Show Summary Details
Page of

Life on the wards 

Life on the wards
Chapter:
Life on the wards
Author(s):

Tim Raine

, George Collins

, Catriona Hall

, Nina Hjelde

, James Dawson

, Stephan Sanders

, and Simon Eccles

DOI:
10.1093/med/9780198813538.003.0002
Page of

PRINTED FROM OXFORD MEDICINE ONLINE (www.oxfordmedicine.com). © Oxford University Press, 2016. All Rights Reserved. Under the terms of the licence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Medicine Online for personal use (for details see Privacy Policy and Legal Notice).

Subscriber: null; date: 23 October 2019

The medical team

The changes to medical training have caused confusion about the names and roles of different trainees. The medical team or ‘firm’ usually consists of four grades of responsibility: (1) consultant level, (2) registrar level, (3) SHO level, and (4) F1 (house officer level). Many firms may have more than one doctor at each grade of responsibility. Indeed, doctors of the same grade may have subtly different professional circumstances, detailed as follows.

Consultant level

These are the most senior doctors on the team; there are several posts at this level:

Academic

Doctors who split their time between research and clinical medicine. They are often called ‘honorary consultants’ alongside an academic grade (eg senior lecturer, reader, professor).

Consultant

The most common post at this level is reached by obtaining the CCT (Life on the wards p. [link]), formerly known as the CCST, or via proof of equivalent training known as the CESR.

Associate specialist

A doctor with consultant-level ability and experience who has not got a CCST/CCT/CESR. They do not have the accountability or management commitments of consultants.

Registrar level

If you describe yourself as ‘a registrar’ most people will assume that you are at this grade. All of these doctors will share an on-call rota that is usually separate from the SHO-level on-call rota. The posts have a natural hierarchy according to experience:

Specialist registrar (SpR)

Doctors training under the old system; virtually none of these remain, but you will still hear the term.

Staff grade/specialty doctor

A non-training post with equivalent experience to a SpR but not working towards a CCT award.

Clinical fellow

A specialty doctor who is undertaking research; they may need to secure an ST3/4 post afterwards.

Clinical lectureship

The academic equivalent of ≥ST3/4 they will split their time between clinical and research.

Senior specialty training registrar (StR, ≥ST3/4)

In most specialties this grade starts at ST3; however, it is ST4 in emergency medicine, paediatrics, and psychiatry. These are posts that work towards the CCT award and a consultant post.

SHO level

Like the registrar-level position there are a range of posts performing similar roles with a hierarchy of experience:

Academic clinical fellow (ACF)

The academic equivalent of ST1–2/3 and CT1–2/3 at this level they will perform a similar role except that they have 25% of their time set aside for research. The situation can be confused in certain posts where the ACFs are appointed at ST3 level.

Junior specialty training registrar (StR, ST1–2/3)

Doctors in specialties with run-through training (Life on the wards p. [link]) who will progress to registrar-level specialist training unless they fail to attain competencies or exams. Despite the title, it is misleading to call them ‘a registrar’.

Core training (CT1–2/3)

Doctors in specialties with uncoupled training (Life on the wards p. [link]) who can apply for registrar-level specialist training posts if they attain the relevant competencies and exams. The difference between ST and CT posts is the specialty, not the experience.

Fixed-term specialty training appointment (FTSTA)

A post for doctors who were unwilling or unable to secure an ST/CT post. The post lasts 1 year and will be at ST1, ST2, or ST3 level; at the end of the year they can apply for an ST or FTSTA post at the next level if they have attained the relevant competencies.

F2

These are doctors in the second year of the FP; this will often be their first experience in the specialty and at SHO level. At the end of the year they will apply for ST/CT/FTSTA posts. Expectations vary: in some trusts/specialties, F2s will share a rota with F1 doctors.

F1 level

These are doctors in their first year with limited registration. They are still sometimes called house officers or prhos from the old system.

Other team members

Mid-level practitioners

A collective term for a group of healthcare professionals including advanced nurse practitioners (senior nurses with additional training) and physician associates (graduates of a dedicated 2yr master’s programme). Specific responsibilities vary and are evolving but alongside doctors and under supervision they can perform clerkings, investigation requests, and medical procedures.

Medical students

Medical students are present in most hospitals and should be allowed and encouraged to be part of the medical team. Medicine is both a science and a vocation, and although studying for exams is important, many of the clinical and non-clinical skills needed to succeed as a doctor are not written in textbooks and can only be learned in a supervised way either on the wards or in the clinic.

The multidisciplinary team

Nurses

These have a ‘hands-on’ role, ranging from administering medications to attending doctors’ rounds. Don’t be afraid to ask their advice—their experience means they can often help you out. Most can take blood and perform ecgs, some can cannulate and insert male urinary catheters (all female nurses should be able to insert female catheters).

Bed managers

These tend to be highly stressed people who are in charge of managing the hospital beds and arranging transfers and admissions. They will frequently ask you when patients are likely to be ready for discharge so they can plan ahead for routine admissions.

Discharge coordinators

These work with social workers, physiotherapists, and occupational therapists to expedite patients’ discharges, and often help in finding social and intermediate care placements (Life on the wards Box 2.1 p. [link]).

Healthcare assistants (HCAs)

These perform more basic nursing tasks, eg help with personal care and recording observations including finger-prick glucose. They cannot dispense medication or give injections, but many can take blood.

Nurse practitioners

These are specially trained senior nurses who can assess acutely unwell patients, perform practical procedures (eg cannulation), and assist in theatre. Most cannot prescribe, although there are some who are qualified to use the nurses’ formulary (Life on the wards p. [link]).

Specialist nurses

These include stoma, respiratory, pain, cardiac, diabetes, tissue viability, and Macmillan nurses. They are excellent for giving advice and are an important first port of call for the junior doctor.

Occupational therapists

These work with patients to restore, develop, or maintain practical skills such as personal care. Assess patients’ homes for changes required to help with activities. Many elderly patients require ot assessment before discharge—nurses usually make the referral. OTs work in primary and secondary care (Life on the wards Box 2.1 p. [link]).

Pharmacists

These dispense drugs and advise you on medication. They check the accuracy of every prescription that is written. Some hospitals have a medicines information line which you can call for prescribing advice.

