Consent for below knee amputation (AMC 120)

A 30 yo man has open crush injury to his L leg in a motor vehicle accident. He’s conscious, no injury
in other area. The orthopaedic registrar has assessed him and immediate below knee amputation has
been recommended. He’s now stable and has been given painkillers.

Task: no need for Hx and exam. Obtain consent from pt and answer examiner’s questions.

How do you feel at the moment?

Before we discuss what should be done, I’d like to ask you a few questions
Do you want me to call your friend or family?
Assess patient’s competency
Do you know what’s today date, month, and year? (time, place, person)
Do you think you can concentrate well, any drowsiness, dizziness?
Are you using any drugs apart from painkillers?
How much damage do you think your leg has?

I’m sorry to tell you that you have a massive wound on your left leg, we called it a crushing type
where some of the vessels, nerves and tissues are completely crushed and not viable
After discussing with the surgical team & my registrar, it seems that you need an urgent operation
You will be managed by a multidisciplinary effort with a team of specialists
The aim will be to save your leg by all possible means. Broken bones, tendons, bleeding vessels,
nerves can be repaired, even a completely amputated leg can be replaced. But I’m sorry in your case,
the blood vessels, nerves and tissues were crushed, nearly dead. Some are irreparable and may be too
graved to be salvaged. In such a situation, the team may need to take a decision in the operation
theatre to amputate your leg which may be necessary to save your life.
Before going to the theatre, we need your agreement and sign the consent to do so
Do you want me to explain again or is it clear
The operation if needed is below knee amputation
With recent advances, this operation is combined with fitting of a prosthesis which is very effective
Most patients with them is fully functioning
You can still follow your compassion with sports

Brian, there are some hazards of not doing the amputation. The dead tissue will release some toxins
and some other products which can have a serious effect on your body like sudden cardiac death, gas
gangrene which is a major cause of death. The infection spread so quickly that is it difficult to control
with antibiotics or medicines.

I’m asking you to give consent as a last resort, that is if everything else fail to save your leg, only then
it will be done. If you still insist to refuse, then the surgeon will not do the amputation, but I want to
confirm again that my explanation is very clear and you are aware how serious it is.
If you need further discussion with the surgeon, it can be arranged.
I’ll tell them about your final decision.

I have some concern about the validity of patient’s consent

I would like to discuss with my supervisor
VALID CONSENT
1. Competency of patient – Patient must be mentally competent
- Patient’s ability to comprehend and retain relevant information
- Patient needs to weigh risk and benefit before making a final decision
2. Patient’s understanding
- Consequences of having and not having the operation
- Different treatment options
3. Making decision free of coercion
 Brain death (AMC 59)
A 38 year-old school principal came to your GP clinic requesting information of brain death because
he needs to make a discussion on it with someone at a seminar. He has already printed out information
about it from the internet.

Brain death
Brain death occurs when a critically ill patient die after being put to a life support. It may be due to an
accident, stroke, or MI. The heart continues to beat but the pt cannot breath anymore. The brain is no
longer functioning. The heart doesn’t need the brain to beat because it has its own system to trigger or
initiates impulse.
In Brain death the person is not alive, not going to recover.

Coma
Coma is similar to a deep sleep with exception external stimuli can trigger the brain to react, either
less or no. No external stimuli can trigger the patient to wake. The patient in coma is still alive. The
recovery is possible.

Vegetative state
vegetative state in which the person has lost higher brain function or cortical function. But the lower
brain function is not damaged. The patient may not be able to swallow by themselves but can still
breath spontaneously. Therefore the heart can beat, respiratory function is still good. Eyes can open
on stimulation but the patient can’t wake up or talk. The limbs can move. HR, RR, BP maintained.
They can cry, get upset, randomly laugh or pull faces. Motor reflexes are present.

Tests: CONDITION 059. TABLE 1. Brain death protocol.

