:INTRODUCTION

Explore how much( patient or relative)

.Good (morning or, afternoon) with shake handETHICS
of patientknow about the illness
Autonomy. consentconfidentiality
Introduce
your
self..
My name
your Driving
position) If patient
follow
up for disease
or is . I am .(
DAMA,,,
one of Best
teaminterest
looking
after you
already have current problem ask him
of patient
.. .Identify patient

you Mr how he feel now

Avoid
harmAre
of patient
Discuss
the task,,,,,,,,,,,,,,
news
or socialto discuss? We willJustice
Confirm
agenda
of meetingany
andbad
take
consent
discussPostmortem
examination
,living
complain?say
that.
I
am
sorry
for
that
today issue related to your illnessthat iswill
alright
CPR
After finish task ask ,,,,, how you think about that

If break bad news inform patient or relative,,,, if he want any one of hisAsk about concern,,,,,,,, do you have any concern ? it is family to attend meeting
important question

premorbid
stat,
social live
, daily activity,
job ask,,,,,,, are you next ofIfAsk
theabout
discussion
with
relative
of patient
you should
kin of Mr. and also ask,,,,,, are you take permission from Mr.,. To
discuss his condition with me.( that to avoid break confidentiality)

INTERVIEW

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 procedureA 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 benefits against
the low possibility of risks makes the procedure is advisable option for
you from medical point of views
DNRI know you have been suffering from this illness for long time..i
know that it is difficult to give me answer but let me to ask , if your heart
was stopped do you want to resuscitate you and 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 finding 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

Social condition-

I need to ask you some rather personal questions is that ok, how does this
problem affect you in your job, how does this problem affect 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 figures everybody is different 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 pt
I dont 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 find out what
went wrong and actions will be taken to stop it happening again now we
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 affected 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 dementiaAsk about the symptoms of dementia like forgetfulness and her insightAsk about causes of dementia like Parkinson, stroke, Alzheimer or .reversible causes like vit, b12 deficiency 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 we cant 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 hopedthe 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 its not limited to one area and .it is rapidly progressive
the prognosis is different 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 cancerExplore the advanced directive and DNRArrange to another meeting with oncologistTell him you will give pain treatmentRefer him to Mac Million nurse-

Pt under 16 age and asked abortion or contraceptive pills

Ask her why you are her todayHow much you understand by sexual history and contraceptive pillsAny plan to inform the father and motherIf you want from me to inform familyIf cannot help you today what do you think might happen-

Advanced direction

To become legal 1-pt has capacity and more than 16 years

Voluntaries -2
Informed -3
specify, resuscitation, nutrition-4
written, witness, signed-5
Continuity -6
Periodic review and may add as codicil Should be continue basic careAsk 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 historyAsk her how much she knows about her illnessAsk her did any one inform her why x ray requested for her?Ask her what her expectation about the result of test isTell 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 causesand 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 ofother 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 testEmphasize that it is not curable disease as the cancer is spread to boneTell 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 controlAsk about the social life, who lives with her and financial support-

Deliberate self harm

ASK her how she feels physically now

always remember her I am here to help youtell her you are physically well now but I concerned for your overall welfare
tell her you will refer her to psychiatristask her how she feels about thattell 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 himPatient 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
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 betterTell him the decision is difficult to taken know. And we will arrange for second meeting
Epilepsy

Tell her about the diagnosis of epilepsy is clinical and I will arrange for
you more specific 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 OCPAsk about fits during sleepLife style change likeSleep 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 fitsMedical error (gentamycin and renal impairment)
How you are feels nowExplore about the symptoms of UTI like dysuria, fever, and vomiting, abdominal pain
Ask him about uremic symptoms as shortness of breath, chest pain, jerkymovement 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 insufficient 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 mistakeInform him as the drug is high level in blood it may be affect other organlike 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
It is very difficult 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 conditionand will start another antibiotic for UTI

