The most important scenarios in

communication
Explaining (A Disease Or A Procedure Or A
Situation or treatment )
Refusal (Treatment/Advice/Admission/
Discharge/…Etc
Angry patient or relative
Break In The System
Medical error
Complication of a procedure or medications
Breaking Bad News
Di cult Situations
Di cult Person (Angry, Noncompliant Patient ,
Harmful Doctor)
Critical situation
DNAR
End Of Life: palliative treatment
Brain stem death
Organ Donation
Withholding machines = Ventilate Or Not To
Ventilate)
Di cult Disease (HIV, T.B, Hepatitis B or C,...)
GENETIC COUNSELING
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 - DRIVING
I am afraid you are barred from driving
for ........ .This legal requirement and i am obliged
to advice you that you should inform the DVLA
and your insurance company .I will have to write it
in your notes that i have advise you. Ask patient
how he feel now OR what is about her mind in
new events.

-Explain procedure
A lot of people under grow this procedure that
done safety however as any medical procedure its
risks which occurs in small percentage of patients
such as ...........eventually weighing the great
bene ts against the low possibility of risks makes
the procedure is advisable option for you from
medical point of views

-DNR
I know you have been su ering from this illness
for long time........i know that it is di cult to give
me answer but let me to ask , if your heart was
stopped do you want to resuscitate you and
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explain resuscitation , tell him if your heart stops
and we managed to resuscitation, we would not
able to keep your heart working except for short
period of time and we cannot promise you to be
able to keep you in good shape at that time
However we are going to provide all other
available treatments and keep you free of pain and
good view

-If daughter does not want

you to tell her mother that
she has serious illness
I appreciate that you know your mother much
better than doctors. However having seen this
situation many times before, telling the mother the
truth is usually what she wants and is best in long
term. Most people know when there is something
seriously wrong and nding out can be a relief. I
would like to know that your mother does not
want to know her diagnosis, I will talk to her and
give her small amount of information and if she
does not want to know, I will not tell her
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 -Social condition
I need to ask you some rather personal questions
is that ok, how does this problem a ect you in
your job, how does this problem a ect your
marital status, do you feel depressed because of
this problem Poor prognosis
No one knows what is will be happened in the
future so I do not like to give gures everybody is
di erent and some people do much better than
others and I know a lot of people have same
condition and enjoyed reasonable life for a
relatively long time

Terminal ill patient

I don’t know if the disease will go away
completely however we can do a lot of things to
help you cope with it and make you free of pain
and in good shape

Angry pt
I am understand your feeling and I am sorry for
this, I will nd out what went wrong and actions
will be taken to stop it happening again now we
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want to focus in the future and the new plan of
care

Consent
So far you are supposed to sign consent for this
procedure. This will include the main points that I
have already explained to you.You should read it
again and if you have any further questions you
may ask me, and event after sign the consent you
have the right not to undergo the procedure if you
change your mind for the procedure before the
scheduled time.

Finishing the consultation

I appreciate we have covered rather a lot there is
there anything you would like me to go over again
I hope our discussion is useful for you, can you tell
me how much you get information from me?
I hope you have found our discussion useful to
you, do you have any further question
 Genetic disease
Tell the pt the disease not inheretant but the pt
with an a ected relative are more likely to get the
condition so the percentage of child to get the
disease is low

Family ask for more

admission at hospital (UTI
with dementia)
Explain UTI can lead to confusion
-Ask him why you suspect your mother has
dementia
-Ask about the symptoms of dementia like
forgetfulness and her insight -Ask about causes of
dementia like Parkinson, stroke, Alzheimer or
reversible causes like vit, b12 de ciency and
hypothyroidism.
-Tell them the pt was assessed by occupational
health and physiotherapy physician, and mental
score test was improved than admission time and
your mother do many tasks now and she now can
mange her day task. If we outweigh the risk of
continue admission as pt may developed hospital
acquired infection, also we take care of that but
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we can’t guarantee 100% -Hospital is best place
for her when she acutely unwell but hospital
setting now is not best place for her
So we will discharge the pt and we will give you
plan as report for GP, home visit, out pt follow up
-Ask about the care of pt at home and how the pt
doing before admission-

Inoperable cancer
-Would you like me to explain the problem as we
understand so far, or are you want to know
everything about your condition?
- I am afraid to inform you the result of test not as
we hoped............the result showed abnormal
growth and it is meaning you have cancer. Tell him
I sorry to inform you these bad news
- (I am afraid that thing more complicated than we
had hoped, it is not likely straight forward)
-Tell him how he feels about that and what are
particular things you are thinking about?
-Tell him the tumor is aggressive type and it’s not
limited to one area and it is rapidly progressive.
-the prognosis is di erent from one pt to another
and the pt may die within days to menthes
-Tell him as the cancer is spread to other area so
the surgery is not indicated and the disease is not
curable
-Ask about the job and if relation with cancer
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-Explore the advanced directive and DNR
-Arrange to another meeting with oncologist
-Tell him you will give pain treatment
-Refer him to Mac Million nurse
Pt under 16 age and asked abortion or
contraceptive pills
-Ask her why you are her today
-How much you understand by sexual history and
contraceptive pills -Any plan to inform the father
and mother
-If you want from me to inform family
-If cannot help you today what do you think might
happen

Advanced direction
To become legal
1-pt has capacity and more than 16 years
2- Voluntaries
3- Informed
4-specify, resuscitation, nutrition
5-written, witness, signed
6- Continuity
- Periodic review and may add as codicil
-Should be continue basic care
-Ask if he want to discuss the advanced direction
with family
 Back pain with breast
cancer
Ask her how she feels today
-Ask about pain, brief history
-Ask her how much she knows about her illness
-Ask her did any one inform her why x ray
requested for her
-Ask her what her expectation about the result of
test is?
-Tell her the result of test is released, I am afraid
to inform you the result not as we hoped,,, the
result showed abnormal growth in the back
-Apologize for delay the diagnosis, tell her the
back pain has many causes and most common
cause is musculoskeletal
-Tell her the breast cancer is slowly growing
tumor and some cell escape from the breast to
other area in the body and slowly growth
-Tell her more test want to be done as biopsy from
the chimer and scan of other area of body to know
the nature of tumor and how it extend
-Tell her now we cannot predict the prognosis as
we need to do more test -Emphasize that it is not
curable disease as the cancer is spread to bone
-Tell her, I will refer you to oncologist consultant
and he will decide the plan of care
 -Tell her you will give her medication for pain
control
-Ask about the social life, who lives with her and
nancial support

Deliberate self harm

ASK her how she feels physically now
-always remember her I am here to help you
-tell her you are physically well now but I
concerned for your overall welfare
-tell her you will refer her to psychiatrist
-ask her how she feels about that
-tell her the psychiatrist is expertise and he able
to assess you to protect you from future self harm
-Tell her that is not mean you are mad but simply
we concerned you have untreated depression
which is mental illness and there is good therapy
available
-If he agrees thank him

