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

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