Apology again for this mistake-

HEALTH CARE GET INFECTION DURING WORK

Show empathyHow much he know about diseaseExplore about the symptomsAsk him where he acquired the virusVaccination historyAny medical check upSexual lifeExplanation of resultPlan, inform occupational health, consultantRestriction of prone procedureAsk him how he feels about nowTell him you know the time is difficult now and I know the new result have serious implication about your surgical career
Check the ethics autonomy, benfincence, non malafincence, justice, confidentiality and consent
Check social, job, financial effectDisablementRefer to hepatologist and HIV physician-

Delay procedure

Let him to speak freeappreciate that the delay not acceptedApologize for himAttempt to take appointment now before he leaveCheck his addressShow for him a plan to rectify the situation to prevent recurrenceIncident report and submit it to trust risk manger (patient advice liaison services)
Inform consultantI the patient wishes to formally complain advice him to contact PALSAvoid documentation of complaint of Pt at his file-

Postmortem

First tell relative we are sorry about sudden death of patient and all staff .looking after him is saddened by this news
Explain the condition of patientExplain 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 find out whether or not the patient had cancer
.Tell them we can find the cause of death by do postmortem examination.Ask how they feel about thatAsk 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 benefitsReassure that no disfigurement of body.Reassure that funeral arrangement would not be necessary delayedExplain who will do the procedure and whereTell her if there is something serious, if she agree for retain tissue for do further investigation, education and research
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
:Benefits of postmortemIllness information, effect 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 postmortemPostmortem 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-

Jehovahs 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 first 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 throughcamera test to looking inside your tummy and first part of bowel that
adjacent to the tummy. Explain the procedure and benefit risk ratio as
injury of the lining of stomach 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 faithExplain the benefits 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 tobleed and the end, he will be died
Explain the if he need other element of blood componentExplain the refusal of type of treatment; it is not affect health care planAsk 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 ifhe 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, Jehovahs Witness liaison,support from family or religious leader
inform him about the consent of camera test and refusal form of the blood transfusion

BRAIN STEM DEATH

Introduce yourselfIdentify the relativeOut 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 meetingTell how much you know about the patient illnessExplain 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 affect 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 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 artificially 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 willExplore the social activity of PtTell ..The patient was died and his organ not damage, ask if Pt expressabout any idea if he in same situation
Explore the opinion of family about the organ donationIf 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 suffering from painIf he wants more time to thinking tell him, we will keep pt on ventilationuntil taking their decision
Should exclude reversible causes as, hypothermia, electrolyte
disturbance and endocrinal illness
BREAKING BAD NEWS

Explore any relative with patientHow feel nowHow 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 procedureDid you informed what is the possibility of the causesInform 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 knowHow much you know about this diagnosisTell Pt ..i dont 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 butIf condition is treatable till him that -1
If the condition not treatable till him, the response to medication -2
Different 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 timeExplore the social status, job, financial, 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 affect the patient systemic .or locally
MRSA about one third are lives in patient without causing harmful and present in skin and nose
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 different 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 staff has any sore or psoriasis should avoid care of patientCarry out the procedure and dressing in room of PtFollow 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 staff
If pt with MRSA need to transferee to hospital, should inform hospital and infection control
Avoid discrimination with PT has MRSAReassure .and advice to be contact with infection control department

Needle stick injury

Tell what exactly happenedWhat 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 HBVAsk about medical checkup and screening for hepatitisTell 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 benefit
Ask if Pt has infectious blood transmitted virusInform Pt, should inform supervisor and occupational healthTell 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 consentExplain advantage and disadvantage of HIV testAdvantage if negative you will enjoy of life and no need medication
If positive we will start medication early
Disadvantage, false positive and false negative, insurance and job loss
Ask about the safe sexual intercourse and inform the partnerTell 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 confidentiality 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 effect of drugs
Tell pt about the seroconversion symptoms and hepatitis symptomsTell 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 testTell her many physician have many needle stick injury and catch
infection is small

HIV TEST

Introduce yourself to PtIdentify ptAsk for permission to start discussionConfirm agendaTell pt how much he know about your illnessAsk him how much he told about his conditionAsk about his expectation for the causes of his illnessInform him the causes of his illness may related to virus that affect immunity
Ask him, did he her about thatInform him the causes may be HIVAsk him how he feels about thatAsk him if he has ever consider the possibility of HIVAsk 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 beforeInform him to do the test, it is blood test, he should be sign written consent from him
Reassure him the test result will be confidential to the staff 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 difference between both
If test is positive and he has opportunistic infection, then he has AIDSIf test be positive, the future insurance will be difficult 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 testTell 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

