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Yup, ready when you will? Ok. Um Hello everybody. My name is Fatima. I'm one of the doctors working in Leicester Hospitals. Currently I'll be running today's session. So the session is based on two of your sy stations. Um The first one we'll cover is difficult conversations and the second one is ethics and professionalism and then we'll do a quick um Q and A at the end. Um Unfortunately, this is a rerecorded um um recording and therefore we probably won't have the, the Q and a bit at the end or the actual acting out. Um But I will pause appropriately so you guys can practice if you're rewatching this. So the first station is difficult conversations. So the way this station runs in the real oy is that it's a 10 minute station. Um You could be covering any aspect of a difficult conversation in any setting that could be palliative. Um Sorry, it is a palliative conversation but it could be in a ward um clinic based um in Ed could be with a patient, could be with a relative. The way the station is split is that we have the first four minutes. Um this is when you speak to the patient and establish what, what they already know, um, how, how they've, you know, why they've presented to the hospital, the sequence of events leading to them coming to the hospital to et cetera. And then in the second half of the station, he will be given some investigations. So you'll have to sort of all these and, um, explain to the patient what these investigations show. Um, also query if they've got any concerns regarding their current symptoms. So as part of this, um you'll also have a particular symptom that you have to manage. And as with all um osk situations, you answer any questions that the patient has any confusion that they have right towards the end. So station time. Um this is the, um and the way it does that you have your first, you have your two minutes at the beginning of the station. Um You can read this information in the two minutes plan, how you're going to approach it in the two minutes before you enter the station. So if you guys want to pause now, um and if you want to act it out with one of the um one of your um colleagues, um you can do that. We did do this in the real um recording, but unfortunately, you'll just sort of have to pause it um and practice with your friends. This is the QR code for any further documentation that is provided this again will not be in this format, the papers will be printed out and, and you can read through them um from the beginning. Um This is the Mark scheme. So what they are expecting um in this conversation. So again, like with any consultation that you do in a sy, you want to introduce yourself who you are, what you do um establish who you're talking to because not always will you be talking to a patient? It could be their relatives. So you want to take permission um or essentially elude that you've spoken to the patient and therefore they've allowed you to speak to their relative and find out what they already know before you divulge any information yourself. Um From that point onwards, you sort of pick up on what they already know and try and fill in the blanks. So you um explain what's happened so far in this patient's journey. Um summarize everything that the patient's relative or the patient themselves have told you um address any of the issues that they have, explain what's gonna happen next um in a manner that both the patient or the relative can understand. Um And then just towards the end, respond to any um questions that the patient will have, make sure to use a very patient centered approach. Um In this setting, you don't need to have the answers to everything. If there are things you don't know. Um You simply say, I don't know. So honesty is far more important than, than sort of making something up that isn't necessarily true. Um So be empathetic, be a nice person. Um say sorry if you've, you know, if there is um if you feel the need to um answer, try and answer all of their questions, offer appropriate silence if we don't need to be speaking all the time. And um so that's just me talking through about the mark schemes um available on um on blackboard. And then the next few uh the next bit is the simulator's mark. So you will have an exam, um an examiner in the room with you as well. And then the simulator is the patient or the relative you're talking to. And they also get to give you some marks and this is more of more so for your communication skills, your ability to show empathy, listening to them, answering any questions, even if you again, don't know the answer to the questions, but just sort of having a go or telling them or um signposting to somebody else who could. So next, we'll just go through some symptoms that you may be um asked to manage, especially in a palliative setting. The first one being pain, um many, many different causes of pain. So the pain can be an effect of the cancer, the malignancy that they already have, it could be a side effect. It could be completely unrelated to the cancer. It could be movement related for all of these different things. We manage it differently. Um And as with any management, we will take a conservative and a medical approach. Um conservative being um a lot of reassurance. Um If they're religious, you could get them seen by somebody. Um You can even have non-religious visitors. Um just to speak to the patient, make them feel a bit more at home in the hospital and then medically pain for pain, we give pain relief. Um All this start off with the really simple stuff, your paracetamol codeine, um and your morphine and other adjuvants depending on if it's like neuropathic pain or pain that's coming from the bones. Um And then the root is also important. So your oral route is obviously less um it it works less better to alleviate the pain compared to your IV and your sub um versus a patch. So you would never give a patch to somebody that is in acute pain and less than until. Um you know, they already came with a patch