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Hello, everyone. Um, my name is Ruth. I am one of the co-lead for the fo one branch of mind, the believe. And thank you everyone for joining us so far. I know as the webinar goes on, you'll be having more viewers. Um, but currently today's webinar is being, um, will be presented by, um, Alex and who will be discussing who's actually the neurology, co-lead of mind, the bleep. And today's topic of discussion is difficult discussions. So here we're looking at some communication, tips and tricks that will be very useful to your fy one. So over to you Alex and thank you very much for taking your time to present today. Brilliant. Uh, yeah, thanks very much. Um, so, hello everyone. Uh, thanks, thanks very much for giving up your, er, Thursday evenings to come and listen to me. Hopefully you can pick up a few, um, hot tips on what is a fairly, er, important bit of the job. So let's crack on with it. Um, so what we're going to cover today is, um, breaking bad news situations of self discharge, dealing with angry, angry patients and angry relatives and then a little bit as well on managing complaints. Um, so first thing we're going to do is, um, if this works is so there is a uh system called men that if people have their phones available or you can go to it online, um, if you can keep the app open, um, there's a QR code here. Hopefully this is working is, um, go to mental. I just want to see what everyone's sort of perceptions are of, um, their confidence in these sort of domains. So if you could log in that would be fabulous. There we go. It's working. This is, uh, good. We've had one response, three responses. That's very good. Yeah. So I will give it about a minute. We've also got the average I'm presuming since we're all at a webinar on, um, difficult combs that I would assume that if you felt like you knew everything you probably wouldn't be here. Um, we'll use this throughout as well. So just keep the tab open. Yeah, those you have just joined. If you go to me dot com, just wanna have a look and we'll do the same thing at the end and hopefully it'll have gone up or stayed the same if it's gone down this whole sessions gone really wrong. Ok. I'm gonna give it 20 more seconds. I think 25% of people putting it in is generally pretty, pretty good. Ok? If you can't log in, don't worry, just have to think about it, but it's just helpful for me to know where everyone's at. Ok. Right. So I can just about see that there's a, sort of people are sort of at best just under 50% of the way there with the sort of confidence on breaking bad news. It's pretty, pretty well taught at med school and hopefully I, I've tried to be a bit more pragmatic with it than just deliver standard stuff. Self diss again, it's sort of, it's one of these big scary things, but actually it's if you, there's a pragmatic way of dealing with it and we'll talk about that as well and then dealing with angry patients and relatives, I will go into it and then managing complaints. I will talk about this sort of process that you can go through. But I've mainly put in a link to another video that was done by the MD U for mine, the bleep who are very much more in the right position to talk about it than me. Um So firstly, what I can and can't do today is the irony of delivering a talk on communication via a one way webinar where I can't see any of you or actually engage with anyone is not lost on me. But what I can hopefully do is provide a starting point or approach to common but difficult scenarios, give you some practical tips from two years of experience on the foundation program and a basic overview of what to do based on real life scenarios that I've experienced that have been changed slightly just to preserve anonymity. Obviously, through this, I can't improve your communication skills. And I'm not going to be able to provide comprehensive medical legal or local systems advice for your hospital on what's going to happen for complaints. But I will sign post you to a really good webinar that was done by M the bleep on the same topic that goes into a bit more depth on the ins and outs of the NHS complaints process from a medica legal point of view. So I think it just going off that how, how to actually work on your communication. I think this webinar basically serves as a sort of a, a springboard really for processes for how to communicate in these scenarios. But the way to actually improve your communication is is to do it and it's a skill like everything else. You just have to learn it in different ways to say biochemistry or physiology um or practical skills like cannulation. The, the, the thing that I would recommend you do straight straight from the off in your f one job is try and observe seniors having challenging discussions um with patients, you're looking after um be proactive and speaking to relatives after ward drowns just um as I said, it's a skill like everything else. So the more practice you get and um the more you proactively engage with people the better you're likely to be in this domain. And then also a key for communicating as a doctor is obviously being knowledgeable and understanding the conditions and prognoses that you're looking at. And so just read around the cases that you see on the war and if you do that, you'll very quickly pick up what to do. So let's start, let's start with breaking bad news. So it was, it was the domain that most people felt confident ish in. It was an average of sort of 2.6 when it's taught in medical schools and then certainly in the UK perspective, it's very often taught in decontextualize. So you're not on the wards, you're not, um you're not having to deal with multiple other jobs. You're just sort of sent into a session with an actor and you can stop and start and the actor will tell you how they feel afterwards. Um And you maybe get one or two hours of that at medical school. Um Certainly I went to a ra communication, heavy medical school. Um And that's, we sort of did get quite good communication stuff but not um not a huge amount of this side of things other than 11 hour session a year, it's, we're mainly going to be focused when we're talking about breaking bad news on communication of poor prognosis or a new diagnosis of something like cancer or treatment failure. Um I'm going to try to provide a pragmatic approach within the context of F one rather than just going over models that you may already be aware of. Um And I kind of want to talk about breaking bad news in the context of both my own experience over the last two years and also what the literature says around breaking bad news as well. So this is a case, I'm going to use the men again in a minute. So this is based on a real life scenario that happened to one of my colleagues. So it's five pm on a Friday clerk shift in acute medicine. So you're