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 affect immune system and it is may be silentfor long time before manifested by systemic illness

Benefit 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 testIncrease anxiety and depressionRisk for job and insurance Positive test meansYou have HIV You can infect other so you have to take precautionYou did not have AIDS but you may get it Negative test meansYou may get HIV in future
If the test will be positive, the test will be repeated and even we will request PCR

Consent for participate in clinical trial

Identify PtIntroduce your selfConfirm agenda Ask Pt about his condition, how much he knowsTell him what response to his medication isExplain to him the research topicExplain to him the new drug was studied for side effectInform him he should agree for participate in study and also he should bevolunteer 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 isHe will be monitoring by same doctor more than usual
His condition may be improved but is no guarantee
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 effect whichis rare and he will be regular reviewed
Explain he would remain in the same medicationExplain 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
affect the future conduct of treatment
Emphasize his identify in study will be confidentiality and if result will be published his identify will be confidential
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 studyIf any illness from trial he will be managed in appropriate wayInform him if he agrees, he should sign the consent-

Poor compliance

Ask him about his symptom and how he feels nowAsk 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 effect, forgetfulness, poor information
Ask how he takes tablet, purpose of taking tablet, about the taste of tablet and difficult tablet
Tell him what his expectation about the poor response to medicine isIf 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 sociallyAsk him what his expectation to improve the complaince to medication is
Inform him that, there is new plan for managementInform him you will inform consultantInform him about job and social activityInform him it is hard for him to hear and you appreciate thatInform him he should inform GPExplain to him way to improve compliance like education, web site and leaflet
-

Deliberate self harm

Introduce your selfTell him how he feels now physicallyTell him I know the time is hard now for you and I appreciate thatInform him, I here to help youAsk him about the type of tablet, dose and if taking at same timeAsk him if he received another tablet or alcohol in excessive amountInform 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 aloneAsk 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 supportask 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 himAsk if he understand why he need helpTell 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 psychiatristAsk him how he feels about thatTell him the psychiatrist will assess him, he expertise in that and he may prescribed for him medication

DVT in pregnancy

Introduce yourself to PtIdentify PtAsk how she feels nowAsk how much she know about her illnessAsk here did you know why we do these scanAsk about here expectation about the result of scanInform 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 limbsthat called DVT
Explain to her what is meaning by DVT and draw to here diaphragmAsk about the symptoms of pulmonary embolismAsk about family history of thrombus any whereAsk about any previous thrombus or previous miscarriageTell her the plan of careInform here she will admit in hospitalTELL HERE SOME INVESTIGATION WILL DONETell 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 affection
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 testTell 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 thatTell 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 obstetricianGive here leaflets and web site for DVT and medication of anticoagulant-

Epilepsy and drive

Ask Pt how he is feeling nowAsk how much he know about his illnessTell him if any one inform him why CT brain, EEG doneTell him the result of CT brain and EEG was normal and these not guarantee that fits 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 planningAsk him if he know the implication of epilepsy about his jobI 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 eventsInform him the risk of driving for him and for the publicTell him it is his responsibility to inform DVLAInform him the insurance policy now is invalidIf he still intend to driving, inform him you know the time is hard and you appreciate that as it may be affect 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 consultantIf 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 file and you will
send letter for him that you disclose information to DVLA and GP

Genetic test

Ask her how his father nowAsk her there is other member of family has diseaseAsk her how much she know about Huntington diseaseTell he about Huntington disease causes, prevention, manifestation, treatment and prognosis
Tell her Huntington disease is a serious disease that affects pt lead to progressive deterioration in both the ability to carry out physical tasks
and mental function to extent that people developed 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 testTell 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 jobInform here she has time to think about test and you will give her website, leaflet
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 confidentialTell her the disease is inherited condition and delay in testing not make any difference