Phlebotomists

These are professional vampires who appear on the wards with the sole aim of taking blood. They often appear at unpredictable times and may not come at all at weekends, so leave blood forms out early. Some can take blood from central lines and perform blood cultures. If asked nicely they may accept requests mid phleb-round.

Physiotherapists

These use physical exercises and manipulation to treat injuries and relieve pain. Chest physios are commonly found on respiratory and surgical wards to help improve respiratory function and sputum expectoration by teaching specific breathing exercises. Involve them early in patient management—nurses usually make the referral, but do not hesitate to discuss your patient’s needs or progress directly with them (Life on the wards Box 2.1 p. [link]).

Social workers

These support patients’ needs in the community. They assess patients and help organize care packages (invaluable for elderly patients). Where residential care is required, they help guide the family and patient through the decision-making process and financial issues. They are also involved in child protection and vulnerable adult safeguarding work.

Daily ward duties

First thing

  • You’re expected to be the first doctor on the ward in the morning

  • Ask the night team (nurses and doctors) about any events overnight

  • Submit any missing or extra blood/cxr/ecg requests

  • Review any new or acutely unwell patients.

Ward round

  • Life on the wards pp. [link][link] for ward round duties, try to keep a jobs list

  • Attempt to start simple jobs (eg ttos, requests) during ward round.

After the ward round

  • Spend a few minutes comparing and allocating jobs between the other team members; try to group jobs by location and urgency

  • Radiology requests (uss, ct, mri)

  • Referrals to other teams, eg surgery/cardiology/psychiatry

  • Complete ttos and other forms

  • Take blood from patients whom the phlebotomists have been unable to bleed or that have been requested during the ward round.

Lunch

  • Do you need to do anything for yourself, eg book holidays, pay bills?

  • You may have teaching/grand round/journal clubs.

After lunch

  • Review patients you are worried about. Liaise with nurses about any problems they have identified and attend to routine tasks they may have

  • Check and record blood results; serial results sheets help

  • Check other results; chase outstanding requests or results

  • Spend time talking to patients ± relatives

  • Submit blood and other investigation requests for the next day

  • Check the patients’ drug cards—do any need rewriting?

Before you go home

  • Review results and outstanding jobs with other team members; make a note of anything that needs doing the next day

  • Check that all warfarin and insulin doses have been written up

  • Prescribe sufficient iv fluids for patients overnight where safe to do so

  • Handover patients who are sick or need results chasing by the on-call doctor (Life on the wards p. [link]); write down their ward, name, DoB, and hospital number and exactly what you want the doctor to do (ie not just ‘check bloods’).

Before weekends

  • Only submit blood requests for patients who really need them

  • Try to prescribe 3 days of warfarin doses where safe to do so

  • Make sure that no drug cards will run out over the next 2 days, rewrite them if they will (this is infuriating to do as an on-call job)

  • Handover to the weekend team according to local protocol; thorough patient summaries on Friday ward rounds help the weekend team immensely. Make sure they are aware which patients are unwell and what the weekend plans are (eg escalation plans if they deteriorate).

Ward rounds

A smooth ward round requires thought and careful planning, with preparation of notes, investigations, and results. Try to predict questions and start the ward round armed with the appropriate answers. See Fig. 2.1 for guidance on recording rounds in patient notes.


Fig. 2.1 Sample of a sample patient list and a ward round entry in the patient’s notes.

Fig. 2.1 Sample of a sample patient list and a ward round entry in the patient’s notes.

Before the ward round

  • Update the patient list with patient details, location, summary of clinical problems, key investigations/results, referrals made, and jobs

  • Ask the nurses if any patients have changed condition overnight and try to avoid any nasty surprises on the round; briefly review individual patients where appropriate

  • Check notes, drug cards, obs charts, X-rays, and blood results are present

  • Clearly document all relevant investigation results and reports in the notes with a brief summary on your patient list

  • Check all notes have continuation sheets headed with the patient’s name, DoB, and hospital number/address (use a hospital sticker)

  • Consider writing out the patient’s problem list/summary beforehand

  • If your patients have moved, find out where they have been transferred to and plot an efficient route through the hospital to visit all your outlying patients

  • Check or chase the dates/times for outstanding investigations

  • Learn your consultant’s favourite questions from your predecessor

  • Consider multidisciplinary issues which may alter further management or delay discharge for the patient (eg home situation, see Box 2.1)

  • Think about management dilemmas you want/need answers to.

During the ward round

  • It is good to have a nurse join the ward round, both for their contributions and to aid handover. If they’re too busy, handover later.

  • If there are two junior doctors then one can prepare the notes, obs, drug cards, and X-rays for the next patient while the other presents

  • When presenting a patient, always begin in the same logical way, eg ‘Mrs Smith is a 64-year-old lady who presented with a 4-day history of worsening shortness of breath’ then proceed to past medical history, investigation, blood results, and then your management plan

  • If you have a spare moment, start filling in forms or doing the jobs generated on the ward round (eg prescribing fluids)

  • If you have any queries about the next step of management or investigation results, ask during the ward round. Also ask about rationale for imaging if unsure as this makes requesting imaging easier for you (Life on the wards p. [link])! … ‘Just for my learning, what is the reason for…?’

  • Referrals made in the presence of your consultant are often more readily accepted and queries can be discussed directly

  • If you have not done something or cannot recall details, be honest.

After the ward round

  • Discuss with your team the plan for the day. You may need senior help with some jobs (eg if there are too many or you need specific input). Seniors may need to go to theatre or clinic. Time-permitting, try to join occasionally: extra educational opportunities like this are good for your career planning as well.

  • Prioritize the jobs and group by location, eg outlying wards, radiology

  • Clarify any gaps in your understanding of the patients’ management.

Being on-call

Being ‘on-call’ occupies an increasing amount of your time and involves care for a different range of patients and specialties than during normal working hours. Requirements, expectations, and priorities are different.

What’s important

  • Ensure you have a clear handover about which patients are waiting to be seen, how urgently they need seeing, and where they are

  • Know who you are on-call with and how best to contact them

  • Identify and focus on sick patients, and get help early

  • Prioritize effectively and stay organized

  • Eat and stay well hydrated—there is always time for a cup of water and you will be much less efficient if you don’t look after yourself.