the f one a patient who presented uh with painless jaundice has just returned from their ct thorax, abdomen and pelvis and it shows a clear pancreatic mass. The radiology report says it is highly concerning for malignancy. There is nobody senior available to tell the patient due to departmental pressures, the patient is medically stable. So I'll leave that up for another five seconds. Ok. So we'll just use men again. If you go back to the tab, I'll start it up. There's the instructions for joining. So just type in just briefly a few words on, what do you think you would do? Would you tell the patient, would you uh sort of hand it over at the end of your shift? What do you think you would do? It's five pm on a Friday just to go back to the context. This is quite interesting. Actually, there's so many different types of things that you could, you could do. But definitely my answer before working, before I started working would be very different to what it would be after actually doing a job in acute medicine as well because that was my first job. Er, so we got a few answers. Inform the patient, the scan showed a potentially concerning mass that needs further investigation. Patient is medically stable and can wait. There's another weight, I wouldn't tell them yet. With hand out at the end of the shift, there's no senior from the ward that has reviewed the scan. Um, inform the patient that the senior will talk to the patient tomorrow. Ask the senior for help, let them properly discuss on Monday. Ok. All right, we will finish up there. There's a variety of answers. So there's someone saying that they would tell the patient, there's someone saying they would hand it over someone saying they would put their foot in it. Um, ok, go and talk to a patient for a minimum 10 minutes. So, yeah, so everyone is sort of, er, no one, no one's done anything completely wrong, but there are no, there are no sort of, there are no sort of right answer to this situation. Obviously, there's a whole spectrum of things that are completely inappropriate and wrong, but no one's done anything that I would say is outrageous there. So this is the medical school approach to the scenario that you often get taught. So this is called the spikes model. It's in lots of the palliative care literature. Um And so we'll go through this now. So they're setting. So, are you in the right place? Is it the right time? Uh Have you got the right people there? What's the patient's understanding of the situation? Ask them how much they want to know that's invitation. Um Tell them what is going on and what the treatment options and prognosis look like. Empathize with them when they are very likely to become upset and then summarize the scenario. So this is a very neat idea of what breaking bad news should go on. So in this case, based on the spikes model, here's what you could do. So you could call the family in, ask them what they know. Um The thing with A MU sometimes is they might have been referred in by A GP and told, we think you probably have cancer but we need you to get further investigations. So they might already have an idea. Do you ask them? Do you want to know the scan results now? And if the family are there, they'll probably like to say yes, explain the disease and care options. Empathize when the patient or family become upset or are likely to become upset and then summarize. And this is this is the sort of medical school simulation expectation in real life. I would argue that it's probably not appropriate to do in this scenario. So, uh I work on gastroenterology at the moment and even on the ward, sometimes when the patient gets a scan result, and I'll explain this in a bit more depth than a minute. Um We don't necessarily dive in immediately and go look, this is, this is cancer. Here's your options. Um So the setting if you're in a busy acute medical unit in a small district, general hospital is anywhere actually going to be available, are you going to be available? Do you have the cardiac arrest sleep? Uh with no one else available to hold it that might go off in the middle of you trying to tell the patient, how are you going to manage all of your other jobs if you've got more unwell patients, the patient's medically stable. Um Do you, what, what if the scan has been interpreted incorrectly? And this is a big learning point actually from the last two years for me when you go for a scan on the day, um the same day scanning may be interpreted by a junior radiologist who isn't a specialist in um gastrointestinal malignancy in this case. But it's the same for um any specialty. Obviously, it's like medicine. You have people who are general medics and then you have subspecialists who have a bit more expertise and actually with sort of cancer scans in particular, a multidisciplinary team are going to need to look at it to come up with a plan, um which will probably involve a specialist gastrointestinal radiologist rather than, for example, an ST three registrar radiologist may have looked at it and gone. There is a mass there. Um And they may, they may be correct, but they may have misinterpreted the scan. Um Not because they're incompetent just because they're not as experienced as say, a consultant, gastrointestinal radiologist, I would say the biggest one though is the knowledge element. So you aren't an expert in the domain. So you or your colleagues that you might have to hand over to on the weekend um aren't particularly other F one S or SS or F two S. Um You're not going to be able to fully lay out um the diagnosis prognosis or treatment options, especially in a time limited acute environment. Um And also the tying into that is emotion as well. So are you causing a lot of upset when no one is actually able to provide support? Um So for example, on a sort of gastrointestinal ward or gastroenterology ward, it may be that um there is a specialist nurse that's able to come down and stay with the patient after the bad news is broken into them. And that's just not something that can be provided as as well in an acute medical environment on a Friday evening. Um So I would argue this is my pragmatic approach at the end of F two spikes is a very nice neat model. Um But in terms of the role as an F one, using it for a brand new finding on a scan is probably not actually appropriate. Are we going into what patients actually want in their scenarios? Uh And this is from the sort of literature available and up to date, um this is what they want. So they want to ensure that there is someone that they can speak to during and after. So it's helpful when these conversations do happen for a consultant to be there. But also you as one of the more junior ward based team, if you work on a wards, normally, um, the specialist counts a nurse, for example, um, and also patient relatives as well, just that everyone is