there is no sinister underlying pathology: the diagnosis of
idiopathic hirsutism is good news, and no further investigations are needed.
 But at the same time remember to be sensitive and ensure that you do not sound as
if you are dismissing any concerns that she might have as no longer being important.
 Explain the basis for her condition: she may find it helpful to learn that some of the
hair follicles on her body are simply a little more sensitive to the normal levels of
circulating androgens (which all women have), leading to a coarsening of these hairs.
 This is a very common problem, and indeed can be viewed as one end of the normal
spectrum for hair distribution in women.
 Emphasise that she is not becoming ‘masculinised’ in any way.
 If appropriate, mention that there are significant racial differences in hair biology
and that hirsutism can run in families: she may know relatives who have had similar
problems.
 Address the patient’s expectations:
 while it is important not to minimise symptoms that are troubling a patient, it may
be appropriate to discuss the difference between the ideal woman portrayed by the
media and the biological norm (in terms of body fat and hair distribution).

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 I can understand why you say that, but it’s not the case.
 You have normal periods and you’re not going to turn into a man at
all, but your body is more sensitive to the normal levels of male
hormones that you and all other women have, and this shows itself
in the way that the hair grows.

 No, that’s unlikely.

 This condition most often causes a reasonably stable level of
unwanted excess hair throughout life, although weight gain can
make the situation worse.
 However, it can become more pronounced at the menopause with
the change in balance between male and female sex hormones.

 It is true that the condition tends to run in families, but different

individuals are affected to varying degrees, and some not at all, just
as some people with the same parents are taller or shorter or have
different hair or eye colour.

 It is important to appreciate that this is not an illness, but rather

one end of the spectrum of body hair growth that is normal for
women.
 Many women have to use cosmetic hair removal to achieve an
appearance that they are happy with and these remain the mainstay
of treatment for you.
 It is important to understand that no tablets are without side effects.
 We can give you a tablet that is likely to reduce the hair growth by
about a third, but you are still likely to need local hair removal
treatments.
 The tablet has a contraceptive action (Dianette), so is not suitable if
you want to get pregnant and has risks associated with other oral
contraceptives, including an increased risk of developing blood clots
in the veins.

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 you are a junior doctor working in the Endocrine Outpatient Clinic.
Miss Alison Jackson, aged 17 years, presented to her GP with short stature and primary
amenorrhoea.
Your initial clinical assessment has revealed numerous features (webbed neck and cubitus
valgus) that are suggestive of an underlying diagnosis of Turner’s syndrome.
The GP had already mentioned this as a possibility, and the patient has read up about the
condition on the Internet.
to explain the meaning of ‘karyotype analysis’ and to ensure that the patient
has an appropriate understanding of Turner’s syndrome.

 What does the patient already know and what are her main concerns?
 Has she heard or read about ‘karyotyping’ or ‘chromosome analysis’?
What has she learnt about Turner’s syndrome from discussions with her GP and her
reading on the Internet?
Explore these matters before embarking on explanations.

 Explain why you (and the GP) believe that the patient might have Turner’s syndrome.
Recap the salient features from the history and examination (and any relevant
available investigations).
 Emphasise the importance of confirming the diagnosis through biochemical testing
and karyotype (chromosome) analysis.
 Explain how studying the chromosome pattern helps to establish the diagnosis.
 Briefly mention the associated features of the condition, but try to avoid an over-
detailed discussion at this stage when confirmation of the diagnosis is still awaited.
 It is important to point out that not all patients manifest all features of the condition.

 Because I think it’s likely that you have a condition called Turner’s
syndrome, and checking your chromosomes is the best way of making
this diagnosis.
 The chromosomes contain the genetic information that governs how all
the cells and tissues in the body develop.
 In Turner’s syndrome there is a distinctive alteration in the chromosome
arrangement – one of the chromosomes called the X chromosome is
missing in some or all of the cells of the body – and this can be easily
detected in most patients by looking at the chromosome pattern in a
small number of cells taken from a simple blood sample.
 This test is called chromosome analysis or karyotyping/karyotype
analysis.

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 No, you don’t have to have any test done that you don’t want, but I
think it would be a good idea to do it.
 You went to your doctor because you were worried that you hadn’t
grown as much as your friends and that your periods hadn’t started.
 If we can find out why this is, then we should be able to help; but if we
don’t do any tests and don’t find out what’s causing the problem, then
I’m afraid that we’re not going to be able do anything about it.

 No, it doesn’t mean that at all.

 The absence of one of the X chromosomes, and the impact that this has
on some of the tissues of the body such as the ovaries, is the reason
why you haven’t grown as tall as your friends and have not yet
developed fully.
 But with the correct hormone replacement treatment we will be able to
help you grow and develop.

 You might not finish up quite as tall as other girls of your age, but
remember that there’s a lot of variation in the population as a whole, as
I’m sure you’re aware from looking at your friends – some are shorter
and some are taller.
 Many women with Turner’s syndrome have similar thoughts/questions
about their femininity, and this has led to the formation of the Turner’s
Society, a patient support group.
 I can give you their details if you like.
 The society’s view is that women with Turner’s syndrome should have
no doubt about their femininity: physically, behaviourally and sexually.

 I think we need to do the chromosome analysis before we say that we’re

sure that you have Turner’s syndrome, so at this stage I don’t think we
should get into very detailed discussion about other conditions that may
be associated with the syndrome.
 But if the diagnosis is confirmed then we will need to talk things
through thoroughly.
 However, do remember that although it is true that Turner’s syndrome
can be associated with a variety of conditions that can affect the heart,
thyroid and kidneys, not all patients with Turner’s syndrome are
affected by these.

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 you are a junior doctor working in the Endocrine Outpatient Clinic.

 Miss Manju Patel, aged 26 years, was referred by her GP because of concern that
there may be an endocrine cause for her obesity(weight 90 kg, BMI 38 kg/m2).
 Her periods are regular.
 She is mildly hirsute and has faint striae over her lower abdomen.
 Examination is otherwise unremarkable.
 Investigations have excluded polycystic ovarian syndrome, hypothyroidism and
Cushing’s syndrome, and the diagnosis is one of ‘simple obesity’.
 Both her parents are also obese.
Miss Patel remains convinced that ‘her glands are to blame’ and states that
she‘wants something done about it.’
to explain to the patient that no underlying endocrine cause for her obesity
has been identified and to provide advice on weight loss management.

 In this common scenario, as in others, it is important to allow the patient time to

explain her view of things before launching in with explanations.
 Why does she continue to believe that her ‘glands’ are at fault, and which ‘glands’
does she believe are not working properly?
 What is she hoping/expecting the doctor to offer her in terms of treatment?

 Explain that there are many different reasons why somebody might become
overweight or obese (see Table 10), but that in most cases it is due to an imbalance
between energy intake and expenditure.
 An individual’s genetic make-up can affect their predisposition to weight gain, but
environmental and behavioural factors are equally important in determining whether
or not this occurs.
 Emphasise that endocrine causes of weight gain/obesity (eg polycystic ovarian
syndrome, hypothyroidism and Cushing’s syndrome) have been looked for and
excluded.
 Explain that further medical tests are not required and that attention must now
focus on helping her to lose weight through dietary and lifestyle modifications,
supplemented with pharmacological/surgical interventions where necessary/
appropriate.

