MRCP PACES communication skills and history taking notes

Session One

MRCP-PACES

ETHICS & COMMUNICATION SKILLS

MRCP-PACES/Medical Ethics & Communication Skills/Dr Zein/201 Copyright: KM-426122-613404

1. Ethical issues: • • • •

Respect for Patient Autonomy Consent Confidentiality/Disclosure/Public interest Justice

2. Public protection: a- Driving; Epilepsy • Diabetes Mellitus • and TIA • and eart disease • b- GU infeci! infeci!n"#C! n"#C!$$%ni $$%nicab cabee 'i"ea 'i"ea"e"( "e"( I! • T" • "! •

3. Breaking Bad News 4. Medico legal issues: Resuscitation/D#R • Ad$ance directi$es • "rain deat% & persistent $e'etati$e state • Coroner referral • Eut%anasia • Postmortem e(amination • Or'ans donation • Reli'ious bioet%ics • 5. ounseling: • • • • • • •

Multiple Sclerosis ID & Cardiac re%abilitation Cystic )ibrosis untin'ton*s untin'ton*s Disease Dise ase R%eumatoid Art%ritis +ncontrolled DM "ronc%ial Ast%ma/COPD


1. Ethical issues: • • • •

Respect for Patient Autonomy Consent Confidentiality/Disclosure/Public interest Justice

2. Public protection: a- Driving; Epilepsy • Diabetes Mellitus • and TIA • and eart disease • b- GU infeci! infeci!n"#C! n"#C!$$%ni $$%nicab cabee 'i"ea 'i"ea"e"( "e"( I! • T" • "! •

3. Breaking Bad News 4. Medico legal issues: Resuscitation/D#R • Ad$ance directi$es • "rain deat% & persistent $e'etati$e state • Coroner referral • Eut%anasia • Postmortem e(amination • Or'ans donation • Reli'ious bioet%ics • 5. ounseling: • • • • • • •

Multiple Sclerosis ID & Cardiac re%abilitation Cystic )ibrosis untin'ton*s untin'ton*s Disease Dise ase R%eumatoid Art%ritis +ncontrolled DM "ronc%ial Ast%ma/COPD


!. Procedures: • • • • •

eart,-un' Transplant. CA" Pacema0ers "ronc%oscopy Endoscopy

)* U+'ae' NICE G%i'eine"( • •

"eta,Interferon in MS Infli(imab 1anti,T#)2 in RA & CD


La,$an Engi"( #er$ous .ee e'g, /an e'ge0( Invai'( Terminally ill Depressed L!1( Give 1a,( Collapse "rain Hea' +iece( Syncope .aining( Gi''ine""( !erti'o Epilepsy/Con$ulsions .i"#Sa2e"( Ringing in ear"( Tinnitus Anus 3ac2 +a""age( "uttoc0s 3!!$( Peg$( Sputum -un's T%be"( P%ffe'#P%ff,( "reat%less MI Hear aac2( Social ser$ices Te 4efare( Ge e "ac2( -ose 3ob S4ollen P%ffe' %+( T%$$,#be,( Stomac%/bo4el Oesop%a'us G%e( #auseated .ee" "ic2( 3een "ic2( !omited )latulence 4in'( - T! bec( bec ( Send 4ind from stomac% 55 55 anus - T! +ar( Motions/stools T!ie"( 4aer( +rine )re6uency Kee+ 1aning ! g!( T! ge %+ a nig( #octuria A mass5 cancer 1also7 t%e big C2 A gr!1( Menses L!"e( Pic%re"#I$aging( 8,Rays )e$er Te$+era%re( Ge bac2#.are( Relapses T! be !!2ing#! %rn e c!rner( Impro$es Confined to bed T! be ai' %+( T! fin' !ne5" eg"( Start 4al0s after illness "ecomes suddenly ill T! ave a ba' %rn( T! ave a b%g( To catc% a $irus/infection T! !"e !ne5" na%re( "ecomes impotent To %a$e a re'ular partner T! g! "ea',(

(Ref: English for Overseas Doctors)


Te

3rii"

Hea

•

uidelines & Policies7 T%e eneral Medical Council 1MC2 • T%e #ational Institute of Clinical E(cellence 1#ICE2 • T%e Scottis% Intercolle'iate uidelines #et4or0 1SI#2 • T%e Royal Colle'es •

•

ospitals 1#S27 SO5 SpR5 Consultants T%e Ps T%e Social Ser$ices System T%e ome ealt% Care Pre$enti$e Section5 CICD T%e -e'al Ad$isor5 t%e Coroner system5 etc Occupational %ealt% ser$ices & re%abilitation T%e #ursin' teams7 , Specialist nurses 1diabetes5 Ast%ma52 , District nurses , Teams 1e.'. McMillan team2 , #ursin' %omes !oluntary a'encies Support 'roups & Societies 1MS2

• • • • • • •

• •


S,"e$

Station 97 ETICS and COMM+#ICATIO# Can'i'ae5" In"r%ci!n"(

o

o

o

You will be given 5 minutes before entering the examination room to read a scenario & to mae !our "lan of action# On hearing the bell$ enter the room & begin the consultation# You will have % minutes to interview the "atient'actor & one minute after he'she leaves the room to organie !our thoughts and to "re"are !ourself for the discussion with the examiners# Dont re*tae histor! from the "atient and dont examine him'her#

In t%is section some scenarios 4ill be presented & 4ill be follo4ed by a su''estion on %o4 to approac% similar situations 4%en you5 %opefully face t%em in your actual e(amination. T%is 4ill be preceded by s%ort tal0s emp%asi:in' essential et%ical & le'al issues and some important 'uidelines e.'. D!-A5 I#) in MS5 End of life decisions etc. A compre%ensi$e 0no4led'e of +; la4 is not re6uired from o$erseas candidates< %o4e$er5 t%ey are e(pected to 0no4 in broad terms rele$ant et%ical & le'al principles. Many candidates fail t%is section of t%e PACES e(amination not as a result of its difficulty5 but because t%ey fail to prepare to it ade6uately. On t%e ot%er %and5 many of t%e successful ones feel t%at 4it% 'ood preparation5 success in t%is section is probably more predictable t%an in any ot%er section of t%is e(am. 666Te 2e, "enence ! "%cce"" i" 7Pracice & +racice i $a"ering8


Station 97 ETICS and COMM+#ICATIO# USE.UL •

•

HINTS

=%en 'i$en t%e scenario outside t%e e(amination rooms ST+D> it carefully & decide at first 4%ic% et%ical/communication principle is bein' tested. T%en on t%e pro$ided paper 4rite do4n t%e points t%at you 4ould li0e to discuss 4it% t%e patient/actor & t%e plan of action needed to mana'e t%e 'i$en problem. On enterin' t%e e(am. room5 start by 'reetin' t%e e(aminers t%en sit facin' t%e patient5 'reet %er/%im & inr!'%ce "ef an' e9+ain r!e e.'. ? ello Mrs. 8. I*m doctor >5 t%e medical SO 4%o is loo0in' after your %usband@. T%en agree e +%r+!"e !f e inervie1 ?=e are %ere today to discuss t%e result of %is bone ima'in'. Is t%at ri'%t =ould you li0e to discuss any ot%er issue@

•

Maintain 'ood eye,to,eye contact 4it% t%e patient & put %im/%er at ease.