there for that discussion and then if the ward nurse is there, they can continue to have discussions with the patient and their family after the ward round has moved on and the patient isn't left on their own pondering a fairly grim diagnosis. Um, patients prefer to be told in person rather than by telephone. Um, interestingly, there's quite a lot around being clear and being direct. And I think, um, when you are discussing these things with people and sometimes the scenario is acute enough that a junior member of the team will need to discuss these things is not to say things like the team is of the opinion that you are going to probably pass away from the malignancy. It just go along the lines of, um, something that's a bit more direct. So it's clear from the scan that this is going to be a terminal illness and it is, and you are going to die from it. Um, honesty and I think sometimes we feel a bit reticent, um, and particularly when we are F ones and we're a bit worried about getting things wrong. Um And everything is very fraught and very new at the start of your job. It's just trying to bear in mind that this goes for everything in general with things when they are difficult or go wrong is that it's not your fault that this has happened to the patient. Um And just reminding yourself that is quite helpful in these scenarios. Interestingly, a lot of the literature is around providing hope, reassurance and positivity, which sounds a bit sort of paradoxical in the context of um a terminal illness, but I'll just go through what, what they actually mean by that next. So generally, the statements recommended are things along the lines of I want you to get better, but it's clear from the scan that this is a very serious illness or I hope that your relative gets better from this infection, but they are incredibly unwell. Um And provide, that's what they sort of mean by providing personal hope and then providing sort of that reality check afterwards. Um from personal experience, reassuring people that you will take steps to make sure that the dying process is not distressing is very helpful for relatives and they're a really great mind, the resources on palliative care. But my general thing is we will take all the steps necessary to make sure that um you're not having any pain, you're not, you're not distressed. Um And that you, it's as calm and as dignified as possible as you reach the end of your life. Um providing reassurance that you're present on the ward or that you are present to have further discussions until a certain time is quite helpful as well. People may want to come back with other questions after the news has been broken. Um And then also people want to know what the ongoing plan is for the patient and that probably is the crux of why breaking the bad news at 5 p.m. on a Friday and A U is a brand new F one is not a brilliant idea. Um Just because you can't provide any sort of um any, any sort of ongoing plan. So we'll just leave the patient in a lot of uncertainty over a weekend. Um When actually the scan result probably could have been dealt with on the Monday. Um There's also these four questions or five things on the on the left that is from atto gos but being mortal, that's a very good read. Um If you uh if you want to read it. Um So it's just about the, the four or five things you can ask people towards the end of their life to make sure that actually you are focusing on their priorities. Um So what's your understanding of where you are and of your illness? What are, what are your fears or worries for the future? What are your goals and priorities? So, quite a lot of the time patients are like, we don't, we don't want to wait for this sort of further investigation to come back. We know that they're likely to pass away and we have limited time left and actually we'd rather have stuff happen at home. Um This is also very helpful if you do things like treatment escalation plan discussions, but I won't go into that today around sort of what outcomes are unacceptable to you for sort of quality of life. Um But it's a good book and it's good to bear in mind because often you can get drilled down into just trying to follow protocol when you are a bit over burdened with stress. So in terms of approaches that could be taken in the scenario that I went through. So things if the patient asks, you could go, we need one of the liver specialists to have a look at your scan. Uh These are all sort of quotes that I sort of have used or some variation of them. Um If the patient really asks what the scan results say. You can go look. I don't really have the relevant expertise to be able to interpret what's going with the scan. I can ask one of my senior colleagues or one of the gastroenterology team to have a look and come back to you with the results or uh along the lines of what I was talking about earlier, which is one of our emergency radiologists looked at the results and I've certainly heard consultants use this before an MDT happens. Um But they aren't a specialist in the imaging of the G I tract. We want one of the specialist radiologists to look at it before we proceed any further. Um So doing this means that you still have a meaningful discussion with the patient and let them feel heard and can discuss their anxieties with them and you're not ignoring the fact that they do potentially have a serious diagnosis and have had a scan. It does function as a slight warning shot as well, which can help patients psychologically adjust and it, it means that you don't leave the patient or family really distressed over a weekend in an in an environment where they can't be provided with support. Um So it allows you to tread that line between um being honest, but also ensuring that you're not causing unnecessary distress um in a patient that's medically stable where actually it is best placed to have a chat with in this case, either an HBB surgeon or a gastroenterologist, um, and a cancer specialist nurse, um, on a Monday in a more sort of controlled environment where all their concerns can be addressed. Ok. So that's breaking bad news. Um, so that's one of the major parts of the talk today. So we'll talk about self discharge now. So I'm gonna go through 33 real life cases that have happened to me over F one and F two. And I want you to have a think uh because we're doing a mentee again about which one of these patients you would say is uh is OK to self discharge and which ones we need to have a bit more of a think about. Um So self discharge scenario, once this happens during um my general surgery placement as an F one. So you get a call from the nurse saying this patient is trying to self discharge right now. Um The nurse hands over to you. The surgeons want him to stay in the hospital for an operation on his ischemic limb. You go and review the observations and results and