 No, we haven’t checked all your glands, but we have checked the
ones that can be relevant to problems with body weight.
 In particular we’ve done tests on the thyroid, the ovaries and the
adrenal glands, and we’ve not found any evidence to indicate a
specific problem with any of these.
 Are there any other glands that you are worried about specifically?

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 How heavy a person is depends on the balance between how much
energy is taken in – how much they eat and drink – and how much
energy they burn – how much exercise they do.
 But people are variable: we all know some people who can eat what
they like and stay thin; and we know other people who put on a lot
of weight without eating an enormous amount, just more than their
body can burn off.
 I know that life’s unfair, and you may not be eating more than some
thin people do, but you are clearly eating more than your body can
burn off.

 Those are easy things to say and they might do some good, but as
I’m sure you know it’s often not as straightforward as that.
 I’d like to offer some help if you’d like to have some: I would like to
refer you to a dietitian who will be able to provide you with
information on the calorie content of different foods and how to
achieve a healthy-balanced diet that will help you to lose weight; and
I think that it would also be very important for you to undertake
regular exercise.
 This could begin with taking a brisk walk each day or swimming,
and doesn’t mean that you have to join a gym! But if you would like
to take up regular supervised exercise, then many gyms can help
out with this.
 It is also important to alter your day-to-day routine, for example use
the stairs rather than taking the lift, walk or cycle to work rather
than using the car, all these things can help.

 I am confident that if you do manage to alter your diet and lifestyle

to achieve a situation where you are expending more calories than
you are taking in, then you will lose weight.
 If this is proving difficult to achieve, then we could consider
prescribing one or other tablets to try to help with this, but I don’t
think we will need to reinvestigate your ‘glands’ unless there are
some new symptoms or changes to indicate that we should do so.
 The glands aren’t the problem, and I don’t think it’s going to be
helpful to keep focusing on them.

 There are three reasons for not racing into tablets or operations
straight away.
 Firstly, adjusting your diet and exercise are the most appropriate

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 and logical first steps to tackle weight gain in this situation because
they directly address the underlying cause of the problem.
 Secondly, tablets or surgery rarely work in isolation, and lifestyle
adaptation is an important component if these are to succeed.
 Thirdly, tablets and surgery can both have side effects and
complications, so we should start with the simple things: diet and
exercise.

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 you are a junior doctor working in the Endocrine Outpatient Clinic.

Mrs Isabel Bur ns, a 35-year-old woman recently diagnosed with primary adrenal
insufficiency (Addison’s disease), has raised several concerns over her lifelong requirement
for steroid treatment.
She is particularly worried about weight gain.

to explain the rationale behind physiological glucocorticoid replacment.

 Patient education is extremely important for those with adrenal insufficiency: this
woman will have to assume responsibility for a life maintaining therapy that requires
adjustment at times of stress.
 But before embarking on a worthy lecture, encourage her to express her concerns.
 Why is she worried about taking steroids?
 Has she ever taken them in the past, or known anyone else who has?
 And did they have problems?

 Explain the following in straightforward terms.

 Physiological versus pharmacological steroid treatment: it is important for the patient
to realise that steroid treatment in this setting is to replace what is normally
produced by the body and not to administer a pharmacological dose, as would be
required for treating inflammatory conditions such as rheumatoid arthritis or
asthma.
 A physiological dose is most unlikely to have side effects.
 The importance of compliance: she requires lifelong steroid replacement therapy.
 Failure to take an appropriate dose leaves her vulnerable to adrenal crises, which
are potentially life threatening.
It is also important to carry a steroid card or bracelet so that in the event of being
unable to communicate (eg if involved in a car accident) appropriate medical
treatment can be given without delay.

 Steroids are essential for life: everyone’s body produces steroids, and
the most important one is cortisol.
 The condition that you have destroys the glands that make this – the
adrenal glands that sit just above the kidney and release cortisol into
the bloodstream.
 This process is important for controlling many systems in the body,
including those that regulate blood pressure and response to stress.
Without cortisol your body cannot respond properly to stress: your
blood pressure can fall, you may suddenly become very unwell and in
rare cases the problem can be fatal.

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 So steroids are important, they’re not something that you or I could
just decide to do without.

 No, it won’t.
 They were almost certainly being given steroids as a drug to treat an
illness: asthma, arthritis – do you know what it was? The aim of
treating you with steroid is quite different.
 Everyone’s body normally makes some steroid, but in you this doesn’t
happen because the adrenal glands are damaged.
 So what we’re aiming to do is to give you back only the amount of
steroid that your body would produce naturally: we’re not intending to
give you any extra.
 Therefore, we don’t think that you should suffer excess weight gain as
a result of this steroid treatment.

 I can understand what you’re saying.

 The important thing is that, if you were to become unwell you might
not be able to tell a doctor looking after you about the fact that you
had Addison’s disease and needed steroids.
 So you need to carry something on you at all times that would give the
doctor this information.
 Some people carry a steroid card in their purse or handbag, some
people wear a Medic-Alert bracelet or necklace, but it’s important that
you carry something.

 When someone gets ill their body naturally makes more steroid.
 However, yours can’t do that, so the simple rule is that you take
double the normal dose if you feel unwell and go back to the normal
dose as soon as you feel better.
 There are no side effects from a few days of double-dose steroid, so if in
doubt just increase the dose.
 If you’re back to normal the following day, then cut back the dose to
normal.

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 you are a junior doctor working on a general medical take.

Mrs Agnes Keane, a 93-year-old woman resident in a nursing home, presents with a
massive haematemesis on a background of long-standing heart failure and chronic renal
failure.
She requires full care in the home for all activities of daily living, both because of her heart
disease and her advanced dementia.
On arrival in the Medical Assessment Unit she is unresponsive, has an unrecordable BP
and is pale, with fresh blood around her mouth and melaena stool evident in the bed.
An intravenous drip has been put in and resuscitation with colloid commenced by the
Emergency Department staff, who ask you to assess her.
You contact the on-call medical consultant who decides that Mrs Keane should not
undergo further investigation or treatment but should be kept comfortable.

to explain the situation and management plan to Mrs Keane’s daughter.

 Begin by finding out the daughter’s understanding of her mother’s condition:

although the situation seems clear-cut, it cannot safely be assumed that the
daughter will recognise this.
 Therefore, you need to explore the daughter’s expectations of what the outcome is
likely to be, and also what she believes her mother would want with regard to
treatment and investigation.

 That Mrs Keane is dying.

 The inappropriateness of aggressive medical interventions in the context of a patient
who is dying.
 That you will listen to the daughter’s concerns, but that you will not ask her to make
decisions about offering or declining particular treatments, which are medical
decisions.
 That doctors are not obliged to provide treatments that they consider to be futile.

 I’m afraid that we don’t know for certain.