if they did you continue. But if they're in acute pain, the patch is not really going to do anything. And then the frequency um regular versus PRN things like paracetamol and codeine was a good idea in palliative patients too. Um prescribe that regularly and then something like or more more um as APR N as and when required basis um in the hospital and um in the community you have the pain team. So you can always refer to the um pain team, whether that be in person or like hearing less than we do it through ice. Next, symptom is breathlessness. Um Again, many different causes of breathlessness. You want to work out whether this is breathlessness that has a cause like a, a medical cause that you can treat anemia, pe heart failure, COPD, et cetera. And if there's anything you can do to alleviate those things, then you do. But if this breathlessness is pretty much a as a result of the anxiety to do with the medical condition that they have, if it's a direct cause of the lung mass, then you sort of treat it a little bit differently. Um Again, conservatively, sitting upright helps a lot, especially in instances of like heart failure, um sitting upright will help them breathe better if it's anxiety related as well, handheld um fans because you'd often find that they're saturating well, but there's a feeling of breathlessness. And again, if they're desaturating, then you will give them oxygen. Um if they need it. Chest physio is also really important, especially in cases where you've got mucus plugging. Um The physio team can really help with stuff like that. They can also help you like wean down oxygen after you've um used your conservative measures, medically, you can use um low doses of opiates or you can use um Midazolam and like I said before, treat any other medical causes. If they come in with a COPD exacerbation, on top of their already known palliative diagnosis, then, you know, you can give them nebulizers and their steroids, et cetera. And um finally, there is a palliative care um team um for all of these symptoms that I will mention, the palliative care team has um their own way of dealing with it. They're also just able to offer um a more lengthier consultation then we sometimes are able to award. So it's a really good idea to refer to them. They can always, um, tweak medications appropriately to what the patient actually requires. They can also help facilitate. Um, so the fast track discharges to homes to hospice and also facilitate things like home oxygen. Next symptom is constipation. Um again, um in, in sort of palliative, um when a patient does become, come towards the end of um their life or in the last few months of their life, um, they're often on a lot of opiates. Um, there can be dehydration because of the lack of privacy. If they've had a prolonged hospital, a um, admission, they're probably also not eating too well. Um, there could be direct um, co like obstruction from the tumor that they have or things like hypercalcemia. Again, um, conservatively, it's a good thing to encourage them to, to drink. Um, you can make things like the commode easily available to them, make sure they have a bell. So they're able to um ring for assistance if possible. Um As how you can encourage mobilization with the physios with these. Um And if they need any adjustments done at home as well, if the toilets you are too far uh from them at home. Um If it's upstairs downstairs and they normally spend their time in one area, the ot can help with that as well. Um Medically you want to um essentially do, do apr examination to um rule out things like impaction but the laxatives, laxatives don't work. Um enema, et cetera. Um just a tip for everybody that you're starting on an opiate. It's a good idea to start them on laxatives and antiemetics anyway, so that we prevent um that constipation from developing at least as a cause of opiates, it can still develop due to other reasons. Next, symptom is nausea and vomiting. So again, um the medications that we use can cause this um a lot of people post surgery can have um gastric stasis, they can have delayed gastric empty and anxiety can be caused beca sorry, um nausea and vomiting can be caused because of anxiety as well. So again, um encourage oral fluids eating as much as they can tolerate in small amounts. So instead of 34 meals, whatever they can tolerate soft foods in, in whatever capacity that they can um tolerate. And then medically we are, we have the um we have antiemetics. Um I've seen either just a single one and for some people that is enough or, um, a combination of the, um, of the lot or, um, sometimes I've even seen, um, palliative care do like a 24 hour syringe driver for people who have got things like, uh, obstruction. Um, and then if, um, the notion will be so severe that they're unable to, um, eat and drink and tolerate anything and it goes on for a few days. You want to get the dieticians involved. Um consider NG feeds or TPN S OK. Next symptom is secretions. Um So secretions can be sly, they can be as a result of a chest infection, somebody could have aspirated or it could be gastric reflux. Um conservatively want to reposition to one side, elevate the chest and to allow for any secretions that can actually drain to do so on, on their own. And then medically, we've got glycopyrronium bromide. And again, if they've got a medical condition leading to these things and you want to treat it, for example, increased secretions because they've got a chest infection, you do want to still be treating them with antibiotics with the nebulizers to help break up um all of that mucus. And I believe finally we have agitation, um agitation as a result of anxiety or sort of the impending end of life or their medical condition. Somebody could have just been told some um bad news, their cancers worsened. They were going to have a surgery and unable to have a surgery. Lots of different reasons. Um Some people are so poorly that they, um it becomes a bit difficult to be, uh to allow them to be discharged. So they could