Difficult consultations

Question 1

Give some examples of bad news you might need to break to patients.

Answer 1

any illness with long term complication (diabetes)
cancers
infertility
miscarriages
counselling someone with a genetic condition
someone dying and informing relatives

Question 2

Key things to do (or not to do) when breaking bad news to patients

Answer 2

• checking patients understanding of what is going on
• silence can be very powerful
• not overwhelming the patient with too much information
• honesty
• not guessing prognosis ‘im sure you’ll be fine’
• dont remove all hope
• confidentiality remains crucial
• private area and space
• not being far apart from the patient when speaking to them
• body language - open and empathetic, potentially touch on shoulder etc.
• pace and tone of voice - slow down speaking to give time to think and respond to patient

Question 3

When might we have a ‘three way’ consultation? What do we need to look out for in these consultations?

Answer 3

• Parent and dependent child
• child and elderly parent
• partners
• family translator
• carer and disabled patient

Look out for

• confidentiality
• monopolisation or abuse

Question 4

What is Gillick competence and Fraser guidelines?

Answer 4

Medical law that decides whether or not a child under 16 can consent to treatment without consent from a parent: The law says that as long as the child (<16) is intelligent and competent, knowing consequences and knowledge on what’s happening, the parent does not need to consent or be informed.

Fraser guidelines related to sexual health and contraception

• young person understands the advice given
• young person cant be convinced to tell their parents
• young person is likely to begin or continue sexual activity
• unless the person receives contraceptive treatment, their physical (STIs, pregnancy) or mental health (or both) are likely to suffer
• it is in their best interest

Question 5

Things to do when consulting a young patient with a parent present.

Answer 5

• Ideas concerns and expectations are different between parent and child.
• Making sure the child is comfortable with the parent being there - Gillick
• We need to make sure we are getting an accurate representation - safeguarding issues.
• Parent anxiety
• Engaging child - its their consultation
• Confidentiality of the child - asking if they prefer to be consulted alone without parent around

Question 6

Things to do when consulting a young patient with a partner present.

Answer 6

• Safeguarding - domestic violence
• Confidentiality
• Engaging patient - its their consultation
• Managing all parties ICE
• Watch for ‘dominant other’ as we may never establish the true issue

Question 7

Things to look our for with family translators

Answer 7

• confidentiality is broken when a family member is translating. We need to watch body language of the pt. and request a formal translator.
• are you getting the true story
• whose history is it?
• confidentiality cannot be maintained
• safeguarding risks

Question 8

Times you might use a telephone consultation?

Answer 8

• covid
• more convenient for those who work and are unable to come into the surgery during times open
• house bound
• keeping relatives updated with the patients consent
• out of hours triage

Question 9

Issues with telephone consultations?

Answer 9

• no verbal cues
• only history available
• can’t examine
• risk management is harder

Question 10

Managing angry patients

Answer 10

• Being ill can make someone angry
• It’s not you who is angry
• Explore the anger
• Apologise - not an admission of guilt but apologising for long waiting times for example
• Don’t accept aggression in the workplace