 The blood is coming from her gut, and it is most likely that she has
developed an ulcer in her stomach or the top of her small bowel: this
has probably developed over a small blood vessel which is now
bleeding.

 she has bled so much that her blood pressure has dropped very low.
 This means that blood is not getting to her brain properly.

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 there isn’t an easy way to do this, and we don’t think it would be right
to put her through a lot of investigations and treatments that wouldn’t
do any good and which would cause her distress.
 The most important thing is that we make sure that she is
comfortable.

 I’m sorry, but I’m afraid that your mother is dying.

 As you know, she has problems with a poor heart, poor kidneys and
her mind has gone with dementia, and in the situation she is in now
she would be very unlikely to survive for more than a short while
whatever we did.
 We are going to make sure that she is comfortable: it would be wrong
for us to prolong her dying.

 at the moment it wouldn’t be safe to have a look into your mother’s

stomach with a telescope.
 She is unconscious and could not protect her airway, and her blood
pressure is too low for the heart to take the strain.
 If we were to try to do a telescope test we would have to begin by
putting her on a breathing machine and giving her a lot of fluid to
bring up her blood pressure.
 Even if we did that it wouldn’t be guaranteed that the test could be
done safely, or that it would be able to find out what’s going on.
 It really wouldn’t be kind or sensible to do this.

 yes I have, and what I’m explaining to you is what he has asked me to
say.
 If you want to speak to him directly then I can try to arrange this.
 Would you like me to?

 I cannot say for sure, not because I’m hiding anything but because I
don’t know.
 She has bled a lot and her blood pressure is very low.
 She could die very soon – over the next few minutes – or it could be
longer if the bleeding slows down, which it can sometimes do.

 yes, she isn’t responding at all at the moment.

 She is unconscious and can’t feel anything.
 But if she did seem to become distressed, if she seemed to be in any
pain, then we would give her something to make sure she was
comfortable.

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 you are a junior doctor working in a gastroenterology outpatient clinic.

Mr David Chan is a 25-year-old man who has experienced symptoms of irritable bowel
syndrome for 8 years and has been extensively investigated previously.
He is convinced that his symptoms have worsened considerably and is particularly worried
about a recent bout of constipation because he thinks it might indicate cancer.
A physical examination is unremarkable and routine tests such as FBC are entirely
normal.
He wishes to have a colonoscopy, but the consultant who saw him previously said that this
was not indicated and declined to perform the investigation.

to explain to the patient the reasons why the test is not indicated nor on offer, and what
the nature of irritable bowel syndrome is.

 This is clearly going to be a difficult discussion.

 Begin by asking the patient to explain to you what he thinks is causing his problems,
and what his fears and concerns are.
 Constipation is a common symptom in irritable bowel syndrome (IBS), so is there any
particular reason why he is worried about cancer now?

 You recognise that IBS causes distressing symptoms, but it is benign in the long
term, ie it does not lead to excess mortality or predispose to developing other
conditions such as colorectal cancer and inflammatory bowel disease.
 Decisions about investigations depend on balancing benefits and risks, and
colonoscopy is not without hazards.
 Doctors are not obliged to offer tests or treatments that they do not think are
clinically indicated.

 even if you do every test possible, it cannot be proved that cancer is

impossible.
 But everything we know about you, including the fact that your
symptoms have been going on for a long time, that everything is as it
should be on examination and that routine blood tests are normal, are
reassuring that you do not have a serious disorder such as cancer.

 no, this wouldn’t be the right thing to do.

 Deciding about tests or procedures is a matter of balancing benefits and
risks, and colonoscopy does carry a small risk of serious complications,
such as perforation of the bowel.
 It wouldn’t be right to put you or any patient at risk of this if there

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 wasn’t a proper reason for doing the test.

 no, that’s not the main reason for me saying that we won’t do the test.
 The main reason is because the test stands more chance of doing you
harm than doing you good, although I agree that it isn’t right to spend
healthcare money on something that isn’t justified.

 no, that’s not true.

 No patient has a right to a test or a treatment that is not clinically
indicated.
 You do have a right to have a second opinion if you want it, and if you’d
like me or your GP to recommend someone then we can do, but you
can’t insist that we do a test that we don’t think is justified.

 no, that’s not what I’ve said and it’s not what I think.
 There is no doubt that the symptoms of irritable bowel syndrome exist
and can be really severe and worrying; and I and the other doctors in
the clinic will help as much as we can to control them.
 However, we won’t do things that we don’t think will help.

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 you are a junior doctor working on a general medical ward.

Ms Cathy Evans, a 34-year-old woman who says that she has recently moved to the area
and is not registered with a GP, is admitted with episodic severe abdominal pain.
At times this seems to be excruciating, such that she rolls around in agony and calls out
for pethidine, but between attacks she seems well and appears unconcerned about her
condition.
Examination reveals two laparotomy scars, the indications for which are unclear.
Routine laboratory tests and plain radiographs are normal.
She has been on the ward for 3 days and matters do not seem to be improving.
It is the opinion of your consultant that the woman has factitious abdominal pain and that
no further investigations should be performed.
Ms Evans is unhappy with the lack of investigation since admission and has demanded to
see someone to discuss this.
Your consultant has asked you to get more information regarding her background history,
which Ms Evans has been unwilling to provide.

to explain to Ms Evans that further details of her medical background are required and
that further investigation is not indicated.

 This is clearly going to be a difficult discussion.

 Begin by asking the patient to explain to you what she thinks is causing her pain
and what she thinks should be done about it.
 Use comments made by her, which she will almost certainly intend as justification
for investigation, as reasons for needing precise details of her past medical history.

 Reassure her that the progress of her illness and the results of investigation do not
indicate serious intra-abdominal pathology.
 Be firm and persistent in requesting specific details: when, which hospital and which
doctor, etc? But do not become confrontational.
 Doctors are not obliged to offer tests or treatments that they do not think are
clinically indicated.

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 you are right that we haven’t got to the bottom of things yet, but the
tests that we have done have not revealed anything worrying, which is
good news.
 We don’t think that a CT scan will add anything useful at this time, but
we do need to find out as much as we can about the previous problems
you’ve had in your abdomen, just in case these are relevant to what’s
happening now.

 you don’t have to tell me anything that you don’t want to, but it is very
difficult for us to manage you safely without knowing about your past
medical history, in particular about the operations that you have had.
 These details may help us get to the bottom of your current problems
and we could miss things if we do not have all the information.
 Can you remember in which hospital you had them done, and when?

 we’re not sure, but we don’t think there is a serious problem in your
abdomen.
 Pain can be caused by a number of things, not all of which can be
demonstrated on blood or X-ray tests.

 no, I haven’t said that.

 I don’t know what’s causing your pain, but you are right that
psychological problems can sometimes present in this way and are a
potential cause for stomach pain.
 They do need to be considered in order to enable us to get expert help if
this is indeed the case.

 we do not think that giving you lots of pethidine to mask the problem is
going to help us get you better.
 But if the pain is continuing to be troublesome, then we would be more
than happy to obtain specialist advice from the doctors in the pain
clinic.

