Comms Flashcards
When to report a death to the coroner?
The job of the coroner (procurator fiscal in Scotland) is to investigate how the person died, where, when and to provide data for death certificate. They decide if a post-mortem is required. Cannot object to the post-mortem.
Generally, a case will be referred to the coroner if the medical examiner determines that the death is:
* violent
* unnatural
* cause unknown
* person was in state custody at the time of death
The medical examiner’s role is to review the cause of death inputted by the medical team, and to decide if referral to coroner is required.
Patient’s relative does not want patient informed about cancer diagnosis
- Need to establish that pt has given permission for you to discuss with relative
- Consider confidentiality and autonomy - whilst the pt’s relative may not want them informed about the diagnosis, they may not want their relative involved in decision-making
- Explore relative’s concerns (usually had previous bad experience with relative in hospital in the past)
- Explain that without further investigations, the patient may not be able to have treatments she would be eligible for
- Explain duty of care lies with the patient
- Advocate joint decision-making between patient and her relative, and acknowledge patient’s right to refuse investigations if she has the capacity to do so
- Summarise and make a plan moving forward with the patient’s relative
Counselling following MI
- Ascertain what the patient understands and knows so far, and what they would like to know
- Explain mechanism of how an MI happens and how the drugs work (DAPT). The majority of medications given are lifelong, but there may be some DAPT which is rationalised after 12 months following stent placement.
- No driving for 4 weeks following MI (we can provide financial support / fitness to work note during this time)
- Summarise at regular intervals
- Lifestyle mods: discuss cardiac rehab, diet, smoking and secondary prevention medications
- Patient question re: sex / exercise - general rule: if able to walk up stairs without SOB / chest pain, then can do the above.
Consenting for coronary angiogram
Procedure:
- Tube threaded up from blood vessel in your groin / wrist to your heart. Dye injected into the vessels supplying the heart, and x-rays are taken to show the dye and see if any narrowings in the vessels.
- Depending on the extent of narrowing / how many there are, we might be able to put a stent in then and there to hold the vessels open. Occasionally, this wouldn’t be possible and we may advise further procedures to be done on the heart in future.
- Whole procedure takes around 30 mins.
Benefits:
- Allows us to identify how severe the disease is in order to decide on the best management for the condition in the long term.
- Allows us to possibly treat the narrowings with a stent in the same procedure.
Risks:
- The tube is inserted via a needle, but LA is given beforehand to numb the area, and the tube inside the body doesn’t cause any pain.
- Infection / bleeding (as piercing the skin).
- We can prevent this by using aseptic technique (cleaning skin, PPE, gloves), and giving antibiotica if any signs of infection. We apply firm pressure to the site of needle puncture to minimise any bleeding.
- It is not uncommon to feel a strange sensation as the dye is injected, but this soon passes. Very rarely, may have an allergic reaction or the dye can harm the kidneys. This usually only happens in people who have poor kidney function to begin with.
- A very rare complication is that the tube dislodges some of the plaque that is furring up the blood vessel, and this can travel to the brain and cause a stroke. This is very rare.
Alternatives:
- There are different, less invasive heart scans that we can do instead, but we would still need access to un-clog the arteries via an angiogram or surgery.
Nothing:
- If you don’t have it, the furring of the arteries could continue and could lead to a heart attack that could leave your heart very damaged, or even kill you.
- We want to stop this happening and treat the problem, along with opening up the vessels to stop you having further pain.
- With all of the complications in mind, it is generally a very safe procedure and significant complications are very rare.
ICE:
- Is there anything you wish to ask me / anything you’re worried about?
- Do you have any questions about the procedure itself?
- Have you spoken to family about it? Is there anyone you’d like me to speak to to explain more?
Consenting for ERCP
Procedure:
- Performed to investigate / diagnose, treat (e.g., removing gallstones or stenting a stricture), or to biopsy.
- Usually done under sedation, and some LA spray is given to the back of your throat.
- We insert a tube about the thickness of my index finger into your mouth, down the food pipe, through the stomach and into the bowel.
- We do this so we can access the bile ducts, the tubes which drain from liver and gallbladder into the gut. It also connects to the pancreas.
- Whole procedure takes around 30 minutes.
Benefits:
- To diagnose / treat disease / relieve obstruction.
Risks:
- To minimise the risks we will give antibiotics at the start of the procedure to reduce the chance of infection, and take a blood sample to ensure the blood is clotting properly.
- Failure of procedure: fail to remove stone / insert stent / risk of disease recurrence.
- In rare cases there are severe complications such as pancreatitis, which is treatable but can be very painful and in very rare cases, fatal.
- 1/1000 chance of perforation (small tear in gut lining during the procedure), which can be very serious and require surgery.
