Discharging

patients
Discharge almost universally occurs in a hospital setting. It is of para-
mount importance that you ensure that the patient feels well enough to
return home. It is equally important to ascertain their ability to cope with
their current living situation, and that they are aware of any changes in
medication or treatment that have occurred since they were last at home.
Try toadvise lifestyle changes that may be helpful tothe patient, andwarn
of any foreseeable impact that their recent hospitalisation may have on
their lifestyle. Finally, when concluding the consultation, make sure that
you have addressed the patients ICE during the consultation:
. Ideas
. Concerns
. Expectations.
133 Discharging a post-MI patient
Scenario
You are a doctor on a busy cardiology firm. Mr Simons, a 56-year-old
man, is about to go home following a non-ST-elevation myocardial
infarction (NSTEMI). Before he leaves he would like to ask you a few
questions about his recent illness and whether there are any precautions
that he must nowtake, especially with regard to his newrelationship with
a woman 20 years his junior.
Preparation before consultation
. Review the patients notes, paying particular attention to how long
ago he had the NSTEMI and whether he has had any previous
episodes.
. Take a look at his prescription chart and TTAto see what drugs he is
going home with.
Introduction and consultation
. Introduce yourself and establish a rapport.
. Explain that you understand the patient is returning home today, and
ask him how he feels about this and whether he feels well enough to
go home.
. Ask him if he has any dizziness or chest pain at the moment.
. Ask whether he has made arrangements for someone to pick him up
from the hospital.
. Informthe patient that a follow-up appointment has been made with
the consultant to see him in the outpatient clinic in 3 months time.
. Warn himthat the DVLAhas issued a statement that anyone who has
had a myocardial infarction is not to drive for 3 months.
. Tell him that he will need an echocardiogram and treadmill test,
which we will organise as an outpatient, in order to ascertain the
strength and function of his heart.
Social aspects
. Ask the patient about his employment situation.
. Tell him that you are issuing him with a certificate of illness for the
length of his stay in hospital and up to 6 weeks thereafter, but
following this period he will need to obtain one from his GP.
. Question the patient about his living situation.
Does he live in a flat or a house?
How many stairs are there?
If he lives in a flat, is there a reliable, working lift?
Who does he live with?
. At this stage he says that he is living with his girlfriend and is worried
about his sexual relationship with her, as he is aware that sexual
activity will put a strain on his heart.
. You need to address this issue with tact and professionalism.
. Explain that his MI does not mean he will not be able to have a sexual
relationship but that, for the time being at least, he will need to take it
easy.
Lifestyle issues
. Discuss the need to optimise his risk factors for ischaemic heart
disease.
. Give advice on smoking cessation and reducing alcohol consump-
tion.
Discharging patients 373
. Advise the patient to take regular exercise.
. Give him dietary advice:
reduce intake of saturated fats
increase intake of polyunsaturated fats.
Management
Discuss and explain the new drugs he has been prescribed:
. statin to reduce cholesterol
. ACE inhibitor (e.g. ramipril/enalapril) to increase the strength of
the heart muscle and decrease blood pressure
. aspirin to thin the blood
. clopidogrel to thin the blood to prevent clot formation
. beta-blocker (e.g. atenolol) to reduce the contractility of the heart
and thereby reduce the workload
. glyceryl trinitrate spray to be sprayed under the tongue when the
patient feels chest pain or tightness
. paracetamol for general pain relief.
Additional information
. Warn the patient that his blood pressure will need tobe monitored, as
it is a major risk factor for MI.
. Remind him that he must seek medical attention immediately if he
experiences persistent chest pain or tightness and pain radiating to
the jaw or left arm.
. Ask him whether he has any questions.
Support
. Give him an information leaflet, or booklets from the British Heart
Foundation.
. Give him the contact details of the local heart attack support group.
. Give him the contact details of the DVLA (or equivalent driving
authority), and remind him that if he drives against regulations he
will be putting not only his own life at risk but also the lives of
members of the public.