Patient consent for DNR

-Mr. there one thing I should discuss with you, that
related to what we might do in the event that
going wrong in your health on admission to
hospital
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-You are in the hospital rather a lot in the last year
and now you are back in the hospital sooner than
you and your doctor had hoped.
-Some person have same similar condition come
bad and suddenly turn for the worse, at this time
you came with deterioration in your breathing and
you using the breathing apparatus last night and
several occasion in the past. We will do all that we
can to improve the situation for you this time
-This always the possibility as with un well pt that
thing could go very wrong that the heart could be
stop or the heart and breathing stop together, how
you ever thought about your wishes might be in
that situation
-If the things go bad and the heart and breathing
stop would you like us to try to restart things with
heart starting machines and breathing tube?
- Tell him if the stage become worse try to rescue
the situation would be in vain, it is simply would
not work
-If he agree till him he should be sign consent and
the decision will be reviewed and alter at any time
-Meantime we will do all that we can to get you
better
-Tell him the decision is di cult to taken know.
And we will arrange for second meeting
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 Epilepsy
Tell her about the diagnosis of epilepsy is clinical
and I will arrange for you more speci c test called
MRI and EEG
-Should ask about any regular medication as
many type of medication interfere with
antiepileptic drugs
-Ask her if she planning for family and if she
received any OCP -Ask about ts during sleep
-Life style change like
Sleep as she should be sleep at night
Swimming
Job as working with machine, driving or night shift
Alcohol should be decreased
Recreational drugs
Food like chocolate
High music sound
-Tell her there is possibility of driving if she free
from ts
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 Medical error (gentamycin and
renal impairment)
-How you are feels now
-Explore about the symptoms of UTI like dysuria,
fever, and vomiting, abdominal pain
-Ask him about uremic symptoms as shortness of
breath, chest pain, jerky movement and vomiting
-Tell him he was started on antibiotic called
gentamycin that appear in urine culture and he is
on regular check up level of this drug in blood and
when the level is low that mean insu cient
treatment and if level is high that mean toxic dose
-The result of level was released and showed that
the level is high that meant it is toxic dose
-Apologize for that and inform that it is a mistake
-Inform him as the drug is high level in blood it
may be a ect other organ like kidney, most of the
cases is reversible when medication stop and it is
small risk to become permanent. I apology for this
mistake.
-Ask about the hearing defect and inform him in
some cases it is reversible but most of the cases
it is permanent
-Tell him no anyone responsible for the mistake
and the responsibility for all team and we will
write incident report to investigate about the
mistake and prevent of recurrence
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-It is very di cult to know what is will happened in
the future with hearing, I will refer you to ear
consultant and nephrology consultant

-Now we will stop the medication to prevent

deteriorate in your condition and will start another
antibiotic for UTI
-Apology again for this mistake

HEALTH CARE GET

INFECTION DURING WORK
-Show empathy
-How much he know about disease
-Explore about the symptoms
-Ask him where he acquired the virus
-Vaccination history
-Any medical check up
-Sexual life
-Explanation of result
-Plan, inform occupational health, consultant
-Restriction of prone procedure
-Ask him how he feels about now
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 -Tell him you know the time is di cult now and I
know the new result have serious implication
about your surgical career
-Check the ethics autonomy, ben ncence, non
male cence, justice, con dentiality and consent
-Check social, job, nancial e ect
-Disablement
-Refer to hepatologist and HIV physician

Delay procedure
-Let him to speak free
-appreciate that the delay not accepted
-Apologize for him
-Attempt to take appointment now before he leave
-Check his address
-Show for him a plan to rectify the situation to
prevent recurrence -Incident report and submit it
to trust risk manger (patient advice liaison
services)
-Inform consultant
-I the patient wishes to formally complain advice
him to contact PALS -Avoid documentation of
complaint of Pt at his le
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 Postmortem
-First tell relative we are sorry about sudden death
of patient and all sta looking after him is
saddened by this news.
-Explain the condition of patient
-Explain that you and consultant were surprised
by sudden death of patient, this may be other
possibility of death like PE or lung cancer but we
are not sure about that
-Ask how many important it is for her/him to nd
out whether or not the patient had cancer
-Tell them we can nd the cause of death by do
postmortem examination. -Ask how they feel
about that.
-Ask how much know about postmortem
examination and how much details she want to
know about details of procedure
-Ask about if the patient had any known objection
toward postmortem procedure before illness
-Discuss what is postmortem, what are bene ts
-Reassure that no dis gurement of body
-Reassure that funeral arrangement would not be
necessary delayed. -Explain who will do the
procedure and where
-Tell her if there is something serious, if she agree
for retain tissue for do further investigation,
education and research
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 -Tell her if she wants to know the result of test, the
result will be send to consultant and she can take
the result from him
-Bene ts of postmortem:
Illness information, e ect on body and explain
causes of death
Help doctor to treat other patient and information
about the disease for research
-Allow limited postmortem if the family not agree
for postmortem -Postmortem carried out in 2-3
working day and examination will take 3 hours, lab
will carry out for 3 weeks
-Retain tissue after approval from family even for
more test or research.

Jehovah’s Witness
-Explain the nature of the disease as he has
change in colour of stool and the colour of sick is
brown so it is may be duo to lesion in the Tommy
or the rst part in the bowel that adjacent to the
tummy as it may be lesion in the lining of the
tummy or bowel . Also it may be another lesion as
abnormal vessels, cancer or other lesion
-Explain that the plan of care is known the causes
of the bleeding through camera test to looking
inside your tummy and rst part of bowel that
adjacent to the tummy. Explain the procedure and
bene t risk ratio as injury of the lining of stomach
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 or injury to the whole stomach wall also the risk of
sedation
-Explain the investigation revealed low blood
count duo sudden loss of blood and this put the
patient in life threaten condition
-appreciate his religious faith
-Explain the bene ts of blood transfusion as he
loss too much of blood and the function of blood
is transmitted of oxygen to the tissue
-Explain the hazards of refusal of blood
transfusion as he may continue to bleed and the
end, he will be died
-Explain the if he need other element of blood
component
-Explain the refusal of type of treatment; it is not
a ect health care plan -Ask if he volunteer to
refuse of blood transfusion or he under any
coercion of relative or other person
-Explain that to patient he should write refusal
form and sign it, tell him if he change his mind, he
have to inform nurse or call me
-Explain to him during the procedure if too much
blood was lost and his life in critical situation,
what is his kind about that (as he lost capacity)
- inform pt there is no discrimination if the pt
refuses the blood transfusion
-Inform consultant and medical defense union,
Jehovah’s Witness liaison, support from family or
religious leader
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 -inform him about the consent of camera test and
refusal form of the blood transfusion