•

Start t%e inter$ie4 4it% open,ended 6uestions ?e.'. 4%at do you 0no4 about your %usband*s condition@ or ?I learned from your P*s letter t%at you %a$e %ad a sei:ure last 4ee0end5 can you tell me more about t%at@

•

+se close,ended 6uestions as t%e inter$ie4 pro'resses.

•

Pro$ide clear & understandable e(planations

•

Av!i' %"ing :arg!n"

•

"t the end o# the inter$iew:

, Agree" a clear course of action 4it% t%e patient , S%$$arie" , Cec2 %n'er"an'ing 1e.'. ?4%at messa'e you 4ill ta0e %ome 4it% you@ or ?4%at are you 'oin' to tell t%e ot%er members of t%e family@2 , S%a0e %ands & say 'oodbye.


PRINCIPLES O. MEDICAL ETHICS Te < Princi+e" !f Me'ica Eic" =* Re"+ec f!r Paien A%!n!$, >* 3eneficence ?* N!n-$aeficence <* @%"ice

1. %especting the patient&s "utono'(: 14is%es & self,rule2 Autonomy7 means self rule i.e.1t%e capacity to t%in05 decide & act freely and independently2. It is t%e patient*s ri'%t to be in$ol$ed in any decision about %is %ealt%. T%is re6uires t%at t%e %ealt% professionals %elp patients in ma0in' t%eir o4n decisions and respect & follo4 t%ese decisions. Respect of autonomy implies t%at doctors treat competent patients in accordance 4it% t%eir informed c%oices5 e$en if t%ese conflict 4it% t%e doctor*s beliefs. 2. Bene#icence: 1doin' 'ood to & promotin' of 4%at is best for t%e patient.2 T%is entails doin' 4%at is best for t%e patient. In most situations B& lead to t%e same conclusions5 %o4e$er5 t%e t4o principles conflict 4%en a competent pt. c%ose a course of action t%at is not in %is/%er best interests.  If suc% a conflict arises 1Autonomy $s. "eneficence27 B. Ma0e sure t%at t%e patient is competent . E(plain t%e possible conse6uences of %is c%oice 1e.'. refusal of treatment2 . Su''est discussin' ot%ers 1a friend5 family member5 etc2 & a senior collea'ue 9. Respect t%e patientFs autonomy 3. Non)'ale#icence: 1do no %arm5 need to a$oid %arm2 =it% re'ard to treatment & procedures5 t%e potential 'oods & %arms and t%eir possibilities must be 4ei'%ed up to decide 4%at5 o$erall5 is in t%e patient s best interest.  T%ese t4o last principles imply t%at7 B. Treatment must be t%ou'%t li0ely to be successful OR t%at5 . Potential benefits o$er4ei'%t potential ris0s. 4. *ustice: 1fairness in pro$ision of %ealt% care2 Refers to t%e duty of t%e doctor to t%e 4%ole society. A. Patients 4it% similar situation s%ould 'et accessibility to similar %ealt% care. ". =%en determinin' 4%at le$el of care s%ould be a$ailable to one set of patients5 4e s%ould ta0e into account t%e effect of suc% use of resources on ot%er patients 1i.e. 4e must try to distribute limited resources fairly2. +sin' t%ese resources to a''ressi$ely treat a terminally ill patient is potentially depri$in' ot%ers of t%e treatment.


•

Sometimes t%e patientFs autonomy conflicts 4it% t%e GPublic InterestG. In suc% a case t%e latter must be respected< as your role for t%e 4%ole society is more superior to respectin' t%e patientFs autonomy.

CONSENTING

PATIENTS

T,+e" !f C!n"en( =* E+pressed: =ritten or $erbal a'reement for t%e procedure >* ,'plied: e.'. t%e patient*s action in response to a re6uest for e(am. ?* -tatuar(: =%en t%e la4 re6uites a particular consent e.'. I!) Ee$en" !f vai' c!n"en( ALID CONSENT B Un'er"an'ing 1+om"etent "atient , -""ro"riate .nformation2  !%nar, 'eci"i!n 1i#e# without coercion2

True informed consent re6uires t%at t%e patient does not merely passi$ely assents to t%e doctor*s decision5 but specifically aut%ori:es t%e doctor to initiate t%e medical plan. Inf!r$ai!n ! be +r!vi'e' ! e +aien( Diagnosis'/rognosis • 0ncertaint! about the diagnosis'need for further investigations • /ur"ose$ details & ex"ected outcome of "rocedures • 1iel! benefits & "robabilit! of success • /ossible side*effects & com"lications • Tecni%e"( , +se illustrations5 4ritten or $isual aids for e(planation , Allo4 a relati$e/a friend to attend if t%e patient a'rees , In$ol$e ot%er staff e.'. a nurse , i$e a balanced $ie4 , Allo4 sufficient time for reflection & decision,ma0in' C!n"en in Engi" a1( 4a i" C!$+eence /Ca+aci,0 A competent patient must fulfill t%e follo4in' re6uirements & demonstrate t%em repeatedly and consistently7 •

•

• •

nderstands a sim"le ex"lanation of his'her medical condition$ treatment and ex"ected outcome# .s able to reason about s"ecific goals of treatment & choose to act on the best of such reasoning# o''unicates his'her choice & the reason for this choice# 0nderstands the conse/uences of such choice# MRCP-PACES/Medical Ethics & Communication Skills/Dr Zein/201 Copyright: KM-426122-613404

N*3* , A patient s%ould not be re'arded as incompetent merely because %e ma0es a decision t%at is a'ainst %is best interest. , Competence is ?function specific@

Consent cont*dH 01 o'petent patient: A. A competent patient may refuse any5 e$en life,sa$in' treatment. Anyt%in' done 4it%out t%e patient*s consent5 e$en touc%in'5 is batter( 1for 4%ic% dama'e may be a4arded2. In contrast to ne'li'ence5 t%e patient doesn*t need to pro$e t%at %e/s%e %as suffered %arm as a result of t%e battery for dama'es to be a4arded. ". T%e patient s%ould be 'i$en information about t%e nature of t%e procedure or ot%er medical inter$entions 1ot%er4ise battery25 common & rare side,effects5 benefits & reasonable alternati$es 1ot%er4ise negligence: failure to 'i$e appropriate information to t%e patient before c%oosin' to accept/refuse a treatment or a dia'nostic test. 02 ,nco'petent patient: P!""ibe a++r!ace"( A. Doctors s%ould act in e be" inere"" !f +aien"* Relati$es & friends may be approac%ed as a source of information to 3ud'e t%e patient*s best interests5 but can*t 'i$e or 4it%%old consent 1i.e. t%ere is n! +r!9, c!n"en for an incompetent adult patient2. #"7 T%!r 'aive 1Partners%ip 'i$in'2 ". S%b"i%e' :%'g$en( =%at treatment option 4ould t%e patient c%oose if %e become competent To ans4er t%is 6uestion5 Consider7 , T%e patient*s pre$iously e(pressed preference , is 'eneral $alues & bac0'rounds , T%e doctor*s e(perience 4it% ot%er patients

C. A'vance Direcive"( S%ould be respected after ensurin' t%at t%e patient 4as competent & %ad all t%e rele$ant information and t%at %e %ad considered t%e clinical situation t%at %as arisen. D. Inv!ve !"+ia5" ega a'vi"er#a++, ! e C!%r if( T%ere are differences of opinions/contro$ersy in t%erapy. E9a$inai!n#e"ing & rea$en 1i!% c!n"en(

