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CHAPTER3 Consulting withpatients
Breaking badnews
GPs break bad news frequently, but it is never easy.
Why is breaking bad news hard?
• Admission of failure When we tell patients bad news, it is often an
admission that we have failed. When we fail we naturally question what
we have done and when looking at our practice in retrospect, it is easy
to nd fault. Feelings of guilt are common
• Fear of the reaction of the patient We all have a desire to avoid
unpleasantness but sharing information with patients may be a positive
way forwards. Even if news is bad, it gives patients control of the situation
Guidelines forsharing bad news withapatient
DO DON’T
• Plan the consultation as far as
possible. Check the facts rst,
and ensure you have all the
information. Ensure privacy and
freedom from interruption
• Set aside enough time
• Ask if the patient would like a
relative or friend with them.
Make sure you introduce yourself
and nd out their name and
relationship to the patient
• Make eye contact— watch for
non- verbal messages. Sit at the
same level as the patient
• Use simple and straightforward
language
• Allow silence, tears, or anger
• Be prepared to go over facts
again
• Answer questions
• Reect on what the patient or
relative has said to allow you to
modify your understanding of
their feelings
• Take into account the patient’s
current health, e.g. if in pain, then
sort out the pain and schedule
a further discussion when the
patient is more comfortable
• Oer ongoing support
• Lie or fudge the issue
• Get your facts wrong
• Break bad news in public
• Give the impression of being
rushed or distant
• Give too much information. It is
better to be concise— the ner
points can be lled in later
• Interrupt or argue
• Say that ‘nothing can be
done’— there is always something that can be done
• Meet anger with anger
• Say you ‘know how they feel’—
you don’t
• Be frightened to admit you
don’t know something
• Use medical jargon
• Leave the patient with no
follow- on contact
• Agree to withhold information
from the patient
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BREAKING BADNEWS
Commonproblems
• What if the relatives do not want you to tell the patient? With adults
of sound mind, information is condential to the patient and can only be
released, even to close relatives, with the patient’s permission. Relatives
who say they do not want the patient to know often do so to protect
their relative. It is important to recognize they know your patient best.
First, explore their worries and point out the diculties of the patient
not knowing. Often once a relative realizes that the patient knows things
are not right and needs help and support to face the situation, they
come round to the patient being told. Stress that you will not lie to a
patient if asked directly
• How do you know if the patient wants to know? Most people (80– 90%)
do want to know. Assume this is the case and then feel your way carefully.
Give the patient ample opportunity to say that they do not want to know
• How do you respond to questions you cannot answer? The best way
to deal with this is to say that you do not have all the answers but will
answer when you can, nd out what you can, and say when you do
not know
Bereavement, grief, and coping with loss E p. 102
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CHAPTER3 Consulting withpatients
Confirmation and certification ofdeath
English law does not require a doctor:
• To conrm death has occurred or that ‘life is extinct’. Adoctor is only
required to certify what, in their opinion, was the cause
• To view the body of a deceased person. There is no obligation to see/
examine a body before issuing a death certicate
• To report the fact that death has occurred
English law does require the doctor who attended the deceased during the
last illness to issue a certicate detailing the cause of death. Certicates are
provided by the local Registrar of births, marriages, and deaths. Aspecial
certicate is needed for infants of <28d old.
Death in the community 1 in 4 deaths occur at home.
Expected deaths In all cases, advise relatives to contact the undertakers; if
you are not the patient’s usual GP, ensure he/ she is notied.
• Patient’s home Visit as soon as is practicable
• Residential/ nursing home If possible, the GP who attended during the
patient’s last illness should visit and issue a death certicate. The ‘on- call’
GP is often requested to visit. There is no statutory duty to do this but
it is reassuring for the sta at the home and often necessary before sta
are allowed to ask for the body to be removed
Unexpected and/ or ‘sudden’ death If called, advise the attendant to call the
emergency services.
Cremation Before a person can be cremated, Cremation Regulations
(2008) require 2 doctors to complete a certicate to establish identity and
that the cause of death is not suspicious. The person arranging the funeral
may see the forms and pays a fee to each doctor. 2 parts:
• Cremation 4 Completed by the patient’s usual medical attendant— in
the community, usually his/ her GP
• Cremation 5 Completed by another doctor who must have held full
GMC registration (or equivalent) for ≥5y and is not connected with the
patient in any way nor directly connected with the doctor who issued
cremation form 4— usually a GP from another practice
• Pacemakers and radioactive implants must be removed from the
deceased before cremation can take place.
