Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5266_Библиотеки_им_академика_М_И_Перельмана
.pdf
228 Clinical Communication Skills in Medicine
suddenly. We initiated resuscitation at once. We pressed his chest up and down to
keep the blood moving. We gave shocks to his chest and injected medicines to try to
restart the heart. We used a bag to expand his lungs and provide oxygen. We tried
our best for more than 45 minutes but could not revive him.’
• You could not get her to be by his side when he died, as his heart stopped suddenly.
‘I am sorry that you could not be present by his side when he died, but his heart stopped
suddenly right after he had the ts. We could not call you inside or come out and talk to
you, as we were all focused on trying to bring him back to life.’
Why was there uid in the lungs? she asks.
• Tell her that acute pulmonary oedema is a complication of acute myocardial infarction.
‘When the heart muscle becomes too weak, it increases the pressure in the lungs and
forces the uid into the airways. We gave him plenty of oxygen and a medicine to remove
the uid from the lungs.’
She asks if he would have suffered.
• Tell her that he was unconscious from the time he had the seizures.
‘We acted very quickly as soon as he arrived to make him feel better. He was unconscious
from the time he had the ts, so he wouldn’t have felt any pain or distress after the rst
few minutes of arriving here.’
She says she felt condent that he was in safe hands from the minute they arrived in the hos-
pital but now feels let down. She asks if it would have made a difference if the cardiologist
had been physically present in the hospital at the time when her husband arrived.
• Tell her that he was managed appropriately and the team tried their best. Reassure her
that he received the best possible care. This is important for her to get closure.
‘We tried our best to save him, but the damage to his heart was too great. I want to
reassure you that we did everything that had to be done. All of us in the team have the
necessary skills and experience to manage people who are critically ill.
‘We informed the heart specialist straightaway, and he was on his way to the hospital to
perform the procedure. Even if he had been here at the time when your husband arrived,
he wouldn’t have been able to perform the procedure, as his heart stopped within a few
minutes of arriving here.’
She asks if she should have called the ambulance instead of driving him to the hospital herself.
• Reassure her that it would not have changed the nal outcome.
‘I think you did whatever you thought was correct at that time. Please don’t blame
yourself. At this time of the night, you probably took the same amount of time that the
ambulance would have taken to get him here. His heart did not stop on the way to the
hospital, so the ambulance personnel wouldn’t have done anything different. They would
Death of Husband 229
have connected him to oxygen and given him the blood-thinning tablet earlier, but that
wouldn’t have changed the nal outcome.’
• If she has no further questions, ask about her family.
She says she has two daughters. They live in a neighbouring town. She told them over the
phone soon after arriving in the hospital that she has brought their father to the hospital.
They are both on their way to the hospital.
End the conversation by conveying your condolences. Tell her that the nurse will shortly take
her to see her husband. Ask her to not hesitate to ask you or anyone in the team if she needs
any help.
SUMMARY
Although acute myocardial infarction is not unexpected in a 59-year-old diabetic man,
the sudden death of a close family member is extremely difficult for anyone to accept.
You will be expected to:
• Gently break the bad news after a warning shot.
• Respond to her emotions appropriately.
• Clearly narrate the sequence of events in layman’s terms but do not give too much
information all at once.
• Reassure her that the team did their best and the physical presence of the cardiolo-
gist would not have made a difference.
• Tell her that she should not blame herself for not calling the ambulance, as it would
not have changed the final outcome.
230 DOI: 10.1201/9781003533337-51
Introduce yourself, and conrm his relationship to the deceased. Make sure you are talking
to the correct person.
• Start by expressing your condolences on the passing away of his wife. Briey ask what
happened at home before he brought her to hospital and what he has been told about
her death.
This 53-year-old woman was brought to the emergency department (ED) by her husband about
three hours ago as she complained of chest and abdominal discomfort at home. She only spoke
through sign language, as she was deaf from birth. Her medical history was otherwise unremark-
able, and she did not take any regular medication.
She could not give any history to the ED doctor but kept making circular motions with her hand
pointing to her chest and abdomen. She was sweating profusely and appeared to be in some kind
of distress. Her temperature was 36.2°C, oxygen saturation 96% on room air, pulse rate 102/
minute, respiratory rate 28/minute, and blood pressure 150/98 mmHg. There was no difference
in blood pressure between the two arms. Her heart sounds were normal, and lungs were clear.
Abdomen was soft and non-tender. Her 12-lead electrocardiogram and capillary blood glucose
were normal. The ED doctor asked for a chest X-ray and planned to do a bedside ultrasound scan
of her abdomen. His admission diagnosis was ‘panic attack’.