%# 2or life*saving "rocedures when the "atient is unconscious'incom"etent to indicate his'her wishes# 3# 4here a "atient is inca"able of giving consent as a result of a mental illness$ the treatment should be based on the "atients best interest6 "rinci"le#


7# 4here a minor (8%9 !ears of age) is a ward of +ourt & the +ourt decides that a s"ecific treatment should be given in the childs best interest#

SESSIO# T=O


U"ef% S2i" in 3rea2ing 3a' Ne1" 33N Se+-b,-"e+( /=0Pre+arai!n( "efore tal0in' to t%e patient / relati$e7 , a$e all t%e facts a$ailable< ensure pri$acy5 uninterrupted inter$ie45 etc , Ma0e sure t%at support is a$ailable from an e(perienced nurse5 a relati$e / friend or an appropriate reli'ious support , )ind out 4it% 4%om you are 'oin' to spea0/Any relati$es around />0 Cec2 a1arene""( Establis% t%e patient/relati$e*s current 0no4led'e e.'. ?a$e you any t%ou'%ts of 4%at mi'%t be causin' your / %er pain or problem ,,, =%at you understand from all t%e tests t%at 4ere carried out ,,, a$e you any idea of 4%at*s 'oin' 4ron' 4it% you@ T%is 4ill %elp to 3ud'e t%e 'ap bet4een t%e person*s perception & t%e reality. I" $!re inf!r$ai!n 1ane' & !1 $%c ?=ould you li0e me to e(plain a bit more Do you li0e to 0no4 e$eryt%in' Don*t force information into t%e patient.

/?0 Give a 71arning "!8( ?I am afraid t%at it loo0s rat%er more serious@ T%en pause to allo4 t%e pt to prepare for t%e ne4s. T%e pt 4ill t%en as0 for clarification or re,maintain an eye contact 4%en ready to listen to more. Ten give f%rer 'eai"F to narro4 t%e 'ap step,by,step. A$oid information o$erload & t%e use of 3ar'ons. Spea0 out slo4ly & clearly. /?0Pa%"ing & ac2n!1e'ging 'i"re""( Don*t be afraid of silence. Allo4 time for t%e bad ne4s to be absorbed & t%e response to occur. =ait for a si'nal t%at t%e pt. is ready to re,en'a'e in t%e con$ersation. Acti$ely ac0no4led'e distress ?I can see t%at 4%at you %a$e %eard %as made you $ery upset@ /<0 Enc!%rage veniai!n !f feeing"( T%is is t%e 0ey p%ase in items of pt satisfaction 4it% t%e inter$ie4. It also 'i$es you t%e c%ance to s%o4 empat%y.


/0 Reaci!n" ! e ba' ne1"( r(ing: A$oid loo0in' embarrassed & let t%e pt 0no4 t%at t%is is understandable & normal be%a$ior5 also a$oid spea0in' 4%ilst t%e patient is reco$erin' %is composure. a$e tissues a$ailable "nger: An'er is from t%e bad ne4s & is not a'ainst you. Remain ob3ecti$e5 stay calm & don*t 'et defensi$e.

enialdisbelie#: A useful copin' mec%anism. e.'. ?Are you sure t%at %e is dead Could t%ere %a$e been some mista0e e.'. identification Are you sure t%at t%ese reports are mineG )irmly5 but 'ently5 reassure t%e person. uilt: e.'. ?I s%ould %a$e made %im come to t%e %ospital earlier@

/0 Di"c%""ing +r!gn!"i"( 1;ey ad$ice7 "e %onest & realistic, A$oid 'i$in' specific time frames.2 66C!$$!n, a"2e' 5" ab!% 'ea & ',ing( "' , going to die67 ?I am afraid t%at your cancer is so ad$anced5 t%at it is li0ely to s%orten your life@ 8ow long ha$e , got67 A useful frame4or0 is ?I can not tell e(actly. It may be mont%s rat%er t%an years5 but it is unli0ely to be a fe4 4ee0s@ A better approac% mi'%t be7 ?Different cancers be%a$e differently in different people & it isn*t possible to predict e(actly %o4 t%ey be%a$e in eac% indi$idual@  Encoura'e %ope7 ?-et us loo0 fore4ord e.'. symptom control5 a birt%day5 8,mas etc@


C!%"i!n 1i reaive"( on&t tell hi' doctor9 the news will kill hi'.

=%en re6uested by relati$es not to tell t%e patient7 B2 Ac0no4led'e t%eir concerns & stress. E(plain t%at you 4ill %andle t%e matter sensiti$ely. 2 Outline t%e et%ical position often %elps. e.'. ? >our %usband1t%e pt.2 %as t%e ri'%t to 0no4 if %e 4ants5 but I 4ill not force t%e information on %im.@ 2 Stress t%at it is best to be open no4 about t%e situation rat%er t%an ris0in' t%e distrust of t%e patient if %e found out at a later sta'e. T%en e(plain t%at tellin' %im about t%e bad ne4s is not all bad ?e mi'%t %a$e t%in's to do5 specific people to be around5 some 4ills to tell5 plannin' for t%e 3ourney5 etc@

/0 I'enif,ing !er c!ncern"( , Elicit all t%e pt*s main concerns 1e.'. pain relief c%emot%erapy5 sur'ery etc.2 before 'i$in' ad$ice or furt%er information. , Reassurance can be 'i$en t%at e$ery effort 4ill be made to %elp t%e patient e.'. 'i$in' t%e best possible care5 %elpin' pain relief etc. , Don*t 'i$e a false reassurance about t%e future. , )oster %ope but don*t allo4 misunderstandin' treatment for cure.

/)0 S%$$arie"F & Cec2 %n'er"an'ing fre%en,( e.'. ?=%at messa'e you are ta0in' %ome 4it% you@ ?=%at you are 'oin' to tell t%e ot%er members of t%e family@

1K2 En"%re c!nin%i, !f care#"%++!r( • •

•

Support7 e.'. ? =e 4ill do our best to ma0e you/%im as comfortable as possible@ E(plain t%e potential treatment a$ailable & s%are 4it% %im/%er t%e mana'ement plan e.'. radiot%erapy for bone metastasis5 feedin' etc Offer a$ailability

1 ocu'ent in the patient&s 'edical records


U"ef% •

• • • •

    

in

33N(

A1a," re"+ec e +aien a%!n!$, . Don*t discuss %is condition 4it% relati$es 4it%out %is consent. H!ne", is t%e best policy. D!n5 e e + $!re an e#"e 1an" ! 2n!1 Never give a "+ecific i$e +eri!' D!n5 a2e a e !+e a1a, < find some reason to be optimistic e.'. encoura'es t%e pt to loo0 fore4ord to a particular e$ent suc% as a birt%day5 a period of remission or pain,free deat%. o4e$er5 you s%ould never give a fa"e !+e*

Pifa" 

Sraegie"

in

3rea2ing

3a'