How to handle the bleep when tired

  • Always try to answer promptly; when you don’t, it will be the boss or someone really unwell

  • Write down who called and the job required

  • Learn common extension numbers so you can spot the call from switchboard, the mess, or your consultant’s office.

Being organized on-call

  • Document every task, otherwise you will forget something—do not use scraps of paper. Use sides of A4 structured into a grid.

  • Have a means of identifying when you’ve done it (i.e. an empty box needs doing, a half-full box is part done, and a full box is a job done)

  • Visit all the areas you cover in order and tell the wards this is what you’ll be doing; ask them to compile a list of non-urgent tasks for when you arrive

  • When you order a test on-call, make a note to check the result as it’s easy to forget.

Prioritizing

  • Sick patients need seeing first; if you have more than one really sick patient then tell your senior. The ITU outreach nurses are your friends!

  • If the patient’s condition is clearly life-threatening then consider asking the ward to bleep your senior while you’re on your way there

  • Check if a task has a deadline (eg before pharmacy closes)

  • If you see an abnormal blood result, check the patient/notes/previous blood results (Life on the wards pp. [link][link])

  • Ask if a job can wait until you’re in that area, tell the nurses when this will be and try to stick to it.

Taking breaks

You are entitled to one 30min paid break for every shift over 5h and two for shifts over 9h. While you must not ignore a sick patient, there will be a constant supply of work that can usually wait. Breaks are not just about food, they keep you alert and reduce stress and tension headaches. It is in your patients’ interests that you recharge. Drink plenty of water. Where possible, arrange to take breaks with the other members of the team on-call—it allows you to catch up and stops you feeling isolated.

Night shifts

Few doctors look forward to their night shifts, especially if they are doing several in a row. Don’t underestimate how tired you feel during and after a run of nights. That said, on nights you will gain a lot of experience.

Things to take with you

  • Food, both a main meal and several quick snacks

  • Stuff for gaps in workload—eg books for private study.

Things to check (on the first night)

  • What areas and specialties are you responsible for?

  • The contact details of your colleagues and seniors, what they are covering, and how best to get hold of them

  • When and where is handover?

What is expected of you

  • Turn up on time; your colleague will be late home if you don’t

  • Prioritize work according to urgency—when bleeped to a sick patient ask for, eg obs, bloods, cannula, ECG to be done while you get there

  • Tour the wards you are covering regularly and delegate simple tasks

  • Document all interventions in the notes.

Hospital at night (H@N)

This system is now in place in many hospitals to improve efficiency and the standard of care provided by the limited number of doctors on duty at night. Some hospitals use mobile phone apps or a night sister to help filter and allocate tasks to individuals most suited to complete them, eg nurses may be able to cannulate but you should assess an unwell patient.

Learning at night

Nights can be a good learning opportunity. Ensure the other doctors on at night know if you have particular skills you wish to learn at that time (eg lumbar punctures). They can then call you to observe or be supervised.

Pitfalls

The potential to make mistakes during night shifts is greater than during the day. If you are unsure, double check. The following are some of the common problem areas:

  • Poor handover; ensure you know who needs review (Life on the wards p. [link])

  • Failing to appreciate a sick patient and not calling for help

  • Fluid prescriptions (eg failing to note renal/heart failure, dm, electrolyte imbalance)

  • Warfarin prescriptions with inrs coming back out of hours.

  • Check you’ve got the right patient when documenting/seeing results.

How to cope when not at work

  • Try to sleep for a few hours during the day before your first night shift; getting up early the morning before can help with this

  • Go to bed for at least 7h each day, even if you don’t sleep you’ll rest

  • Make your room dark and quiet—eye masks/earplugs help; ensure anyone else in the house knows you are working nights

  • Eat plenty and have regular meals, even if you don’t feel like it

  • Travel home safely. If you feel too tired to travel home safely, trusts are obliged to provide a place to rest or transport to take you home.

Writing in the notes

Most new F1s are unsure about writing in medical notes since this is rarely practised as a medical student. There are a few rules which everyone, irrespective of grade, should conform to (Fig. 2.2):


Fig. 2.2 Example of entries in medical notes.

Fig. 2.2 Example of entries in medical notes.

Notepaper

The patient’s name, DoB, and hospital number or address should identify every sheet (using a hospital sticker is preferable).

Documentation

Each entry should have the date and time. It is useful to have a heading such as ‘wr st2 (Smith)’ or ‘Discussion with patient and family’. Sign every entry and print your surname and bleep number clearly.

What to write

Document the condition of the patient, relevant changes to the history, obs, examination findings, the results of any new investigations, and end with a clear plan. The notes should contain enough information so that in your absence someone else can learn what has happened and what is planned for the patient. Always allow yourself plenty of space when writing in the notes, especially if documenting a ward round—your seniors may mention a point of the plan early on (which needs to go at the end of the entry) but then perform a detailed examination which you should document in the space you have left. Try to document everything that is discussed or observed—it is extremely frustrating for a senior to ask a series of detailed questions with medicolegal implications and then to find nothing documented.

Problem lists

It is helpful to write a problem list in the notes either every day if there are frequent changes (eg new admissions or in icu/hdu), or less frequently for chronic conditions. This should include medical and social problems (Life on the wards Box 2.1 p. [link]). Having problem lists also makes it easier for on-call teams to understand the patient if they are asked to review them, as well as refreshing your memory at the start of the next ward round. See Fig. 2.3.

What not to write

Patients can apply to read their medical notes and notes are always used in legal cases. Never write anything that you do not wish the patient to read or that would be frowned upon in court. Documenting facts is accepted (eg obese lady) but not subjective material (eg annoying time-waster). Never doodle in the notes and do not write humorous comments.

How to write

Write clearly in black; poorly legible notes result in errors and are indefensible in court. Use only well-recognized abbreviations and don’t worry about length as long as sufficient information is documented. Always write in the notes at the time of the consultation, even if it means asking the ward round to wait a few moments.

Making changes

If you wish to cross something out simply put a single line through the error and initial the mistake. Never cross it out so it cannot be read as this looks suspicious. Previous entries should not be altered, instead make a new entry indicating the change or difference.

