The family of a patient under your care on the Stroke Ward has requested to see you. The patient (Thomas Davey, 52 years old) was admitted 8 days ago following a CVA. CT showed a large MCA territory infarct. He has made little or no improvement since it happened. He has a dense right hemiplegia, with a homonymous hemianopia and a severe dysphasia. He has poor sitting balance and has an NG tube in place. Medication: Aspirin 300 mg, atorvastatin 40 mg, paracetamol prn
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It is important for the candidate to spend time understanding the patient’s current situation and discussing this with the patient’s wife. Following this, it is important to elicit the wife’s concerns and expectations. The candidate should recognise the wife’s frustration and offer solutions and apologise for the conflicting information given. The candidate should not offer to refer the patient to a private facility. However, after offering solutions, if the wife remains unhappy, the candidate should offer to talk with their seniors, in particular the consultant in charge. Exploring the psychosocial impact on the wife may help to establish the wife’s true concerns.
Marks are allocated for both your communication skills and demonstration of your knowledge base. Ensure that you read the clinical vignette carefully before entering the room, and make sure you take note of the task. What is it that you need to get across during the consultation?
Take note of your role. Invariably, you will be the junior doctor or junior registrar. It is also important to note your location. Are you in A&E, an Outpatient Clinic, or the ward?
Think about how you want to direct and structure the conversation, and any frameworks you want to employ around which to construct your discussion, such as ICE or SPIKES. Take note of the key points to cover. Write notes or make a sketch diagram. Consider what questions may be asked, and what information sources or resources you could direct the recipient to.
Finally, do not make things up. Practice phrases like ‘let me check this, and I’ll get back to you’ or ‘let me check with my consultant and I’ll get back to you’.
Moving on, the first ethical issue highlighted in this case is that of consent. If the patient has capacity, then you should ensure that you have obtained their consent to discuss their case with the relative. In any case, you should always establish the identity of the person you are speaking to. You are also breaking bad news to the relative about the fact the stroke is extensive, and the patient is unlikely to recover back to their usual premorbid status. They’ll also be left with a degree of deficit. The other issue that you are dealing with is making decisions in the patient’s best interests. The patient’s wife wishes to explore the option of care in the private setting; however, you are aware that best practice advises that patients with an acute stroke should be managed on an Acute Stroke Unit, as this is associated with better patient outcomes. It is your duty to inform the patient’s relative of such.