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 You are a junior doctor in a rheumatology outpatient clinic.
Mrs Hope Adams, aged 50 years, has recently been referred to the outpatient clinic with cold fingers.
The clinical suspicion from the initial consultation that she has secondary Raynaud’s in association with
systemic sclerosis has been supported by the detection of anti-centromere antibodies in her blood.
She tells you that, despite her doctor’s concern, the Raynaud’s does not trouble her too much and she can
control her symptoms by avoiding cold weather and wearing gloves.
To explain to Mrs Adams the diagnosis of systemic sclerosis, including the uncertain
prognosis and lack of curative treatment.

 How does she currently view her problems?

 Does she appreciate that she may have a serious chronic condition, and that the disease may progress
beyond the symptoms of her Raynaud’s?
 Approach this by asking what she was told at the last clinic appointment: was it mentioned that her cold
fingers could be a feature of a more widespread disease?
 This is a ‘warning shot’ before explaining the diagnosis.

 Tests have suggested that she may develop more than cold fingers in the future: they are associated with
a disease called systemic sclerosis, or scleroderma, which means ‘hard skin’.
 In this condition the skin, usually of the hands and feet, swells and thickens and becomes stiff, tight and
shiny.
 This ‘hardening’ or fibrosis can also affect internal organs, which can cause a variety of symptoms
depending on which organ is involved.
 As and when other symptoms develop, they can be addressed and treated.
 However, there is no effective treatment for the underlying condition.
 Regular reviews are required to direct symptomatic treatments, anticipate problems with screening tests
and provide support.
 If the patient does develop other problems, referral to a regional centre with a relative special interest
may be appropriate.

 that’s a good question: it’s because of the blood tests.

 They show that you have an antibody that is linked with a condition called
scleroderma, and it is common for people with this condition to have cold hands –
Raynaud’s – for many years before they develop skin thickening or any other
problems.

 I’m afraid that I cannot say for certain, not because I’m hiding anything, but because I

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 don’t know.
 Sometimes it just causes very slow thickening of the skin, especially of the hands and
feet.
 But sometimes it causes thickening of the tissues of internal organs, and that can lead
to a variety of problems.

 I don’t want to cause you unnecessary concern because all these things certainly don’t
happen to every patient, but it can cause problems with the gut, particularly difficulty
with swallowing, a variety of problems with the lungs, and problems with the kidneys,
including very high blood pressure.

 I can give you a leaflet on scleroderma today, and also the contact details for the
Raynaud’s and Scleroderma Association.

 I’m afraid that we don’t have any good treatment that will cure the scleroderma: we
don’t have anything that will make it go away, but what we can do is to help the
problems that it causes.
 For instance, if it causes problems with indigestion or swallowing then there are tablets
that we can recommend – strong anti-indigestion tablets – that can help.
 If it causes problems with your blood pressure, then it’s important to try to control this
very carefully to prevent serious complications.

 as I said, we don’t have any treatment that will cure scleroderma, but we can do things
that will help.
 By monitoring you in clinic we can try to pick up any problems early on, rather than
waiting until things have got really bad.
 For instance, we would keep a careful check on your blood pressure and your lungs,
and we would recommend treatment if problems were developing.
 Good treatment of blood pressure would be very important in cutting down the
chances of you developing kidney failure, or other problems.

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 you are a junior doctor working on a general medical ward.
You have admitted a 58-year-old woman for urgent investigation.
She has a 2-week history of low back pain which is now keeping her awake at night.
Over the past 2 days she has noticed progressive numbness and weakness of both legs, and also sphincteric
weakness.
She had breast cancer with axillary node involvement 4 years ago, but was told at her last outpatient
appointment in the oncology clinic 6 months ago that she was‘fine’.
On examination she has bilateral lower limb sensory impairment and lower motor neuron weakness.
A plain radiograph of the spine shows at least one suspicious lesion.

to explain to her that she has cord compression of uncertain cause but with a strong suspicion of malignancy.
The plan will be for her to have MRI of the spine and that surgery will probably be recommended, but that this
will not be curative.

Your discussion with the patient should cover the following areas:
• her understanding of the problem;
• your explanation of her symptoms;
• the probable underlying cause;
• the treatments available;
• the likely prognosis.

• That there is a problem with the patient’s spine: it is pressing on her spinal cord and causing a blockage of the
nerve signals to the lower half of her body.
• That this is a serious problem, probably related to her breast cancer, which needs urgent investigation and may
require surgical intervention.

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• That, even in the worst case, there will always be support and a plan of management.
In routine clinical practice (and in PACES, although the offer will inevitably be declined) encourage the
presence of a close friend or relative if the patient wishes it.
As well as providing support, this will spare the patient the necessity of repeating the explanation and may
improve her overall understanding of the problem.

 I don’t know, but I’m afraid that there is a good chance that it could be the cancer.
 We won’t know for certain until we have done some tests.
 We’ll start off with a scan, an MRI scan, of the spine and then probably perform an
operation to relieve any pressure on the spine and take samples for analysis.
 If it is the cancer, we will arrange for you to see the cancer specialist to talk about
further treatment.

 I know, because at that time you hadn’t got any back pain or any problems with your
legs.
 If this is the cancer coming back, then it seems as though that’s happened just in the
last few months.

 that’s a good question, but I’m afraid that I don’t know the answer.
 Scans of the spine aren’t organised as a routine, only if there seems to be a problem.
 However, this is something that you could discuss with the oncologists if and when
you see them.

 you’re right in saying that all surgery has risks, but this is not something we’re going
to race into.
 The surgeons will look at your scans very carefully and will discuss things with you
before you make the final decision.
 They will only recommend going ahead if they agree that there is a good chance of
success.
 If you didn’t have surgery, your legs might get worse and it would be difficult to
know what was causing the problem or how to treat it.
 Is there anything in particular about the surgery that is worrying you?

 if it is possible to remove it, then the surgeons would do so.

 However, trying to remove the whole tumour may well damage your spinal cord so
it’s likely that the surgeons will just take enough to relieve any pressure.
 If further treatment is necessary, then radiotherapy treatment or medication will
probably be recommended, but this is something on which the oncologists would
advise.

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  if it is cancer, then you are right in thinking that we probably won’t be able to get rid
of it completely.
 But having said that, there are treatments that can work pretty well and it is possible
for some people to live a relatively healthy and normal life for some time, even
though the cancer is not completely removed.

 It is important that you are realistic in your explanations.

 This patient will undoubtedly need to have trust and confidence in her medical team in the future.
 Although it is important to be as positive as you reasonably can be in your attitude, a falsely over-
optimistic assessment at this stage is likely to result in increased distress and loss of trust in the medical
team in the future.

you are a junior doctor in a rheumatology outpatient clinic.

You are seeing a 38-year-old woman who is attending the clinic for her first follow-up
appointment.
She was first seen in the clinic 6 weeks ago (by the consultant), when she gave a 3-year
history of widespread pain, profound fatigue and poor quality sleep.
These symptoms were associated with significant disability, and she reported spending
much of her day in bed and being heavily dependent on her family.