Ne1"(

""# 4it%out e(plorin' t%e patientFs 4illin'ness to 0no4 t%em "ein' unsure of t%e information to 'i$e to t%e patient ""# too early 4it%out preparin' t%e patient by a reasonable G4arnin' s%otG Delayin' t%e bad ne4s in a fear of t%e patient reactions ettin' s%a0y or %esitant 4%en as0ed direct Ls by t%e patient li0e GIs it cancerG Or GIs s%e 'oin' to dieG Remember to brea0 t%e "# at an appropriate time & to lea$e ade6uate amount of time to deal 4it% t%e patientFs reactions5 ot%er concerns5 or discussin' ot%er rele$ant issues e.'. D#R5 Postmortem5 etc


Session T%ree


C!%n"eing f!r an HI e"ing

Ob:ecive" !f Pree" 'i"c%""i!n(

%# 3# 7# #

;o clarif! wh! the "atient have to be tested & what are his ex"ectations ;o "rovide information on technical as"ects of the test ;o "rovide information on "ossible im"lications of the test ;o educate about riss of transmission & ris reduction

C!n"ening f!r HI e"ing( , In most cases informed consent is sou'%t. =ritten consent is only re6uired from blood donors and for life insurance. , Implied consent can be assumed 4%en an indi$idual is re6uestin' to be tested. , =%en testin' a seriously ill patient in order to ma0e a dia'nosis5 t%e doctor s%ould act in ?t%e patient*s best interest@. Informed consent s%ould normally be obtained. Pree" C!%n"eing( Pretest discussion checklist .ntroduce !ourself & clearl! identif! !our role • -ssess ris factors & ex"lore <.='-.D> • Ex"lain the test "rocedures • Discuss "otential advantages'disadvantages • Discuss co"ing with the test results • .dentif! "ersonal$ social & medical su""ort s!stems • Discuss how to "rotect sexual "artner(s) in the meantime (safer sex and'or • safer drug use) .f a female$ discuss "regnanc! & fertilit! • •

Tecnica a"+ec" !f e HI e"( A simple5 clear & 3ar'on,free e(planation of t%e test s%ould be 'i$en to t%e patient. =ritten materials s%ould be a$ailable as some indi$iduals may li0e to defer t%e test. E(amples of information t%at patients need to be told7 , It is a simple blood test & its result 4ill be a$ailable t%e same day. , It reflects t%e I! status in t%e pre$ious t%ree mont%s 1e(plain in a simple lan'ua'e


t%e 4indo4 period2. A sin'le test at  mont%s 4ill dia'nose t%e ma3ority of patients. , E(plain t%at if t%e test is positi$e5 a confirmatory test 4ill be re6uired on anot%er blood sample in t%e same day. , If someone is labeled as I! positi$e5 t%is means %e is confirmed positi$e.

A'vanage" an' Di"a'vanage" !f HI e"ing

3enefi"

/A'vanage"0

!f

HI

01 ,ndi$idual health bene#its: B. Early dia'nosis & institution of anti,retro$iral t%erapy Ri"2" /'i"a'vanage"0 !f . Prop%yla(is a'ainst opportunistic infections e.'. PCP B. T"5 )alse positi$e/ne'ati$e results . Screenin'/prop%yla(is a'ainst STD5 etc 9. Appropriate $accinations . Psyc%olo'ical reactions . Possible loss of 3obs . Institution of ot%er %ealt% measures 9. and Conse6uent problems 4it% mort'a'e N. "etter moti$ation for safer se( dru's use . Difficulties in 'ettin' life insurance . N. Social relations%ip prospects 02 Public Bene#its: . "reac% of confidentiality B. Reduction of %i'% ris0 be%a$iors & attitudes . Monitorin' of I! epidemiolo'y . Impro$ement of t%e 'eneral a4areness of I! 9. O$erall reduction of t%e pre$alence of I!/AIDS


e"ing

HI

e"ing

HI( Inr!'%ci!n ! 'i"c%""i!n

, A discussion of dia'nostic possibilities & results of in$esti'ations to date may %elp. , C%ec0 a4areness of7 , #ature of t%e test , Difference bet4een I! and AIDS , Ris0 factors/ris0 reduction met%ods , If t%ere is e$idence of I!5 t%e patient s%ould be told of t%is. , As0 %im/%er if t%ere are any t%ou'%ts as to 4%at t%e illness mi'%t be , En6uire about ris0 factors in an indirect 4ay e.'. marital status5 se(ual acti$ities5 partner1s2/5 e(posure to %i'% ris0 be%a$iors5 P/ STD5 tra$el abroad5 dru' use5 blood transfusion etc , As0 about any pre$ious test or recent blood donation. , As0 if %e 4ould li0e to %a$e an I! test performed E'%cae( , Met%ods of transmission5 ris0 factors & %o4 to reduce t%em. , T%at e$ery day social & domestic acti$ities are safe. , T%at t%e patient 4ill %a$e continued medical care re'ardless of t%e test result. , Discuss ad$anta'es & disad$anta'es of testin' and %o4 %e/s%e 4ill cope 4it% result. , Inform of t%e a$ailability of social & psyc%olo'ical support. C!nfi'eniai,( , Patients can be reassured t%at t%eir I! results 4ill only be seen for ?Medical@ reasons by doctors& nurses in$ol$ed in t%eir care. , Samples may be labeled ?i'% Ris0@ & p%rases li0e ?-o4 T9 Count@ or ?Retro$iral Illness@ may be used. , Reassure t%e patient t%at t%e front of t%e notes 4ill not be c%an'ed to identify t%e infection. 1See section of #S !enereal Disease Re'ulation B92 , It is important to discuss 4it% patient 4%o t%ey 4ant to made a4are of t%eir illness e.'. a partner5 family doctor etc , As a 'eneral rule5 information is best disclosed on ?A #eed to ;no4@ only.


HI(

Giving

e

re"%

,# the result is P;-,<,=E: o o o o o o o o o o

o o

""#7 ,,, S%oc05 an'er denial etc ,,,,,  EMPAT> IS IT I! OR AIDS Pan !f aci!n( Q =%at is t%e ne(t step Q =%o 4ill be loo0in' after t%e patient Q =%at furt%er tests need to be done Q Any t%erapeutic measures/inter$entions Q =it% 4%om t%e patient 4is%es to s%are t%e information Q Educate7 safer se(5 in3ectin' practices etc Q "e ready to ans4er t%e patient*s 6uestions & 6ueries5 e.'. ?o4 lon' %a$e I been infected@ In t%is case t%e patient 4anted to discuss 4%o else mi'%t %a$e been infected Q i$e 4ritten information Q Pro$ide t%e patient 4it% a list of $oluntary a'encies5 support 'roups5 and social 4or0 facilities.

,# the result is NE>"<,=E: o o o

Ad$ice to repeat t%e test after  mont%s 1;he 4indow /eriod 2 Assertin' safer se(ual or in3ectin' practices 1 Ris Reduction2 Clearly emp%asi:es to t%e patient t%at a ne'ati$e test does not mean t%at %e/s%e is immune a'ainst I! infection unless t%e present practice is modified.