BRAIN STEM DEATH

-Introduce yourself
-Identify the relative
-Out of respect to Mr.........I want to know to whom
I speaking
-Are you next of kin?
-Do you want one of family to attend this meeting?
-Tell how much you know about the patient illness
-Explain to .....when the patient arrive at ER he is
not conscious and his condition is critically
ill ,mechanical intubation done ,sedation
started ,CT brain done that showed extensive
hemorrhage ,and destruction of brain tissue that
a ect the breathing .The patient was assessed by
neurosurgeon and neurologist ,and decide that
neurosurgery would be inappropriate and the
prognosis is poor as there is no sign of
improvement
-There two consultant assess the patient
condition twice and do for him brain stem test,
and the result showed that the patient is
technically dead -As there is massive destruction
of the brain cell so, the patient has irreversible
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brain damage, as these cell will not recover again
so you father will not awake again
-The Pt is relying on machine to do the breathing
for him and the breathing will stop is we
disconnect the machine and the heart will stop
after so the heart and lung now is arti cially
maintained and the patient is clinically dead
-Explain that the continuity of ventilation for
person who actually dead it is inappropriate and
the next step we will stop the ventilation
-Explain that the decision is for medical team
looking after the patient, and it is not the
responsibility of the family
-Explore about advanced directive or living will
-Explore the social activity of Pt
-Tell .....The patient was died and his organ not
damage, ask if Pt express about any idea if he in
same situation
-Explore the opinion of family about the organ
donation
-If agree tell them we will conduct the transplant
team, that will approach the family about this
issue
-We will keep the patient on mechanical
ventilation to allow the organ vital until organ
retrieved
-Explain that the patient will not su ering from
pain
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-If he wants more time to thinking tell him, we will
keep pt on ventilation until taking their decision
Should exclude reversible causes as,
hypothermia, electrolyte disturbance and
endocrinal illness

BREAKING BAD NEWS

-Explore any relative with patient
-How feel now
-How much ....know about your condition
-What is your expectation about your illness?
-Did you know why we do this procedure?
-Did you informed why do this procedure?
-Did you informed what is the possibility of the
causes
-Inform the procedure done and the result was
released then .......................pause ,the result not
as we hoped, I am afraid to inform you the result
showed disease called ............
-How you feel know
-How much you know about this diagnosis
-Tell Pt .....i don’t know the details of treatment , I
will refer you to expertise physician who will
decide the plan of care
 -The medication for this condition may be
chemotherapy or radiotherapy and the expertise
physician may request some investigations
-The prognosis of the disease is not expected but
1- If condition is treatable till him that
2- If the condition not treatable till him, the
response to medication Di erent from one to
another Pt, as we can not expected what is will
happen in the future
-I will give you some pressure and web sit to know
much information about disease
-Tell him this my contact number and feel free to
call me at any time- -Explore the social status,
job, nancial, which lives with patient at home,
how the patient will go to home today
-Ask pt if he has any concern

MRSA IN LTC PATIENT

-Inform about what is daily need of Pt ....assistant
mobilization, feeding, toileting and for ulcer
dressing
-MRSA is isolated from the ulcer and it is not
a ect the patient systemic or locally.
-MRSA about one third are lives in patient without
causing harmful and present in skin and nose
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-MRSA can lead to infection of skin and it is easily
treated but in patient with immunocompromissed
or deep wound may lead to systemic infection
-MRSA is di erent from other staphylococcus
aurous that is it has resistance to some antibiotic.
-Care of patient with MRSA required good hygiene
precautions, so resident with MRSA not at the
risk, the patient with MRSA should be lives normal
life and not isolated, also Pt can share room but
avoid to be contact with patient has open wound
or catheter, also Pt can attend social acclivity
without restriction only covered the ulcer with
good dressing -The sta has any sore or psoriasis
should avoid care of patient
-Carry out the procedure and dressing in room of
Pt
-Follow up the infection control precautions as
hand washing and alcohol hand rub
-Not screen for MRSA until there is reason like
systemic infection, new sores or worse the wound
-Processes of admitting patient in LTC inform
manger, GP, infection control sta
-If pt with MRSA need to transferee to hospital,
should inform hospital and infection control
-Avoid discrimination with PT has MRSA
-Reassure .......and advice to be contact with
infection control department
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 Needle stick injury
-Tell what exactly happened
-What the precaution done before start, it I deep
penetration? ,what is happened after needle stick
injury,
-Tell the risk of transmission of HIV is 0.3 and also
there is risk of hepatitis B, C
-Ask about if the patient immunized to HBV
-Ask about medical checkup and screening for
hepatitis
-Tell patient what is will do now for minimized risk
of transmission of infectious disease
-Tell her to write incident report as if the test is
positive to claim for compensation or disablement
bene t
-Ask if Pt has infectious blood transmitted virus
-Inform Pt, should inform supervisor and
occupational health
-Tell we will do blood test now for hepatitis and
HIV and will repeated it after 6 months
-Tell if Pt agree for HIV test as this test need
informed consent
-Explain advantage and disadvantage of HIV test
Advantage if negative you will enjoy of life and no
need medication If positive we will start
medication early
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Disadvantage, false positive and false negative,
insurance and job loss -Ask about the safe sexual
intercourse and inform the partner
-Tell Pt that avoid blood donation and avoid
exposure with pt have open wound and extraction
of blood
-Tell Pt the result of test will be con dentiality and
not released by email or letter
-If patient is female ask her about LMP and if she
is pregnant the medication will be started to avoid
vertical transmission
-Tell pt about the post exposure prophylaxis and
about the side e ect of drugs
-Tell pt about the seroconversion symptoms and
hepatitis symptoms -Tell pt if test is positive it will
released to the communicable diseases
surveillance center
-Tell her to use contraception and safe sex until
we see result of test Tell her many physician have
many needle stick injury and catch infection is
small
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 HIV TEST
-Introduce yourself to Pt
-Identify pt
-Ask for permission to start discussion
-Con rm agenda
-Tell pt how much he know about your illness
-Ask him how much he told about his condition
-Ask about his expectation for the causes of his
illness
-Inform him the causes of his illness may related
to virus that a ect immunity
-Ask him, did he her about that
-Inform him the causes may be HIV
-Ask him how he feels about that
-Ask him if he has ever consider the possibility of
HIV
-Ask about the other risk factors for HIV as
sharing needle and unprotected sexual
intercourse or he contact with other person has
HIV -Ask if he do the test before
-Inform him to do the test, it is blood test, he
should be sign written consent from him
-Reassure him the test result will be con dential
to the sta looking after him and result would not
be released to any one without his consent
-The test is not test for AIDS, it is only test for HIV
and there is di erence between both
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-If test is positive and he has opportunistic
infection, then he has AIDS -If test be positive, the
future insurance will be di cult to get, but the
prior insurance will be valid
-Inform him it is his responsibility to inform his
partner if test is positive and she should do the
test to see if she has HIV or no
-Tell him that if he not inform partner and she
know by other way what is her feeling about him
-He should do safe sex until the result of test
-Tell him he should inform his GP if the test
positive as if he has any complain , his GP will
take in his consideration the possibility of
infection in immunocomprmised infection also to
avoid transmission to his GP if he request blood
sample , if he still insist for refuse to inform GP tell
him just inform him to take standard precaution to
prevent transmission of infection also if he in
travel away he should be inform the physician that
he will look after him to take in consideration
standard precaution
-reemphasize the decision for him and he should
not feel pressurized , also he have time to think
about the test ,also if he decide to agree for
test ,he have the right to refuse to do test before
procedure