HRT

Introduce yourself for ptAsk her how she is feeling nowAsk why she feels this symptoms related to menopauseAsk her about other symptoms of menopause like hot flush, dyspareunia,loss of libido and change of mood
Ask how much she know about HRTTell her menopause duo to decline of hormones secreted by ovary and we can confirm that by check estrogen level
HRT is natural estrogen with or without progesteroneHRT can be given orally, injection, implant or locally-Advantage of HRT improve menopausal symptoms and prevent osteoporosis
Disadvantage of HRT is Thromboembolism and cancer breastAsk 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
Tell her the side effect of HRT is breast swelling, vaginal discharge, -increase appetite and weight gain
Inform here these symptoms will disappear after 3 monthsInform her to inform her GP-

Asbestosis

Introduce your selfIdentify Ptconfirm agendaExplore how he is nowExplore how he know about his illnessExplore did any one inform him why this test done for himAsk him what his expectation about the result of test isTell him the result of image showed scarring of the lung tissue with thinking of the lining around lung and there is calcified plaque
Tell him the lung function test showed decrease of lung volumeAsk him what his expectation about the cause of these symptoms isTell him all these result may be due to exposure to asbestosTake 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 ableto claim for industrial disablement benefit
Explain that he must go to local social security office where he should ask form which cover occupational lung disease
Explain he will be visited by medical officer who will judge the degree of disability based on this, benefit per week will determined
If he disagrees with the disability verdict, the patient can appeal althoughonly within one month of date of letter confirming the decision
Paid will be 15 weeks from first day of claim in lung fibrosis but from first day if mesothelioma
Benefit cannot paid for more than 3 months before date of claim unless known mesothelioma
Industrial benefit will not affect insurance benefits such as incapacity benefit or retirement stat pension

Informed consent of emergency operation (extradural hematoma)

Introduce your self -identify PtInform relative, out of respect to .i want to whom I speak. .Ask are you next of kin to MrAsk if she want one of family to attend this meetingAsk her what is she know about your father illness and what is previous medical history
Ask her what last time she sees her father isTell 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 suffered from pain and that done by expertise team
Tell her. I am sorry for this bad newsTell 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 thatTell 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 thatTell her the operation to evacuate blood clot through opening in the skulland it is straightforward but one cannot guarantee about the recovery
Tell her, it is may be some neurological deficit 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 deficit
If she tell you, her father did not like to life with neurological deficit, tellher 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
deficit 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 hasnt valid living
Will and you will arrange meeting with consultant

Refusal of medication by the pt and daughter want to give him medication (anticoagulant)
Introduce your selfIdentify relativeTell here out of respect to .., I want to know to whom I speakAsk her are you next of kin ofAsk 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 illnessAsk her what your view on this matter isTell 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 effect 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 find any misconception
Ask her why her father did not wish to be anticoagulantShe 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 fatherTell her there is no evidence that her father cannot make informed decision duo to lack capacity
Tell her father is legally allowed to refuse treatmentAs 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

Internet therapy for bronchial asthma

Introduce yourselfIdentify ptconfirm agendaAsk him how he is feeling nowAsk him about the adherent to his medication in details Ask about the periceptating factor of asthma and he should be away fromtrigger factor
He will ask about the new device for asthma that he see him in internetTell 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 tosee it is effect 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 treatmentTell him, he should follow the same specific rule of asthmaTell him, he should avoid exposure to allergen and use anti-inflammatorymedication
Tell him, you did not see any trials to use these devicesTell 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 andyou 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 yourselfIdentify ptconfirm agendaAsk him how much he know about his illnessTell 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
Reassure him many people do well after heart attack and that the reason of the tablet to offer 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 benefit and risk of medicationInform 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 affect 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 consultationInform him about exercise and rehabilitation program that he will meet with other people have same condition and sharing experience, also
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 clinicExplore the job and advice him for rest up to one monthInform him he should avoid sexual intercourse for 2-4 weeksTell him he should not drive at least for one month and he should inform DVLA and insurance company
Tell him, I will give you leaflet 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 ptConfirm agendaAppreciate her feeling and apologize to her by saying I am sorry that thisincident has occurred
Acknowledge that it is a mistakeExplain this breakdown in communication which should not happened, as we dont know that you have allergy to penicillin and apologize for
that
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 effect 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 youTell 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 ptIf the pt wants to do complaint give her the appropriate pathway .first thepatient advice liaison service
Tell pt the complaint will not affect the plan of treatmentTell the pt, another drug will prescribe for him to control of infectionTell him if he wants to know the result of his complain he should follow with concerned person
If the pt tell staff nurse before she give him medication, it is called near miss ask him if nurse was verified his identification through wristband
or verbal before give him medication