Notes and the law

It is unlikely that your notes will be used in court. If they are, you want them to show you as a caring and clear-thinking individual; make that clear from how you write. As far as a court is concerned, if it’s not documented then it didn’t happen.

Hints and tips

Bullet points are a useful and clear means of documentation. It is acceptable to write about a patient’s mood and it is useful to document if you have cheered them up or discussed some bad news (Life on the wards p. [link]). It is also acceptable to document ‘no change’ if this is the case.

Common symbols in the notes

Life on the wards

Home

Life on the wards

Normal

Life on the wards

Plan

Life on the wards

Left

Life on the wards

Right

Life on the wards

Temperature

dd/DD/δδ‎/∆∆

Differential diagnosis

x/Dx/∆

Diagnosis

Imp

Impression

Rx

Prescription or drugs

Sx

Symptoms

Tx

Treatment

Ix

Investigations

O/E /OEx

On examination

–ve

Negative

+ve

Positive

+/–

Equivocal

+

Presence noted

++

Present significantly

+++

Present in excess

h/o

History of

d/w

Discussed with or discussion with

WR

Ward round

r/v

Review

f/u

Follow-up

ATSP

Asked to see patient

IP

In-patient

OP

Out-patient

c/o

Complains of or complaining of

Pt

Patient

c–

With

@

At

E+D

Eating and drinking

N+V

Nausea and vomiting

D+V

Diarrhoea and vomiting

BO

Bowels open

puing

Passing urine

blds

Bloods

°/x/

No/negative (as in °previous MI)

Primary

Secondary

mane

Tomorrow morning

N/S

Nursing Staff

Anatomical terms and planes


Fig. 2.4 The anatomical position and anatomical planes.

Fig. 2.4 The anatomical position and anatomical planes.

Table 2.1 Commonly used anatomical terms and their meanings

Anterior/ventral

Front of the body

Contralateral

On the opposite side

Coronal/frontal plane

Divides anterior from posterior

Distal

Away from the trunk

Inferior/caudal

Away from the head

Ipsilateral

On the same side

Lateral

Away from the midline

Medial

Towards the midline

Palmar

Pertaining to the palm of the hand

Plantar

Pertaining to the sole of the foot

Posterior/dorsal

Back of the body

Prone

Face down position

Proximal

Close to the trunk

Radial

The lateral (thumb) aspect of the forearm

Sagittal plane

Divides left side from right side

Superior/cephalic

Towards the head

Supine

Face up position

Transverse/horizontal/axial plane

Divides upper and lower sections

Ulnar

The medial (little finger) aspect of the forearm

Discharge summaries (TTOs/TTAs)

‘ttos’ or ‘ttas’ (to take out or away) are summaries of the patient’s admission from the ward doctors sent to the patient’s GP and are often the most complete summary written (Box 2.2). TTOs are written on a computer (very rarely by hand with carbon copies); you should receive training on the local system as part of induction. They form a point of reference at future clinic visits or admissions. They also provide clinical coding information with which the hospital bills primary care for care provided.

When to write TTOs

ttos should be written as soon as you know the patient is likely to be discharged. This allows the drugs to be dispensed from pharmacy as soon as possible so that the patient’s discharge is not delayed. See Fig. 2.5.

  • Begin to enter information on the TTO at the earliest opportunity; check any queries with your team, particularly regarding the principal diagnosis

  • Check the duration of the medication for discharge (eg ABx) and stop any unnecessary drugs (eg prophylactic low-molecular-weight heparin)

  • Check drug doses and frequencies with the BNF, your seniors, a pharmacist, or by calling your hospital’s drug information-line

  • Check required follow-up appointments, give details, and be clear on who will arrange them (eg the ward clerk or the clinic administrators)

  • Phone the gp if the patient needs an early check-up, has a poor social situation, or self-discharges. It may take several days for a TTO to reach the GP: written instructions such as ‘check K+ in 3/7’ are unsafe

  • Hand the tto and the patient’s drug chart to the patient’s nurse or inform them that you have completed it to avoid unnecessary bleeps

  • If you are unsure whether the tto has been done check the drug chart; there is often a tick in a box showing if TTOs have been dispensed

  • Discuss the diagnosis, results, and discharge plan with your patient; if they understand the management plan they are more likely to comply.

Controlled drugs for TTOs

These are slightly more complex, but can still be written by F1 doctors in most trusts. They must include all the information in Table 2.2. CD prescriptions are only valid for 28d from the date of signing and only 30d of CDs can be dispensed on a single prescription. See also Fig. 2.6 and Box 2.3.

Table 2.2 Controlled drug TTOs must meet the following requirements

Content rules

  • The prescriber’s name and work address

  • Signed and dated by the prescriber

  • All the information included in a regular tto

Drug rules

  • The drug name, dose, frequency, and route

  • If the drug is a ‘preparation’ (ie liquid), state the concentration

  • The total volume (mL) or weight (mg) of the preparation or the total number of tablets/capsules/patches in words and figures


Fig. 2.6 Sample TTOs for controlled drugs excluding the patient and prescriber’s details.

Fig. 2.6 Sample TTOs for controlled drugs excluding the patient and prescriber’s details.

Fitness to work notes

As the most junior member of the team, the writing of ‘fit notes’ (Statement of Fitness for Work, Form Med 3) will usually fall to you. These notes provide evidence that your patient has a condition that will impact their fitness to work and enables statutory sick pay and social security payments. You can advise that a patient is ‘not fit for work’ or ‘may be fit for work’ under restricted conditions. A separate form (Form Med 10) may be required for periods of time spent as a hospital inpatient. These forms are available in both electronic and paper formats from the Department for Work and Pensions—ask the ward clerk for advice. A sample is shown in Fig. 2.7.1 Patients can self-certify as ill for 7 days.


Fig. 2.7 Example of Statement of Fitness for Work (Med 3).

Fig. 2.7 Example of Statement of Fitness for Work (Med 3).

Reproduced from Life on the wardshttps://www.gov.uk/government/uploads/system/uploads/attachment_data/file/349915/fitnote-hospital-guide.pdf. Contains public sector information licensed under the Open Government Licence v3.0.