Notication of death to the coroner The coroner can be contacted
via the local police but electronic notications are preferred. Reporting a
death to the coroner does not automatically entail a postmortem. Once
circumstances are clear, the coroner may advise the GP to tick and initial
box Aon the back of the death certicate, which advises the registrar that
no inquest is necessary. Deaths that must be reported to the coroner in
England, Wales, and Northern Ireland are listed in Box 3.2.
0 In Scotland, deaths are reported to a procurator scal. In addition to the
list in Box 3.2, deaths of foster children and newborns must be reported.
Medical examiners From April 2019, local ‘medical examiners’ will
start checking all death certicates issued by treating doctors for accuracy
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CONFIRMATION AND CERTIFICATION OFDEATH
and coroner notication obligations. This eectively extends to burials the
second certication function that already occurs for cremations. Initially
medical examiners will only scrutinize deaths in hospitals (46% of deaths),
but the scheme will eventually be extended to deaths in the community
as well.
Recording deaths Death registers are useful. Routine communication
of deaths to all members of the primary healthcare team and other agencies involved with the care of that patient (e.g. hospital consultants, social
services) avoids the embarrassing and distressing situation of ongoing appointments and contacts being made for that patient. Record the death in
the notes of any relatives/ partner registered with the practice.
Bereavement, grief, and coping with loss E p. 102
Benets available afteradeath
• For widows/ widowers E p. 102
• Budgeting loans for funeral payments E p. 105
Box 3.2 Deaths must be reported tothe coroner if:
• The deceased was not seen by the certifying doctor either after death
or within 14days before death
• The death was violent or suspicious
• Death may be due to an accident (whenever it occurred)
• Death may be due to self- neglect or neglect by others
• Death may be due to an industrial disease or related to employment
• The death may be due to an abortion
• The death may be a suicide
• Death occurred during or shortly after police/ prison custody
• Death occurred while the deceased was subject to compulsory
detention under the Mental Health Act or a Deprivation of Liberty
Safeguards authorization (DOLS)
• Cause of death is unknown, suspected to be unnatural, or there are
any other concerning features
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Patientadvice
• What to do after someone dies M www.gov.uk/ after- a- death
• What to do after a death in Scotland M https:// www.gov.scot/
Publications/ 2016/ 11/ 6948
Further information
Ministry of Justice (2012, updated 2018) Medical practitioners:guidance on completing cremation forms.
M https:// www.gov.uk/ government/ publications/
medical- practitioners- guidance- on- completing- cremation- forms
Oce for National Statistics (2010). Guidance for doctors completing
medical certicates of cause of death in England and Wales. M https://
www.gro.gov.uk/ Images/ medcert_ July_ 2010.pdf#
Wessex LMCs Deprivation of Liberty Safeguarding (DOLS) and death. M
https:// www.wessexlmcs.com/ deprivationoibertysafeguardingdols
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CHAPTER3 Consulting withpatients
Organdonation
Over 6000 people in the UK are waiting for an organ transplant that could
save or dramatically improve their life, but ~5000 transplants are carried
out each year. There is a need for more donors. In 2017, >400 people died
while awaiting a transplant.
Absolute contraindications to any organ donation:
• Creutzfeldt– Jakob disease (or other neurodegenerative diseases
associated with infectious agents)
• Ebola virus infection
• Cancer that has spread within the past 12mo
• HIV or hepatitis C infection— although, rarely, organs may be used by
other patients already infected
Donor cards and the NHS Organ Donor Register Potential
donors should always discuss their wishes with their relatives. They can
register their desire to donate their organs after death by adding their
names to the NHS Organ Donor Register and obtaining an Organ Donor
Card. Contact the NHS Organ Donor Line F 0300 123 2323 or sign up
online at M www.organdonation.nhs.uk.
0 In Wales, unless an individual ‘opts out’, it is assumed that they have no
objections to organ donation. It is anticipated that a similar ‘opt- out ’ system
will become operational in England in April 2020, and Scotland also plans to
move to an ‘opt- out’ rather than ‘opt- in’ system in the future.