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The notes record that she was ‘sad, withdrawn and angry’.
Examination revealed very widespread tenderness with numerous tender ‘trigger points’,
but movement of her joints was unrestricted and no neurological abnormality could be
detected.
The consultant felt that a diagnosis of fibromyalgia was likely, with some evidence of
associated depression. Various investigations including FBC, erythrocyte sedimentation
rate, C-reactive protein, bone/liver/ kidney/muscle biochemistry, thyroid function tests, a
screen for autoimmune/vasculitic disease and a CXR were performed and all were normal.
to explain the diagnosis of fibromyalgia to the patient and suggest a graded
exercise programme, and also the possible benefits of treatment for depression.

 This consultation would be likely to be difficult, even for an experienced clinician.

 It is important to:
find out what the patient thinks is causing her problems and what her expectations
are – discussions are likely to be easier if you are aware of the patient’s perspective;
pursue the role that depression and other psychological factors might be playing in
the illness.

 It is essential to establish an atmosphere of trust, taking the patient’s physical

symptoms seriously and acknowledging their reality.
Explain fibromyalgia as a pattern of muscular pain that can be severe and
distressing, but which is not associated with any tissue damage.
 Explain that factors such as sleep disturbance, loss of physical fitness (conditioning)
and low mood can perpetuate the pain and make it worse.
 Some patients find it difficult to accept that depression can cause pain, but most will
see how pain and sleep disturbance can cause depression.
 It is rarely productive to get drawn into a ‘chicken or egg’ argument about pain and
depression, and it is usually easier and more helpful to explain how vicious circles
between these factors can worsen the pain (see Fig. 23), viewing low mood as a
practical problem to be solved in helping to overcome the pain.
Explain that treatment is not easy and that a complete, rapid cure is unlikely, but
also that addressing the perpetuating factors can improve function and quality of life
for most patients.

 no, your pain is real and is clearly causing you distress and
affecting your life.
 Many kinds of rheumatic pain do not lead to changes in the blood
or abnormalities on X-rays.
 Nevertheless, it is good that fibromyalgia is not associated with any

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 long-term damage to the tissues.

Doctor:  this is a very common concern for people with fibromyalgia,

because exercise can certainly make the pain and tiredness worse.
 Nevertheless, we know that graded exercise programmes are one of
the most helpful treatments for patients with fibromyalgia.
 The key thing is to approach exercise in the right way, and this
usually needs help from a physiotherapist.
 You need to start with an amount of exercise that you can cope
with easily, repeat this regularly, and just gradually increase the
amount you are doing.
 You will only improve if you are able to exercise three times a week
or more.
 At first the exercise will cause some discomfort, but if you are able
to come back and do the same again within a day or two, then this
is fine.
 However, if you get so much pain after exercise that you cannot do
anything for a week, then you have started at too high a level.

 you are right that amitriptyline is an antidepressant, but low doses

of amitriptyline and similar drugs are often used in the treatment
of long-standing pain, particularly when the pain disturbs sleep.
 The doses used to manage pain are much lower than those used in
cases of depression.
 I’m suggesting that you take it simply because I think it might help.

 I honestly find it very difficult to know.

 For obvious reasons, people with painful conditions often become
depressed and depression makes any sort of pain worse.
 Treating depression can sometimes be easier than treating pain
and it can certainly do a lot to improve your quality of life.

 no, it isn’t addictive.

 It’s generally safe and well tolerated, although it can cause morning
drowsiness in some people, especially at the beginning of
treatment.

 people with fibromyalgia often have a lot of pain in other parts of

their bodies, and irritable bowel syndrome is very common.
 In most cases treatments for fibromyalgia, such as amitriptyline,
tend to improve irritable bowel syndrome.

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  tiredness is one of the most distressing symptoms in fibromyalgia,
and is also a big problem in many other painful conditions.
 One of the most important causes of the tiredness is sleep
disturbances due to pain, and these often improve with drugs such
as amitriptyline.

you are a junior doctor in a rheumatology outpatient clinic.

Mrs Susan Terrell, a 40-year-old secretary, has recently been diagnosed with erosive
rheumatoid arthritis after she presented with a 3-month history of disabling joint pains
affecting her wrists and fingers.
She has a strongly positive rheumatoid factor and has had a persistently elevated serum C-
reactive protein of 40–75 mg/L since presentation, both of which are adverse prognostic
factors.
Although it has been explained to her that treatment with a disease-modifying
antirheumatic drug (methotrexate) is her best hope of preserving joint function in the long

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term, she is unconvinced of the need to start treatment with this drug at this juncture on
account of its possible adverse effects.

to explain to Mrs Terrell why it is in her best interests to take methotrexate.

 The decision whether to take any drug should depend on the balance of benefits and
risks.
 Anxiety about drug-induced adverse effects is entirely understandable, and
methotrexate can certainly be toxic, but the key issues to explore here are the
patient’s perceptions of the benefits and risks to her.

 Do not be dismissive of the patient’s concerns: recognise her anxiety regarding the
impact of the diagnosis and what the future might hold.
Explain the reasoning behind the recommendation to commence methotrexate rather
than use symptomatic treatments alone, ie she has active disease with adverse
prognostic indices comprising radiological evidence of joint erosions coupled with a
persistently elevated C-reactive protein and a positive rheumatoid factor.
 Emphasise that the risk–benefit ratio of treatment in this situation is heavily tilted
towards treatment.
 Explain the potential long-term consequences of not undertaking treatment with a
diseasemodifying antirheumatic drug.
 Offer to introduce her to a clinical nurse specialist in rheumatology for more detailed
discussion.

 as you know, it’s impossible to guarantee that any drug will not cause
problems.
 Deciding whether or not to recommend any drug is always a matter of
balancing benefits and risks, but most people who take methotrexate
do not get any problems with it and it’s a very effective drug for
treating rheumatoid arthritis in many cases.

 adverse effects such as nausea, loss of appetite and diarrhoea occur

in up to 1 in10 patients, but most of these individuals usually get
better on their own without the need to stop treatment.
 Low blood counts may occur in up to 1 in 20 patients, but these
should be detected by routine monitoring, which is necessary for
anyone taking the drug, before they cause a problem.

 like any medication which dampens the activity of the immune

system, methotrexate may suppress production of white blood cells in
the bone marrow and increase your susceptibility to infections.
 It also has the potential in a few patients, less than 5% of cases, to
cause liver problems or lung inflammation.

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  yes, in most patients both bone marrow suppression and liver or lung
problems are reversible.
 Regular follow-up and blood test monitoring means that we would
pick up evidence of them at an early stage.
 It would be equally important that you told us if you felt unwell or
developed a cough or shortness of breath while you were on the drug,
so that we could check things over promptly

 yes, there are other drugs which modify disease activity, but all of
them have side effects, many similar to those of methotrexate.
 Methotrexate is the one that’s been around the longest and none of
the other drugs are clearly better, so that’s why we recommend
methotrexate in the first instance.

 yes, I would take methotrexate or one of the other disease-modifying

antirheumatic drugs if I had evidence of active erosive disease,
because of the strength of evidence showing that early treatment
prevents further joint damage.

 you can wait if you want to, but that’s not what we recommend.
 Damage is occurring in your joints – we can see it on the X-rays – and
if that damage gets worse, then there isn’t any treatment that will
turn the clock back.

you are a junior doctor on call in the acute medical assessment unit.