Usage

Typical uses include surgical patients who have been admitted routinely for a procedure and require time off work to recover postoperatively. Medical patients may also require time to convalesce, while patients with wounds or injuries may require workplace adjustments during their recovery period on return to work. Patients can self-certify for the first week of any illness so do not require a note if they will be able to return to work within this time. Never instruct a patient to ‘see your GP for a sick note’ where the need for this can be anticipated at the time of discharge—the duty to provide a Med 3 rests with the doctor with clinical responsibility for the patient.

Format

You should fill in the patient’s name, a brief explanation of their needs (sickness absence, adjustments to the workplace, or modified duties), and accurate clinical diagnosis (without mentioning intimate details that might be damaging to the well-being of patient for their employer to discover). Sign and date the form. You need to give an appropriate amount of time for the patient to recover from their illness as reasonably anticipated at the time of discharge, up to a maximum of 3mths. If recovery takes longer than you anticipate, the patient can then see their GP for a further note.

Referrals

Referring a patient to another medical team can be one of the most difficult parts of the job. The other doctor is often very busy and will inevitably know more about the patient’s condition than you (hence the referral). At times it can feel like they are trying to make you feel stupid—this is rarely the case. Consider this from the point of view of the other doctor: They need to establish:

  • How unwell the patient is

  • How urgently they need to be seen

  • What investigations have already been done and what still need to be done to assist them in their review

  • If they are the right person to see the patient.

You will often be asked to refer a patient by your senior. Ask them directly:

  • To help my referral and for my learning, why do they need referring?

  • What do they want the other team to do (advise over the phone, formal review, take over care, see in clinic, procedure/operation)?

  • How urgent is the referral?

Next, think about what information the other doctor will want. Many specialties have additional components to history and examination that you will need to be able to describe, see the pages in the history and examination chapter (Box 2.4); if necessary, go and see/examine the patient yourself:

Before referring make sure you have the following in front of you:

  • Hospital notes with patient’s name, DoB, hospital number, and ward

  • Obs chart (including latest set and trends) and the patient’s drug card

  • Most recent results or serial results sheet.

Phone the relevant specialist, introduce yourself, and say, ‘My consultant has requested that I refer one of our patients who has [medical condition] with the view to [taking over care, advising on treatment, etc]’.

Offer a brief summary of their condition and management; look up the relevant condition or referral page (Box 2.4) before calling so that you know what you are talking about. It is never acceptable to make a referral for a patient you know little about just because it’s on the jobs list.

Always know what investigations have been performed so far, and what the results were—sit at a computer with these already called up when you make the call.

Before you put the phone down determine exactly what action the specialist will do and when this will take place. Write the referral and outcome in the notes along with the specialist’s name and bleep number.

Referral letters

The basics

These may be used for within-hospital referrals (using a specific referral form) or for referral to outpatient clinics or other hospitals (use hospital headed notepaper).2 Try to make referral letters as professional as possible. It is essential that the referral contains the following information:

  • Who you are and how to contact you

  • Who the patient is (full name, DoB, hospital number, ± address)

  • Why you want them to be seen.

Fig. 2.8 is an example of a referral letter for you to follow.


Fig. 2.8 Example of a referral letter.

Fig. 2.8 Example of a referral letter.

Diagnoses

List all the patient’s active diagnoses and relevant past diagnoses; try to put the ones most relevant to the specialty you are referring to near the top.

Presenting complaint

Start with a statement telling the other doctor what you would like them to do (eg see on the ward, in clinic, or give written advice). Give a brief description of the patient’s presentation and management during this admission as if you were writing a discharge summary.

Medical information

This will form the bulk of the referral. Think carefully about what information will help the other doctor in deciding when to see the patient and how to manage them; see the relevant history and examination page (Life on the wards pp. [link][link]). Try to set the referral out like a brief medical clerking and make sure you include:

  • Relevant investigation results

  • Latest medications

  • Relevant social history (particularly if this will affect how they are seen in clinic, eg poor mobility, language difficulties).

Finishing the referral

You should write your name, post, and consultant’s name. If sending an outpatient or inter-hospital referral, you should also include who the letter is copied to (‘cc’ stands for carbon copy) which will include the notes and gp. It is recommended practice to send a copy to the patient though this varies between trusts and doctors.

Sending the letter

Ask your ward clerk for assistance. Print off several copies, sign them, and ensure it is clear where each copy should be sent.

Faxing a letter

If you need to fax a copy then include a header sheet. This is simply a piece of paper saying who the fax is to, who it is from and the number of pages (and whether this includes the header sheet). You may need to add a number to the fax number to get an outside line, eg ‘9’. File the faxed letter and the sent message confirmation (with date and time sent) in the patient’s notes.

Investigation requests

These are almost always handled electronically. For paper forms, complete:

  • Full name and at least one other patient identification detail (ie DoB, hospital number, or address); G+S/X-match requires at least two more

  • Status (in-patient/out-patient) and location (ward or home address)

  • Name, position, and contact details of doctor ordering the test

  • Date, test(s) requested, and reason for request.

Clinical information

Appropriate information on request forms affects how the test is performed and reported; too much information is better than too little. Justify the investigation requested. Always consider if a test is really required, no matter how trivial—daily ‘routine’ bloods are often unnecessary, waste resources, and cause patient discomfort.

Blood tests

Brief clinical details may be acceptable, eg ‘chest pain’, ‘suspected PE’. Some tests require more information, eg blood films, antibodies, hormones, drug levels (doses and timing of doses), genetics.

Histology

Describe the macroscopic appearance of the tissue as well as the clinical suspicions, radiology findings, and any specific questions.

Microbiology

As a bare minimum include the sample type (eg urine) and current/recent antibiotics; the more information you include the better the microbiologist will be able to interpret laboratory results.

Radiology

Life on the wards p. [link].

Radiology

Life on the wards Since Wilhelm Röntgen’s first hazy images of the bones of his wife’s hand in 1895, radiological imaging has revolutionized the approach of physician and surgeon alike in diagnosis and treatment.

Imaging modalities

X-rays

These exploit the different absorbance of a pulse of X-ray radiation by different anatomical structures and foreign bodies. This allows the visualization and distinction of metal, bone, soft tissue, fat, fluid, and air.

Fluoroscopy

This uses X-ray images acquired in real time, often with addition of a contrast material, eg coronary angiogram or barium swallow.