Nee'e-"ic2 in:%rie"( 1See attac%ment2


Session )our


En' !f Life Deci"i!n" & Ter$ina Care Di"c%""ing Re"%"ciai!n Sa%" & DNR 1i +aien" an' reaive" *usti#ications #or 'aking o) Not) %esuscitate 0N% decisions: =* =%en a fully,informed competent patient as0s not to be resuscitated >* A poor 6uality of life follo4in' a successful CPR is anticipated ?* )utility7 t%e c%ances of t%e patient sur$i$in' CPR are so lo4 t%at it can be re'arded futile. T%is is a clinical decision5 4%ic% doesn*t need in$ol$ement of t%e patient5 & t%ere is no obli'ation to attempt CPR in suc% cases. E(amples7 disseminatin' mali'nancies5 septicaemia5 se$ere ) etc " N% decision isn&t necessar( to discuss with patients: B. If t%e patient is incompetent . If t%e decision 4as made on 'rounds of futility . If a competent patient indicates t%at %e/s%e doesn*t 4is% to discuss it 9. T%is may also be 3ustified in competent patients5 4it%out obtainin' consent5 if decision is based on basis of ?poor 6uality of life@. Di"c%""ing DNR 'eci"i!n 1i +aien" & reaive"( 1. o'petent patients: , T%e discussion s%ould aim at determinin' t%e patient*s $ie4s of %is/%er 6uality of life. , Relati$es s%ould only be in$ol$ed in discussion 4it% t%e patient*s consent. , Relati$es may be discussed if t%e decision is made on ?Poor 6uality of life@ "asis & t%e patient donFt li0e to discuss t%e issue. 2. ,nco'petent patients: , T%e doctor s%ould decide on t%e ?"est interest@ of t%e patient. , Relati$es & friends can be discussed for t%e purpose of 'ettin' a better idea of t%e patient*s 4is%es and also to determine 4%et%er t%ere is an Ad$ance Directi$e 1-i$in' 4ill2 4a fac" nee' ! be !' ! e +aien - T%e patient s%ould be fully informed about t%e dia'nosis & pro'nosis , T%at CPR is usually unsuccessful. , About B Q  sur$i$e to lea$e t%e %ospital & for one year after4ards , T%e possibility of sur$i$al 4it% a neurolo'ical dama'e s%ould be pointed out. o4e$er5 t%ese are relati$ely uncommon< B Q sur$i$es in a Permanent !e'etati$e State 1P!S2 , Elderly patients 4it% c%ronic illnesses %a$e   c%ance of sur$i$al to disc%ar'e. - Ascertain t%at t%e patient understand t%at if t%ey %a$e a cardio,respiratory arrest & t%ey don*t %a$e CPR5 t%ey 4ill almost certainly die. , T%at a D#R is a Consultant decision. MRCP-PACES/Medical Ethics & Communication Skills/Dr Zein/201 Copyright: KM-426122-613404

Session )i$e


S%''en Dea !f a fa$i, $e$ber /A "+ecia f!r$ !f brea2ing ba' ne1" a re%ire" grea e$+a,0

/A0 Te inervie1 1i e reaive; 3rea2ing e ba' Preparation: , C%ec0 your facts about t%e deceased per son5 %is illness5 etc. , Put %im at ease. , Ma0e sure t%at support is a$ailable 1an e(perienced nurse/ot%er %ealt% professional5 a relati$e/friend5 reli'ious support5 etc2.

ne1"(

(%) ,ntroduce !our self$ ex"lain role & identif! the relative# Also c%ec0 4%et%er ot%er relati$es are around / need to attend t%e inter$ie4. (3) Establish his current in#or'ationnowledge of the situation: (7) ?ive a warning shot : () 4ait for his res"onse$ then BBN: , Don*t 4ait too lon' as t%is 4ill a''ra$ate t%e a'ony. , "e ready to confirm direct 6uestions e.'. ?Is %e dead@ , If t%ere is no direct 6uestion7 +se a clear & simple lan'ua'e to 'i$e a brief description of t%e illness and e(plain t%at treatment/resuscitation %asn*t been successful & t%e patient %as died. (5) ?ive relatives the chance to $entilate # E+press e'path( & give more details when needed# , Insure & s%o4 continued care and support to t%e family. E.'. Q Offer transport to %ome5 'i$e details of contact 4it% t%e department for more e(planation etc. , Allo4 accessability to t%e deceased body5 it is important for some people to see and %old t%eir dead lo$es ones & to 0eep a loc0 of t%eir %air. , Pro$ide clear e(planation of any $isible in3uries /J0 "lwa(s -u''ari?e @ check understanding.


/30 A

Re%e"

f!r

Organ

D!nai!n(

A* Many relati$es as0 about or'an donation. 3. Ot%er4ise you can sensiti$ely & at t%e suitable time5 brin' t%e issue for discussion. T%is can be addressed in many 4ays< one approac% is to as0 4%et%er t%e deceased %ad e(pressed any 4is%es/ad$anced directi$e in t%is re'ard 1c%ec0 also if %e %as a donor card2. >ou can also in$ite t%e discussion by tellin' ot%er people*s e(periences e.'. ?Some people in a situation similar to yours li0e to ma0e 'ood to t%eir lo$ed ones by donatin' t%eir or'ans to some patient 4%o are in desperate need of t%em.@ ?is internal or'ans can be used for ot%er patients 4%o need t%em to maintain t%eir li$es@ Re* C!rnea D!nai!n( T%e e,e" must be remo$ed 4it%in  !%r" if t%e corneas are to be donated. • Contact t%e eye %ospital. • If deat% %as to be reported to Coroner5 %is/%er permission must be obtained • before or'ans are donated. /C0

Re%e"ing

+er$i""i!n

f!r

a

P!"$!re$

E9a$inai!n(

,Approac% in a sensiti$e & understandin' manner t%at allo4s relati$es to ma0e 4ell, informed decisions. , E(plain t%e specific reason for t%e PM re6uest & t%e benefits of PM e(am. , T%e re6uest s%ould be made in a 4ay t%at doesn*t put pressure on relati$es. , Relati$es s%ould be 'i$en enou'% time to t%in0 about t%e issue & to discuss 4it% ot%er members of t%e family if t%ey 4is% to do so. , Try to e(plore relati$e*s misconceptions re'ardin' PM & to find out t%e reasons for refusal and t%en to clarify t%em1refer to information bo( 2. , Relati$es s%ould be informed of t%e PM results as soon as possible. - linicians should be: , Able to anticipate & cope 4it% t%e concerns and reactions of relati$es at t%e time of berea$ement. , A4are of t%e possible cultural/reli'ious impacts related to deat%5 funeral arran'ements & attitude to4ards PM. , A4are of t%e administrati$e procedures. , Able to e(plain t%e difference bet4een medico le'al & academic PM. 1#". In non,medico le'al PM consent is re6uired from t%e ne(t of 0in2. , Able to consider possible alternati$es in case of PM refusal E.'. limited PM5 laproscopic/endoscopic e(am. etc , 3e a1are !f 'ea" re+!rabe ! e C!r!ner


%easons #or consent #or a Post'orte' e+a'ination: B, To establis% t%e precise cause of deat% , To confirm t%e dia'nosis , To %elp ot%ers / medical researc%es etc 9, To respect t%e 4is%es of t%e deceased / family , Or'an donation

%easons #or re#usal o# Post'orte': 1) Concerns about dis#igure'ent of t%e deceased 2) Interference 4it% #uneral arrange'ents 3) Aack o# in#or'ation about t%e reason for PM 4) %eligious  ultural 1e.'. Muslims5 Je4s5 Afro, Caribbean*s5 C%ristian Scientists2 5) Respect for t%e deceased & t%eir 4is%es !) Too upset to consider it ) A desire to finis% t%in's as soon as possible C) Ob3ection from ot%er family members

eaths reportable to the oroner: B, T%e deceased 4asn*t seen by a doctor 4it%in B9 days prior to deat% , If t%e deat%7 A. Is of suspicious circumstances5 t%ere is a %istory of $iolence or may be lin0ed 4it% an accident ". May be lin0ed 4it% an abortion C. Is related to a medical procedure or treatment D. ad occurred durin' an operation or before full reco$ery from anest%esia 1or in any 4ay related to anest%esia2 E. Is due to lac0 of medical care ). Is due to industrial disease or in any 4ay related to t%e deceased employment. . Occurred durin' or s%ortly after detention in police or prison custody. . T%e actions of t%e deceased may %a$e contributed to %is deat%.