his new score is three or early warning score is three for a heart rate of 92 and a systolic BP of 100. His white cell count is 34 and that's risen up uh over the last 24 hours from 30 his CRP is 80. Um And it was previously 55 yesterday, he's had a CT angiogram of his legs three days ago and he's got complete occlusion of his common iliac artery in his left leg. And he's currently on a heparin infusion. He's trying to self discharge all the other bloods are normal. Um And there's no further information provided in this case for. Now, this is scenario two. So again, real case, 18 year old woman who was admitted with a paracetamol overdose and has received NS to cysteine. You see her mother on the ward who tells you she's worried that she's going to attempt to take another paracetamol overdose. Multiple boxes have been delivered to the house again today despite the admission yesterday, um the patient's mum then leaves and the patient then tries to leave the ward five minutes later and successfully exits the doors of the ward. Um So that's scenario two and then scenario three is a 50 year old man in the acute medical unit who's there having been found to have a new A K I stage two. He works in a very high skilled job um but has an intense fear of hospital environments due to tra traumatic admissions as a child in the hospital on telling the patient you think he needs admission, he immediately says he wants to leave the hospital. You then go and get your sh which is what I did in the scenario. And you try to explain to him that he should stay due to the risk to his health, but he can't recall the contents of the discussion where the sho and yourself have just tried to speak to him. So if we go back to men again, if I can get it to work, which based on the available information in the cases, and I appreciate that it's quite contrived and I've excluded quite a lot that you'd want to look for. Which if the, if any, would you allow to leave the hospital or not want to put some sort of deprivation in and we'll go into that in a minute. So it's m you can pick multiple options as well. So all of them could be right. All of them could be wrong. Ok. Interesting. Ok. I'm gonna give it 15 more seconds. I can see the question on the previous thing. So I haven't been checking it that frequently, but hopefully I have established what I would have done in the breaking bad news scenario. Ok. Right. So which if any of these patients? So 11 people, uh, 11 of 17 are gonna allow, uh, the patient in case one to go, er, three people are gonna allow case two to leave and um, three p seven people are gonna allow a case three. So, um I'll tell you what happened. So case one was allowed to leave the hospital, er, he had full capacity. Case two was detained under section 52 of the mental Health Act and Case three, which is arguably the most interesting one of the case considering that he was working a very high skilled job, but couldn't retain any of the contents of the discussion um was placed under a declaration of liberty despite being a completely independent fit and well man. Um he just because he was so petrified of being admitted to hospital, genuinely couldn't um retain any of the information and therefore didn't have capacity, which almost Hoodwinked me at the time. But this is why you call him for senior help in these situations. So we'll go through this now, but he was deemed to not have mental capacity to make a decision about his physical health because he couldn't retain information despite having a very, very high performing job in society. Um So yeah, that's my top learning tip from today is make sure that you're very explicit at the time. Um So in terms of self discharges or people that want to leave against medical advice, um there's sort of three frameworks. So essentially, there's common law which is um not very common at all, but it's essentially you use physical restraint against a patient, I mean using any physical restraint um or keeping someone somewhere they don't want to be is unless we have legal protection is essentially assault or false imprisonment. So we need to make sure that we're doing it within, within the law. Um but hospital isn't a prison and actually, if people don't meet any of these criteria, they are free to leave. So common law is generally things like patients are imminently about to self harm, patients are imminently about to assault other patients or things like lighting cigarettes um in an oxygen filled bay in a respiratory ward, um restraining the patient in the least sort of restrictive way possible under common law is legal deprivation of liberty, safeguards. We'll talk about that, but that's when people don't have mental capacity to make a decision about something to do with their physical health. And then section 52, you cannot do that as an F one, you have to be fully registered, so I'm not going to go into it. Um But you need to call an sh um and your psychiatric liaison team. If you think someone needs to be detained under section 52 of the Mental Health Act, which is essentially a 72 hour stopping measure that can be done by any fully registered medical professional and some psychiatric professionals um to allow them to be assessed about whether they need to be detained under section two or section three. I'm sure that that is a very oversimplified definition, but for the purpose of this, the other. So the, the top three are all things that you would do if the patient is still on the ward, if the patient has left already. Um And this is in an article on the mind the bleak website as well. There essentially needs to be a judgment call based on the nursing staff who know the patient and previous documentation. So it's quite common that we have patients that are being admitted with antibiotics and are completely fine and are fed up of being in a hospital. Um and are normally completely capac who just decide to up and leave and that's their, that's their right. Um But for example, if you had a patient with dementia or um who there was concerns about capacity while they were on the ward and the nursing staff know they've gone AWOL. Um And no one knows where they are. That's the point to call the security and all the police. Um This is the sort of basic framework for an on haul on board cover. There are lots and lots of caveats. Um And it's worth if you work in the emergency department, which I haven't done and can't answer questions on unfortunately, asking them what their procedure is because you can't um detain people that aren't admitted to hospital. Um And Ed is technically not an admission to hospital. So that's a word of warning if you've got an emergency department job, um just ask them and ask a consultant that you, you will be on with about what to do if the patient does abscond in that case. So we'll go through the Mental Capacity