-inform him, I know information is hard for him at

this time and I appreciated that
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-Ask about social activity (job, marital status, if
female ask about pregnancy, insurance)
- If the test is positive we will do further
investigation for hepatitis and may be need
vaccination and plan of management may need
treatment or just follow up
-If test is positive we will request blood test to
check immune level by check number of cells
which is may low in HIV
-Tell him HIV is virus which a ect immune system
and it is may be silent for long time before
manifested by systemic illness
-Bene t of test: If test positive, you have
advantage to start medication early with follow up
your condition
- You will know if you infected to other or not
- I test is negative you will feel less anxious
- If you plan for family, you will know if test is
positive You will start medication to avoid vertical
transmission
of HIV -Negative aspect of test
-Increase anxiety and depression
- Risk for job and insurance -Positive test means
- You have HIV
-You can infect other so you have to take
precaution - You did not have AIDS but you may
get it
-Negative test means
You may get HIV in future
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 - If the test will be positive, the test will be
repeated and even we will
request PCR

Consent for participate in clinical

trial
-Identify Pt
-Introduce your self
- Con rm agenda
-Ask Pt about his condition, how much he knows
-Tell him what response to his medication is
-Explain to him the research topic
-Explain to him the new drug was studied for side
e ect
-Inform him he should agree for participate in
study and also he should be volunteer and there is
no pressure. Also inform him the continuity of the
consent as he has right to refuse at any time even
after started the trials -Emphasize about the care
will be continue if he refuse to participate in trials
-Advantage of participate in trials is
He will be monitoring by same doctor more than
usual
His condition may be improved but is no
guarantee
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 It is helpful to discover the new therapy for other
with same similar
condition
-Explain the drug was tested before and there is
possible side e ect which is rare and he will be
regular reviewed
-Explain he would remain in the same medication
-Explain that the participate is totally voluntary
and he does not have to decide now
-If he decide not participate, his care will continue
as usual and if he decide to take part he can still
withdraw at any time and this would not a ect the
future conduct of treatment
-Emphasize his identify in study will be
con dentiality and if result will be published his
identify will be con dential
-However in to meet legal criteria should inform
sponsors, local ethical committee and GP
-Explain how will follow the treatment; also
explain that the result are not predictable.
-Explain also there is other patients in other
center participate in study
-If any illness from trial he will be managed in
appropriate way
-Inform him if he agrees, he should sign the
consent
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 Poor compliance
-Ask him about his symptom and how he feels
now
-Ask him about the medication, and how he feels
about his tablet and compliance to his medication
-Ask him why he not adherent to his medication
duo to what side e ect, forgetfulness, poor
information
-Ask how he takes tablet, purpose of taking tablet,
about the taste of tablet and di cult tablet
-Tell him what his expectation about the poor
response to medicine is -If the pt deny that and
told you he still taking medication, inform him that
the most causes of poor response is the patient
not adherent to medication
-Tell him what is the important to treat his disease
healthy and socially -Ask him what his expectation
to improve the complaince to medication is
-Inform him that, there is new plan for
management
-Inform him you will inform consultant
-Inform him about job and social activity
-Inform him it is hard for him to hear and you
appreciate that
-Inform him he should inform GP
-Explain to him way to improve compliance like
education, web site and lea et
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 Deliberate self harm
-Introduce your self
-Tell him how he feels now physically
-Tell him I know the time is hard now for you and I
appreciate that -Inform him, I here to help you
-Ask him about the type of tablet, dose and if
taking at same time
-Ask him if he received another tablet or alcohol in
excessive amount -Inform him you know the time
is hard and Ask him to tell you why he taking this
medication
-Ask him what is happened before attack, like
suicidal note , making plan, choice time to be
alone, intend to kill him self
-Ask him what is happened during attack like
close door, to be alone -Ask him what is happened
after attack, if he informs other people for help
-Ask him about past history of psychiatric
problem, suicidal attack or drug intake
-Ask him if he feeling hopelessness, life
worthlessness, low mood, poor sleep poor
appetite or hallucination
-Ask him about family history and social support
-ask him if he want to die and about his sought
after taking drugs and if still feeling to die
-Explain to him that you are here to help him
-Ask if he understand why he need help
-Tell him that, I here to help you and mange you
medically and you will follow you medically
-Tell him he needs to be assessed by psychiatrist
-Ask him how he feels about that
-Tell him the psychiatrist will assess him, he
expertise in that and he may prescribed for him
medication

DVT in pregnancy
-Introduce yourself to Pt
-Identify Pt
-Ask how she feels now
-Ask how much she know about her illness
-Ask here did you know why we do these scan
-Ask about here expectation about the result of
scan
-Inform here the result os scan was released and
it is showed something not good
-Tell her the scan showed blood clot in the pipe of
here lower limbs that called DVT
-Explain to her what is meaning by DVT and draw
to here diaphragm -Ask about the symptoms of
pulmonary embolism
-Ask about family history of thrombus any where
-Ask about any previous thrombus or previous
miscarriage
-Tell her the plan of care
-Inform here she will admit in hospital
-TELL HERE SOME INVESTIGATION WILL DONE
-Tell her, she will receive now injection called
LMWH to thinning of blood and prevent further
thrombus formation, and explain to here
advantage and disadvantage of using injection
and she will learn how to inject these medication
by here self
-Tell her after labor ,other medication will add for
here ,it is tablet also lead to thinning of blood but
we cannot star it now as it lead to a ection of her
baby and may lead to bleeding in the labor and
after start these tablet for 5 days ,the injection will
stop
-Tell here follow up of response to medication by
blood test
-Tell her, I will refer you to hematologist who will
take further investigation and he will decide for
how long she will continue the medication
-Ask here how she feels about that
-Tell her the symptoms of PE and inform here if
these symptoms happened to her, she should be
call her physician
-Tell here you will give here medication for pain
control and she should be wear stocking
-Inform here she will followed also by obstetrician
-Give here lea ets and web site for DVT and
medication of anticoagulant
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 Epilepsy and drive
-Ask Pt how he is feeling now
-Ask how much he know about his illness
-Tell him if any one inform him why CT brain, EEG
done
-Tell him the result of CT brain and EEG was
normal and these not guarantee that ts will not
happen
-inform him the diagnosis is epilepsy and mostly
cause is idiopathic and the diagnosis is clinical
-Tell you will refer him to neurologist as he
expertise in this disease and he will give him
instruction and plan of care
-Ask about his job, social live and if female ask
about the family planning -Ask him if he know the
implication of epilepsy about his job
- I am afraid you are barred from driving for one
year. This legal requirement and i am obliged to
advice you that you should inform the DVLA and
your insurance company .I will have to write it in
your notes that i have advise you.
-Ask patient how he feel now OR what is about
her mind in new events -Inform him the risk of
driving for him and for the public
-Tell him it is his responsibility to inform DVLA
-Inform him the insurance policy now is invalid
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 -If he still intend to driving, inform him you know
the time is hard and you appreciate that as it may
be a ect your livelihood
-Inform him you will inform social worker and
occupational; health that may be found for him
another job not put him at risk.
-If still intent tells him can you take time to think
but at this time you must be not drive
-Tell him you will arrange for meeting with
consultant
-If he still insist inform next of kin, also if he still
insist tell him you will inform the DVLA and you
will document that in his le and you will send
letter for him that you disclose information to
DVLA and GP