Blood donation New donors aged 17– 65y are accepted. Donors may
donate whole blood or platelets. Dierent blood transfusion services operate in the devolved nations of the UK. Contacts:
• England F 0300 123 2323 M www.blood.co.uk
• Northern Ireland F 08085 534 666 M www.nibts.hscni.net
• Scotland F 0345 90 90 999 M www.scotblood.co.uk
• Wales F 0800 25 22 66 M www.welsh- blood.org.uk
Bone marrow donation Bone marrow donation is open to people
aged 18– 49y who are blood donors (although may register at the time of
rst donation). Volunteers are HLA tissue- typed using DNA from white
blood cells. Tissue type is recorded in the British Bone Marrow Registry.
Donation involves a small operation in which bone marrow is harvested—
usually from iliac crests.
Stem cell donation Peripheral stem cell donation is open to people
aged 18– 49y who are blood donors (although may register at the time of
rst donation). As for bone marrow donation, volunteers are HLA tissuetyped using DNA from white blood cells. Their tissue type is recorded
within the British Bone Marrow Registry.
Donating stem cells involves daily injection of a growth factor (lgrastim)
for 4d; this releases stem cells into the peripheral blood. Stem cells are
harvested on day 5 using a cell separator from venous blood collected from
1arm; the blood is returned through a vein in the other arm.
Cord blood stem cell donation When delivering their babies in certain
hospitals in England, women can opt to donate cord blood for stem cell
harvesting. Further information:M www.nhsbt.nhs.uk/ cordblood
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ORGANDONATION
Surgical organ donation from living donors Two main types:
• Donation at the time of routine operation Femoral heads can be
donated at the time of hip replacement; skin can be donated at the time
of cosmetic surgery (e.g. apronectomy); amniotic membrane can be
donated at the time of Caesarean section
• Surgery to remove living organs 1 kidney, part of lung, liver, or small
intestine. Usually close relatives. Removal of the organ/ part- organ
involves a major operation for the donor. Risks to donor must be
weighed against benets to recipient
Heart- beating donation after death Donors must be maintained
on a life- support machine at the time of death and until the organs are removed. The role of the GP in these situations is pre- emptive (information
about Organ Donor Register) and to support families to make the decision
whether to donate. Organs that can be donated:kidneys, heart, liver, lungs,
pancreas, corneas, heart valves, bone, and skin.
Non- heart beating donation after death Donation can occur up
to 24h after death (sometimes up to 48h). Tissues that can be donated:
No upper age limit <60y
• Corneas • Heart valves
• Skin • Tendons
• Bone
Donation of whole body for medical education The donor must
give authorization for donation prior to death. Relatives should contact
the medical school with which the donor has made arrangements after the
donor’s death. Medical schools arrange collection of the body and a simple
funeral. Not all bodies are accepted. Further information:M https:// www.
hta.gov.uk/ donating- your- body
Tissue or brain donation after death for research purposes Can be done in addition to donation for transplantation— organs
for transplant are taken rst. Further information:M https:// www.hta.gov.
uk/ guidance- public/ donating- your- tissue and M https:// www.hta.gov.uk/
guidance- public/ brain- donation
Approach to relatives Many families nd the act of donation a source
of comfort. Even when the person who has died is on the Organ Donor
Register, donation will be discussed with family members. However, if a
person has agreed to donation prior to death and this is recorded on the
Organ Donor Register, the family has no legal right to overrule that decision.
The coroner For any patient normally referred to the coroner, the
coroner’s permission must be gained before tissues are removed.
Further information
NHS Blood and Transplant F 0300 123 2323 M www.organdonation.nhs.uk
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Chapter4
Social aspects of primary
care
Social factors and health 82
Multicultural medicine 84
Domestic violence:the GP’s role 86
Victims of crime 88
Occupational illness 90
Time o work 92
Certifying tness to work 94
Fitness to make decisions 96
Fitness to drive 98
Fitness for other activities 100
Bereavement, grief, and coping with loss 102
Benets for people on low income 104
Pensions 106
Benets for sickness and disability 108
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CHAPTER4 Social aspects of primary care
Social factors andhealth
‘The task of medicine is to promote health, to prevent disease and to
treat the sick. . .These are highly social functions’
H.E. Sigerist, Civilization and Disease (1943)
Health inequalities are dierences in people’s health across the popula-
tion and between specic population groups. They are socially determined
by circumstances generally beyond an individual’s control and unjust as they
are avoidable if social inequalities were addressed.