Act now just because like I've said section 52 isn't something you would be doing as an F one because you're not fully registered with a license to practice. So the five things that the Mental Capacity Act are, is the first thing is to assume the patient has capacity, which is kind of the point of case one that I showed you is that there was nothing in there to assume the patient didn't have capacity. Um So um that patient was free to leave. Um And when I assessed him, he could do all of the next four things. The second thing as well is the patient um capacity is decision specific. So a patient might not have capacity to leave the ward but might have capacity to refuse drugs, for example, or refuse cannulas. Um But just if anyone's asking you to ever fill out a mental Capacity Act, um just need to just clarify what it's for and if it's for a blanket thing, it, it just needs to be slightly better thought through um than just filling out a blanket capacity form for patients because otherwise, that's when we end up restricting people unnecessarily or beyond what's proportionate. So this is the sort of key within all documentation in self discharge for physical health decisions. So, can can the patient understand the decision to be made? Can they retain information that you're talking to them about? Based on the information you're giving them, can you weigh up? And this is something that people often neglect is that yes, the patient can understand and can essentially repeat what you're saying, but they're not weighing up the information in a way that is coherent with capacity. And I'll go into that in a minute. And then are we allowing the patient to communicate in, in a way that um in a way that means that, that they can communicate the decision properly? So for example, on stroke units, when people are grossly aphasic, that often required us to fill in deprivation of liberty under the Mental Capacity Act because they were unable to communicate. And we were having to um treat with things like fluids when they weren't able to communicate with us, whether they would want that or not due to their stroke. Um So in terms of the pragmatic approach to these scenarios, so the first thing is please never like feel pressured to absolutely run to a patient who's self discharging. Obviously, it needs to be prioritized, but it's not something that you need, you never need to run to an emergency, but your job is to assess the patient's capacity. Your job is never to convince the patient, it's the patient's right to leave if they want to. If the patient apps cons before, before you're able to get there, the nursing staff can make a judgment call about whether they want to call security or not based on their understanding of the patient, in terms of understanding, retaining, weighing up and communicating this is sort of table that I was thinking of um in terms of, of relevant data around people's comprehension within the general public. So the average UK reading age is nine years old, which is um sort of surprisingly low. Um but it's not uh as in um doctors generally will have a higher reading age than that. Um And so you just need to adjust the way that you speak to people to make sure that you're giving that patient every possible chance to understand what you're talking about rather than using lots of medical jargons. So use short sentences and use lots of nontechnical language that you could easily explain to a child. And you are probably giving that patient the best chance of understanding the information to be able to make a fully informed decision retain. So there's these sort of psychological studies that have been done that shown that your short term memory can only retain on average seven pieces of new information plus minus two. So if you aim for five pieces of new information at a time, um then you are probably in the right ball park of again, allowing that patient to be able to make a fully informed decision. Now, you don't need to know the numbers to be an F one. But you can say, and you are a medical expert, you can say if you do this, you are more likely to die than if you stay in the hospital, for example, you won't need to throw specific numbers at them and we know that people's ability to interpret risk in terms of numbers is pretty poor. Anyway. Um The other thing to say, of retain and this is what saved us in case three with the guy who had the really high functioning job. But an A K I is you need to be really explicit in your assessment of capacity. It sounds really silly. But when you say it, you need to say, um can you just repeat your understanding of this to me just so that you can back yourself that the patient does have full capacity weighing up is a little bit more of a judgment call. So it's asking them things like to determine their decision if they want to leave. So how are you going to get home? Have they spoken to their relatives? So I had a young lady recently who was saying that I just want to die. You understand what I mean? And I was like, I do understand what you mean, but how are you going to get home? And she was just going well, I just will. And then I spoke to her partner on the phone who was like, no, she's like, not been like this at all today. And it turned out she actually had a delirium from an endocarditis. Um So it's just a, a sort of judgment call about is this person the way behaving the way that they, that we would normally expect them to act and making decisions that are sort of fully, fully informed and rational. So, for example, if they live halfway across the country and are saying, um, I'm just going to be able to get home and sort of very unwell. Um, they, they probably, it probably is worth having a chat with the senior, but don't just go, they can understand and retain and therefore ignore the fact that they can't weigh up. Um Which because it's the hardest bit to assess is often the bit that we fall down on. Um The other thing with weighing up is just bearing in mind whether it's a problem with them articulating their decision because they're really frustrated and being wound up by all these people trying to keep them on a ward or if it's a genuine difficulty in weighing up. And like I said, it's a judgment call and this is often the reason to call in senior senior help. Um So for example, in that first case, generally a good thing to do would go let you have a clot in your leg. We are giving a medication to stop it growing to stop it. If you leave the hospital, it could stop the blood supply to your leg. If this happens, it is very likely to kill you and framing information like that. There's four discreet points um will allow the patient the best possible chance of demonstrating their capacity and you being confident that you have come up with the correct call. Ok. Now we have to talk about angry patients or