Genetic test
-Ask her how his father now
-Ask her there is other member of family has
disease
-Ask her how much she know about Huntington
disease
-Tell he about Huntington disease causes,
prevention, manifestation, treatment and
prognosis
-Tell her Huntington disease is a serious disease
that a ects pt lead to progressive deterioration in
both the ability to carry out physical tasks and
mental function to extent that people developed
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 advanced dementia Emphasize about the
diseased not cure and not prevented, as the
treatment only symptomatic and nursing
Ask her why she wants to do test
-Ask her how much she know about test
Tell her, she should be sign consent for do test
and ask he if there is any coercion from the
company, relative or husband to do test
-Tell her the test is blood sample
-If she agree to do test you will send here to the
genetic center and multidisciplinary meeting will
done that include social worker, neurologist,
psychiatrist, genetic physician –
--Inform here the test may be false positive or
negative
-Inform here if the test is positive we cannot
expect what is time of symptoms will start and
what's about the severity, kind of symptoms
-Inform her there is implication on her social life,
insurance and job -Inform here she has time to
think about test and you will give her website,
lea et
-Tell her if she agrees to do test, she should
inform here husband and he should attend the
next meeting
-Emphasize about the result of test will be
con dential
-Tell her the disease is inherited condition and
delay in testing not make any di erence
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 HRT
-Introduce yourself for pt
-Ask her how she is feeling now
-Ask why she feels this symptoms related to
menopause
-Ask her about other symptoms of menopause
like hot ush, dyspareunia, loss of libido and
change of mood
-Ask how much she know about HRT
-Tell her menopause duo to decline of hormones
secreted by ovary and we can con rm that by
check estrogen level
-HRT is natural estrogen with or without
progesterone
--HRT can be given orally, injection, implant or
locally
-Advantage of HRT improve menopausal
symptoms and prevent osteoporosis
-Disadvantage of HRT is Thromboembolism and
cancer breast
-Ask about previous history of embolism or family
history of embolism or breast cancer
-Ask if she has other risk factor for heart disease
or she receive other medication
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 --Tell her the side e ect of HRT is breast swelling,
vaginal discharge, increase appetite and weight
gain
-Inform here these symptoms will disappear after
3 months
-Inform her to inform her GP
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Asbestosis
-Introduce your self
-Identify Pt
-con rm agenda
-Explore how he is now
-Explore how he know about his illness
-Explore did any one inform him why this test
done for him
-Ask him what his expectation about the result of
test is
-Tell him the result of image showed scarring of
the lung tissue with thinking of the lining around
lung and there is calci ed plaque
-Tell him the lung function test showed decrease
of lung volume
-Ask him what his expectation about the cause of
these symptoms is
-Tell him all these result may be due to exposure
to asbestos
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 -Take history about the exposure to asbestos for
how long and degree of exposure
-Explain to him, unfortunately the treatment is
limited and the progress is slowly
-Reassure him there is no evidence of lung cancer
or cancer in lining lungs which may occurs in
asbestosis lung disease
-Ask if he is aware that he has an occupational
lung disease and he is able to claim for industrial
disablement bene t
-Explain that he must go to local social security
o ce where he should ask form which cover
occupational lung disease
-Explain he will be visited by medical o cer who
will judge the degree of disability based on this,
bene t per week will determined
-If he disagrees with the disability verdict, the
patient can appeal although only within one month
of date of letter con rming the decision
-Paid will be 15 weeks from rst day of claim in
lung brosis but from rst day if mesothelioma
-Bene t cannot paid for more than 3 months
before date of claim unless known mesothelioma
-Industrial bene t will not a ect insurance
bene ts such as incapacity bene t or retirement
stat pension
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Informed consent of emergency
operation (extradural
hematoma)
-Introduce your self -identify Pt
-Inform relative, out of respect to .......i want to
whom I speak
-Ask are you next of kin to Mr. .......
-Ask if she want one of family to attend this
meeting
-Ask her what is she know about your father
illness and what is previous medical history
-Ask her what last time she sees her father is
-Tell her, your father was in car accident as
pedestrian, when he arriving to ER he was
unconscious ............then he incubated and
sedation was given to him as he su ered from
pain and that done by expertise team -Tell her. I
am sorry for this bad news
-Tell her brain image was done urgently as the
condition of your father is critical and the result
not as we hoped
-CT shown there is extensive blood clot in the
lining outside brain and lead to compression of
brain tissue with shift of the center line of brain to
other area
-Tell her I am sorry to inform you that
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-Tell her the blood clot is large and it is
compressed in the most of vital center of brain
which responsible for breathing, conscious level
and movement
-Tell her you father now in assisted machine to
help him for breathing and he on sedation to
alleviate pain
-Tell her the condition of your father is critical so I
inform neurosurgical team that assessed your
father and advice these blood clot should be
evacuate otherwise you father will die
-Tell her, I am sorry to inform you that
-Tell her the operation to evacuate blood clot
through opening in the skull and it is
straightforward but one cannot guarantee about
the recovery -Tell her, it is may be some
neurological de cit duo to damage of brain cell or
duo to hemorrhage not rectify by operation
-Ask he about the wishes of her father if he in this
situation, ask about if he has advanced directive
or living will
-Explore wishes of her father if he knows he will
live with neurological de cit
-If she tell you, her father did not like to life with
neurological de cit, tell her there is any document
by this decision
-Tell her that the will do by expertise person and
he do this operation many times before and may
be your father did not get any neurological de cit
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and he will enjoy with his life but emphasize that
no guarantee -Tell her the decision will be for the
consultant in charge and it is legally to do for best
interest of Pt if he loses capacity and he hasn’t
valid living

