Breaking Bad News 3
Station 3
Grandma’s fallen again.
Candidate Instructions
Setting:
You are a Foundation Year doctor working in the Emergency department. You have been asked to talk to a patients daughter. You will be provided with results, and asked to explain the results to the patients daughter.
Janet Melbourne (patient)
83 Years olds.
Tasks:
1. Please observe the results, there is NO need to interpret to the examiner.
2. Discuss the results with the patients daughter and explain the diagnosis.
3. Answer any questions they may have.
Other than addressing the families questions, there is no need to give a plan going forward.
Simulated Patient Instructions
Diagnosis
Neck of Femur Fracture.
Briefing
You are Stephanie Melbounre, daughter of Janet Melbourne.
You have driven your mother in today becuase of ongoing pain in her hip.
The doctor has been asked to explain the results of your mothers hip XR
Appearance and Behaviour
You're annoyed and agitated.
Opening Statement
“Come on then, out with it! I knew there was something wrong! I can't believe they discharged her when she couldn't walk!”
Further Information
Your mother had an endoscopy 2 days ago and was admitted overnight because of low blood pressure.
She had a fall whilst on the ward. You knew something was wrong but they refused to X-ray her and the whole team said nothing was wrong when she clearly couldn't walk! She was discharged earlier today.
Main symptoms - she has severe right hip pain
Background - she's been having increasing falls over the past few months but no fractures
Background - your mother has severe dementia and you have full power of attourney and make all medical decisions.
Other details - she was under upper GI for an endoscopy for unrelated investigation.
PMH
Dementia
Falls risk
High BP on BP medications
DH
You can't remember her full list of medications but will find it later.
SH
You have power of attourney both legal and financial
Your mother lives alone despite multiple recent falls
Your mother has carers once a week to help with cleaning
Your mother usually walks with stick. She lives in a bungalow and struggles with stairs.
ICE
Ideas - you think she's broken her hip.
Concerns - your mother might not be allowed surgery now she's waited a day for imaging.
Expectations - the reason why this wasn't x-rayed sooner will be investigated by someone.
Discussion / Questions
The doctor will explain the results of the investigation and break the news that your mothers hip is broken.
They may ask if you want someone in the room with you- if so say “don’t worry I’m happy on my own”.
You are very upset by the fact the diagnosis is delayed. The doctor should apologise and give you ways to raise a complaint, if not then become more irate as the consultation goes on.
Patient Results
Name: Janet Melbourne
Age: 83
Start the Timer and Begin
Examiner Instructions
Please show the following XR to the candidate prior to their patient interaction.
Name: Janet Melbourne
Age: 83
Intro
Gathering Information
As the patient - get slowly more angry if the doctor does not address your concern that this wasn’t looked into sooner. If the candidate is empathetic and apologetic then allow them to move on and ask you more information.
Giving Information
Conclusion
Submit for Scoring
Summary
Apologising for mistakes is part of working within medicine, we are human and it happens. Owning up to, and apologising for mistakes is also part of the legal duty of candor doctors have toward their patients. Despite this, these situations require formal investigation and without the whole picture you should never point the finger at a colleague. Just apologise sincerely and move on, after highlighting the formal complaints process (or in very severe cases, raising the issue yourself through official pathways).
After your time and reassurance spent with Janet and her daughter you received a wonderful card saying they were thankful for your time and expertise. You restored their broken trust in the healthcare team within the hospital. Janet went on to have a hip hemiathroplasty and returned home with a physiotherapy package and increased carers just 1 week later. She’s now safely back home.
Tags | Counselling | Neck of Femur Fracture | Breaking Bad News | OSCE communication station
Station Written by: Dr Benjamin Armstrong
Peer Reviewed by: Dr