CT

This uses a series of 2D X-ray images acquired in different planes to construct cross-sectional 3D images. IV or PO contrast can be used to accentuate, eg blood vessels or the GI tract.

MRI

This uses strong magnetic fields to align hydrogen nuclei (protons) within tissues. Disturbance of the axis of these protons by radiowaves allows the recording of radiowaves emitted as the protons return to baseline. MRI offers excellent soft tissue imaging and does not require ionizing radiation exposure. Image acquisition can be slow and require multiple different ‘sequences’ while the patient lies in a cramped space.

Ultrasound

This exploits the differential reflection of high-frequency sound waves to visualize structures, including soft tissues in real time. Overlying air and fat compromise signal quality, and bone penetration is poor.

Nuclear medicine

This depends upon the detection of radiation emitted by the decay of radiolabels attached to substances with affinity for certain body tissues. Positron emission tomography (PET) is a specific form of nuclear medicine that typically uses radiolabelled glucose analogues to detect regions of metabolic activity, eg in cancer. These techniques are especially powerful when combined with anatomical imaging approaches such as CT/MRI to increase localization (eg PET/CT or PET/MRI).

Requesting

Selecting, performing, interpreting, and managing medical imaging resources falls to the specialty of radiology. These doctors often have little direct contact with your patient and depend upon effective communication from you to select and prioritize imaging modalities (including appropriate use of contrast agents and imaging sequences), as well as inform their image interpretation; always include specific clinical questions on request forms.

Radiologists have a vital duty to limit unnecessary exposure to ionizing radiation. Doses involved can range from minimal (eg CXR: <1% annual background radiation exposure) to substantial (eg contrast CT C/A/P: 710yr background radiation). Even a trivial radiation exposure will be associated with an appreciable cancer risk to a population if performed often enough.3

Always ensure you know why any investigation you are asked to request is needed, how urgent it is, and how it will change the patient’s management. For less urgent investigations or simple X-rays, it is usually enough to submit a request giving sufficient clinical information. For more urgent or specialist imaging, request the scan or fill in the form, then phone or go to the radiology department, and speak to the duty radiologist. Be polite, explain why the test has been requested (and by whom), and ask if there is any way it could be performed today if necessary. If this fails and the test is very urgent, your registrar should discuss with the radiologist directly.

Pain

Think about

Headache (Life on the wards pp. [link][link]), chest pain (Life on the wards pp. [link][link]), abdominal pain (Life on the wards pp. [link][link]), back pain (Life on the wards pp. [link][link]), limb pain (Life on the wards p. [link]), infection (Life on the wards pp. [link][link]).

Common

Postoperative, musculoskeletal, chronic pain.

Ask about

(SOCRATES) Site, Onset, Character, Radiation, Alleviating factors, Timing (duration, frequency), Exacerbating factors, Severity, associated features (sweating, nausea, vomiting).

PMH

Stomach problems (acid reflux, ulcers), asthma, cardiac problems;

DH

Allergies, tolerance of NSAIDs, analgesia already taken and perceived benefit;

SH

?Drug abuse.

Obs

↑hr and ↑bp suggests pain; rr, pupil size and gcs if on opioids.

Look for

Source/cause of pain, masses, tenderness, guarding.

Investigations

These should be guided by your history and examination; none are specifically required for pain.

Treatment

No patient should be left in severe pain, consider titrating an iv opioid after an antiemetic (Life on the wards pp. [link][link]). Use the steps of the who pain ladder (Table 2.3). Ensure regular analgesia is prescribed, with adequate PRN analgesia for breakthrough pain. If a patient has moderate or severe pain start at step 3 or 4; using paracetamol and nsaids reduces opioid requirement and consequently side effects.

Table 2.3 WHO pain ladder

Strong opioids

Weak opioids

nsaids

Paracetamol

Step 1

Step 2

Step 3

Step 4

Source: data from Life on the wardshttp://www.who.int/cancer/palliative/painladder/en

Paracetamol Contraindications

Moderate liver failure.

Side effects

Rare.

  • Paracetamol 1g/4h, max 4g/24h PO/PR/IV.

NSAIDS

Good for inflammatory pain, renal or biliary colic, and bone pain;

Contraindications (BARS)

Bleeding (pre-op, coagulopathy), Asthma, Renal disease, Stomach (peptic ulcer or gastritis). 10% of asthmatics are NSAID-sensitive, try a low dose if they have never used them before. Avoid use in the elderly. Increased risk of CVA/MI;

Side effects

Worsen renal function, gi bleeding (upper and lower—co-prescribe a PPI or high-dose H2-blocker for those at risk: ≥65yrs, previous peptic ulcer, use of other medicines with GI side effects, or major comorbidity). Both NSAIDs and COX-2 inhibitors are associated with increased risk of mi and cva; use with caution in those at risk.

  • Ibuprofen 400mg/6h, max 2.4g/24h po, weaker anti-inflammatory action, but less risk of gi ulceration

  • Diclofenac 50mg/8h, max 150mg/24h po/pr (also im/iv, see bnf).

COX-2 inhibitors

These are similar to nsaids and share an increased risk of mi and cva, but with less risk of gastroduodenal ulceration.

Weak opioids

Dependence and tolerance to opioids do not occur with short-term use for acute pain. Consider prescribing regular laxatives and prn antiemetics, use with caution if head injury, ↑icp, respiratory depression, alcohol intoxication;

Side effects

n+v, constipation, drowsiness, hypotension;

Toxicity

↓rr, ↓gcs, pinpoint pupils (see Table 2.4).

  • Codeine 30–60mg/4h, max 240mg/24h po/im, constipating

  • Dihydrocodeine 30–60mg/4h, max 240mg/24h po, constipating

  • Tramadol 50–100mg/4h, max 400–600mg/24h po/im, stronger than others and less constipating for long-term use.

