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“You are the registrar on the ward and have been asked by the nurses to talk to the daughter of a man with dementia, and a chest infection, to discuss resuscitation. The patient has quite cognitive impairment but still mobilises and is able to feed himself, but needs constant attention as he wanders and is not orientated in time nor person and so is not able to speak for himself, but is recovering well and is going to be discharged within a day or so.”

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This communication skills station is about do not attempt cardiopulmonary resuscitation. There are different laws in different countries, but in the United Kingdom, it is now mandatory for all patients to be provided with this discussion, unless there is a compelling reason they cannot. In this scenario, the patient lacks the capacity to discuss the topic due to his dementia.

For more information, please visit the following sites:

http://www.gmc-uk.org/guidance/ethical_guidance/end_of_life_DNACPR_decision.asp

https://www.resus.org.uk/dnacpr/

For your own country, please visit the relevant web sites.

The doctor checks she is talking to the correct person and first asks what she understands about her father’s illness. It is important to obtain an understanding of the person’s knowledge so you know how much you need to explain.

The doctor briefly goes through his treatment and recuperation. Then she asks what his functional status is with the dementia. Everyone has different views of acceptable quality of life, and you should not impose your own views on what this is, and determine the patient’s view.

The doctor broaches the subject carefully given that this is a difficult subject.

The doctor ensures that the relative understands that this is not related to the current situation, and importantly not related to standard treatments, such as fluids and antibiotics and investigations such as bloods and X-rays.

The doctor then explains that the aim is to have a calm conversation what is in the best interests with what is feasible, for her father.

Importantly she checks whether there has been an Advanced Directive or any previous conversations or wishes expressed. For more information, please look at the following:

http://www.nhs.uk/Planners/end-of-life-care/Pages/advance-decision-to-refuse-treatment.aspx

The doctor explains DNACPR based upon what occurs, despite treatment and acknowledges several times that the conversation is distressing, which helps to get through a difficult conversation.

The doctor explains about how likely CPR is to work, and the complications and side effects.

The doctor also checks in that she has understood the conversation. She also offers some reading material to allow the relative to have time to go through it. There is no urgency at this moment to make a decision, and this is an initial conversation. Do not feel, as you are under exam pressure conditions, that there has to be a definitive outcome by the end of the station.

Notice how the doctor uses lay language and does not use a lot statistics – you can use this in your discussion with the examiners, but not with the relative/patient, unless they ask.

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