Mr Chang, aged 35, has been referred by his GP with chest pain, malaise, lethargy and a
productive cough.
His symptoms have been present for 4 days.
He is otherwise fit and well, and takes no regular medication.
He is a smoker of 20 cigarettes per day.
Investigations have shown that he has right lower lobe pneumonia, and his CURB-65 score
is 0/5 (the British Thoracic Society guidelines scoring system, indicating non-severe
pneumonia in this case).
You feel that his illness could be managed at home, but he thinks he should be admitted

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for treatment.

to explain the nature of his illness and treatment plan, including discharge
with continued treatment at home.

 What are the patient’s concerns regarding discharge?

 Are there any problems with regards to discharge and recuperation at home?
 Is there a support network available if he is discharged?

 Explain the diagnosis and that the treatment plan is in line with current national
recommendations.
 Explore issue of smoking cessation in light of the patient’s current illness.
 Give details of who he should contact if he has any concerns, and suggest
reattendance if any there are problems.
 Explain follow-up plans after discharge.

 no, I don’t think so.

 The investigations have shown us that you have an uncomplicated
pneumonia, and we have started the appropriate antibiotics and
expect that your symptoms will improve over the next few days.
 I’m pleased to say that you do not have any signs of severe
pneumonia, and your treatment can be safely carried out at home.

 I can understand why you might say this, but it’s not true.
 If we felt that you needed to be admitted for treatment, then we would
do so.

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  yes, I am, at least partly.
 People who don’t smoke can get pneumonia, but smoking damages
some of the mechanisms that clear infection from the lungs, so as a
smoker you are more prone to respiratory illnesses.
 Smoking will also delay your recovery from such an illness, so it is
important to consider stopping seriously.
 If you want to try to do this, I would suggest that you discuss matters
with your GP or contact one of the relevant support groups.

 as I said, I don’t expect your symptoms to deteriorate.

 However, if things do not improve or if there are any problems then
you should contact your GP for advice.
 And if things got really bad, which I am not expecting, then you could
come back up to the Emergency Department, although I think it very
unlikely that this will be necessary.

 yes, if all goes well it would be sensible for you to organise an

appointment with your GP to get checked over in a few weeks’ time.
 They will listen to your chest and organise a chest X-ray to check that
everything has cleared up as expected.

you are a junior doctor on call in the acute medical assessment unit.

Mrs Diane Johnson, aged36 years, is complaining of mild, right-sided chest pain.
She is normally fit and well and is a lifelong non-smoker.
On examination she is comfortable at rest and is not breathless.
Her pulse rate is 85 bpm, her respiration rate 14/minute and her oxygen saturation is 98%
(on air).
On auscultation there are reduced breath sounds on the right.
A CXR reveals a small rightsided pneumothorax.
You are happy to discharge her with no further intervention, but with a recommendation to
avoid strenuous exercise (also flying and diving) until review, which you have arranged in 2
weeks.

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She wants further treatment and feels she needs to be admitted.
Her husband is also very concerned.

to explain to Mrs Johnson and her husband that no further intervention is required and
that it is safe to discharge her.

 What are their concerns regarding treatment and planned discharge?

 Is an appropriate environment and support network accessible on discharge?

 Explain the diagnosis, and the reasons for observation versus further intervention.
 Give advice on activity limitation, ie flying, diving and strenuous exercise.
 Explain that in the unlikely event of deteriorating symptoms, she needs to re-attend.
 Explain follow-up arrangements.

 there are treatments that could remove the small amount of the air
that has leaked into your chest, but these involve putting needles or
tubes through the chest wall and so they are not without risk.
 We use them only when patients have a bigger pneumothorax than
yours – so large that it makes them breathless – or the lung is very
collapsed on the chest X-ray.
 I’m pleased to say that you have only got a small pneumothorax on
the chest X-ray and it’s not making you breathless.
 Therefore, the best advice is to wait: in 80% of cases it will get better
on its own.

 it is unlikely that you will, but if you get more breathless or if the

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 pain gets worse, then you should come back to the hospital
immediately.

 we will arrange for you to be seen in outpatients in 2 weeks’ time,

with a repeat chest X-ray.
 If there are any concerns prior to this, contact us or your GP.
 As I’ve already said, if you have more breathlessness or chest pain
you should reattend immediately.

 you are right in thinking that if you have had one pneumothorax
then you are at greater risk of having another one than someone
who has never had
 the problem at all.
 It’s difficult to put a figure on this, but the chances of you having
another pneumothorax are probably about 30–40%.
 But the fact that you do not smoke and are fit and well reduces your
risk of recurrence.

 yes, it’s important that you inform your travel insurance company –
you should always do this if there’s a significant change in your
medical condition – but it should be all right for you to travel.
 The standard advice is that you should not fly for 6 weeks following
complete resolution of a pneumothorax, and diving on holiday,
which changes the air pressure in your lungs, is not recommended.

you are the medical junior doctor on duty on the oncology ward

Mr Ian Booth, the son of a 56- year-old woman with advanced colon cancer who is an
inpatient under your care, asks whether he and his children are at risk of colon cancer.
You have checked his mother carefully, including taking a full family history.
Her brother died of colorectal cancer aged 45 years and her older sister has endometrial
cancer.
Their father also died of colon cancer aged 52 years.
At the multidisciplinary team meeting, it has been noted that the occurrence of cancers in
different members of this family raises the possibility of hereditary non-polyposis colon
cancer (HNPCC), and there was a presentation on the topic.

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The mode of inheritance for HNPCC is autosomal dominant.
A set of criteria, referred to as the‘Amsterdam Criteria’, has been established to assist in
the clinical diagnosis of HNPCC:

1. three or more members of a family have histologically confirmed colorectal cancer, one of
whom is the first-degree relative of the other two;
2. colorectal cancer extends over two or more generations;
3. colon cancer in one member of the family has been diagnosed before the age of 50 years;
4. exclusion of familial adenomatous polyposis.

The risk of colorectal cancer in HNPCC patients is about 70% by the age of 70 years
compared with 2% in the general population.

the son asks you about the risk of him and his children developing cancer
and what to do about it.

This scenario raises a number of issues, including:

 a member of the public asking for advice without appropriate referral;
 consent to release information about one member of the family to another;
 implications of genetic testing not confined to an index case;
 dealing with an anxious relative.