COUNSELING RELATIES .OR A POSTMORTEM EAMINATION ,# a relati$e is concerned about PM e+a'ination: -peak to the relati$e ai'ing at: e+ploring their 'ain concerns about PM9 i'pro$ing their understanding @ gi$e Dusti#ications and bene#its o# PM e+a'. e.g. ) ;he /@ ma! "rovide useful information that was not available when the deceased was alive# ) ;he /@ results ma! assist relatives overcoming their grieving reaction# .t ma! lead to "eace of mind b! nowing the cause of death & that the a""ro"riate care was given# ) ;he /@ can be beneficial$ not onl! to medical "rofession$ but also to the famil! & the societ! in general (give exam"les) ) @edical "rofession can gain vital feedbac about accurac! of diagnosis$ effects of treatments$ etc# 01 %eassurance re. dis#igure'ent: T%e PM e(am. is similar to a sur'ical operation & is carried out by • medically,6ualified pat%olo'ists. T%e out4ard appearance of t%e deceased 4ould not be altered in ant 4ay • & no e(ternal mar0ers 4ould be $isible apart from incision scar. 02 %eassurance re. possible inter#erence with #uneral arrange'ents: PM e(am. 4ill only need a s%ort time to perform. • In ur'ent cases5 t%e PM can be e(pedited. • T%e mortuary staff can liaise 4it% t%e funeral director to release t%e body in a reasonable time.


<8E BENE,<- ; PM ". or the relati$es: ;no4led'e of t%e precise cause of deat% / Confirmation of t%e dia'nosis. • Reassurance & peace of mind. Alle$iation of 'uilt by reassurance t%at deat% • 4as ine$itable & t%at all t%e needed care 4as pro$ided. Identification of possible %ereditary conditions. • elpin' ot%ers e.'. or'an donation. • Assistance in ad$ances in medical 0no4led'e. • Insurance & compensation claims. • B. or the 'edical pro#ession: To establis% t%e precise cause of deat%. • i$es a feedbac0 about t%e accuracy of t%e clinical dia'nosis. • Aids in medical audit & ris0 mana'ement. • Enables researc%es & ad$ancement in 0no4led'e. • Impro$es accuracy of epidemiolo'ical statistics. • . or the societ(: Impro$ement of accuracy of epidemiolo'ical statistics. • Or'an donation. • Identification & pre$ention of en$ironmental and occupational %a:ards / • infectious diseases & epidemics. Impro$ement of medical 0no4led'e. •


Session Si(


COUNSELLING

uidelines

for

i$in'

Information

to

a

/=0 Cec2 !1 $%c inf!r$ai!n ! give* E.'. test result5 dia'nosis5 mana'ement plan5 ad$ice on life style5 etc 4ould !ou lie to now the result of !our bone scanA Do !ou want to discuss an! thing elseA T%en e(plain accordin'ly. />0 S%$$arie" e +aien5" +r!be$"* E.'.  You have told me that !our -sthma isnt as well controlled as it used to be# .s thats rightA /?0 Cec2 e +aien5" Un'er"an'ing !f i" c!n'ii!n* E.'. 
MULTIPLE

SCLEROSIS


Patient

Fhat should the patient be told6 , As0 t%e patient if %e/s%e %a$e -n! thoughts about what might be wrong with !ouA -n! "articular condition worries !ouA , ""# step,by,step , Educate7 4%at is MS , C%ec0 understandin' ?4hat are !ou going to tell !our famil!A - C!n"e%ence"( Difficult to 'et life insurance or promotion at 4or0 • Alteration of life style • Psyc%olo'ical & emotional burden • - P!"iive a"+ec" !f 'iagn!"i"( #OT a brain tumour & #OT a mental disease • "enefits of early dia'nosis & treatment 4it% Interferon beta & copolymer • - Ear, f!!1-%+ a++!in$en( To 'i$e t%e patient t%e c%ance of as0in' 6uestions in a calmer state of mind. - Pr!vi'e "%++!r & inf!r$ai!n( =ritten information5 $ideos • Specialist nurse • Social 4or0er • Occupational t%erapist for self,support measures • -ocal MS society, s%ouldn*t be rus%ed as an early $isit may be depressin' for a • ne4ly,dia'nosed patient

Fhat in#or'ation to gi$e6 MS is a c%ronic disease affectin' B7B of +; population • Cause is #OT 0no4n • At present #O medical cure5 but t%ere are treatments 4%ic% can %elp many • symptoms C!%r"e( ,!ariable & is $ery difficult to predict. • , Different in eac% indi$idual , Initially may be relapsin' & remittin' 4it% full reco$ery bet4een t%e attac0s. -en't% of relapses 1flares2 is 9 %rs.,B mont%s. Rate of relapses is around B7B/year. Relapses are more common in t%e first  years & particularly t%e first year. , May become pro'ressi$e at any time5 secondary pro'ression affects 9 patients by B years & N by B years. Pro'ression is not ine$itable. , Primary pro'ression from t%e onset occurs in B, cases. , T%ere is a clear relations%ip bet4een pro'ression & late a'e of onset , )oster %ope by 'i$in' e(amples of 'ood predicti$e features applicable to t%e patient.


E'plo('ent:

Different studies7 , In t%e first  years7 up to  4ere in full 4or0 &  capable of some 4or0 , "y B years7 B, 4ere in full 4or0 & 9 of lon',term sur$i$als are capable of some useful acti$ity. Spastic paraparesis is t%e ma3or cause of loss of 4or0. More patients could 4or0 from %ome.

Ai#e e+pectanc(:

, Is stron'ly predicted by t%e de'ree of t%e disability. , Deat% isn*t directly caused by MS but results from infecti$e complications , -ife e(pectancy 4as found to be only N, years less t%an population 4it%out MS for t%e a'es , & t%is is e$en less after t%e a'e of . , Many indi$iduals %a$e normal life e(pectancy.

Pregnanc(:

, )ertility isn*t reduced , #o increased ris0 of abortion or stillbirt% , #o specific complications of labour , #o contra,indications to breast feedin' , T%ere is sli'%t ris0 of relapse durin' t%e first  mont%s after deli$ery.

>enetics: MS doesn*t occur more common in relati$es t%an in 'eneral population. T%e ris0 of a c%ild bein' affected is B,9.

-el#)help 'easures: , #o specific diet alters t%e course of MS. , Symptoms may be a''ra$ated or induced 4it% e(ertion. Ad$ice to a$oid e(cessi$e fati'ue5 but ot%er4ise to continue normal acti$ities.