Table 2.4 Weak opioid to oral morphine converter

Drug and dose (oral route)

Equivalent to oral morphine

Codeine 8mg

0.7mg oral morphine

Codeine 30mg/6h

10mg oral morphine/24h

Dihydrocodeine 10mg

1mg oral morphine

Dihydrocodeine 30mg/6h

12mg oral morphine/24h

Tramadol 50mg

5mg oral morphine

Tramadol 100mg/6h

40mg oral morphine/24h

Paracetamol and weak opioid combinations

Useful for tto analgesia; it is better to prescribe the components separately in hospital:

  • Co-codamol 30mg codeine and 500mg paracetamol; two tablets/6h po, nurses must give 8/500 dose if 30/500 not specified

  • Co-dydramol 10mg dihydrocodeine and 500mg paracetamol; two tablets/6h po

  • Co-proxamol Contained dextropropoxyphene and has been withdrawn owing to its potential toxicity and poor analgesic properties. Some patients may still be taking this, but it is not prescribed to new patients.

Strong opioids

Morphine is used for severe pain. Use regular fast-acting opioids for acute pain with regular laxatives and prn or regular antiemetics. See ‘weak opioids’ for cautions, side effects, and toxicity. Use only one method of administration (ie po, sc, im, or iv) to avoid overdose:

  • Oral eg Sevredol® or Oramorph® 10mg/2–4h

  • SC/IM Morphine 10mg/2–4h or diamorphine 5mg/2–4h

  • IV titrate to pain; dilute 10mg morphine into 10mL H2O for injections (1mg/mL), give 2mg initially and wait 2min for response. Give 1mg/2min until pain settled observing rr and responsiveness.

Long-acting opioids

These are used after major surgery or in chronic pain. Use standard opioids initially until morphine requirements known (Life on the wards p. [link]) then prescribe a regular long-acting dose along with prn fast-acting opioids to cover breakthrough pain (equivalent to 15% or one-sixth of daily requirements). Laxatives will be needed.

  • Oral mst® dose = half total daily oral morphine requirement (Life on the wards p. [link]) given every 12h, usually 10–30mg/12h, max 400mg/24h

  • Topical Fentanyl patch lasts 72h, available in 12–100micrograms/h doses.

Naloxone

This given orally antagonizes the constipating effects of opioids, but is metabolized on ‘first pass’ through the liver and does not interfere with analgesic effects. Compound preparations oxycodone/naloxone preparations (eg Targinact®) may be of benefit for chronic pain relief in those who develop painful constipation despite regular laxatives.

Other analgesic options/adjuncts

Nefopam

A non-opioid analgesia that can be given with paracetamol, nsaids, and opioids;

Contraindications

Epilepsy and convulsions;

Side effects

Urinary retention, pink urine, dry mouth, light-headedness.

  • Nefopam 30–90mg/8h po.

Hyoscine butylbromide

This gives good analgesia in colicky abdo pain;

Contraindications

Paralytic ileus, prostatism, glaucoma, myasthenia gravis, porphyria;

Side effects

Constipation, dry mouth, confusion, urine retention.

  • Buscopan® (hyoscine butylbromide) 20mg/6h po/im/iv.

Diazepam

This acts as a muscle relaxant, eg spasm with back pain;

Contraindications

Respiratory compromise/failure, sleep apnoea.

Side effects

Drowsiness, confusion, physical dependence (use for short-term only).

  • Diazepam 2mg/8h po.

Quinine

This is used for nocturnal leg cramps;

Contraindications

Haemoglobinuria, optic neuritis, arrhythmias;

Side effects

Abdo pain, tinnitus, confusion.

  • Quinine 200mg/24h po—at night.

Patient-controlled analgesia (pca)

This is a syringe driver that gives a bolus of iv opioid (usually morphine, but occasionally tramadol or fentanyl) when the patient activates a button. A background infusion rate, bolus dose, and maximum bolus frequency can be adjusted to prevent overdose/pain; changes to the pca are usually undertaken by the pain team (see Box 2.6). The patient must be alert, cooperative, have iv access, and their pain under control before starting. Check hospital protocols.

Epidurals

These are inserted by the anaesthetist in theatre usually prior to surgery. A local anaesthetic infusion (± opioid) anaesthetizes the spinal nerves, and usually produces a sensory level below which the patient has little or no feeling; if this level rises too high (higher than T4 (nipples)) there is risk of respiratory failure. The anaesthetist or pain team (see Box 2.6) usually look after epidurals and their dosing post-op. Complications include local haematoma, abscess (causes cord compression, Life on the wards p. [link]), or local infection; if there are concerns about an epidural speak to the anaesthetist covering acute pain immediately.

Syringe driver

These are used mainly for palliative analgesia and symptom control (Life on the wards p. [link]).

Neuropathic and chronic pain

Neuropathic pain is caused by damage to or chronic stimulation of nerve fibres, eg radiculopathy (nerve root pain), peripheral neuropathy, and phantom limb pain. The pain tends to be difficult to describe or pinpoint and is often aching, burning, throbbing, or shooting in nature. Chronic conditions can cause significant pain, eg chronic pancreatitis, arthritis, post-traumatic, dm, trigeminal neuralgia; there is frequently a psychogenic component. Standard analgesia is often ineffective and the services of a chronic pain specialist should be sought. See Box 2.7. Commoner chronic pain therapies include:

Tricyclic antidepressants

Given at a low dose;

Contraindications

recent mi, arrhythmias;

Side effects

Dry mouth, constipation, sedation. This is the first-line treatment for neuropathic pain according to NICE guidance.4

  • Amitriptyline 10–75mg/24h PO.

Pregabalin Contraindications

Hypersensitivity, pregnancy, lactation;

Side effects

Dizziness, tiredness, cerebellar signs. Can be used instead of amitriptyline as first-line treatment for neuropathic pain.

  • Pregabalin 75–300mg/12h PO.

Duloxetine Contraindications

Uncontrolled hypertension, pregnancy, seizures;

Side effects

Nausea, dizziness, somnolence, dry mouth. First line for painful diabetic neuropathy. Avoid abrupt discontinuation.

  • Duloxetine 60–120mg/24h PO.

If first-line drugs are unsuccessful, combination therapy with two or more agents can be considered. If this is unsuccessful then referral for a specialist opinion should be considered. The following are examples of more advanced therapies a pain specialist may prescribe.

TENS

Transcutaneous Electrical Nerve Stimulation is believed to affect the gate mechanism of pain fibres in the spine and/or to stimulate the production of endorphins. Use at a high frequency for acute pain or slow frequency for chronic/neuropathic pain.

