Communication Skills: Explanation of Procedures and Gaining Consent

In your OSCE, you may be asked to explain a procedure and gain consent for it. You may even be provided with a consent form for the patient to sign after your discussion. It is vital to remember that FY1 doctors should not be gaining consent for procedures, and that a doctor should be able to perform a procedure before they can consent a patient for it. Below are some common procedures that are discussed in OSCE stations, along with a structure about how to explain it to a patient:

• Liver biopsy
• Endoscopy
• Endoscopic retrograde cholangiopancreatography
• Colonoscopy
• Bronchoscopy

For all of these possible stations, simple and clear drawings can be really helpful in trying to explain complicated procedures to patients, and shows that you have a good understanding of the procedure to both the patient and the examiner.

• Wash hands, introduce self, ask patient's name and ask permission to discuss procedure with them
• Ensure you are both seated on a level
• Try to approach the consultation at a steady pace to ensure that the patient has time to clarify or ask questions
• "Chunk and Check" - whenever giving patients information, make sure that you stop often between segments of information and check that the patient has understood

• Do you know why you have come in today?
• What do you understand about this procedure?
• Explain the reason for the procedure:
  • E.g.: may aid diagnosis of liver disease
  • Can give prognostic information about a disease
  • Establishes severity of disease
• Pre-procedure:
  • You will usually have a blood test done shortly before the biopsy to check how well your blood will clot.
  • We will not be able to do the procedure until the results of this test are given to us
• The procedure itself:
  • Takes 10 minutes
  • Local anaesthetic into the right upper quadrant, so you will be awake
  • US guided
  • You must take a deep breath in and hold for 10 seconds
  • Needle then inserted and a piece of liver is removed
  • This will then be tested in our lab
• Post-procedure:
  • You will have to lie flat for 6 hours after the procedure
  • Can go home after this if observations are normal
  • Blood pressure and pulse will be taken half to one hourly through this period
• Complications: important to mention a few of these to a patient before they can consent to a procedure.
  • Common:
    • RUQ or shoulder tip pain
    • Localised bruising
  • Uncommon:
    • Haemorrhage
    • Severe abdominal pain
    • Perforation
    • Infection
  • These may require admission and possible surgery

• Do you know why you have come in today?
• What do you understand about the procedure?
• Reason for the procedure:
  • E.g.: to investigate dyspepsia
  • Identify cause of bleeding, anaemia, etc.
• Pre-procedure:
  • Make sure you have fasted for past 6 hours of all but water
  • Make sure you have got someone to take you home if you would like sedation
• Procedure:
  • Sedation if needed, or LA sprayed at the back of the throat
  • You lie on your side on a couch
  • Fibre-optic tube 1 cm in diametre passed down the oesophagus, into the stomach and duodenum
  • Enables doctor to look at these regions for anything abnormal on a screen
  • Doctor may take a sample of tissue, a biopsy. This will be sent of for various tests.
  • The doctor may also be able to remove anything that looks unusual, e.g.: a polyp
  • The procedure should last around 15 minutes
• Complications:
  • Common:
    • Sore throat
  Uncommon:
  • Tears - small or large. If large they may require surgery
  • Perforation leading to pneumomediastinum
  • Mediastinitis - requires antibiotics

• Do you understand why you have come in today?
• What do you understand about the procedure?
• Explain the reasons for the procedure
  • E.g.: investigation/treatment of gall stones
  • Investigation cause of jaundice
• Pre-procedure:
  • Make sure you have fasted for past 6 hours of all but water
  • Make sure you have got someone to take you home if you would like sedation
• Procedure:
  • Sedation or local anaesthetic sprayed to back of throat
  • Fibre-optic tube 1 cm in diametre passed through the mouth, through the stomach and into the first part of the small bowel and through the ampulla vater
  • Dye is injected through the papilla back up into the bile and pancreatic ducts (a 'retrograde' injection). This is done via a plastic tube in a side channel of the endoscope.
  • X-ray pictures are then taken.
  • If a gall stone is found, a small cut will be made in the sphincter of oddi. Then a wire basket cage will be passed up around the stone and removed. The doctor may have to make several attempts at this
  • If unsuccessful, this may require another attempt or an operation
  • If the x-rays show a narrowing or blockage in the bile duct, the doctor can put a stent inside to open it wide. A stent is a small wire-mesh or plastic tube. This then allows bile to drain into the duodenum in the normal way. You will not be aware of a stent which can remain permanently in place.
• Complications:
  • Common:
    • Sore throat
  • Uncommon:
    • Bleeding
    • Infection
    • Perforation
    • Pancreatitis
    • Cholangitis

• Do you understand why you have come in today?
• What do you understand about the procedure?
• Explain the reason for the procedure:
  • E.g.: change in bowel habit, blood or mucous in stool, unexplained anaemia
• Before the procedure:
  • Warn patient they will need bowel preparation?
  • Check if patient has someone who can take them home if they would like sedation
• The procedure itself:
  • It will take 15 minutes
  • Sedation iv used
  • You will lie on your side on a bed
  • A fibre-optic tube 1 cm in diametre is passed through the anus and into the large bowel
  • Gas will be used to inflate the bowel. This may feel a little uncomfortable.
  • The doctor will be able to see the bowel on a screen
  • He or she may then be able to diagnose any changes seen in the bowel
  • A biospy may be taken for further testing
  • Anything abnormal may be removed at the time, e.g.: a polyp
• Complications:
  • Common:
    • Abdominal discomfort
    • Memory loss from sedation
    • PR bleeding
  • Uncommon:
    • Perforation - small or large. Large may require surgery, small may be treated with antibiotics
    • A defunctioning colostomy may be required if there is peritoneal soilage
    • Infection

• Do you know why you have come in today?
• What do you understand about the procedure?
• Explain reasons for procedure:
  • E.g.: haemoptysis, suspected cancer, persistent cough
• Pre-procedure:
  • Tell patient they should fast for the preceding few hours
  • Tell patient they should have someone to take them home if they want sedation
• Procedure:
  • Lasts around 30 minutes
  • You may be connected to monitor to check your heart rate and blood pressure during the procedure. A device called a pulse oximeter may also be put on a finger. This does not hurt. It checks the oxygen content of the blood and will indicate if you need extra oxygen during the bronchoscopy.
  • Local anaesthetic sprayed or a sedative given
  • A fibre optic tube around 1 cm in diametre is passed through your nose, into your throat and into your wind pipe
  • It is then passed through your upper airways
  • The doctor can see what this looks like via a video screen
  • Bronchoscopes have a side channel down which a thin 'grabbing' instrument can pass. This can be used to take a small sample (biopsy) from the inside lining of a bronchi, or to remove small objects from the airways (such as an inhaled peanut).
• Complications:
  • Common:
    • Sore throat
  • Uncommon:
    • Chest infection
    • Haemoptysis
    • Lung collapse

• Ask the patient if they have any further questions (and give a reasonable time to allow for this)
• Provide the patient with a leaflet and give them the option to come back if they have any further questions or want to discuss something further
• Ensure that you offer reassurance that the team will be working their hardest to make the procedure safe and comfortable

Downloads / Links

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Comments:

pashtun says...

Brilliant resource!!! It allows the reader to obtain the structure of information giving, which can be applied to any procedure requiring explanation.

My only additional comments would be to add a closing gambit such as "I hope everything goes well, good luck"

POSTED ON: 02/11/12, 19:12

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