. Ensure that a comprehensive discharge plan is in place.
374 Essential OSCE Topics for Medical & Surgical Finals
Closure
. Arrange the patients outpatient appointments and tests.
. Tell him that a full explanatory letter will be sent to his GP to ensure
continuity of care.
. Wish him well and say goodbye.
134 Discharging a patient with COPD on steroids and
oxygen therapy
Scenario
You are a doctor on a respiratory firm. Mr Andrews, a 68-year-old man
with chronic obstructive pulmonary disease (COPD), was admitted with
acute exacerbation of his COPDand is about to be discharged with home
oxygen. He has also been given a prescription for treatment with oral
steroids. Discuss his condition with him before he leaves.
Preparation
. Obtain the patients notes and familiarise yourself with his past
medical history.
He was assessed for home oxygen and the domiciliary teamare to
install it in a few days time. In the mean time he has a portable
oxygen cylinder.
The occupational therapists writtennotes about himstate that he
is independent and has no problems with washing and dressing.
His drug chart shows that he will be taking prednisolone for a few
weeks, and also a course of antibiotics.
. Speak to the nurse and the physiotherapist who are looking after him
to find out about his progress and mobility.
His chest infection is clearing up and his mobility has improved.
Introduction
. Introduce yourself to the patient and establish a rapport.
. Ask him if he is feeling well enough to go home.
He tells you that he cannot wait to get home.
. Explain that now he is going to have oxygen at home, no one should
smoke in the house as it is a fire risk.
He assures you that he has stopped smoking.
Discharging patients 375
. Also tell him that he is to wear the oxygen prongs when he is sitting
down and relaxing, and that the local branch of the British Oxygen
Company (BOC) will deliver oxygentohimwhenhis supply runs out.
Management
. Explain that in addition to his usual inhalers he has been given a short
course of steroids. Warn him that he is not allowed to stop this drug
himself, but that the GP will gradually taper off the medication.
. In the mean time he should be aware that steroids:
cause skin thinning
depress the immune system.
. Tell him that he will require the flu vaccine.
Lifestyle
. Explain that he may put on weight, so must take regular exercise and
eat sensibly.
. More importantly, the patient must carry a steroid patient card and
wear a Medical Alert bracelet to warn medical personnel that he is on
steroids.
. Tell him that he must also inform his dentist about his medication
before undergoing even minor dental procedures.
. He must stop smoking and avoid secondary smoke.
. Confirm that he has understood everything you have told him, and
give him any relevant literature.
Social aspects
. Enquire into his living situation.
Who does he live with?
Can he cook or does he have meals on wheels?
Who does his shopping?
Are there any stairs at home? If so, how many?
Has his home been modified by the occupational therapists?
. Determine the level of his independence.
Can he wash, dress and feed himself?
Is he continent?
. Ascertain the level of support he receives from family and friends.
376 Essential OSCE Topics for Medical & Surgical Finals
Closure
. Ask the patient whether he has any questions or concerns.
. Tell him that the consultant will see him in clinic in 3 months time,
but that he should visit his GP if he has any problems in the mean
time.
. Tell him that a full explanatory letter will be sent to his GP to ensure
continuity of care.
. Wish him well and say goodbye.
135 Discharging an elderly patient
Scenario
You are a doctor in elderly care. Mr Alfred, an 85-year-old man, was
admitted with confusion and unsteadiness and is due to return home
today. Discuss his discharge plans and home situation before letting him
leave.
Preparation
. Obtain the patients notes and familiarise yourself with his past
medical history.
. Read the minutes fromthe multi-disciplinary teammeeting concern-
ing Mr Alfred.
. Talk to the nurse and the physiotherapist who have been looking
after him about his progress and mobility.
. Review Mr Alfreds drug chart and note down the drugs that he will
be taking home with him. You may also wish to look through the
British National Formulary to familiarise yourself with the possible
side-effects that he may experience, especially with any drugs he has
been started on since admission.
Introduction and consultation
. Introduce yourself to the patient and establish a rapport.