A few minutes after the initial assessment and before any of the imaging investigations could be car-
ried out, she was suddenly found unresponsive by the nurse. Cardiopulmonary resuscitation (CPR)
was initiated straightaway as she was pulseless and not breathing. The cardiac monitor showed
asystole. She was pronounced dead after 50 minutes of CPR. Blood samples that were drawn
before she arrested showed that her blood counts, liver function tests, serum creatinine, urea and
electrolytes, amylase, D-dimer, and troponin were all normal.
The husband has already been told that she has died. Your task is to now inform him that you will
be referring to the coroner, as the cause of her death is unexplained. You are the medical registrar
on call.
Case 45
The 53-Year-Old Woman Whose
Death Is Unexplained
Referral to the Coroner 231
He says his wife was in good health, with no major medical issues. She seldom saw a doctor
during the 30 years that he had been married to her. She was not taking any regular medica-
tion. She never smoked or drank alcohol.
They were sitting on the sofa at home, watching television, when she suddenly expressed
to him in sign language that she was not feeling comfortable. He decided to bring her to the
hospital as she kept pointing to her chest and tummy. He says he is deeply shocked and did
not expect her to die. The doctor who conveyed the news of her death told him that the team
was not sure why she died, as everything happened very quickly.
Tell him that:
• The cause of her death is unexplained.
‘Yes, we are not sure what caused her death. Heart attack, a large blood clot in the lung,
a tear on the inner lining of the big blood vessel that leaves the heart, and losing a lot of
blood internally are some of the possible causes for someone to develop chest or tummy
pain and die so suddenly. However, we did not nd any evidence of those conditions
when we examined her.
‘Her heartbeat and breathing were faster. Her blood pressure was a little high, and she
was sweating profusely. There was otherwise nothing else abnormal to nd. The tracing
of her heart and the blood test results were all normal. We, too, did not expect her heart
to stop so suddenly. Iam sorry that despite our best efforts, we could not revive her.’
• [After a brief pause] You will not be able to complete the medical certicate of the cause of
death (MCCD), as the cause of her death is not known.
‘When someone dies, we normally complete a certicate that states the cause of death.
You need this certicate to register her death and get the death certicate. I’m afraid we
won’t be able to complete that certicate for her, as we do not know what caused her
death.’
• You will have to refer to the coroner.
‘We must therefore refer her to a coroner. We refer all unexplained deaths to the coroner.
A coroner is a judicial ofcer who works with the police and a medical expert called a
pathologist. They’ll try to establish the cause of death when doctors are unable to do so.’
The husband gets upset when you mention the word ‘police’. ‘Why do you have to refer to
the police?’ he asks.
• Tell him that the coroner works with the police as some unexplained deaths are not
due to natural causes.
‘They work as a team. The police ofcer is part of their team, as some of the deaths that
are reported to the coroner are not due to natural causes. He might ask to speak to you
and some of us in the medical team to nd out what happened. For most cases, the coro-
ner and the pathologist will go through the medical notes and conclude that the death is
232 Clinical Communication Skills in Medicine
due to a natural cause. If the coroner is unable to determine the cause of death, he might
ask for a post-mortem to be performed.’
The MCCD can be completed only if (1) the identity of the person is known, (2) the
cause of death can be established, and (3) the death is due to a natural cause (all three). Acor-
oner’s referral should be made if (1) the identity of the person is unknown, (2) the deceased
was not attended by a medical practitioner during the last two weeks prior to death, or (3)
the death is unexplained, unnatural (e.g. suicide, related to accident or trauma), suspicious,
iatrogenic (e.g. related to a drug, procedure, surgery, or anaesthetic), or custodial (e.g. death
of a person in prison or police custody). The family can also approach the coroner if they
suspect that the death was due to lapse in medical care.
The coroner must establish who died and when, where, and how the death occurred. The coro-
ner will decide if (1) the cause of death is natural, (2) a post-mortem examination is required, or
(3) an inquest should be opened. The coroner will open an inquest if the cause of death is not
clear even after the post-mortem examination, the death is unnatural or due to lapse of care, or
the person died while in custody. An inquest is an inquiry, which may be followed by a court
hearing to establish the facts about the circumstances of the death.
The husband asks if it is possible to nd out the cause of her death without doing a
post-mortem.
• Ask if there is a religious reason for his request (an important question to ask when an
objection or concern is raised).