Inverse care law Julian Tudor Hart’s inverse care law states that ‘the
availability of good medical care tends to vary inversely with the need of
the population served’. This paradox is true across dierent diseases and
healthcare systems. Health inequalities are not inevitable and addressing
social factors can contribute signicantly in reducing them; 60% of health
improvement in the past century is not attributable to advances in medical
care but instead to changes in social factors, such as better housing.
Deprivation Social deprivation is linearly associated with death from all
causes, with no threshold and no upper limit. Most pronounced eects are
in relation to infant mortality, morbidity/ mortality from chronic illness (particularly musculoskeletal, CVD, and respiratory conditions), and teenage
pregnancy. This is not a new problem nor one unique to the UK. Disparity
in health is closely related to income. In the UK, a greater proportion of
the population is now living on <50% of average income than 20y ago— the
mortality gap has grown proportionately.
Benets for people with low income E p. 104
Impact of social factors on general practice Factors such as
population age, number of people in residential care, high list turnover, rurality, and deprivation have a signicant eect on GP workload. This is recognized in the UK by the Carr- Hill Index which adjusts allocation of funds
to practices according to these factors (E p. 33).
Homelessness
Temporary accommodation Adverse eects of living in temporary accommodation are well documented:
• Adults have an i incidence of depression than people of similar social
standing in their own homes
• Homeless women are 2× as likely to have problems in pregnancy and
3× as likely to require admission in pregnancy
• ¼ of babies born to women living in bed and breakfast accommodation
are of low birthweight (national average <1 in 10)
• Children from homeless families are less likely to receive their
immunizations, more likely to have childhood accidents and have higher
incidence of minor respiratory tract and diarrhoeal diseases
Sleeping rough Poor diet, poor accommodation, and lack of access to medical services are universal problems in this group; <70% are registered
with a GP. Many homeless people will suer from a triad of poor physical
health, mental health, and substance misuse; homeless people have a higher
than average use of emergency and hospital inpatient services as a result.
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SOCIAL FACTORS ANDHEALTH
The average age of death is 40– 44y. If primary care services are provided,
homeless people do use them.
Divorce Divorcees of all ages are at greater risk of premature death than
married people (2× i for men aged 35– 42y)— mainly from cardio- and
cerebrovascular disease, cancer, suicide, and accidental death. There is also
a similar i in morbidity. Children of divorced parents have i risk of ill health
from the time of separation until adult life— with children <5y old when
their parents separate being particularly vulnerable. These children are also
more prone to psychiatric illness later in life and are more likely to become
divorced themselves.
Employment andunemployment
‘Without work all life goes rotten’ Albert Camus
Eects of work have been compared to eects of vitamins— we need a
certain amount to be healthy, then there is a plateau where extra does not
help— and too much is harmful. There is good evidence that unemployment causes both i mortality (from CVD, cancers, suicide, violence, and
accidents) and i morbidity (depression, CVD). Threat of unemployment
alone can cause morbidity— in one study, GP consultation rates rose by
20% and referral rates by 60% after it was announced a factory would close.
Increases were found in other family members too.
Refugees and asylum seekers The Geneva Convention denes a
refugee as any person who, ‘owing to well- founded fear of being persecuted
for reasons of race, religion, nationality, membership of a particular social group
or political opinion, is outside the country of his nationality and is unable or,
owing to such fear, is unwilling to return to it’. Refugees are entitled to free
healthcare in the UK. Consider:
• Language, cultural, and religious issues (E p. 84)
• Physical health needs Diverse depending on country of origin and
previous level of healthcare. Always consider infectious diseases, e.g.
hepatitis B, HIV, TB, and malaria. Ensure refugees claim all health- related
benets available to them (e.g. free prescriptions)
• Psychological needs Depression, anxiety, panic attacks, agoraphobia,
and poor sleep are common. Symptoms are often reactions to past
experiences (including torture) and current situation. Social isolation,
unemployment, deprivation, hostility, and racism compound them. Use
medication if appropriate but also address other issues. H Although
telling their story is helpful for some refugees, ‘active forgetting’ is the
way some cope
• Family Many will have left family members behind. They may not know
their whereabouts or even if they are alive. The Red Cross or Red
Crescent can help with tracing (M www.redcross.org.uk)
Useful contacts
Freedom from Torture M www.freedomfromtorture.org
Refugee Council M www.refugeecouncil.org.uk
Relate Relationship support. M www.relate.org.uk
Relationships Scotland M www.relationships- scotland.org.uk
Shelter Help for homeless people. F 0808 800 4444 M www.shelter.org.uk
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