spend their last moments at home and a lot of that can cause um AAA good amount of anxiety. Um how we manage this is conservatively. We, we want to reassure them. Um, they can also speak to other nurses like C NS nurses. Um We can speak to palliative nurses. Um The physios, the ot S dieticians, um hospital volunteers as well and then medically um for agitation, we use Midazolam. You should ideally sort of avoid it if you can. Um it's better to use the conservative approaches, but sometimes you will need them. So it's not wrong as such to respond to this. And this is just um a much um brief summary of what we've just said. Um top tips for the station. Um I'd like to say this is not a um not a medical station. So while it's, it's good to be able to say, oh, we'll give you something called. Um My dad's allowed to help you with this. If you do, if, if you do end up forgetting, you know what drug you were going to give, um it doesn't have to say I can give you a medication that will help you with your agitation. You don't have to say exact things and exact doses. This is more so looking at your ability to co communicate, to be an empathetic doctor to listen to your patients. Um And that leads on to the second point of pick up on web cues. Um Essentially, it's a script, right? So that they um examine the actor has a script and there's certain things that they want to say and um they want you to pick up on those cues. So you cover everything that is in the Mark scheme. So anything that they say, if they say I've been feeling this way, you ask them a question and they say I've been feeling this way, you don't want to go back to the question you asked and focus on what you want to ask. You want to pick up on that last sentence that they said and kind of allow them a little bit to, to control the conversation, obviously, not too much because you do only have 10 minutes. Um Next practice. Um These stations are difficult. II can't think of anybody that has these conversations regularly as a medical student, especially so they can be awkward. They can be quite daunting. And so I think practice is the only thing that can help you feel um safe when you enter that AKI station and you know what you're doing then. And um there's basically for all of the OSC, there's a, a lot of reading material. So um in your two minutes if you are given the reading material, read through it and, um, summarize if you're given blood results, if, if we see high C RP, you know, it's an infection, just summarize that one sentence in your head. Um, and that's what you'll relay to the patient. The patient doesn't need exact numbers. But if you keep on going back and forth between the, the, the paperwork, um, you'll be losing time. Ok. Um, Moving on to the second session that we'll cover this is ethics and professionalism and we've split this into two parts. We've done a um a patient focussed one and then we have um another one that you have with your colleagues and any, any professionalism problems you will have with people you may be working with. So a few things that will cover um confidentiality, um consent and mental capacity, duty of candor and safeguarding and some of the examples I think they're good um good stations to practice with your friends. If one of you makes, if you, if you guys make up content for these stations and some of these, we will also be providing so you can practice with your friends. But these are, these are the most common ones. I don't think the station they tend to throw you off by giving you stuff that you will have no idea about. Um they, I in my opinion, they, they generally give you very common stuff. So the way the layout is, is you have the first eight minutes. It's a free conversation. Um You have a consultation with the simulator, the AA and it will test any of the ethical issues um that have been mentioned in the good medical practice. And then right at the end, you have two minutes by the examiner will help um, ask you questions pertaining to the ethical or the professional issue that we, the station had discussed. So again, um station time. So this is the information you are given in the first two minutes and again, sort of plan what you're going to do, how you're going to approach um splitt your stations. I would, I normally split them into headings of everything. I'm going to talk about in the two minutes. And even if I don't stick to my plan, um when there's moments where I don't know what to say, I will refer back to him, then have something to say. So that's, um that's essentially the station again if you pause it right now and then um do the station with your friends and then you can have a look at the um exam criteria after. So, questions from the examiner. Um What is duty of condo? We'll talk a little bit about these questions. Um After what systems are in place to ensure that an error such as this does not happen again. And then finally, what is the day? Um this is the, this is the mark scheme. So they've got this um on blackboard, very similar way of approaching opening the consultation, telling um you know, introducing yourself, asking who they are and setting out the purpose of discussions or something like in a medical era situation, something like I'm really sorry, you're meeting under these circumstances. You've said you're sorry, right at the beginning, you acknowledge that, you know, a mistake has happened and I think that can help put somebody at ease if you've just said sorry from the get go, and then you're kind of certain what people already know about what's happened, like the previous station. You and, um, you try and, um, um, um, you try and find out what the relatives or the patient's main, um, main concerns are because they will, they, they'll accept that an error has happened. But at the back of their mind there, there's going to be what, you know, what is, what is the long term effect of this. And they would want you to ideally answer those things. Um, after this point, there comes a, a bit where you, you talk the most. Um