Medical opinion for fitness for anesthesia (COPD)

Introduce yourself to the patientIdentify ptconfirm agendaTell him, I see you today to evaluate you from medical siteAsk him about his medical conditionAsk about shortness of breath, cough, phlegm, chest pain, lower limb edema, effect of the disease on his daily activity
,Ask about other medical problem like DM, HTN, IHDAsk about the regular medication and adherent to this medicationAsk about the previous surgery and type of anesthesiaask about drug allergy and diet allergyAsk about family history of previous problem with an aesthesiaTell 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 fit or not fit to anesthesia and the one who responsible for that is anesthetist, I am only
assess the medical point

Obesity

Introduce yourself to the ptIdentify ptconfirm agendaAsk her how much she know about her illnessTell her what is told by previous doctorAsk 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 problem that cause weight gain and emphasize
about that it is good news
Ask her how you are feeling nowShe 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 lostAsk about why she thinks why you are failed to decrease your body weight
Ask about life style like exercise and daily activityAsk about her jobAsk about her opinion to join gym or groining to swimmingTell 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
effect
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 SIf she asked about 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 yourselfIdentify ptconfirm agendaAsk pt how you are feeling nowAsk pt how much he know about his illnessAsk pt what his expectation about the cause of his illness isExplain to pt the finding of CT brain non significant and it is normalExplain that the most cause of blurring of vision is BIHAsk her if she know thatInform 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 visioncan you use diagram
The best way to treat this condition is lumber punctureAsk pt are you heard about thatExplain to pt what is meaning by lumber punctureExplain to pt the outcome of the treatment is good but it is important to have regular eye check and spinal fluid check to minimize the progress
visual problem
Tell pt, before procedure some investigation will be request like bleedingtime 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 hoursTell pt the procedure may be need to repeated until CSF pressure return back to normal
Ask pt how he feels about thatIf 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 leakageof CSF
Tell him risk and benefit. Risk if done and risk if not doneTell him there is expertise physician will do this procedureRemind him you can change your mind about the decision at any timeTell him he can ask for second opinionTell him I will inform consultant about his opinionAsk him how he get from this conversation-

Postponing an investigation (lung biopsy in pt on warfarin)

Introduce your selfIdentify ptConfirm agendaAsk pt how he feels nowAsk about how he is told by consultant in the last visitTell him as he has DVT he should be abstained from warfarin at least for48 hours before procedure
Ask him if any one inform him about thatapologize 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 procedure carried out today as there is risk of bleeding
The warfarine must stopped at least 48 hours before carry out procedure to allow it is effect to wear off
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 misunderstandingTell him if he has any questionTell 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, tellhim I will inform ambulance desk to know he will be going to home soon
Reemphasize about he must be stopped warfarin before the biopsy date by 48h