Will and you will arrange meeting with consultant

-Refusalof medication by the pt

and daughter want to give him
medication (anticoagulant)
-Introduce your self
-Identify relative
-Tell here out of respect to ..........., I want to know
to whom I speak -Ask her are you next of kin
of............
-Ask her if she take permission from her father to
discuss his illness with team looking after him
-Ask her how much she know about her father
illness
-Ask her what your view on this matter is
-Tell her, I appreciate your feeling about your
father but this issue was discussed with your
father in details
-Tell her, we discussed the advantage of
anticoagulant as reducing the stroke and blood
clot anywhere and at the same time we inform him
the possible side e ect of anticoagulant
-As the result of this discussion, your father made
informed decision not to be anticoagulant
- I explore all reason why he may not want
anticoagulant and I did not nd any
misconception
-Ask her why her father did not wish to be
anticoagulant
-She may tell you that her father is old and he
cannot take decision and she is next of kin and
she can take decision
-Tell her that you appreciate her feeling about her
father
-Tell her there is no evidence that her father
cannot make informed decision duo to lack
capacity
-Tell her father is legally allowed to refuse
treatment
-As these discussion the physician cannot enforce
her father to take medication even if the next of
kin try to overrule their decision
-Try to reassure her father now on medication that
reduce the risk of storks and this medication is
aspirin although warfarin is drug of choice
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 Internet therapy for bronchial
asthma
-Introduce yourself
-Identify pt
-con rm agenda
-Ask him how he is feeling now
- Ask him about the adherent to his medication in
details
-Ask about the periceptating factor of asthma and
he should be away from trigger factor
-He will ask about the new device for asthma that
he see him in internet -Tell him the purpose of
internet is to supply general medical information
and allow communication with societies
-Tell him that any new medication or devices
should be put under trials to see it is e ect and
her we follow up our guideline that already trialed
in our organization
-Tell him our health organization gives us up-to-
date in the treatment -Tell him, he should follow
the same speci c rule of asthma
-Tell him, he should avoid exposure to allergen
and use anti- in ammatory medication
-Tell him, you did not see any trials to use these
devices
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 -Tell him to give you the website and inform him
you will about it and ask our consultant and our
health organization about it
-Tell him, you will arrange meeting with him in the
next appointment and you will give too much
information about the device
-Inform him until this appointment he should be
follow the same rule of asthma and receive his
medication
-Tell him that you should be prepared yourself that
the device may be not successful but there is no
harm in trying

Counsel after ACS

-Introduce yourself
-Identify pt
-con rm agenda
-Ask him how much he know about his illness
-Tell him what is meaning by heart attack and can
you draw diagram about that
-Tell him heart attack means blockage of the pipes
that supply you heart with blood and that lead to
result in damage of the cardiac muscle and lead to
chest pain
-Tell him he early and he received medication that
help to clear some of the blockage
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-Reassure him many people do well after heart
attack and that the reason of the tablet to o er
some prevention from second heart attack
-Tell him you are following me, you can interrupt
me if you have any question
-Explain to him we should be working as a team
and you are the most important player of this
team. There is a plan for him
-Explain to him the medication indetalis bene t
and risk of medication -Inform there is a test we
will arrange for you, it is called exercise ECG and
we will arrange in the next few weeks and we will
inform him about the date and site that the test
will done
-Tell him the ECG will determine if there is serious
occlusion a ect the blood vessels of the heart if
so further test will request
-Inform him the heart attack is serious and may be
happen at any time so you should be work to
prevent it from recurrence
-Tell him, heart attack may lead to sudden death,
arrhythmia and more blockages of blood vessels
-Tell him the medication only is not enough to
prevent heart attack from recurrence also your life
still should be optimize
-Inform him about diet and dietician consultation
-Inform him about exercise and rehabilitation
program that he will meet with other people have
same condition and sharing experience, also
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 rehabilitation team will answer any enquires and if
he has anxiety the team will give him relaxation
therapy
-Explore about smoking and refer him to smoking
cessation clinic -Explore the job and advice him
for rest up to one month
-Inform him he should avoid sexual intercourse for
2-4 weeks
-Tell him he should not drive at least for one
month and he should inform DVLA and insurance
company
-Tell him, I will give you lea et and website to
assess you to understand information and if you
have any question, you can call me

Adverse incident (allergy to

penicillin)
- Introduce yourself
-Identify pt
-Con rm agenda
-Appreciate her feeling and apologize to her by
saying I am sorry that this incident has occurred
-Acknowledge that it is a mistake
-Explain this breakdown in communication which
should not happened, as we don’t know that you
have allergy to penicillin and apologize for that
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 -Tell her this medication is the best medication
given in similar condition and also given in best
interest of you and we use it if the pt did not have
allergy to penicillin
-Once the mistake occurred, the appropriate
treatment was started rapidly and the adverse
e ect had stopped
-Tell pt now all symptoms was stopped and he will
be under strict observation
-Tell him now I will inform the consultant looking
after you
-Tell pt we already have policy to deal with this
incident and we have plan to prevent it from
recurrence
-Tell him, I will incident report, the report will
submit to the risk management physician
-Risk management team, will discuss this issue
and he will give us point to prevent this incident to
be happened again
-Every now and then try to apologize for pt
-If the pt wants to do complaint give her the
appropriate pathway . rst the patient advice
liaison service
-Tell pt the complaint will not a ect the plan of
treatment
-Tell the pt, another drug will prescribe for him to
control of infection -Tell him if he wants to know
the result of his complain he should follow with
concerned person
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 - If the pt tell sta nurse before she give him
medication, it is called near miss ask him if nurse
was veri ed his identi cation through wristband
or verbal before give him medication

Medical opinion for tness for

anesthesia (COPD)
-Introduce yourself to the patient
-Identify pt
-con rm agenda
-Tell him, I see you today to evaluate you from
medical site -Ask him about his medical condition
-Ask about shortness of breath, cough, phlegm,
chest pain, lower limb edema, e ect of the
disease on his daily activity
-Ask about other medical problem like DM, HTN,
IHD,
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 -Ask about the regular medication and adherent to
this medication -Ask about the previous surgery
and type of anesthesia
-ask about drug allergy and diet allergy
-Ask about family history of previous problem with
an aesthesia
-Tell him, I will request for some investigation like
blood count and liver function, renal function and
blood glucose. Also for image like x ray chest,
spirometry and ECG.These investigation will help
the anesthetist to decide what is about your
condition
-Tell him I will discuss your case with consultant
and I will write back to the concerned physician
-Tell him I am not the right one to decide you are
t or not t to anesthesia and the one who
responsible for that is anesthetist, I am only
assess the medical point

Obesity
-Introduce yourself to the pt
-Identify pt
-con rm agenda
-Ask her how much she know about her illness
-Tell her what is told by previous doctor
-Ask her about her expectation about the causes
of obesity and why she expected that
-Tell her all result of blood test was normal and
that is good as there no possibility of gland to be
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problem that cause weight gain and emphasize
about that it is good news
-Ask her how you are feeling now
-She may be upset and she may tell you she try to
adjust diet and her body weight not decrease
-Ask about diet history in details including snacks
like chocolate and cakes, ask about vegetable and
fruits
-Ask about how much her weight and how much
she lost
-Ask about why she thinks why you are failed to
decrease your body weight
-Ask about life style like exercise and daily activity
-Ask about her job
-Ask about her opinion to join gym or groining to
swimming
-Tell her there is many gym and swimming pool
have session to the overweight person also she
can meet other people have same condition and
sharing information with them
-Tell her there are many drugs to reduce the
weight but it is only given as adjuncts and not
instead of dietary plan and also these drugs have
side e ect
-If she asked about surgery, tell her that it is last
choice and it is very risky with both anesthetic and
surgical risk
-Emphasize about the risk of obesity on the other
system by follow up 3 S -If she asked about
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 eltroxin, tell her it is not advisable in presence of
normal thyroid function
-Tell he to write the type of food in a diary and
revise that with dictation