HUNTINGTON5S

DISEASE

, Pro'ressi$e c%orea & dementia in middle life are t%e %allmar0 , Onset7 , years. Pre$alence is B7 . AD 4it% full penetrance. , Mutation in t%e s%ort arm of C% 9 4it% $ariable e(pression of CA, repeat in e(onB. T%is results in translation of an e(tended 'lutamine se6uence in %untin'tin< t%e protein product of t%e 'ene. Pa!!g,( , Cerebral atrop%y 4it% mar0ed loss of neurons in t%e C#&P. , C%an'es in neurotransmitters C!%r"e(

, Pro'ressi$e illness & deat% occurs bet4een B, years of onset. , #OT a cancer & #OT a psyc%iatric disorder , Initial symptoms7 personality or be%a$ioral c%an'es5 uncontrolled a''ression or se(ual be%a$ior. Serious depression is common & suicide is a ris0. -ater, ri'idity & a0inesia ,  bed ridden & emaciated ,  deat% , #O cure. , #O treatment to arrest t%e disease alt%ou'% p%enot%ia:ines1e.'. sulpiride2 may reduce c%orea. Tetraben:ine %elps to control mo$ements. , C%ronicity & disability ,  psyc%olo'ical impact on family7 Consider residential care , Supportin' t%e family is essential.

.a$i, Screening(

, C%ildren of patients %a$e B7 c%ance of %a$in' t%e disease & t%eir c%ildren %a$e B79 ris0 , +sin' molecular 'enetics. "lood D#A samples are re6uired from as muc% family members as possible. , Mutation analysis 1accurate &specific2 is a$ailable for pre,symptomatic testin' of family members. Centers performin' t%ese tests %a$e a common nationally a'reed protocol for counselin'. , Pre,natal dia'nosis is possible.



MRCP-PACES Station 2: HISTORY TAKING (SHOULD BE PROBLEM-FOCUSED & ELL STRUCTURED ITH SPECIAL CONSIDERATION TO SOCIAL CIRCUMSTANCES!

THE

"

MAIN

#$ OPENING THE ENCOUNTER: , , , ,

G%t ' na) Int%o*+, ./0ain %o0 A1% t3 a1n*a E./0ain not-ta4in1

2$ MAIN DISCUSSION , , ,

Gat3%in1 in5o%)ation T3 )ain 4i005+0 ta4 to /%o)ot *i,0o+% ICE (I*a Con,%n & E./,tation!

"$ CLOSURE: , , , , ,

En,o+%a1 t3 /atint to a4 6+tion & ./% I*a Con,%n & E./,tation (ICE! Co+n0 on 3a0t3 /%o)otion A1% a )+t+a00 ati5a,to% /0an an* 5o00o7 +/$ C3,4 +n*%tan*in1 & Co%%,t 73n n,a%$ Goo*' & O55% a8ai0a'i0it$


TASKS:

MRCP-PACES Station 2: HISTORY TAKING A$

O/nin1

t3

n,o+nt%:

En1a1)nt (Sta%tin1 t3 int%8i7!: , , , , ,

B$

G%at ' na) Int%o*+, o+%05 & E./0ain o+% %o0 B+i0* 1oo* %a//o%t A1% t3 a1n*a E./0ain not-ta4in1

Gat3%in1

t3

in5o%)ation:

P%ntin1 Co)/0aint (PC!: , ,

E0i,it t3 )ain /%ntin1 /%o'0)(!$ An ot3% /%o'0)9

, , , , , , , , , , ,

F+00 *tai0* 3o a,3 ,o)/0aint 5%o) ont to *at$ C0a%i5 a,3 /%o'0) '5o% )o8in1 to t3 n.t$ A//%o/%iat0 + o/n & ,0o-n** 6+tion$ Nat+%: $1$; o+0* o+ t00 ) )o% a'o+t t3 /%o'0))/to); Ont: ;3n it ta%t*9; D+%ation: ;Ho7 0on1 it 0at*9; Patt%n: - Contin+o+Int%)ittnt E/io*i, (5%6+n, 8%it & *+%ation o5 a,3 /io*! Co+% to *at:(tati, /%o1%i8 o% i)/%o8in1! P%,i/itatin1R0i8in1 5a,to%$ Ao,iat* )/to)$ Patint< 8i7/%,/tion o5 3i3% /%o'0): ;An t3o+13t o5 73at )i13t ' ,a+in1 t3i /%o'0)9; ;Do o+ 7ant to a** ant3in1 73i,3 I )i13t 5o%1t to a4 a'o+t9; E55,t o5 )/to)/%o'0) on 6+a0it o5 0i59 S+))a%i=$

HPC:

, , ,

PMH: , , , ,

O/n >: ;3at a'o+t o+% 3a0t3 ot3%7i9; Si)i0a% /%o'0)9 S/,i5i,: DM HTN HD BA t, Ho/ita0i=ation & O/%ation

FH: , , , ,

O/n >: ;3at a'o+t t3 3a0t3 o5 o+% 5a)i09; A00 #t *1% 3a0t3 (/a%nt i'0in1 ,3i0*%n! I5 an *at3: A1 & ,a+ o5 *at3$ S/,i5i,: DM HTN HD BA t,


DH: , , , , , , ,

A4 a'o+t t3 *%+1< 0it$ En6+i% a'o+t a,3 *%+1: Do 5%6+n, *+%ation Do it 30/9 Co)/0ian,$ SE: ;Ha8 o+ ./%in,* an /%o'0) 7it3 t3i *%+19; An %,nt ,3an1 in )*i,ation9

ROS (R8i7 o5 t)!: , , ,

A07a a4 a'o+t: 1n%a0 700'in1 58% a//tit 7t 0o1ain %a3 B%i50 n6+i% a'o+t a,3 'o* t)$ T3n a4 in )o% */t3 a'o+t a55,t* t)$

SOCIAL Hit$ (SH!: #$ O,,+/ation: P%nt & /%8io+; 3at *o o+ *o 5o% 0i8in19; I5 +n)/0o* a4 a'o+t /nion$ 2$ Ma%ita0 tat+: 9/a%tn%(! .+a0 0i5o%intation "$ S)o4in1$ ?$ ALCOHOL: Dtai0*: 6+antit t/ an* 5%6+n,$ CAGE @$ Finan,: in,o) +//o%t in8a0i*it 'n5it ot3% a00o7an, & a*6+a, o5 t3$ $ A8ai0a'i0it o5 S+//o%t: P%a,ti,a0 & )otiona0: Ho) 30/ *it%i,t n+% o,ia0 7o%4% o,,+/ationa0 t3%a/ t, $ I)/a,t o5 /%o'0): A'i0it to 7o%4 ,o/in1 7it3 *ai0 a,ti8iti )oo* /%ona0 %0ation t, $ Ho+: 50at t/ )o*i5i,ation $ A,ti8iti o5 *ai0 0i8in1: 9Co/in1 30/ #$ Ho''i9 ani)a0 /o%t ##$ T%a80: #2$ Dit$ #"$ I))+ni=ation & /%o/30a.i$


A0,o3o0 3ito%: , ,

D%in4in1 3a'it: 3at t/9 Ho7 )+,39 Ho7 5%6+nt9 Fo% 3o7 0on19 >+antit: # UNIT a0,o3o0  #2 Pint o5 '%  # 10a o5 7in  # )a+% o5 /i%it

,

CAGE test: C: Ha8 o+ 8% 50t t3 n* to C+t *o7n on *%in4in19 A:     Anno* ' ,%iti,i) on *%in4in19 G:    3a* G+i0t 50in1 a'o+t *%in4in19   ta4n a0,o3o0 t3 5i%t t3in1 in t3 )o%nin19 E:  (E o/n%!