relatives. So, er, there's a couple more men things in here and this is a bit, a bit shorter than the other sections and ties into complaints as well. Um, so again, these are real cases that I've sort of, um, anonyms slightly. Um, so case one, so a relative phones through at 5 30 on a Friday. Um This relative was put through to my bleep by the switchboard. Um just as I was about to leave, um They are absolutely furious about their mother's discharge summary um for a patient that was recently discharged from the ward which has multiple incorrect errors including an entry for a completely different patient. They are demanding to speak to the staff members in question who have written and are named on the discharge summary who are unavailable to speak because it's 5 30 on a Friday. So if we go back to men again, what would you do? We'll give it a minute or so sorry. I will get the uh code backup. This one person saying they would slam the phone down and just get home, someone who's put the assist pic, which I haven't actually heard it before if you want to type that in the chat just for the benefit of everybody else. Ok. So I will close things down now. So lots of people saying apologize, which I would say is, is, is generally the correct thing to do. It's quite an interesting situation just because of the, the, the time limitations on it. Um, ge so what I did was obviously listen to what they had to say, apologize but was sort of advised, you can say it in a confident fashion, just say I'm really sorry. There is none of the people who wrote that report are working currently because it's after five o'clock on a Friday. But I appreciate that. Um There is incorrect information on the discharge summary and that that's not right. What I can do is give you the number for the patient advice and liaison service. And if you call this number back on Monday, we're much more likely to be able to deal with your complaint on the ward by trying to issue a new discharge summary when our ward clerks here. And that's exactly what happened. Um But it enabled me to essentially um manage to diffuse the situation slightly, but also allow the relative to feel heard and get um and get the correct outcome. So the main learning point is firstly dealing with angry relatives is really challenging. So this this particular relative um was incredibly angry on the phone. Um and sometimes you just need to let people speak. Um And that's really hard, especially at the end of a 9 to 5 day on a Friday, in particular, when medical wards can be quite hard work. Um The key really with really angry people that potentially are making demands that you can't or sort of asking for stuff that you can't fulfill at the time is just to try to be pragmatic and reach an outcome. Um which is what I was able to do in this case, just by listening and essentially you can be objective but still say no to stuff. And I would just encourage you to not be afraid of saying no, but try to do it in a nonconfrontational way. You've all been to medical school for at least at least four years. Um And you wouldn't be here if you weren't good at communicating. So you will all know what you're doing. Um So here's what I did. I said I'm really sorry that there is incorrect information there. I did highlight there was no way of contacting the staff members in question as they weren't in work, which is very difficult for anyone to get angry about. Um I reassured that we could issue a new discharge summary to the GP so that her mother's care wasn't compromised, which was the main concern and directing the relatives of the patient advice and liaison service to further discuss, making a complaint in a proactive fashion. So if you point that out in the middle of the discussion, you show that you're on the same side rather than sort of go on the defensive when they say that they want to make a complaint. Um, you are much less likely to end up in trouble yourself. Obviously, we want to help people. That's not the reason, but that is an added bonus. Ok. So case number two. Um, so this happened to me on short stay ward. So patient relative approaches you at the front desk on the ward while you're trying to see lots of other jobs, they're demanding to know why their mother-in-law is being sent home. You've only looked after her for today. She's clearly too unwell to get home and can barely stand up. The patient has already had a failed discharge and the relative is worried it will happen again. So let's go again. Say what you gonna do in this case. Thank you jean for putting that in the chat. That's really helpful. And it's a sort of similar one to the one that I have come up with myself. Uh Can you see this scenario again? I will uh if mental stays open. Yes, that'd be great. So patient relative wants to know why their mother in law has been sent home. Clearly to un well to go home, can barely stand up. Um Patient has already had a failed discharge and relatives worried it will happen again. There we go. Had one response. Explain your reasoning, explore her concerns, apologize. She feels that way. Ok. We'll discuss the uh yeah, we'll discuss the, I apologize that you feel that way. Comment, er, because that can generally go, it generally goes more wrong than right. Let's have a look. Ok. Ok. So yeah, it all looks, it all looks relatively sensible. My only comment is like I said, the I would say, um, saying I'm sorry that you feel like that comes across normally as pretty disingenuous. So I would try and avoid trying to, um, try to avoid saying that. Um But yes, generally acknowledging a concern and listening to people is always the right call. Um And I will tell you what I did. Um So the the learning point really is that in this case, this, this relative was quite understandably very worried that having had already had a failed discharge. Um And not really seeing what the difference was this time round. Um They were worried that the same thing was going to happen again and their relative was going yo yo I/O of the hospital. The second thing to say is that when you get approached by an angry relative at the desk where you're trying to do something else that's not ideal. And actually what I wish I'd done in this case is said, um do you mind if we have a chat um in a few minutes just to give me some time to have a look in the notes and understand what's going on with the case just because that leads to a much more constructed discussion, then you being caught off guard and on the back foot and being a little bit flustered. Um, because that generally isn't very constructive for anybody in general with discharge decisions. So this is quite, it's quite a common reason that patients get and their relatives get frustrated is either not understanding what's going on with their care. So it's a communication issue or perceptions that things haven't got better and