Morning fellow medics,
I am going to breakdown the different concepts behind the “Discharge Planning “ Station. I have witnessed them in many OSCEs, both from a trainee and examiner point of view. This is an important station, as it tests the knowledge of the NHS, fundamentals to minimise unnecessary over crowding of hospital wards along with the awareness we need as doctors of “community care”. So lets set a case and then think about the way we would tackle it:
Example:
You are a FY1 working on an elderly ward. You have been asked to speak to Mrs Smith’s Daughter, Joanne. Mrs Smith was admitted into hospital with a left hip fracture, which has been operated on. She has made a good recovery, and has been seen by the physiotherapist, the occupational therapist and the consultant and subsequently been deemed MFFD (medically fit for discharge). Mrs Smith has capacity and would like to go back home.
The plan is for her to be discharged back to her home today. Joanne would like to discuss her mums discharge as she has a few questions.
This station might go two ways 1) it is a simple station - with no aggravated relative or 2) Joanne is not happy that you are discharging her mum back to her home.
So here are the crucial concepts to think about which will allow this station to flow, look genuine and also help with any conflicts.
1) Build a rapport.
I have said this time and time again- but there is a reason! Firstly you want to show you care and you want to know more about the patient and daughters ideas, concerns and expectations (yes ICE!). Secondly, it helps you get an idea of what the situation is, as sometimes the relative/actor might give you hints to the history or story that you may have missed from looking at the vignette.
So start simple:
“Hello Joanne, I am Dr X, I have been looking after your mum. How can I help you?”.
Allow the relative to speak, to express their concerns and listen to them. Use verbal and non verbal cues to show you hear them and appreciate their concerns.
2) Have you got consent to speak to the relative?
Confidentiality is key to speaking to relatives. In the real world, it might be that you have always spoken to the relative in front of the patient, but has consent ever been sought? This may be documented somewhere on the notes, there may be a code that has to be given when the relatives calls the ward. Whichever way, it is prudent that this is considered. For the sake of the exam, you might need to ask or it may be written down, but as long as you acknowledge that you are aware of this, it shows you work with integrity.
“Before I explain your mothers current treatment, can I just clarify that I have your mothers consent to discuss this with you?”.
This may be followed by the examiner intervening, the relatives agreeing or it may be written down.
3) MDT approach
The general approach to safe discharge planning from hospital care to community is based on a MDT approach. So if Joanne (Mrs Smiths daughter) was not happy that her mum is being discharged but you have all the documentation to make you feel confident this is going to be a safe discharge, then USE this information. Explain that her mother has been seen by the : occupational therapist (OT); the physiotherapist; the pharmacist has put their medications together; the social worker has assessed the house and the consultant is happy from a medical point of view.
4) Think about the social aspect
Discharge planning is more than just a patient being “fixed” in hospital and then being discharged back to the community. As an all round caring compassionate doctor, you need to take the social aspect into consideration. Does Mrs Smith have the correct equipment at home (ie has she been seen by the OT?). If she is moving back in with her daughter, can Joanne cope? Are the family happy to have the patient home? Will it impact on their home life? affect them financially? These are all areas of the “social” history to ask about.
“I can see that the decision to discharge your mum has upset you, and you have spoken about the stress you have at home. Please can I ask about further about these stresses, so I can help you?”
5) If in doubt, ask your seniors.
I have seen in many OSCEs, the trainees get frustrated because they feel they are not seeing “eye to eye” with the relative/patient. But this shouldn’t be the case. The whole point of this OSCE is not to “win”, it is about “communication and management skills”. If you are getting towards the end of the consultation and despite your efforts, the relative is still not happy, do what anyone would do- consult your seniors! This should be part of your management plan. It shows initiative, humility and that you are able to resolve conflict appropriately.
“Joanne, thank you for meeting with me today. I understand that the situation is very frustrating, and you do not feel happy that your mum is being discharged. Would it be possible to arrange a meeting with myself, the consultant and maybe some other team members ie occupational therapy and a social worker"?”
I hope the above has given you some ideas of how to tackle these type of cases. As i always state, it is not about memorising what to say, but about understanding WHY you are saying it (meaning less things to remember!).
Keep practicing and keep that focus on the end goal.
Keep safe :)