, , , , , ,

3at a'o+t %,%ationa0 *%+19 Ha8 o+ 8% in,t* *%+19 S3a%* n*0*9 Ma%i+ana ;/ot; Co,ain ;,o4; H%oin ot3% A% o+ +in1 t3) no79 Ho7 o5tn9

D%+1:

S)o4in1: , , ,

Do o+ )o49 Ha8 o+ 8% )o4*9 T/ a)o+nt 5o% 3o7 0on19 Di* o+ 8% t% to 6+it9


"$

C0o+%:

C3,4 Un*%tan*in1: ;It ) 7 *i,+* )an i+ an* I n* to )a4 +% t3at 7 3a8 t3 a) +n*%tan*in1 o: , 3at )a1 o+ ta4 3o) 7it3 o+9 , 3at o+ 7i00 t00 to a 5a)i0 ))'%(! i5 t3 a4*9;

A1% a ,0a% ;P0an o5 a,tion;: In8ti1ation )ana1)nt 3o/ita0i=ation t,

Di/o A//%o/%iat0: In t3 ,0oin1 /o%tion o5 t3 int%8i7 o+ )a: , In5o%) t3 /atint o5 o+% o/inion a'o+t t3 i00n (*ia1noi )ana1)nt /%o1noi! , En,o+%a1 t3 /atint to a4 > & to ./% ,on,%n , N1otiat a )+t+a00 ati5a,to% /0an , Co+n0 a'o+t 3a0t3 /%o)otion , O55% a*8i, in,0+*in1 5o00o7-+/ , An >9 , O55% a8ai0a'i0it , T3an4 & a 1oo*'


COMMUNICATION SKILLS

U5+0

S4i00

to

/%o)ot

*i,0o+%

Eye contact: Eta'0i3* at t3 ont o5 t3 int%8i7 & )aintain* at %aona'0 int%8a0 t3%o+13o+t t3 ,on+0tation$ R-ta'0i3 73n t3 /atint )ntion i)/o%tant /i, o5 in5o%)ation$ Acknowledin ! e"#lo$in %e$&al c'e(: B t3at o+ %50,t t3at o+ a% int%t* in t3 /atint /%o'0)$ Non)%e$&al c'e(: Pi,4 a**% ./0o% & a,4no70*1 t3)$ $1$ ;Yo+ 0oo4 an.io+ ,an + 'a% to a 739; O#en)di$ecti%e *(: Yo+ ,an 1at3% 0ot o5 in5o%)ation ' +in1 o/n-n** >$ T3 a% t3 t/ o5 > t3i% an7% a% not  & no$ $1$; Can + t00 ) )o% a'o+t o+% 'o70 /%o'0)9; Clo(ed)ended *(: T3 a% +* 73n a /,i5i, /i, o5 in5o%)ation i n**$ $1$ ;Do t3 /ain 1o an73% 09; Cont$ol ! Sen(iti%e $edi$ection: Gnt0 ,ont%o0 t3 int%8i7$ I5 t3 /atint %ai* a %08ant i+ 73i0 o+ a% *i,+in1 anot3% i)/o%tant on o+ ,an +11t /ot/onin1 t3 i+ t i00 + 5ini3 7it3 t3 5i%t on$ Ho78% i5 t3 i+ %ai* i not i)/o%tant o% i%%08ant o+ ,an +11t 0a8in1 it 5o% anot3% ion$ Neotiation: A07a n1otiat o+% /0an 7it3 t3 /atint & t% to %a,3 an a1%)nt$ Ho78% i5 o+ 5ai0* to *o o t3 /%io%it i 5o% t3 /atint< a1n*a$ +$eci(ion: $1$ ; Yo+ a + 3a8 'n +55%in1 *i==in$ Can + *,%i' .a,t0 73at 3a//n 73n + ./%in, t3i9; E,#at-y: U I & o+$ $1$; I ,o+0* i)a1in 3o7 t3at ./%in, 3a* a55,t* yo'; ;I +n*%tan* yo'$ ,on,%n a'o+t o+% o'; ;I ,an  t3at it i 3a%* 5o% yo' to ,a% 5o% o+% *a* & t3 2 4i*;


Ed'cational 'e((e(: S3a% t3) 7it3 t3 /atint$ $1$ ;3n 7 a% ta04in1 I 1ot t3 50in1 t3at o+% *ia't 3a* a55,t* o+% o' & t3at + 0oo4 %at3% 7o%%i* o5 0ooin1 it;

.acilitation ! Silence: Fa,i0itation: ' no**in1 o% ' ain1;  I  1o on +3-3+3 o% 73at 0; & ' 0oo4in1 attnti80 to t3 /atint$ N8% 1t /ani, ',a+ o5 i0n,$ T3i i)/o%tant 5o% 'ot3 o5 o+ & t3 /atint to o%1ani= t3o+13t an* to t3in4 o5 ;73at i n.t9; Re#etition: U* to 5ot% 0a'o%ation$ Yo+ ,an %/at t3 /atint< 0at ntn, $1$; ,3t /ain9; Cla$i/ication: Yo+ 3a8 to ,0a%i5 an in5o%)ation o+ a% not ,0a% a'o+t$ $1$; I<) not +% I +n*%tan*$ o+0* + ./0ain it a1ain9; ;Do + )an9; ;Co+0* o+ ./0ain to ) 73at o+ + )an ' 0i13t-3a**9; Enco'$ae,ent ! S'##o$t: - Fin$ T3at< 1%at$ Yo+<% *oin1 5in ,a%% on$ - Yo+ 3a8 /+t 1%at 55o%t to 30/ o+% i,4 )+)$ - I<) 3a// t3at o+<% 7o%4in1 3a%* to ,ont%o0 o+% BP$


MRCP-PACES Station 2: HISTORY TAKING

SUGGESTED STRATIGY In t3 @ )in '5o% nt%in1 t3 .a)ination %oo) )a4 o+% /0an in t3 /%o8i** 3t o5 /a/%:

#$

OPENING , , , , ,

Int%o*+, o+%05 Ro0 P%i8a, A1n*a An %0ati8 to attn* E./0ain not ta4in1

2$ MAIN DISCUSSION , , , , , , ,

PC HPC ROS PMH FH DH SH

"$ CLOSUING , , ,

A1%in1 a /0an o5 a,tion C3,4in1 +n*%tan*in1 Di/oa0

+AIN: SOCRATES Sit Ont C3a%a,t% Ra*iation Ao,iation Ti) (*+%ation! E.a,%'atin1R0i8in1 S8%it


MRCP-PACES T3 Mot Co))on Ca Hito%i o o o o o o o o o o o o o o o o o o

A'*o)ina0 /ain (IBD! a+n*i,CLDPBC Ma0a'o%/tion Dia%%o3a - Co0ia, Ha*a,3 E/i0/ TIA (5+nn t+%n!CJA IHDCADCHF SOBPa0/itation(PAF! BACOPD P+0)ona% 5i'%oi B%on,3i,taiCF DM Goit%t3%oi* *ia P%.iaDiaao3a 5o00o7in1 5o%i1n t%a80 A%t3%itiRA SLE HBJHIJ L+4)iaL)/3o)a


MRCP PACES communication skills and history taking notes

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