 You are not allowed to release medical details about one person to another without
consent.
 You are not responsible for his or his children’s medical care, and if any medical
testing is necessary he should be advised to seek this via his GP.
 Nonetheless, it would be appropriate and caring to answer his enquiries to help guide
him, and it may be appropriate to obtain blood from his mother (your patient) for
genetic testing with her consent.


 several cases of cancer within a family can occur by chance since one
in three people in the UK will develop cancer.
 However, the young age of your uncle (45 years) and the pattern of
cancers in your family are both suspicious, indicating that some
cancers might run in your family.

 I cannot be sure at the moment, but I am concerned that your family

may be affected by a condition called – I’m afraid it’s a bit of mouthful
– hereditary nonpolyposis colorectal cancer, that’s HNPCC for short.
 I’ll write it down for you.
 This increases the risk of colon and some other forms of cancer.
 If your mother has this form of cancer – and I don’t know for certain if
she does, but she might – then she has a one in two chance of passing
this risk on to you.

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 there are a number of criteria that are used to define families with
HNPCC and your family’s history does suggest that you may have a
higher risk of cancer.
 Genetic testing of blood samples from as many members of your family
as possible may help to work out whether you and your children have
inherited this increased risk.
 This service can be provided, with consent and explanation, by a
cancer genetics clinical service.
 Your GP can refer you to the doctors who run this service and will
know how to do this.

 you first need to see a cancer geneticist to find out if they recommend
that a blood sample from your mother would be useful in establishing
the risk for you and your children.
 If so, we can discuss with your mother the reasons for asking for a
blood sample to help find out if other family members are at risk,
explaining that it will not be of help in treating her.
 She will need to give permission for the drawing of the blood sample
and its use for genetic testing.

 if you (and your children) have inherited this risk, then there are
screening programmes that aim to detect a cancer early at a curable
stage.
 This involves regular inspection of the bowel with a special telescope,
called a colonoscope, every 2 years to look for early cancers that are
not yet producing any symptoms.
 In addition you should look out for any symptoms that might be
suspicious, such as a change in the way your bowels are working –
diarrhoea or constipation, and blood in your motions – or in your
general health, for instance if you lose weight.
 These should be reported immediately to your GP, who would then
refer you to the appropriate hospital specialist.

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 you are the medical junior doctor working on the oncology day unit

Mr Chris Thomson, a 28-year-old single man with newly diagnosed stage 4B Hodgkin’s
lymphoma, is about to start six cycles of intravenous chemotherapy of Adriamycin
(doxorubicin hydrochloride), bleomycin, vinblastine and dacarbazine(ABVD), given as an
outpatient on day 1 and 14 of each 28-day cycle.
The patient has already been given written information concerning the treatment, including
the Cancer BACUP booklet about Hodgkin’s disease and summary information about ABVD
chemotherapy covering the drugs that are used, how the treatment is given, how often
treatment is given, and the possible side effects.
The information provided states that with no treatment the patient is likely to die in weeks
or months; that with the treatment proposed the chance of surviving 5 years is 70 –80%
(with the possibility of high-dose chemotherapy and peripheral stem-cell transplant in the
event of relapse); and that the most significant side effect of chemotherapy is vulnerability
to infection.
you are asked by the chemotherapy clinical nurse specialist to obtain

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written consent.

 Before you examine, treat or care for competent adult patients you must obtain their
consent.
 The main issues here are to establish competence to consent, and to explain the
benefits and risks of the treatment proposed or of other courses of action.
 Adults are assumed to be competent unless demonstrated otherwise.
 If you have doubts, the question to consider is: can this patient understand and
weigh up the information needed to make this decision?
 Unexpected decisions do not prove the patient is incompetent, but may indicate a
need for further information or explanation.
Patients need sufficient information before they can decide whether to give their
consent (in this case, the benefits and risks of chemotherapy).

Is the patient competent?

Can he or she understand and weigh up the information needed to make the decision?

An unexpected decision does not mean that the patient is not competent.

 Does Mr Thomson understand the key issues, ie prognosis without treatment,

prognosis with treatment, side effects of treatment, and possibility (or lack) of
alternative treatments?

 the aim of this treatment is to cure you of the disease.

 With this chemotherapy, your chances of surviving for 5 years are
probably around 70–80%.
 Furthermore, even if the disease were to come back, it is often still
possible to cure Hodgkin’s disease using high-dose chemotherapy
and peripheral stemcell transplantation – that is a sort of bone-
marrow transplant using your own cells.

 if you have no treatment for your Hodgkin’s disease, then I’m afraid
that there’s no doubt that it will continue to grow and spread, and
will lead to your death.
 This is likely to occur within weeks or months.

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 the ABVD chemotherapy regimen is given by injection through a
flexible plastic tube into the vein, with you being treated as an
outpatient every 2 weeks for 24 weeks.
 Before each cycle a blood test is performed to ensure that it is safe to
give the chemotherapy.

 it may be possible to tell simply by examining you, for instance if the

swollen glands that we can feel get smaller, or we may repeat the CT
scan after 2–3 months of chemotherapy, which will tell us more about
the swollen glands inside your chest and abdomen.

 chemotherapy often causes unwanted side effects and it is difficult to

predict who will develop these.
 Some people are lucky and get very few side effects whilst others have
a rougher ride.
 Many possible side effects can happen and some are more common
than others.
 I will tell you about the more common ones and will give you a written
patient information leaflet that describes them in greater detail.
 If you have any questions, either before you start the treatment or
during the course of therapy, then please ask me or one of the
nurses.

 yes, that is one of the possible side effects: your ability to father a
child may be affected by the chemotherapy.
 You should already have had the chance to store a sperm sample so
that if your fertility is affected then it can be
 used for you to have a child in the future, but if you have not done so
then we can make arrangements.
 However, despite this, you must not assume that because you are on
chemotherapy you are not fertile.
 It is important that you do not father a child whilst on the
chemotherapy because the drugs could affect the growing baby.
 It is important that you use effective contraception whilst on the
chemotherapy and for at least a few months afterwards.

 the most important thing to be aware of is that chemotherapy lowers

your resistance to infection.
 If at any time after starting the chemotherapy you get a high
temperature (over 38°C or 100.5°F), feel hot and sweaty or shivery, or
you suddenly fell unwell then you must contact the hospital oncology
team right away.
 This is the most important thing because it may happen to you when
you are at home and it is something that you have to deal with.
 I have written down all the ways to contact us any time, day or night.

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  If you cannot get in touch with us, come straight to the Accident and
Emergency Department and explain that you are a patient on
chemotherapy.

 if you do get an infection you will be admitted to hospital, have blood

tests and other tests taken to find out the cause of the infection, and
be given injections of antibiotics into your veins.
 This normally settles things down within a few days or a week.

 yes, I am afraid that they can, but this isn’t likely.

 They usually settle with antibiotics and other treatments, but it’s true
that sometimes they can get very bad.

Further comments
 Excellent patient information is available for cancer patients from resources such as
CancerBACUP(www.cancerbacup.org.uk) and these should be provided for all
patients as part of the informed consent process.
 In addition all cancer patients should have a ‘key worker’ who helps to coordinate
their care pathway and is usually their first point of contact.
 All patients starting chemotherapy must be provided with instructions on how to
access the oncology team in the event of an emergency at any time of the day or
night.