Alternatives:
- There are alternative imaging modalities to diagnose, but they aren’t as effective, and we wouldn’t be able to treat the disease without this procedure.
Nothing:
- If we do nothing, there is a possibility of worsening of your condition / infection / further pain etc.
ICE
Consenting for lumbar puncture
Procedure:
- Takes about 20 minutes
- Need to get a sample of the fluid that bathes the brain and spinal cord, to rule out an infection / bleed on the brain.
- We do this by getting you to roll onto your side and curl up your legs. We then clean an area on your lower back and give you some local anaesthetic to numb the area.
- Once that has taken effect we pop a thin needle between the bones of your spine so we can reach the cavity where the fluid is.
- It shouldn’t be painful, but you might feel some pushing and pulling as I do the procedure.
- Once we’re in the right spot, I’ll let a few drops of liquid into the bottles and send them off to the lab. I’ll then remove the needle and put a dressing over it.
- After the procedure I’ll ask you to lie down for a few hours, give painkillers and ensure you have a drink / some food.
- We’ll need a blood test to be done sometime around the time of the spinal tap to do some special tests and compare them to the fluid in the spine. The results should be available in around 6 hours.
Benefits:
- To confirm the presence of a bleed or infection so we can give you the right treatment.
Risks:
- Because we’re putting a needle through the skin, there’s a risk of bleeding and introducing infection. However, we prevent this by checking your blood clotting prior to the procedure, and we perform the technique in a sterile manner.
- The main problem reported is that in about 40% of patients, they might get a headache after the procedure. It is usually easily manageable with painkillers and will resolve within hours / days.
- Sometimes we may touch a nerve during the procedure and if that happens you may feel pain running down your leg. If that happens, please let us know as we’ll need to change the position of the needle.
- Occasionally, the procedure may not be successful and we may not be able to obtain a sample.
- A very rare complication is the formation of a collection of blood in the spine, that very rarely can worsen and may require spinal surgery to resolve - however, this is vanishingly rare.
Alternatives:
Nothing:
- Performing the procedure would help us treat and diagnose you, and focus what we are treating with more accuracy.
ICE
Consenting for chest drain (thoracocentesis)
Procedure: a needle will need to be inserted between two of your ribs, and then will be replaced with a plastic tube. We use a local anaesthetic to reduce the discomfort of the procedure, and will also give you painkillers.
The drain usually stays in place for a day or two, but occasionally requires 1-2 weeks to drain all the air / fluid.
Benefits: the benefits are to treat the condition (pneumothorax / pleural effusion) and relieve symptoms.
Risks: there are always risks when we perform an invasive procedure, but we believe that the benefits outweigh the risks. The more common complications include bleeding, pain and infection. Occasionally air or blood can be introduced into the lung cavity, or damage to nearby structures. Failure of the procedure is also another risk.
Alternatives:
Nothing: if we do nothing, we could risk the condition getting worse or your symptoms getting worse.
ICE
Consenting for ascitic drain (abdominal paracentesis)
Procedure: the fluid in your abdomen is called ascites. Drainage of ascites is performed either to diagnose the cause of it, or to relieve symptoms that you may be experiencing such as pain, nausea, shortness of breath and discomfort. To relieve the symptoms associated with ascites, it may be necessary to place a small tube in the abdominal cavity to drain the fluid.
The ascites can be drained using a plastic tube inserted into the abdomen. Before the procedure, an ultrasound scan may be used to ascertain the best position for the drain to go.
The area where the drain will be placed will be cleaned and then numbed using an injection of local anaesthetic. The drainage tube will then be inserted and attached to a bag.
Once the fluid has been drained (usually takes at least 6-8h), the tube will be removed and a small dressing applied.
Benefits: to relieve symptoms and/or diagnose cause of ascites.
Risks: fluid leak, tube blockage, low blood pressure, infection, bleeding, pain, bowel perforation (0.6%). If a life-threatening complication occurs then you may require additional procedures such as surgery.
Alternatives: treatment of ascites usually starts with water tablets and fluid and salt restriction. Sometimes this either doesn’t work or isn’t safe, and this is when we offer drain insertion.
Some people who require regular drainage may be suitable for an alternative procedure called a TIPSS.
Nothing: if we do nothing, there is a likelihood that the ascites will continue to get worse and your symptoms will get worse.
ICE
Explanation of epilepsy and DVLA rules
- Abnormal EEG with fit = 12 month driving ban
- Normal EEG with fit = 6 month driving ban
- If patient is female, discuss teratogenicity of some AEDs and plans to conceive. Need to be on contraception when starting AEDs and all pregnancies should be pre-planned and discussed with a doctor if possible
- Lifestyle risks: sleep deprivation, alcohol/drugs, don’t take baths / work at heights (risky situations if pt were to have an unwitnessed seizure)