Consent is only required for a hospital post-mortem, which is usually requested when
the cause of death is not clear (e.g. the cause of illness was not evident during life) or for edu-
cation or research purpose. Consent must be taken from the next of kin for this kind of post-
mortem. According to the Human Tissue Act, it is an offence to remove, retain, or use human
tissues, so a separate consent is required if any of this is intended. Relatives have the option of
asking for a limited autopsy to be performed. For a coroner’s post-mortem, however, consent
is not required, and relatives cannot object to it, as it is a statutory process.
Some people may object to a post-mortem on religious grounds (e.g. Muslim, Jewish) or ask
for the body to be released on the same day. It is not up to the medical registrar to make a deci-
sion regarding this in the middle of the night! Your job is only to tell the family why you must
refer to the coroner and what will happen next. You can, however, reassure the family that the
coroner will take their beliefs into consideration and discuss with them directly.
Coroners will never order a post-mortem examination without careful consideration and
when there is the option of a non-invasive autopsy with computed tomography scan, which
may reveal the cause of death in most cases. However, if required by law, a full post-mortem
will have to be carried out (e.g. suspected foul play and the cause of death is not clear after
a non-invasive autopsy).
Referral to the Coroner 233
He says there is no religious reason for his request; he just didn’t want his wife’s body to be
mutilated.
• Gently tell him that he cannot object to a coroner’s post-mortem.
‘The coroner and the pathologist will go through her medical notes and consider the facts
very carefully. They’ll take the decision to do a post-mortem only if it is absolutely necessary.
I’m afraid we cannot object if the coroner decides to proceed with the post-mortem, as it is
a legal process.’
He asks what exactly happens during a post-mortem and if that will denitely reveal the
cause of her death.
• Briey explain the process of post-mortem examination without going too much into
the gory details.
‘Post-mortems are done by the pathologist, who will be assisted by qualied technicians.
They will make an incision on the chest and tummy, remove the organs to study them,
and then put them back. If they decide to retain the organs for further study, they will
inform you. They will neatly close the wounds and dress the body, so even if you decide
to use an open casket, no one will know that she has had a post-mortem. They’ll take
great care to ensure that the appearance of your wife is not altered.’
• Tell him that the autopsy may or may not reveal the cause of her death.
‘The post-mortem may or may not reveal the cause of her death. The coroner will decide
the next steps if the post-mortem is unhelpful.’
He asks what will happen next.
• Tell him that the coroner will be informed.
‘We will now inform the police, who will take your wife’s body to a special mortuary.
They’ll inform the coroner, who will then consult the pathologist and decide if a post-
mortem is required. Please do not make any funeral arrangements until you hear from
the coroner. He will let you know as soon as her body is ready to be released. Once the
investigations are completed, the coroner will register the death, and you can get the
death certicate.’
End the conversation by providing information on bereavement services. (‘I’ll give you
some information on bereavement services. They’ll provide the necessary support to you
and your family, which Iam sure you will nd immensely helpful during this very difcult
time.’)
234 Clinical Communication Skills in Medicine
SUMMARY
This scenario tests your skills in explaining the process of referral to the coroner for
an unexplained death. You will be expected to:
• Demonstrate your understanding of (1) the situations in which you cannot complete
an MCCD, (2) the process of referring to the coroner, and (3) the issues around
performing a post-mortem examination.
• Sensitively communicate this to the bereaved husband, who is in a state of shock
after losing his wife unexpectedly.
Before you walk into the room, the main challenge to anticipate is an objection from the
husband for a post-mortem to be carried out or a request for the body to be released
on the same day (usually for religious reasons). As it is a statutory process, giving them
incorrect information or conveying false hopes (e.g. telling them that a post-mortem
can be skipped if they do not consent) will result in an unsatisfactory mark for clinical
communication, addressing concerns, and clinical judgement.
A variation of this scenario is to ask for consent from a relative to perform a hospital
post-mortem for a patient who dies after a prolonged unexplained illness. You must (1)
discuss the reasons for proposing a post-mortem (it may be important for families, too,
to know the cause of death and get closure), (2) tell them that the knowledge gained
from performing a post-mortem can be applied to similar cases in the future, (3) offer
the option of a limited post-mortem, and (4) ask for permission to retain the organs
should it be necessary.