Predetermined criteria before test (make sure to check)

• Body temperature  35 °C after resolving the temperature with blankets for 20 minutes
• No drugs which depress the central nervous system (CNS) given for the last 48 hours (longer if
CNS depressants given in large amount or for a long time)
• No neuromuscular relaxants given for the last 12 hours
• No endocrine problems eg hypothyroidism, hypopituitarism
• PaC02 > 50 mmHg  check ventilator
• No hypoglycaemia

TESTS to confirm :
• 1. Pupils fixed and unresponsive to light - CN- 2, 3
• 2. Absent corneal reflexes CN - 5, 7
• 3. Absent pain response in cranial nerve distribution CN- 5
• 4. Absent gag reflex on endotracheal tube movement CN- 9, 10
• 5. Oculocephalic reflexes absent (no 'dolls' eyes' response)
• 6. Vestibulo-ocular reflexes absent (no nystagmus) -CN- 8 COWS
• 7. No spontaneous respiratory response after 10 minutes (patient ventilated on 100% oxygen at a
rate of 4 breaths/min with a tidal volume of 7 ml/kg). Arterial blood gases taken at 5 and 10
minutes.

Diagnosis to be made by 2 doctors independently including the intensive care consultant. Neither will
be a member of the transplant team where organ donation is considered. 2 groups of tests, preferably
separated by 24 hours. The results of examination must be recorded in the case notes or a suitable
devised form.

Organ donation: it should be mentioned in driving license.

End-of-life request from a terminally ill patient (AMC 124)
Guidelines:
1. Refuse to do saying by law in Australia we are not allow to do it.
2. Empathy
3. Solve the problem- eg pain, palliative care team, make the pt comfortable
4. Palliative support group
5. Tell them the truth

Classification
1. Suicide Self-killing by means such as hanging, drug overdose or carbon monoxide
poisoning. No involvement of others.

2. Physician-Assisted Suicide Provision of means for patient to kill themselves, such as a

prescription for self-poisoning, or insertion of an intravenous line for a patient to inject
lethal drugs. Requires involvement of doctor.

3. Passive Euthanasia I Refusal of treatment by competent person Refusal of antibiotics in

advanced malignant disease, or advance directive refusing resuscitation. No direct
involvement of others.

4. Passive Euthanasia II Withdrawing or withholding life-sustaining treatment from

incompetent patient . May require involvement of others.

5. Active voluntary euthanasia  doctor involves voluntarily, active participation, assisting

patient to die

6. Active non-voluntary euthanasia

7. Doctrine of double effect give lethal dose of one drug

PASSIVE Euthanasia
- Refuse to take medication
- DNR  do not resuscitate
- Stopping life support
The doctor has to respect the wish of the competent patient. The best interest of the patient 
dying with dignity.
Stop resuscitation if there is no improvement.
Take consent from family.

Domestic violence
Your next patient in general practice is Fiona Cresp, a 25 year old mother of 2, well known to you.
She has visited you 4 times in the last 6 months. First time she came with 5% burn on the left hand,
second time she came with some injury on the right hand. The other two times she came with a
complaint of tiredness for which you investigated her thoroughly and everything was normal. At
the time you counselled her accordingly and advised about life style changes and stress
management.
This time she has come with a complaint of an injury to her head.

Task: focused Hx, examine the pt, discuss Dx and Mx the pt.

HOPC: “Two days ago Fiona accidentally hit her head on a door frame when she was rushing
around the house chasing her son. She did not think much about it and thought it was not bad,
however, today the area appeared quite swollen and painful. She thought it might be better to have
it checked out and to have some antibiotics”.
If the candidate asks more detailed questions Fiona will admit that she actually was hit by a kitchen
plate which her husband had thrown in an anger tantrum and she was in the wrong spot and got hit.
She assures you that her husband did not mean to hit her with it but that he just became angry
because he was told on that day that he lost his job as a personal care assistant. He got drunk when
he came home, became very angry and started to throw things in the kitchen, when Fiona got hit by
a plate he was throwing. Fiona believes he did not want to hurt her, but he has had a history of
being short tempered and often has arguments with her and also with people at work and in other
situations.
If the candidate shows empathy and asks further questions you can tell her/him that he actually
often becomes aggressive towards you, especially when he drinks alcohol and over the last 6
months he gets regularly drunk at least twice a week and on a number of occasions he has hit you,
causing bruising at several sites of the body. The beating started shortly after the birth of the last
child when the family faced financial problems because you couldn’t go back to work but had to
care for your child. Your husband also lost several jobs because of his aggressive behaviour and
most of your friends have withdrawn from your family and you are very lonely. Even his and your
parents have become disenchanted because of his argumentative and aggressive behaviour.
You haven’t spoken to anybody about the situation because you had hoped that it would rectify
itself and be only short lived, because when your husband is sober he promises regularly that he
will change and improve.
PHx. + FHx.: unremarkable
SHx.: You live with your husband and 2 children, 3years and 8 months respectively. Your younger
child has got cerebral palsy following premature birth and some hypoxic event during delivery.
You are aware that the prognosis is not very good and hence stopped taking him to the hospital.
You take care of him at home though you are very busy with his care but you can save some
money. He has not developed any complication yet, but his limbs are very stiff. You feed him by
spoon and he takes that and he has settled in at home quite well. You used king as a PCA but
stopped working since your delivery. Your husband does house keeping job but has lost that too
2days back (the same day you got injury). He is short tempered and had argument with his
supervisor and hence was sacked. He drinks alcohol and sometimes excessively.
You don’t drink alcohol, don’t smoke and you are not on any medication. You don’t have any
suicidal thoughts though you feel depressed. You have lost interest in sex as your husband is very
aggressive in that too. No loss of appetite, weight or sleep. No loss of energy.
 Examination : distressed looking lady, vitals stable. There is a 2 x 2 cms laceration present on the
head, looks 2 days old, red, tender and swollen. Multiple unexplained scars on the head and
multiple bruised in different areas of her body are present.
Take photographs of the injuries!