Anti tuberculoses and pregnancy

Introduce yourselfIdentify ptconfirm agendaAsk her how she feels nowAsk her about how much she know about her illnessAsk her about improvement symptoms and sign like appetite, weight gain, fever, night sweet and ask about side effect of drugs
Ask her why she stops medication, she will ask I am pregnantCongratulant for that and ask about the previous pregnancyTell her that the drugs are safe in pregnancy and there is no any adverse effect from these drugs
Tell her what is risk of stop these drugs like reactivate TB, loss of her baby duo to affection of her general condition
Tell her benefit of continue medication as cure of TB and prevent of recurrence of TB
Emphasize about the benefit and riskTell her, I will arrange for meeting with health advisor of TB to contact with her
Ask her also breast feeding is safe with these drugsTell 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 selfIdentify ptConfirm agendaAsk how he isExplore about the pain site, sort, severity, character, radiation, effect on sleep and daily activity
Ask about pain medication and complains to medicationAsk about the relief of pain by medicationAsk about the type of medication and how he received itAsk him why you didnt receive medicationTell 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 benefit of pain reliveInform him the side effect like constipation, confusion or addictionTell him how he feels know about pain controlTell him you will arrange meeting with consultant for future planAsk him if any one of family affect his decisionArrange for future x ray and isotope scan to check any bone depositAsk if there is other analgesic relives painTell 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 fatherIdentify relativeConfirm agendaAsk her if she want one of family to attend this meetingAsk her how much she know about her father illness<<<<<<<Tell her I am sorry to inform your father is very illTell her the time is very hard to herTell 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 poorevery now and then inform her, I am sorry for this bad newsTell 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 isincurable and there is no benefit 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 hein critical situation
Tell her the team looking after your father decides that your father is not <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<for resuscitation
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 benefit to your fatherIf 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 fatherTell her, your father will transferee to side room and strong analgesic will be prescribed also IV fluid 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 yourselfIdentify ptConfirm agendaTell him what is about blood pressure controlAsk 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 thisinformation
Ask why he want to do screening for prostatic cancer, family history, pressurized by relative
What is he read about screening of prostatic cancerExplain that prostate gland what is mean and draw diagramReassure that there are no symptoms of prostatic cancer it is unlikely thathe will have prostate cancer
Agree with him that prostate cancer is the most common cancer in men but it doesnt cause the largest number of cancer death
Describe the ways to investigate the possibility of prostate cancer,,,,,,P/Rexamination,,,,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 ptIdentify ptconfirm agendaAsk pt how much he know about his illnessAsk him what is he expect about the cause of emphysemaExplain 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 smokingAcknowledge that smoking is habit-forming and it is difficult to stopFirst ask him why he smokes-Ask if he try to stop smoking. If yes ask him what is happenedAsk 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 isAsk him what the risk of smoking is if he knowsTell him the risk of smoking like premature death, atherosclerosis, lung cancer, lip cancer, esophageal cancer and social affection on his family
Tell him it is not late to stopped smoking and stopping smoking now willhelp to slow down the rate of progression of emphysema
Tell him, you will notice the difference in breathing after stopped smoking
Encourage him, there is many people have successfully to stopped smoking
Tell him what affection of stoping smoking on his social life isAsk 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 first 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 leaflet and web site to encourageyou to stop smoking
Give him another appointment to reinforce this issueUnrelated 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 kinAsk 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 illnessTell her that I appreciate how your husband sufferingAsk her how much she know about live organ donationTell 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 difficult to know when a suitable organ will be available
Tell him, non related organ donation will take him off the waiting list I appreciated your decision and you want to help your husband Tell her benefit that no needs to continue dialysis which allow him to enjoy social life
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 lifeInform her there is some implication in her work and insurance companyas she should inform her insurance company and her occupational health,
also her chairman as she may be off 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 teamReemphasize 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
Life style change

S models is best to follow the life style change 3

Susceptibility to illnessSeriousnessSolutionsTell 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
Downs syndrome
Introduce your self
Identify pt
Confirm agenda
Ask for husband to attend the meeting, or other family member
Tell her first of all I would like how you are feels physically now
Ask about her social history, marital status, child how many and their
health, financial
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 Downs syndrome
Ask her how she feels about that
Tell her Downs syndrome is chromosomal defect that occur in the old
female that get pregnant in some percentage. it is extra chromosome
know as trisomy 21
Downs 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 leaflets
about Downs syndrome and you will refer her to genetic counselor and
obstetrician
As the risk on the child to be mental and physical affection and affection
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 Downs syndrome

Refuse of PEG by the family as the patient has advanced multiple

sclerosis

If the PEG not put, the patient will suffer more as she will be dehydrated
and to be starvated, at this time the dying is not good way as your wife
will be distress. If the PEG inserted it will be reduce her suffering
Benefit and risk of the PEG
Consent
If still refuse tell him, you will inform consultant, offer second opinion,
or as court or IMCA