235
A
acute myeloid leukaemia (AML), 23 – 26
breaking bad news, 24
diagnosis, 24
prognosis, 25
treatment options, discussion,
24 – 25
adult-onset polycystic kidney disease, 41
antenatal diagnosis, 41
genetic counselling, 41
advance care planning (ACP), 94
advance decision to refuse treatment (ADRT),
199 – 203
advanced pancreatic cancer, 18 – 22
breaking bad news, 19
diagnosis,
19 – 20
prognosis, discussion, 20
treatment options, 21
against medical advice (AMA), discharge,
101 – 104
alcohol use disorder, 73 – 76
addiction treatment, 75 – 76
Alcoholics Anonymous (AA), 76
detox treatment, 76
rehabilitation, 76
alternative medicine see complementary and
alternative medicine (CAM)
anaphylactic reaction,
68 – 72
diagnosis, explaining, 69
EpiPen information, 70
treatment, 70
ankylosing spondylitis (AS), 144
anti-hypertensive medication,
125 – 127
anti-phospholipid syndrome, 51, 53
asthma, difcult to control,
134 – 138
asthma, explaining, 135 – 136
diagnosis, 135
management, key aspects, 136
B
back pain, acute vs. chronic back pain, 149
MRI scan, demanding for,
143 – 146
opioid use and, 148 – 151
brain haemorrhage, 221 – 225
brain death, diagnosis, 222 – 223
organ donation, 222, 224 – 225
tests, brain death, 223
brain tumour,
3 – 7
abnormal CT scan, 4 – 5
complaint about GP, 6 – 7
MRI scan, need for, 5
seizures, explaining,
3 – 4
treatment options, 5 – 6
BRCA gene testing, 123
C
cancer diagnosis, 106 – 109
breaking bad news, 109, 110
palliative measures, 108
prognosis, 107
treatments,
107 – 108
withholding diagnosis, 109
cardiogenic syncope, 46
cardiopulmonary resuscitation (CPR) attempt,
decision of medical team,
204 – 207
‘do not attempt cardiopulmonary
resuscitation’ (DNACPR) decision, 207
central line insertion, explaining complication of
pneumothorax,
177 – 178
chronic back pain, opioids, 148 – 151
acute vs. chronic back pain, 148
management, chronic pain,
150 – 151
chronic disease, new diagnosis, 12
chronic obstructive pulmonary disease
(COPD),
212 – 215
explaining COPD, layman’s terms, 213
mechanical ventilation, decision, 214
clinically assisted hydration, 219
clinically assisted nutrition, 219
coeliac disease,
27 – 31
anti-TTG result, explaining, 29
biopsy, small bowel, 29
gluten-free diet, discussion,
28 – 29
complementary and alternative medicine (CAM),
130 – 132
COVID exposure, hospital, 179 – 182
advice on isolation, 182
monitoring symptoms at home,
181 – 182
Index
236 Index
transmission risk, 181
updating son/next of kin of patient’s progress,
179 – 180
CT scan, chronic back pain, 143 – 147
explaining back pain management, 145 – 146
explaining why scan is not benecial, 145
exploring patient’s beliefs about back
pain, 144
lung cancer, 147
D
deep vein thrombosis (DVT), 50 – 51
diabetes mellitus T2, poorly controlled, 59 – 62
acknowledging difculties, 61
consequences of poor management, 60
dietary advice, 61
exercise, 62
patient education,
59 – 62
smoking, 62
diagnosis disagreement,
156 – 160
dealing with difcult relatives, 159 – 160
polymyalgia rheumatica (PMR), 156, 157
dialysis refusal,
91 – 94
palliative measures, 94
possible complications of end stage kidney
disease, 93
exploring reasons for refusal, 93
recommending dialysis, 92
discharge against medical advice,
101 – 105
assessing patient’s mental capacity, 103 – 104
exploring patient’s reasons for discharge,
101 – 102
explaining seriousness of condition, 102
signing form, 104
discharge refusal,
139 – 142
discharge measures put in place, 141 – 142
explaining that breathlessness is due to
interstitial lung disease (ILD), 140
explaining why no need for further hospital
stay,
140 – 141
prioritizing patients in ED, 141
disseminated gonococcal infection (DGI),
111 – 112
‘Do not attempt cardiopulmonary resuscitation’
(DNACPR) decision, 207
drug seeking behaviour, 149
E
encephalitis, lumbar puncture, 86
EpiPen,
70 – 71
F
fainting, recurrent episodes, 45 – 49
explaining vasovagal syncope, 46
rst-line measures,48
precautions, 48
risk of syncope,
47 – 48
seizure, 46 – 47
syncope causes, 46
falling off bed in hospital,
174 – 177