Role: you are the medical junior doctor working in the oncology clinic

Mr Frank Lewis, a previously healthy 51-year-old man, is found to have a 3-cm right upper
lobe mass on his CXR during a medical insurance check-up.
He has a 30 pack-year smoking history, but no history of hypertension, diabetes or heart
disease.
A CT scan confirms the right upper lobe mass.
No hilar or mediastinal nodal enlargement is seen, and there is no evidence of chest wall,
liver or adrenal involvement.
A transbronchial biopsy of the mass reveals squamous cell cancer (SCC).
A PET scan is positive in the primary tumour and in the right hilum, but is otherwise

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negative.
The patient undergoes a right upper lobectomy and full hilar/mediastinal node dissection.
He tolerates the procedure well and has a rapid, uneventful postoperative recovery.
Pathology confirms a 4-cm SCC.
Two hilar lymph nodes are involved with the tumour, but the mediastinal nodes are clear.
The pathologic stage is T2N1M0(IIB).
At the multidisciplinary team meeting following surgery, adjuvant cisplatin-based
chemotherapy is recommended.

Your task: explain to the patient the rationale and benefits of the adjuvant chemotherapy
that was described in the multidisciplinary team meeting as follows: data from a large
(1,867 patients), randomised, controlled trial suggest a modest survival advantage (44% vs
40% at 5 years) for patients who receive postoperative adjuvant platinum based
chemotherapy.
Patients with good performance status should be offered the option of adjuvant
chemotherapy provided they understand that the expected benefit will be very modest.
The side effects reported in the trial included 0.8% of the patients dying from
chemotherapy toxicity, whilst 23% of them had at least one episode of grade 4 toxicity:
severe neutropenia (17%), severe thrombocytopenia (3%) and severe vomiting (3%).

 As in the previous scenario, the issue again is one of consent, which in this case
involves the discussion and understanding of a finely balanced risk–benefit analysis.

 Discuss the risk of recurrence and the estimation of the benefit of adjuvant
chemotherapy compared with its side-effect profile.
There are many times in medicine when the benefits and risks of treatment are finely
balanced and there is no ‘right’ and‘wrong’ answer.

 even after the operation there is a chance that the lung cancer can
come back, probably because some cancer cells had already spread
but were too small to be seen on any of the scans that you had before
the operation.
 Giving people anticancer drug treatments into the blood can help to
kill any cancer cells that could be present and this will reduce the
chance of the disease returning.
 Unfortunately it does not completely eliminate the risk of the cancer
returning and does potentially have many unpleasant side effects.

 there is no way of telling for an individual person if the chemotherapy

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 is helping because at the time it is given there are no cancer cells
visible on scans.
 All we do know is that giving chemotherapy after curative surgery for
your type and stage of lung cancer reduces the chance of the disease
coming back and improves your chances of being cured.
 The chemotherapy improves your chances of being alive in 5 years’
time by about 4%, from 40% to44%.
 Or putting it another way, if we give 25 people this treatment, then
one of them will be cured that would not have been if they did not
have it.

 of course the chemotherapy does have many side effects and I will
discuss these further with you before you decide, but the chance of
dying because of the chemotherapy is under 1%.
 I will give you some written information that has been produced for
patients in your position who have to make this difficult decision.

 yes, of course.
 Whether you decide to have the chemotherapy or not we will still look
after you in this clinic.

 that’s a very hard question to answer! There are some people who will
put up with any treatment, however unpleasant, to increase their
chance of being cured of lung cancer.
 There are others who feel that the small increase in survival is not
worth the possible side effects and interference in quality of life.
 Without being flippant, it really is like the half-drunk pint of beer: to
some it is half full and to others half empty.
 There isn’t a right or a wrong answer.

 no, I would suggest that you read the information that I’ve given you
and think about it, and about the things we’ve just talked over.
 Once you have done that then we need to talk things over again,
perhaps along with someone from your family or a friend if you’d
prefer.
 But we do need to decide within the next couple of weeks.

Further comments
Caring for people with cancer requires careful deliberation and consultation with the
patient.
To enable patients to participate in this decision-making process they have to be fully
informed, and thus clear delivery of information is essential.
A number of resources are available to supplement the information given by clinicians to
their patients.
These include web-based resources as well as patient information leaflets published by
charities including CancerBACUP and individual tumour-type patient groups.

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 you are the medical junior doctor working on the oncology clinic

The daughter of a 72-year-old man approaches you immediately before you are due to call
her father in for his first visit to your outpatient clinic.
The father has been referred by the urologists, who have made a diagnosis of metastatic
prostate cancer.
His histology and radiology have been reviewed in the multidisciplinary team meeting.
The patient has T4N1M1 poorly differentiated(Gleason 4+5) adenocarcinoma of the
prostate.
There are widespread bone metastases on the bone scan and bilateral obstructive

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hydronephrosis causing chronic renal failure.
The daughter states emphatically that ‘Doctor, you must not tell him what’s the matter.
I know it will kill him.
He will fall apart like Mum did.’
to discuss the situation with the daughter.

 Collusion is generally an act of love that aims to protect the patient.

 Colluders often argue that they know the patient better than the doctor and are
better able to judge what the patient should be told.
 It is important to first acknowledge the colluder’s unique relationship with the
patient.
 The next step is to explain that it is your responsibility and duty to give her father
the information that he wants about his illness.

Collusion is generally an act of love, which should be acknowledged.

Information should never be forced on a patient who clearly does not want to receive
it.

You must explain that her father is unlikely to request information that he is not ready to
hear, and reassure her that you will check this out with him with each piece of news.
Any information will be given gently and sensitively, with opportunities to reflect and ask
questions.

 I understand why you say that: you want to protect your father and
that is because you care so much about him.
 Of course you have known him all your life and I have yet to meet him.
 I will only be asking him what information he wants to know – it’s my
responsibility and duty to tell him what he wants to know about his
illness, and answer any questions or anxieties that he has.
 However, I won’t force any information onto him that he doesn’t want
to hear.

 he is not likely to ask questions about his illness if he is not ready to

hear the answers.

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 I will answer honestly any questions that he asks me, but I will make
sure that he wants to hear the answers before giving them.
 I won’t ram the cancer diagnosis down his throat if he doesn’t want to
discuss it, but equally I will not lie to him if he asks me directly if his
illness is cancer.
 Very often I find that the patient already knows it’s cancer, but is
trying to hide the truth from loved ones to protect them too.
 When that happens it becomes a lot easier if both of you know the
diagnosis and then you can talk to each other about it.

 I agree, and I will ask him if he wants anyone to be present when we

discuss the test results.
 If he says yes, then we can all talk together.
 If he says no – which I think is very unlikely – then I will talk with him
first, and then ask if he’s happy for us all to talk.
 Answering his questions about the diagnosis with you present will
help you both to talk openly about the cancer.
 It will allow him to discuss his feelings with you.
 In my experience, being able to talk within the family about the
diagnosis can dramatically improve the quality of life of someone with
cancer and often helps everyone in the family.

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