explaining firstly what the role of an acute hospital is can be helpful. So um saying things like we're here to make sure that that you don't need to be in the hospital. But with our trying to get people back to 100% is not the aim of the hospital. And there are other rehabilitation needs that can be dealt with in the community. And actually the thing to do in this case was direct, the relative to the occupational therapist or the physiotherapist because the patient had already been declared medically fit for discharge. So we treated their infection, but they were deconditioned from being in the hospital. And that's relatively common with elderly people and actually using other members in the multidisciplinary team is both helpful for um making sure that the right outcome happens for the patient when they get discharged from hospital. So just a recap, physiotherapist will look at the mobility of the patient. So things like not being able to stand will be their remit but worrying about how the relatives going to cope at home in their environment would be the occupational therapist. So having a chat between yourself and the occupational therapist and physiotherapist in this case was the key to sort of resolving it. Um The other key learning point and it's difficult when medical rotors are so changeable when people are getting pulled left, right and center, but try and be proactive in communicating with relatives where possible. Um, especially when patients are declared medically fit for discharge. Um Obviously with, with patient permission, having a chat with their relatives to just say, look, we're happy that we've treated whatever the underlying condition is now and we'd like to get them home. Do you have any concerns? It's helpful for trying to avoid complaints, um, and avoid situations that we found ourselves in here. So this is my personal approach to diffusing situations that is sort of the, the system on it has been put in the chat and it's very similar. But, but the key with anger really in anybody angry is just to ask yourself what, why are they angry in the first place? Is it? And it's normally one of three things. So it's normally their idea, um, of what healthcare should look like is, is very different to the reality and I've had that a couple of times. Um, they're, they're really worried that there is sub optimal care going on or their expectations of what, what the outlook for their relative looks like is different. Um, so it's all to do with mismatched perception. Um, and I think in medicine we sometimes get pretty bad because we see these situations all the time. Actually, we don't appreciate that often. This is, people will have to deal with sick relatives maybe once or twice in their lives. Um, so helping people through that is really important and it is an area you can make a massive impact as MF one. So why are they angry, avoid taking it personally? And it is difficult, like I said, when you get caught off guard and someone kind of um approaches you while you're sat and trying to do a job. Um that is um challenging, but just taking that time out to just try and few things objectively labeling emotions is really important. So saying, I, I can see that you're frustrated and um is can help to diffuse situations and empathizing with their situations as well. Summarizing back to the patient just that this is a sort of part one of this sort of Wales Monarch that I've come up with um summarizing back to them, the reasons for their concern is really helpful for them moving on to the second bit. So you need to try and come out of this with some sort of pragmatic solution. Um So just be very clear about actions you can and cannot take like in that first case, um I'm really sorry, I, I would like to get hold of them but I can't at the moment, um, because they're not in work, um, be explicit in how you can prevent stuff happening if, if a mistake has happened to anyone else or ensure there's learning from the incident if appropriate. So I recently had a patient who was, er, had accidentally not, had their regular meds prescribed for three days and I said, look, this is, I'm really sorry this has happened, this shouldn't have happened. Um, what I will do is I will fill in a data form and just to make sure that this won't happen to anyone else in future and we'll give you all your medications now, but no harm has happened. You will have been completely fine. Um, in terms of your short term health, despite the fact this has been missed and then just apologized. Um, if the relative or patient wants to submit a formal complaint, try to direct them to patient advice and liaison because then it allows it to be dealt with formally and make sure that there's oversight of the process rather than if potentially a potential in a particular individual is implicated in their complaints, say a colleague, um, that they want to make a complaint about, um, just to make sure that that process has gone through correctly. Um, and then also just make sure that you really clearly document precisely what you discussed and what what the outcome of the discussion was like anything else? Just because you may, if it does go to a formal complaint as we're about to go through, have to comment on it in the future. Um And it's really helpful to be able to look back on very, very clear records about what you said and what happened, what happened and what didn't happen. So in terms of complaints, I'm gonna go through this very briefly. I'm not a medical legal expert. Um And well, I would say it's because uh I'm really good at my job but I'm sure it's luck. Uh I haven't had um any formal complaints made against me or been involved in any complaints. So I don't necessarily feel er, like the best person to speak about this in depth. However, obviously dealing with angry or disappointed people is a major part of dealing with complaints and if you can do that, well, you are likely to avoid escalation to a major complaint. This is a QR code to an NDU webinar that was done for Min the leep um by one of the MD U representatives um through Facebook live that I have looked at today and I've watched it in full and it is very, very helpful. Um So if you do want to know a bit more about complaints and the full process and what the medical legal advice is, have a look at that in terms of the generic process for complaints. So like we've just spoken about. So if someone is angry or sort of has problems with their care, just attempt to resolve it locally or in person, everyone should have sat the situational judgment test either through the UK process or in P lab. Um and then um whatever the issue is, follow the due process in the same rationale as would be provided in the situational judgment test. And that's generally a good system to follow. Um If the patient does want to escalate the complaint formally, despite