Communication Scenario

Question 1

Cancelling an operation due to high blood pressure

1. Explain how you’d break the news to a patient
2. Explain the risks of high blood pressure when operating
3. Explain how you’d reassure the patient
4. Medical management of high blood pressure

Answer 1

1. I’m afraid this isn’t the news you wanted to hear today, but due to the high blood pressure readings, it wouldn’t be safe to proceed with the operation. We will have to postpone it.
2. Having a high blood pressure reading during the operation can increase the risk of bleeding. This can be catastrophic for your vision. During and shortly after an operation, the risk of stroke and heart attack is higher than usual, and a high blood pressure can increase this further. Weighing up the risks and benefits means it wouldn’t be safe to proceed for today.
3. I want to reassure you that once the blood pressure is under control, I’d like to reschedule you for the operation at the earliest opportunity. I know this isn’t what you expected today, but I hope you can understand our decision.
4. To control your blood pressure, I’d like to start you on some medication today. I’ll also write to your GP to let them know of this cancellation, to continue dispensing your medications and to review your blood pressure on a regular basis. This may include blood test checks also and a review of the side-effects. Sometimes, the dosage to control blood pressure may also have to be increased. To arrange follow up in pre-op clinic.

-Mention reducing salt intake
-Healthy diet and exercise

Question 2

Cancelling an operation due to high sugars
1. Explain how you’d break the news to a patient
2. Explain the risks of high sugar readings when operating
3. Explain how you’d reassure the patient
4. Medical management of high blood sugars

Answer 2

1. I’m afraid this isn’t the news you wanted to hear today, but due to the high sugar readings, it wouldn’t be safe to proceed with the operation. We will have to postpone it.
2. Having a high sugar reading can increase the risk of infection during the operation, which can be catastrophic to your sight. Higher sugars also narrow and harden your blood vessels, making healing of wounds more delayed.
3. I want to reassure you that once the blood sugar readings are controlled, I’d like to reschedule your operation as soon as it is safe to do so.
4. I’d like to check your ketones before you leave, to check for any diabetic ketoacidosis. I’ll then write to your GP to inform them of this problem, and they can review your medications and start you on some treatment to bring your sugars down. They might need to review you with blood tests or BM checks. Once this is under control, I will arrange another appointment at the pre-op clinic

Question 3

Cancelling an operation due to anticoagulation / high INR
1. Explain how you’d break the news to a patient
2. Explain the risks of high INR when operating
3. Explain how you’d reassure the patient
4. Medical management of high INR

Answer 3

1. I’m afraid this isn’t the news you wanted to hear today, but due to the high INR readings, it wouldn’t be safe to proceed with the operation. We will have to postpone it.
2. Having a high INR during an operation can increase the risk of bleeding, this can be detrimental to your vision. It also increases the risk of uncontrollable bleeding in your body, and this can be life-threatening.
3. I want to reassure you that once your INR is in target, I am happy to reschedule the operation at a date and time that suits you.
4. Because your INR is high at the moment, I’d need to speak with the medical doctors for some advice and see what they want to do. They may want to hold the dose of Warfarin and / or give some Vitamin K. I will also write to the GP of their plan so they can follow you up on discharge.

Question 4

Fear of surgery after a retinal detachment

Answer 4

1. Delay or refusing can worsen a retinal detachment, as it is a medical emergency, causing catastrophic vision loss
2. Risks of surgery; NO SURGERY IS WITHOUT RISKS, BUT I WANT TO REASSURE YOU THAT COMPLICATIONS RARE BUT MANAGEABLE
   mild irritation & blurred vision, should settle
   pain but we can give you pain relief afterwards,
   inflammation but we can give steroids,
   risk of infection but we sterilise the eye well and give antibiotics post-op,
   if you avoid strenuous activity and follow post-op care, should be less risky
3. We also do pre-op checks to check everything is in order, such as your blood pressure, sugar levels, clotting levels to minimise any complications
4. We do post-op checks to review healing - close monitoring, vision may take weeks to months to return
5. Offer speaking to a specialist nurse or consultant afterwards
6. Leaflets or visual aids to explain the surgery
7. Refer to psychological support if very anxious
8. Operation is performed by a skilled surgeon, often there many be several surgeons in the room and these procedures are very protocol driven with an organised, careful sequence
9. Offer anything else to reassure patient
10. Explain high success rates and outcomes post-op

“Our goal is to protect what vision you have left remaining”

Question 5

Worsening glaucoma

Answer 5

1. Glaucoma is initially a silent condition, leading to irreversible vision loss.
2. Main aim of treatment is to preserve what vision we have, rather than restore what we once had, Unfortunately there isn’t a cure, it is progressive but with the right treatment we can delay worsening
3. Referral to glaucoma clinic to do further checks and monitoring
4. Maintain compliance with drops - any concerns with non-adherence, why?
5. Monitor blood pressure and diabetes
6. Report to DVLA, unsafe to continue driving
7. Referral to ECLO for practical advice and support
8. RNIB (Royal National Institute for Blind People)
9. Low-vision aids / magnifiers
10. GP to help signpost

Question 6

Difficulty putting drops in

Answer 6

ASSESS WHY THEY ARE STRUGGLING
1. For side-effects; can offer preservative free, or give an alternative
2. For forgetfulness; setting alarms, reminders (app medication reminders, linking drops with a routine
3. For doubts of benefit; regular follow up will remind patients if they’re making progress; can check acuity, pressures, colour charts
4. Offer leaflets
5. Is anyone at home, can they help? especially if asleep
6. Ensure follow up to check compliance in 3 months time

Question 7

Unhappy with near vision post phaco

Answer 7

1. Surgery corrected for distance vision, leading to requiring glasses for close-up work
2. This outcome is normal, but can be a surprise if it was not explained to you
3. Does not represent a failure in surgery
4. Prescription glasses for near distance vision
5. Can try multi-focal lenses for seamless transition for near and distance vision
6. Can try a multifocal IOL in other eye if they wish in future
7. Offer to speak with consultant or explain right for a second opinion
8. Referral to optician for low vision aids
9. Reassure that with this support, they can adapt over time
10. Relay info to seniors to ensure improved consenting in future