Management :
1. Cleaning and dressing of the wound, pain relief if necessary.
2. Explain to the patient that it looks like domestic violence and that she needs some help. If patient
refuses tell her that she is unsafe in her situation now and there are various resources available with
which this can be stopped and a crisis management plan can be instituted:
 Offer to organise admission to a refuge
 ensure informed consent for all actions
 consider notifying police (if she agrees)
show empathy
build the victim’s coping skills and self esteem
mention about community sevices
 support services
 women’s support group
 domestic violence resource centre.
 social services/ police social workers.
Don’t forget to see her child with child protection services (CPS) and fix an appointment
once this issue get solved.

Possible questions to be asked if suspect domestic violence

 has your patner ever physically threatened or hurt you
 is there a lot of tension in your relationship
 sometimes partners react strongly in arguments and use physical force. Is this
happening to you?
 Have you ever been afraid of any patner.

other approach – HELP

H – hear what the woman has to say about her
History – what effect has the violence and abuse had
onset and pattern of abuse
worse case of abuse and greatest fear
E – assess women’s self ESTEEM
L – assess her life situation
does she have regular partner
any supportive people
what is the financial situation
P – PRAISE her efforts so far for whatever she has done
 Domestic violence
A 13 year-old girl, Sarah, with her Mother came to your GP clinic for certificate because she
has missed school for a couple of days. You noticed the girl has poor eye contact. Physical
examination you found bruise on arms & legs.

Task: take further relevant history, manage the case.

Hx: (confidentiality)
I understand Julia, Sarah does not want to talk to me
I’d like to talk with Sarah individually---No, I’d like to stay
(If yes  I’ll ask my nurse to be the chaperone while you wait outside and I talk to Sarah)
I’d like to ask why you want a medical certificate for Sarah---she missed her school
Why did she miss her school?---she had flu
Any other reason?---no
During the PE I noticed some bruises on Sarah’s arms & legs. Is this the first time---no
How did she get the bruises?---maybe she hit somewhere
Does she have any blood clotting problem?---no
Any family history of clotting problem?---no
Is she on any medication?---no
How about her general health?---everything is all right

OK Julia, everything we talk here is confidential, except if it cause harm to you or others

Are you living with Sarah’s Father?---no with my new partner

Do you have other kids---Yes, I have a 9-month old boy
Any problem at home, how is your relation with your partner and Sarah?
How does your partner cope with Sarah?---very badly
How is your relation with your partner?---he hit me and Sarah
Does he hit your other kid?---no

Does anyone at home smoke?---yes

Does anyone drink alcohol at home?---yes, my partner
Anyone taking illicit drugs?---yes, my partner, he’s taking marijuana
How about Sarah?---no, she does not smoke, drink alcohol nor take any illicit drugs
How is Sarah doing at school, how is her progress?---not good recently, since the new
partner came
Anything happen recently?---yes, he hit me and Sarah wanted to help me

Explanation:
You’re not the only one who’s suffering from domestic violence. Do you want me to inform
police?
It’s OK Doctor, my partner will change
OK, we’ll see what will happen. If you change your mind, I’m here to help.
But for Sarah, she is still minor, it’s my medical obligation to inform the DHS.