you trying local measures to resolve, um don't, don't resist that, just say this is the number for patient ad advice and liaison. Um And this will make sure that your complaint is dealt with fully. Um And that this can be dealt with at the right levels of the hospital. Um The hospital is obliged to acknowledge a complaint within three days that they make through pals. Um And then from there, you may be asked to make a comment if you've been directly involved in the case. Um And this is generally what's recommended if, if you're required to respond to a formal complaint, um which you will know about. Um So generally have a meeting with your educational supervisor or clinical supervisor to discuss what's happened. I would also call your medical legal advisor regardless. Um They're very, very helpful. So either MD or MP S um write a reflection for your own records including the time and date of what happened. So just say what happens, what do the patients say or relatives say happened? Why do you think they might have said and how are you going to change your practice in future? Review the notes and comment on what is objectively written. So I wouldn't, what they don't recommend is saying things like I can't recall. It. Just say the notes say this, I can't recall this, but the patient is saying this um just be just be very objective in what you write that MD U webinar is brilliant for laying out a few examples. I would have liked to have included them, but they're all copyrighted. Um So I can't um in general, this is what's recommended. And like I say, this would be after consultation with your educational supervisor, your clinical supervisor who may have been involved in the case, maybe the consultant that was also involved and your medical legal representative. So generally, as always apologize, just so the patient feels heard. Um And also because it's important, obviously that we apologize, um write down what happened from the clinical notes, explain why why something happened or what didn't happen and what should have happened and then what have you done as a result to change practice to make sure it won't happen again and it won't happen to someone else. And that generally is what patients want. We know from the literature when there is a complaint made, they want an apology and they want to know what has changed, that it won't happen to someone else in the future. And that is just the, uh, QR code again, se for the end of that, we did this right at the beginning. Uh, and the timing has somehow been pretty good. Uh, despite the fact I've whittled on for an hour. So how confident are you compared to the beginning about in the context of f one breaking bad news, dealing with self discharge, dealing with angry patients or relatives and managing a complaint. Good. It's got, it's gone up slightly with one person. So that's a, that's a relief. Oh, ok. It would have been nice to have it side by side. But I don't quite have the technology. Uh, what we got, if they haven't mentioned making a complaint, do you suggest it to them by letting them know that it's available to them? Um, it's context dependent. To be honest, I wouldn't, I wouldn't just blanket say, oh, you'd like, you'd like to make a complaint, would you? Um, because that could probably inflame the situation quite a lot. But if they say if it's very clear that they're very angry and, and want to make a complaint or what, like in that scenario I gave, where they want to speak to the people in question, um, directing them to pals rather than the people in question is the correct, is the correct route to go down rather than letting um potentially letting a colleague get an ear full, um which won't really help anyone in the situation. Ok. Um So we've got 11. So generally we, we've gone from an average of sort of just under three to an average of just under four. And like I said, this wasn't about trying to make you all excellent communicators. It was mainly about trying to make you all hopefully a bit more familiar with the context. Um The context within which all this stuff sits and being an F one to give you a bit of a spring board to have a bit more confidence to deal with these situations when you are face with them. But like I said, the best way to deal with this stuff is to observe senior colleagues dealing with it and also sort of upskill yourself by making sure that you are knowledgeable about the conditions that you're dealing with, um in terms of diagnosis and prognosis and treatment and then speaking proactively to relatives and you can avoid a lot of these negative scenarios. So we've talked about breaking bad news. We've talked about self discharge, we've talked about angry, angry relatives and patients, we've talked about complaints very briefly. Um And that's it. Any questions I will. Um Thank you very much, Alex. I think you've covered a wide sort of breath of things and definitely, as you said, um, last you learn a lot on the job and to learn, the best way to learn is actually being by being present at these family meetings or difficult conversation scenarios. Um, and whenever you get the chance, especially in medicine, I think it gets done perhaps a bit better compared to other, like, specialty such as surgery. Um, and it's, it's really important that you guys go to these family discussion, um, and, and sit and just, just be an observer and just listen how it's done. Um And, and that's how you learn and that's how you practice as well. And then soon, I think by the end of not even end of F one, sometimes, you know, once you've become quite confident with your day to day things, they might even start asking to do questions, you know, difficult questions, a difficult um discussions with your patients such as DNA CPR. I know this is not something that's covered here. Um But we will be covering that in the palliative section in, in um in August. Um I know DNA CP is not just for palliative patients, but it's just being covered in that in that section. Um So, yeah, thank you very much. Thank you. Thank you very much Alex. That was really informative and I really liked the way you presented it as well. Um But any other questions from anyone, but also we've got feedback form if you don't mind um completing because that would be really, really useful for us Um, I've just putting it, I've just put it in the chat. Um, so please take a moment to fill it maximum two minutes really of your time. Um, so that we can improve. But yeah, pretty much, I don't think there's any further questions. Everyone's been very grateful. Um, appreciate it for your time. Yeah, we'll just hang about whilst everyone pretty much done. Yeah, I guess that's it really. Um, I'll just hang about just so that people can finish off their feedback forms. But Alex, you're more than welcome to, to. All right, thanks very much. Thank you.