. Explain that before he is discharged you would like to discuss his care
at home.
. Find out about his living situation (e.g. council flat, top floor, living
alone, nursing home, presence of ramps, rails, commode, etc.). If
appropriate, ask him if he would consider moving somewhere else.
Discharging patients 377
. Assess the patients cognitive capacity by conducting a Mini Mental
State Examination:
patients name
month and year
location
remember address
name three objects
dates of World Wars I & II
name of Prime Minister
count down from 20, etc.
Social aspects
. Enquire about the social aspects of the patients living situation.
Who does he live with?
Can he cook or does he have meals on wheels?
Are there any stairs at home? If so, how many?
Has his home been modified by the occupational therapists?
. Determine his level of independence.
Can he perform activities of daily living such as shopping and
cleaning?
Can he wash, dress and feed himself?
Is he continent?
. Ascertain the level of support he receives from family/friends.
. Ask whether he has any worries about returning home.
. ICE: Address each.
. Discuss Mr Alfreds medication and determine whether he is com-
pliant. Consider a dosette box prescription.
. Ensure an adequate package of care is in place:
GP, occupational therapist, physiotherapists and social services
meals on wheels
carers.
. Arrange a follow-up appointment in clinic in 3 months time and
inform the patient that a letter will be sent to his GP to ensure
continuity of care.
Closure
. Ask the patient whether he has any questions.
. Ask himif he has someone coming to pick himup or whether hospital
transport needs to be arranged.
. Wish him well and say goodbye.
378 Essential OSCE Topics for Medical & Surgical Finals
136 Discussing nursing home placement with the
patients relatives
Scenario
You are a doctor in elderly care. Mr Lambeth is an 86-year-old man who
is hemiplegic, doubly incontinent and partially sighted. He is a widower
with two adult children. He was admitted following a fall. Previously he
was living at home on his own with a carer. During the fall he sustained a
hip fracture and his mobility has deteriorated. At the multi-disciplinary
teammeeting it was felt that Mr Lambeth would benefit from, and would
be an ideal candidate for, a nursing home placement. Please discuss this
with members of his family.
Preparation
. Obtain the patients notes and familiarise yourself with his past
medical history.
. Read the minutes fromthe multi-disciplinary teammeeting concern-
ing Mr Lambeth.
. Gather brochures and leaflets about local nursing homes.
. Contact the social services/welfare officer and talk to them about
nursing home placement.
Introduction
. Introduce yourself to the patient and establish a rapport.
. Determine which members of the patients family are present.
. Explain that you have been looking after Mr Lambeth during his stay
at the hospital, and that he is recovering well.
. Ask his relatives whether they have any questions.
Explanation
. Explain that Mr Lambeths overall health has deteriorated and he is
now unable to look after himself as he did previously.
. Tell themthat since his stroke he is only able tomove andfunctionally
use one side of his body, and therefore his mobility has been signifi-
cantly reduced.
. Tell them that at the multi-disciplinary team meeting it was decided
that he would be an ideal candidate for a nursing home placement.
. Ask the family their opinion.
Discharging patients 379
Information and support
. Explain the different options with regard to provision of care:
own home with carer
respite care temporary while carer gets leave
sheltered accommodation with warden
residential home with no nursing facilities
nursing home with full-time care with nursing staff.
. Informthe family that a nursing home would be most appropriate to
Mr Lambeths needs, and ask themif they would be happy with this.
. Tell them that Mr Lambeth does not have the capacity to make this
decision and that, as his next of kin, it is their responsibility now.
. Give them leaflets and brochures about local nursing homes.
. Tell them that a meeting will be arranged with social services, and
that Mr Lambeth will remain on the ward until a placement can be
found.
. Give them the name and contact details of the discharge nurse who
will be in touch with them about the placement.
Closure
. Ask themto look through the leaflets and to contact you if they have
any questions or queries.
. Thank them.
380 Essential OSCE Topics for Medical & Surgical Finals