They will organise some tests and they will do some service what is good for Sarah
We need to work in a multidisciplinary team, GP, DHS, and Police at a later stage
I don’t want to inform anyone Doctor
DHS will provide safety for Sarah and a counsellor for you & Sarah

Julia, I understand you do not agree to inform the Police

If you change your mind, when you agree to inform the Police, I will help you
If baby  admit the baby to the hospital

DOMESTIC VIOLENCE:
Arguments  Build up  Violence  Repentance  Honeymoon  Arguments

If Violence happen, what you need to look:

- Safety
- Offer  take picture as documents (DHS will take pictures)
- Sometimes not physical, but mental abuse
 Confidentiality (Ethical dilemma)
A 70 year-old man with bowel cancer in sigmoid colon, presented with complete obstruction.
He had an emergency operation. CT abdomen showed metastasis in the liver. Now the
daughter has come to you and you’re the HMO in the surgery ward. She wants to tell the
diagnosis & prognosis to her father by herself.

Task: Manage the lady with ethical dilemma, tell her what to do and what will be the
prognosis to her father and what is the management for the father.

Do you have the authority from your father, the next of kin…
Do you have the consent….
Legal obligation of the doctor to tell the patient
Talk to my consultant…
This is my legal obligation to tell your father
Palliative care – not survive for a long time, as long as he lives he need the palliative care, try
to keep him comfortable life

EXAMINER, does she have the consent from the father…

Do we have the consent from the patient to talk to his daughter….
Good morning, how can I address you, my name is….
I see from the note that you want to talk to me about your father
What is your main concern….
SORRY we can’t allow you to do that because it’s our legal obligation to tell the patient what
happened and what’s going to happen….
In my knowledge in Australia the doctor is legally obliged to tell the patient…..
If you need more information…I will ask my consultant to talk to you…

Look your father had this problem….

From the scan it showed that it has gone to the liver….
Do you know what does it mean….
This is beyond our control, it’s not treatable anymore, he will not live for a long time but we
don’t know until when, we will make him comfortable
The oncology/multidisciplinary team will refer him to the palliative team

Can he go home?
He can go home if it’s manageable, depends on his condition and progress, the palliative
team will see him and decide
He will go back to the aged care facility (low care and high care)
A nurse will visit him at home….
 Confidentiality (AMC )
You’re a GP. Your next patient is Bill, 67 years old, after you finish his annual check-up,
he’s asking you how his wife was. His wife, Ann, is 65 years old, who’s also your regular
patient. Three days ago, she told you that her husband Bill keeps telling her that she was
forgetful and vague. You assessed her and found nothing wrong. Bill also told his son &
daughter that they need to put Ann in the nursing home.

Task: respond to Bill’s question and request about her condition.

I respect my patient’s privacy

I can arrange family meeting to discuss together

How long have you been married

How’s the relationship between you & Ann
Between parents & children
Any financial stress
Any stress in your life
What exactly is your concern
Has there been any accident because of her forgetfulness
Has she been lost
Any incidence with the grandchildren
Any history of fall

The role player will keep on insisting and at the end became abusive

I’m sorry I cannot talk about your wife’s condition because of confidentiality
I understand that you’re very worried about her but I cannot expose her records to you
without her consent. I have some legal obligations towards my patient and I have to respect
the patient’s right. Your worry for your wife is very natural but there are ethical issues
involve here. I’m happy to arrange a joint consultation with both of you where we can discuss
this in further details. I’m sorry I’m not able to help you in this matter. Do you have any other
questions?
 Jehovah’s witness with heavy vaginal bleeding (AMC )
A 31 weeks pregnant lady with heavy vaginal bleeding. She’s conscious, BP 80/50 mmHg. She’s
Jehovah’s witness and refuses blood transfusion. Her husband is overseas.

Task: counsel the patient.

You have a condition called antepartum haemorrhage, where there is heavy vaginal bleeding
The reason for that is because the placenta is in an abnormal position
It can be placenta abruption
It’s a risky situation for you & your baby
Your BP is quite low and you need blood transfusion
The blood transfusion is necessary in order to prevent the high likelihood of death either you or your
baby due to blood loss.