Consent for lumber puncture for

BIH
-Introduce yourself
-Identify pt
-con rm agenda
-Ask pt how you are feeling now
-Ask pt how much he know about his illness
-Ask pt what his expectation about the cause of
his illness is -Explain to pt the nding of CT brain
non signi cant and it is normal -Explain that the
most cause of blurring of vision is BIH
-Ask her if she know that
-Inform her BIH is increase in the pressure inside
the brain and spinal cord and this is putting
pressure in the back of eyes that lead to blurring
of vision.........can you use diagram
-The best way to treat this condition is lumber
puncture
-Ask pt are you heard about that
-Explain to pt what is meaning by lumber puncture
-Explain to pt the outcome of the treatment is
good but it is important to have regular eye check
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and spinal uid check to minimize the progress
visual problem
-Tell pt, before procedure some investigation will
be request like bleeding time and coagulation time
and ask if he has any back problem or previous
surgery at back and ask pt about drugs like
aspirin or anticoagulant -During procedure the pt
will lie in left side, keeping very sill and aseptic
technique will done to the back
-Then local anesthesia will be done in the back
and you will sense of numbness so you will not
feel any pain
-Then the needle will insert in the back between to
vertebral bone of spinal cord and volume of CSF
will take out, reassure that he will not feeling pain
after initial needle struck and sting
-After procedure you should lie at the back for 4
hours
-Tell pt the procedure may be need to repeated
until CSF pressure return back to normal
-Ask pt how he feels about that
-If agree tell pt there is consent he should be sign
it , he can read it and if you have any question you
can call me at any times
-Complication of the procedure is headache,
infection and leakage
of CSF
-Tell him risk and bene t. Risk if done and risk if
not done
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 -Tell him there is expertise physician will do this
procedure
-Remind him you can change your mind about the
decision at any time -Tell him he can ask for
second opinion
-Tell him I will inform consultant about his opinion

-Ask him how he get from this conversation

Postponing an investigation (lung

biopsy in pt on warfarin)
-Introduce your self
-Identify pt
-Con rm agenda
-Ask pt how he feels now
-Ask about how he is told by consultant in the last
visit
-Tell him as he has DVT he should be abstained
from warfarin at least for 48 hours before
procedure
-Ask him if any one inform him about that
-apologize for pt about this misunderstand and
tell him to give you opportunity to explain the
reason why the procedure is postponed
-First ask him why he did not stop warfarin
(instruction not clear, fear from DVT, forgetfulness)
Explain to him the procedure should be
postponing ask there is risk for him if the
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bleeding
-The warfarine must stopped at least 48 hours
before carry out procedure to allow it is e ect to
wear o
-Tell him there is minimal risk of DVT if the
warfarin was stopped for 48hours
-Tell him the INR will be checked before carry out
procedure and the procedure will carry out if INR
less than 1.5 and at this level the blood is not too
thin
-If he tell you, I may have cancer and he does not
want wait to next appointment
-Say to him, the consultant is unclear if the lung
shadow is cancer or not so that he want to carry
out the procedure to exclude that is cancer or not
-Tell him, I appreciate that and I will radiologist
consultant now. to arrange for another
appointment at earliest at possible and I will give
you now the date and time of next appointment
before you leave
-Again apologize for this misunderstanding
-Tell him if he has any question
-Tell him, I will inform my consultant and
histopathilogist about the new appointment
-Ask him how he traveled today to hospital, if he
came by ambulance, tell him I will inform
ambulance desk to know he will be going to home
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warfarin before the biopsy date by 48h

Anti tuberculoses and pregnancy

-Introduce yourself
-Identify pt
-con rm agenda
-Ask her how she feels now
-Ask her about how much she know about her
illness
-Ask her about improvement symptoms and sign
like appetite, weight gain, fever, night sweet and
ask about side e ect of drugs
-Ask her why she stops medication, she will ask I
am pregnant -Congratulant for that and ask about
the previous pregnancy
-Tell her that the drugs are safe in pregnancy and
there is no any adverse e ect from these drugs
-Tell her what is risk of stop these drugs like
reactivate TB, loss of her baby duo to a ection of
her general condition
-Tell her bene t of continue medication as cure of
TB and prevent of recurrence of TB
-Emphasize about the bene t and risk
-Tell her, I will arrange for meeting with health
advisor of TB to contact with her
-Ask her also breast feeding is safe with these
drugs
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 -Tell her, you should follow up with pulmonogist to
arrange of plan as you did not receive medication
for 2 weeks and until these time you should start
drugs again
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Refuse pain medication in

terminal ill pt (LUNG CANCER)
-Introduce your self
-Identify pt
-Con rm agenda
-Ask how he is
-Explore about the pain site, sort, severity,
character, radiation, e ect on sleep and daily
activity
-Ask about pain medication and complains to
medication -Ask about the relief of pain by
medication
-Ask about the type of medication and how he
received it -Ask him why you didn’t receive
medication
-Tell him that some pt receive morphine have
worries tell him that it is normal and team looking
after him can help him
-Tell him that bene t of pain relive
-Inform him the side e ect like constipation,
confusion or addiction -Tell him how he feels
know about pain control
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 -Tell him you will arrange meeting with consultant
for future plan -Ask him if any one of family a ect
his decision
-Arrange for future x ray and isotope scan to
check any bone deposit -Ask if there is other
analgesic relives pain
-Tell him feeling of addiction in terminal ill pt is
unwarranted

Resuscitation status in terminal

ill pt (speak to daughter)
-Introduce yourself as you are physician looking
after his father -Identify relative
-Con rm agenda
-Ask her if she want one of family to attend this
meeting
-Ask her how much she know about her father
illness
-Tell her I am sorry to inform your father is very
ill>>>>>>>
-Tell her the time is very hard to her
-Tell her, your father has lung cancer and the
cancer is spread to other area of body like brain
and bone
-As the tumor outside the lung that the prognosis
is poor
-every now and then inform her, I am sorry for this
bad news
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-Tell her, your father now is unconscious and x ray
showed lung is not working
-Tell her your father was assessed by oncologist
that decides the cancer is incurable and there is
no bene t of chemotherapy or radiotherapy so
outlook of your father is poor>>>>>>>>>>>>>>>>>
-Explain that as the condition of your father
deteriorate so the death is expected in few hours
-Ask her, I want to know if your father express
about his opinion when he in critical situation
-Tell her the team looking after your father
decides that your father is not for
resuscitation>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
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-Explain what is meaning by resuscitation, that
means restore of breathing and spontaneous
circulation
-Tell about the resuscitation is invasive treatment
and consist from chest compression, electrical
shock, injection of drugs and ventilation of lung.
This may be followed by period of monitoring at
ICU.Some patient need mechanical ventilation,
inotropes and other invasive procedure
-Complication of CPR, irreversible brain damage,
rib fracture, organ injury as rupture of spleen, liver
and tension pneumothorax
-Tell her the resuscitation is harmful than bene t
to your father
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 -If she sad as she away from her father at last
days tell her that the progress of case cannot
prevent
-Tell her that this order done in the bases in best
interest of father
-Tell her, your father will transferee to side room
and strong analgesic will be prescribed also IV
uid and oxygen will continue that alleviate any
sense of uncomfortable by your father
If the pt in terminal illness but not cancer tell
relative the decision of not for resuscitation will be
reviewed regular