incident report, 177
monitoring,
175 – 177
operative intervention, 175
physical restraint, 176
feeding tubes, concept of, 209
focal seizures,
3 – 4
functional dyspepsia (FD), 55 – 58
endoscopy, 56
evaluation, 57
management of, 57
G
generalised seizures, 4
Non-compliance, driving, 115
Glasgow Coma Scale (GCS), 163, 176
gonorrhoea diagnosis, non-disclosure to wife,
111 – 115
reasons why wife needs to know, 113 – 115
sexual history, 112
H
HIV test result, 13 – 17
and AIDS, 15
lifespan, 15
needlestick injury, 14
pregnancy, 16
risk factors for, 14
HIV testrefusal,
96 – 100
condentiality of test results, 98
partner notication, 99
Pneumocystis jirovecii, 97
recommending HIV test, 97
risk factors for HIV, 97
treatments, 99
Huntington’s disease (HD) test,
119 – 122
blood test, 121
genetic counsellor, 121
in layman’s terms, 120
lifespan, 122
pre-implantation genetic testing,
121 – 122
hypertrophic obstructive cardiomyopathy
(HOCM),
37 – 41
driving risk, 39
echocardiogram, 38
genetic testing, 40
implantable cardiac device, 39
management of, 38
risk of sudden cardiac arrest, 39
strenuous exercise,
39 – 40
hyponatraemia, 63 – 66
uid restriction, 66
osmotic demyelination syndrome, 66
syndrome of inappropriate anti-diuretic
hormone secretion,
63 – 66
traumatic brain injury, 65
Index 237
I
insulin resistance, 60
interstitial lung disease (ILD),
139 – 140
J
Jehovah’s witness, 95
Junior doctor, underperforming, 195
L
lasting power of attorney (LPA), 201 – 202
living will, 199 – 203
ADRT, 201 – 202
advance statement, 202
dos and don’ts of ADRT, 201
implications of refusing treatments, 200
lasting power of attorney, 201
proxy decision-maker, 202
lumbar puncture objection,
85 – 89
alternative tests, 87
benets of, 89
procedure, 87
risks, 87
treatments, suspected encephalitis,
86 – 88
lung cancer
CT scan, demanding for, 147
lupus nephritis,
78 – 81
high-dose steroids, counselling, 81
renal biopsy, complications of, 81
risks of renal biopsy, 80
SLE,
79 – 80
lymphoma herbal treatment, 129 – 132
CAM treatments, 131 – 132
herbal treatments, effects of, 131
side effects,
130 – 131
treatments, 130 – 131
M
medical certicate of the cause of death
(MCCD),
231 – 232
medical error, 191 – 195
investigation, 193
missed diagnosis, 191
second victim, 191
talking to junior doctor, emotional rst
aid, 192
medical defence organization,
193 – 194
medications, avoiding, 124 – 127
anti-hypertensive medication,
alternative, 126
home blood-pressure monitoring,
126 – 127
hypertension and consequences of, 124 – 125
lifestyle advice, 127
side effects of medication, 126
medication error,
169 – 172
incident report, 172
prolonged QTc interval, 171
mental capacity,
103 – 104
Mental Capacity Act 2005, 199
Mental Health Act (MHA), 88
missed diagnosis, pulmonary embolism,
167 – 168
Montgomery test, 188 – 189
motor neurone disease (MND), 208 – 211
aspiration pneumonia risk, 209
dysphagia and dysarthria, 209
feeding tubes concept,
209 – 211
PEG, 209 – 211
SALT, 210
mycobacterium tuberculosis,
32 – 34
myocardial infarction death, 226 – 229
acute pulmonary oedema, 228
death news, 227
N
Neisseria gonorrhoeae, 111
no diagnosis,
152 – 155
fever of unknown origin, 153
PET-CT scan,
154 – 155
non-compliance, methotrexate, rheumatoid
arthritis, 127
non-specic back pain,
143 – 146
ankylosing spondylitis, 144
simple back pain,
144 – 146
non–STelevation acute coronary syndrome
(NSTE-ACS), 101
O
organ donation, 222, 224 – 225
P
pain team, multi-disciplinary,151
palliative measures, 108
paracetamol overdose, 105
patient’s wishes, 205
percutaneous endoscopic gastrostomy (PEG)
feeding,
209 – 211
Pneumocystis jirovecii, 96 – 97
polymyalgia rheumatica (PMR),
156 – 157
positron emission tomography-computed
tomography (PET-CT),
152 – 155
post-mortem
Coroner’s,
231 – 233
Hospital, 234
postural syncope, 46
pulmonary embolism (PE),
50 – 54
anticoagulant treatment, 51 – 52
heparin, 52 – 53
imaging tests, 52
low-dose aspirin, 53
missed diagnosis,
167 – 168
warfarin, 52 – 53
Predictive genetic testing, 123
Соседние файлы в папке Библиотека им академика М.И. Перельмана