I understand your religious opinions and do respect them but you need to understand that this is a
dangerous situation

We can give you blood products such as:

- the major blood products like :
1. RBC
2. Platelets
3. fresh frozen plasma
- minor blood products like :
1. fibrinogen
2. anti thrombin 3
3. factor VIII
4. factor X

Urgent delivery by C section is the best measure to save mother’s and baby’s life. The fetus may
survive if operation is done immediately but if blood transfusion is refused, the chance of maternal
death is high. The baby does not die of blood loss but of hypoxia.

Synthetic blood substitutes like Haemacelle or Macrodex (volume or plasma expander) are not very
useful because they do not carry oxygen. They can improve the blood volume but cannot improve the
hypoxia. This is the limiting factor.

We may have to do a C section or remove your womb to save your life. We need consent from you.
I’ll try to contact your husband and discuss this matter with him.

I can call the Jehovah’s witness group to be with you.

You’ll have to sign a form for consent for C section and refusal of blood transfusion.

What is the legal issue?

The patient has right to autonomy and self determined her treatment.
In Australia, the fetus has no rights justifying treatment being forced on mother against her wishes.
Once the baby’s born, the scenario changes.

Management of patient:
- Continue with the volume expander
- Urgent C section
- If required hysterectomy
 Valid consent for cholecystectomy
You are the surgical resident in surgical outpatient. A patient came for an elective
cholecystectomy who has a recent episode of cholecystitis.

Task: obtain a valid consent for the operation, answer examiner’s questions.

What, why, how

Explain in broad term about the surgery
Why the patient is having the surgery
Draw a picture and talk about the risk and complications
Complete with patient signing the consent form (ask pt to sign)

Causes
4F – fatty, fertile, female, forty
- Hereditary
- High cholesterol
- Heavy drinking
- Obesity

Procedure
Laparoscopic cholecystectomy + intraoperative cholangiogram  keyhole surgery (4 holes)

Risk
Bleeding, infection
Bile duct injury 1 in 300, leaking of bile may convert to open surgery  subcostal incision

Duration of stay is overnight if keyhole surgery due to patient’s recovery

Send gallbladder to pathology and result back in 2 weeks
Dressing remove in 2 days
Back to normal activity in 2-3 days
No heavy lifting for 4 weeks
No driving for 2 weeks
Everything will be fine in 2 weeks

(If patient is 85 years old, dementia, came from nursing home and has fracture of neck of
femur, need surgery  ask any power of attorney or consent from next of kin)
 Palliative care – Leukemia relapse
A 55 yo lady has been diagnosed with leukemia 2 years ago. She was under remission for the last 2
years and she’s doing regular follow-up. She’s here in your GP clinic because of her blood test result
which she has done in her last visit. Blood picture showed 10% blast cells. You spoke with the
haematologist who said that she had recurrence and it will not respond to treatment. She has no other
medical treatment, her husband was in the waiting room.

Task: tell patient about the result, counsel and answer patient’s questions.

Hx:
How are you? I understand you’re here for the test result. Are you all right to hear your test result or
do you want me to call your husband
I don’t have good news for you. Your test result showed that your leukemia has come back

Can I have chemotherapy or radiotherapy?

I have discussed with your haematologist, unfortunately there is no treatment option

How do you feel now? I know that it would be very hard for you, it’s upsetting, but Salina we have a
lot to do. You’re not alone. You have my support all the way, also support from the palliative care
team

What is the palliative care team?

Let me explain to you the aim and what they will administer to you
Aim:
- Provide you with the best quality of life during your illness
- The team anticipates the complications of your illness and prevent them or treat them
- The team is consisted of me as your GP, nurse, specialist, oncologist, religious leader,
physiotherapist, occupational therapist, dietician, psychologist, counsellor, social worker, pain
specialist, volunteer worker, committed support group
What you need to do:
- Need to lead a healthy lifestyle and diet
- Do regular exercise
- Always think positive

What Palliative Team administer:

- Patient can stay at home
o Patient can feel free, happy
o Family member present
- Patient can stay at an aged care facility
o Supervised by GP and palliative care nurse
- Tertiary hospital or palliative care unit
- Hospice
o Environment like at home
o Supervised by a special nurse

You have all the specialists support

What you need, we’re ready to help you
We can arrange family meeting for mental support, if children overseas they can come

Complication of leukemia
- Bleeding
- Infection
- Hyperviscosity