Screening for prostate cancer

-Introduce yourself
-Identify pt
-Con rm agenda
-Tell him what is about blood pressure control
-Ask him about prostatic symptoms like poor
starting, poor stream, postmicturation dribbling,
dysuria and hematuria
-Ask him how much he know about prostatic
cancer and where he get this information
-Ask why he want to do screening for prostatic
cancer, family history, pressurized by relative
-What is he read about screening of prostatic
cancer
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-Explain that prostate gland what is mean and
draw diagram
-Reassure that there are no symptoms of prostatic
cancer it is unlikely that he will have prostate
cancer
-Agree with him that prostate cancer is the most
common cancer in men but it doesn’t cause the
largest number of cancer death
-Describe the ways to investigate the possibility of
prostate cancer,,,,,,P/R examination,,,,PSA
test ,US prostate ,if there is any abnormal
prostatic biopsy will done
-Tell him there is multiple factors should be put in
consideration that PSA may be raised as prostatic
infection, UTI, BPH,
-Tell him that the test may be false positive but it
is uncommon and that may need biopsy for
intervention to exclude cancer
-Also tell him there is may be false negative
although the cancer is present
-Emphasize that the screen not 100% guaranteed
to detect or dismiss the presence of cancer
-Tell him that digital examination and the test will
be done and there is second appointed to discuss
result
 Smoking cessation advice (pt
with emphysema)
-Introduce yourself to the pt
-Identify pt
-con rm agenda
-Ask pt how much he know about his illness
-Ask him what is he expect about the cause of
emphysema Explain to him what the meaning of
emphysema is
-Inform him one of the most causes of
emphysema is smoking and continue smoking will
deteriorate his condition
-Start the conversation about stopped of smoking
-Acknowledge that smoking is habit-forming and
it is di cult to stop --First ask him why he smokes
-Ask if he try to stop smoking. If yes ask him what
is happened
-Ask about his social life, job, marital status, child
and his economy income
-Ask him any one of family is smoking and what
his health condition is -Ask him what the risk of
smoking is if he knows
-Tell him the risk of smoking like premature death,
atherosclerosis, lung cancer, lip cancer,
esophageal cancer and social a ection on his
family -Tell him it is not late to stopped smoking
and stopping smoking now will help to slow down
the rate of progression of emphysema
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-Tell him, you will notice the di erence in
breathing after stopped smoking
-Encourage him, there is many people have
successfully to stopped smoking
-Tell him what a ection of stoping smoking on his
social life is
-Ask him if he fear to stop smoking. He may
inform you about nicotine withdrawal symptoms
like restlessness, irritability, lack of sleep) -Explain
to him there are many ways to stopped smoking
and tell him in the rst few days you can change
your routine to avoid situation where you would
usually smoke and you should completely stop
smoking and not decrease the number of
cigarette.
-To prevent nicotine withdrawal, you can use
nicotine replacement therapy like gum, patches
and inhaler
--Explain the form of smoking cessation therapy
like bupropion and vareniciline but these drugs
should be avoid in some situation
-Tell him, you will give him information lea et and
web site to encourage you to stop smoking
-Give him another appointment to reinforce this
issue
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 Unrelated live organ donation
(with wife)
- Introduce yourself to pt relative
- Identify pt relative
- Tell her that, out of respect to Mr.............I want to
know to whom I speak
-Ask her are you next of kin
- Ask her if her husband know, you are her today
to discuss some point related to his illness
-Ask her how much she know about her husband
illness
-Tell her that I appreciate how your husband
su ering
-Ask her how much she know about live organ
donation
-Tell her live organ donation is better outcome
than donation from deceased person as kidney
not transport from one site to other site so the
kidney in better condition
-Tell her your husband know in waiting list and it is
di cult to know when a suitable organ will be
available
- Tell him, non related organ donation will take him
o the waiting list
- I appreciated your decision and you want to help
your husband
- Tell her bene t that no needs to continue dialysis
which allow him to enjoy social life
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-Tell her, you will gain psychological satisfaction
from helping her husband, as you able to give
loved one a near normal quality of life
-Tell her before going to transplantation, there is
some blood test and images need to done, also
there is need assessment for her and her husband
by medical and psychological teams
-Tell her there is organ donation is major surgical
operation that requires about a week in hospital to
recover and few weeks 8- 12 weeks postoperative
to recover fully
-Tell her most of people lives with one kidney and
enjoy their life -Inform her there is some
implication in her work and insurance company as
she should inform her insurance company and her
occupational health, also her chairman as she
may be o from work
-Tell her risk on her husband as failure of
transplantation, long-term management
-If she wants to go ahead tell her I will transferee
you to transplant team -Reemphasize about that
her decision should be volunteer and there is no
payment, also her decision will be continuity as
she can withdraw her consent before procedure
done
-The unrelated live transplant regulatory authority
should be informed and approval should be
obtained
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 Life style change
3 S models is best to follow the life style change
-Susceptibility to illness -Seriousness
-Solutions
Tell pt that, I know that it is hard for you the new
change in life style but with the time you will feel
better with the new life style change

Down’s syndrome
Introduce your self
Identify pt
Con rm agenda
Ask for husband to attend the meeting, or other
family member
Tell her rst of all I would like how you are feels
physically now Ask about her social history,
marital status, child how many and their health,
nancial
Tell her the result of the test was released and it is
not as we hope
The test result revealed that the fetus has
chromosomal abnormalities and that know to be
Down’s syndrome ............
Ask her how she feels about that
Tell her Down’s syndrome is chromosomal defect
that occur in the old female that get pregnant in
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 some percentage. it is extra chromosome know as
trisomy 21
Down’s syndrome has many defects in the other
system in the body like heart, mentality, bowel,
blood diseases
Ask her how you are feels know
Tell her, I know the time is hard and I appreciated
that but I want to ask you what is about the future
plan of this fetus
Ask her about the opinion of her husband
Tell her the decision is hard and you will give her
web site and lea ets about Down’s syndrome and
you will refer her to genetic counselor and
obstetrician
As the risk on the child to be mental and physical
a ection and a ection on social life, it is your
choice for abortion
Tell her if you get pregnancy again there is still
percentage to get another baby has Down’s
syndrome

Refuse of PEG by the family

as the patient has advanced
multiple sclerosis
If the PEG not put, the patient will su er more as
she will be dehydrated and to be started, at this
time the dying is not good way as your wife will be
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 distress. If the PEG inserted it will be reduce her
su ering
Bene t and risk of the PEG
Consent
If still refuse tell him, you will inform consultant,
o er second opinion, or as court
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