So this is when you explain that error has occurred where it's occurred, how it's occurred. Um And then explain that the patient is currently well, if they've addressed any concerns before you started talking, um, then you want to address these concerns and sort of say, you know, the patient is doing well at the moment or if they're doing unwell. If that's part of the um, scenario you've been given, then you say that, um, and then acknowledge the relatives on work. Uh, it's, um, any relative, anybody, any patient would be angry if a mistake has happened. So you want to provide reassurance, you don't want to blame other people and, and, um, you know, that we're involved. So, in this instance, the registrar or the nurse or whoever, you don't want to um play the blame game, you sort of just accept that as a team mistake as it could and we'll, we'll, you know, there are things um that are in place to rectify, um, and what you can do if you do want to um complain, which is essentially the um patient advice and liaison service and then the day, right? So what is, so this station cover duty of can, what exactly is this? So this is to be open and honest with people that are in your care. If something has gone wrong with their treatment or with their care, you want to tell the patient when something has gone wrong. Um So admit your mistake, admit that a mistake has happened instead of hiding it or, you know, especially if the patient hasn't come to any harm. Um And if you feel like, you know, patient hasn't realized nobody's realized, but you still owe it to the patient, to be honest to them. Once you're honest, there is going to be some sort of a reaction. Some people are understanding, some people are, um, angry and, and, you know, they have every right to be. So, in which instance, you know, you want to, uh, in both of these instances, you want to apologize them. Once you apologized for a mistake, you've made, you want to sort it out, you want to remedy it, you want to put um, things right? So if, if, you know, if they've been over dosed on a drug, you're gonna tell them, you know, we'll do the drug levels, et cetera. If they've been, um, if there is an antidote, then you want to give them that, um, that kind of stuff. If, um, if an antibiotic has a certain side effect, um, that another specialty can, uh, deal with that. You will say, you know, I'll refer them to XYZ specialty. So they can also come have a look if you're concerned, those kind of things are offering essentially a solution and then always kind of explain the short term and the long term effects of what's happened just to reassure them. Um, and, and then also tell them what they can do if they did want to complain on how to, to go about that. Next thing is data. So what a dax is, is basically a, um, a risk management sort of s system. It's not a complaint against a particular somebody at all. It's sort of analyzing what in the system has gone wrong. It's an incident reporting, not on like person reporting service, you report an incident, everything gets analyzed what's gone wrong, what you know, what other things that have gone, right? And how can we improve this um, in the future and to prevent any further future? Never events from happening? Um So this can be quite daunting, but they're not a complaint. Um, they're not a complaint against you personally. They're kind of a complaint for the incident that's happened. And, and, and again, there are many reasons why something may have happened and many different factors that play in and not just one individual or one thing that is to be blamed. Got it. So top tips for this session. Um Is this um the station, um you've got the good medical practice in actions in her. I think they're quite good. They cover, uh they cover a bro, broad range of topics and they're far more interactive than the, like the PDF file version, which is, um it doesn't really allow you to see things in real life. So the interactive sessions are really good. Um Again, like I said before practice, majority of these have very, very similar um templates like the start wha whatever it might be, you know, you're always introduced, find out what's going on, offer your own explanations and then ask any questions and you, and so they, they pretty much all have the same template um in the two, use your two minutes um gather. So in this, you don't get given too much information. But if you just have what you're going to say, what steps you're going to take once you enter that consultation, because when you're speaking to a patient, um the conversation can be led in too many different directions. And at the end of the day, you do still have um an exam to pass. So if you steer them back towards what you want, so if you have a plan in place, you can bring them back. Um and again, say sorry, um you are allowed to say sorry and in fact, you should say sorry, um whether it was you who made the mistake or if you just say sorry on behalf of the team, like if it was a night team looking after the patient and another member that's not available anymore and um spikes, so spikes, we all come across it in like more of a difficult conversation. Um palliative care, advanced care of that kind of setting. But ii basically think every conversation you have with a patient. If you use this kind of um outline, there is not much that you will miss or and and your conduct will also be good if, if you're doing this. So offering them like a place to say, if they want a relative, et cetera, that that's, you know, you're being kind and empathetic and understanding this is difficult. Um and then again, finding out what they know, giving them information and summarizing, it's, it's um a really good outline to use. So that brings us to the um the end of to the end of this session um for these two sessions, I think we're also going to be putting up some um example stations with um with what the actor does and also the Mark scheme. So I'd really encourage all of you to um also practice those with your friends. Thank you.