Steroids and nerve blocks

Injections of steroids combined with local anaesthetic into joints or around nerves can reduce pain for long periods. This needs to be done by a specialist.

Sympathectomy and nerve ablation

The ablation of sensory and sympathetic nerves by surgery or injection; used as a last resort in some forms of chronic pain.

Acupuncture

Effective in some trials and with a greater evidence base than most complementary therapies.

Counselling

and cognitive behavioural therapy (cbt) to develop coping strategies are widely studied in chronic pain and may be considered by appropriately skilled specialists. Concern remains that it makes things worse for some patients.

Thinking about death

Life on the wards Death is inevitable and even the best medicine can only delay it. Patients often die in hospital and as a trainee you will have a vital role in supporting patients and relatives through it. As with everything in medicine this requires knowledge, skills, and compassion, and getting it right can be challenging but rewarding. The following should help guide you.

Fears

It is natural for patients to be scared of dying, however be aware that many are not and are entirely at ease with the idea. If they are afraid, try to find out why. It may be the loss of dignity/control, the symptoms (suffocation or pain), their relatives seeing them suffering, or the unpleasant death of a loved one. Many of these can now be carefully managed or avoided. When death is not expected or deterioration is sudden, then your role in talking to the patient and allaying their fears cannot be overstated. This will be emotionally difficult and you must never hesitate to seek support yourself.

Breaking bad news

Life on the wards p. [link].

Other sources of help

Even with sudden deteriorations there are many other sources of help:

  • Macmillan nurses and the palliative care team (Life on the wards p. [link])

  • The acute pain team (usually part of anaesthetics)

  • The chaplaincy.

Do not forget you’re working with nursing staff who may know the patient much better than you, so discuss their care with them.

Sorting arrangements

Needless to say, marching in and offering a priest and solicitor will be insensitive, but the hospital will be able to provide legal support or an appropriate religious official if asked. Many patients’ strongest wish is to die in comfort, often in their own home. Get the Macmillan and/or palliative care team involved early as this can frequently be arranged.

Do not resuscitate orders

Towards the end of life, attempts at resuscitation can be more harm than good; however, the decisions and discussions around DNAR forms are complex and should be initiated at a registrar or consultant level. Patients must now be involved in discussions unless it may lead to ‘psychological harm to the patient’ (see Box 2.8). Nursing staff must always be informed.

Palliative care

Palliative care is the non-curative treatment of a disease; originally focused on terminal cancer, but now covers other disorders. In practice, cancer patients are still able to access more services, including the excellent Macmillan nurses who should be involved as early as possible. The aim is to provide the best quality of life for as long as possible—this may include admission to a hospice (often temporarily).

Pain

(Life on the wards pp. [link][link]) This is a common problem in palliative care; opioids are often used. It is important to use all modalities of treatment. Consider:

  • Treating the source (urinary retention, bowel spasm, bony mets)

  • Non-opioid analgesia (nerve blocks, tens, neuropathic pain)

  • Alternative routes (intranasal, pr, transdermal, sc, im, iv).

Table 2.5 is a guide to converting between opioids, it is not an exact science and changes need to be monitored for over- or under-dosing.

Table 2.5 Opioids and their potency relative to PO morphine

Opioid

Route

Typical dose

24h max

Relative

Codeine

po

60mg/4h

240mg

0.1

Dihydrocodeine

po

30mg/4–6h

240mg

0.1

Tramadol

po

50mg/4h

600mg

0.2

Oral morphine

po

10mg/1–4h

n/a

1

Oxycodone

po

5mg/4–6h

400mg

2

Morphine

sc/im/iv

5mg/1–4h

n/a

2

Diamorphine

sc

2.5mg/1–4h

n/a

3

Fentanyl

Topical

25micrograms/h

2400micrograms

100–150

Other symptoms

Many of the treatments listed in Table 2.6 can be used in non-palliative patients. For further information on prescribing in palliative problems see Life on the wardsBNF and ohcm10 p. 532.

Table 2.6 Symptom management in palliative care

Symptom

Treatments

Breathlessness

O2, open windows, fans, diamorphine, benzodiazepines, steroids, helium and oxygen (for stridor), SC furosemide

Constipation

Life on the wards pp. [link][link], also bisacodyl

Cough

Saline nebs, antihistamines, simple/codeine linctus, morphine

Dry mouth

Chlorhexidine, sucking ice or pineapple chunks, consider Candida (thrush) infection, synthetic saliva

Hiccups

Antacids, eg Maalox®, Gaviscon®, chlorpromazine, haloperidol

Itching

Emollients, chlorphenamine, cetirizine, colestyramine (obstructive jaundice), ondansetron

Nausea/vomiting

Life on the wards pp. [link][link], also levomepromazine and haloperidol

The dying patient

For patients who have reached the final stage of their illness and are not expected to survive, the decision may be taken by a senior doctor to withdraw active treatment and focus on keeping the patient comfortable. These decisions and discussions are highly emotive and should be handled with consideration and skill (Life on the wards p. [link]). Much emphasis has been placed on achieving better deaths for all dying patients (see Box 2.9).5

Identifying the dying

The patient will often (but not always) be bed-bound with minimal oral intake and reduced gcs. This simple definition has poor specificity, with potential for recovery, while timescales can be difficult to predict. Since considerable uncertainty will always persist, effective and honest communication is vital, along with regular review of treatment decisions by the senior responsible clinician.

Communication

Wherever possible, discussions should happen with the patient and their relatives well in advance; all views should be documented and used to draw up a care plan. Even where an illness progresses rapidly, the withdrawal of active treatment needs to be carefully considered and every effort made to discuss with the relatives; withdrawal of care by junior staff during out-of-hours periods should be avoided.

Stopping medications

Administering drugs may cause unnecessary distress, particularly those aimed at prophylaxis of long-term conditions. Review all medications with a senior and stop those deemed to be unnecessary. The decision to stop antibiotics can be a particularly difficult one, but again, this is made easier by well-documented prior conversations.

Resuscitation

Attempts at cardiopulmonary resuscitation in patients with end-stage disease are inappropriate (see Box 2.9). Although the decision rests with the senior responsible, patients must be involved in the conversation unless clinicians feel it would cause them ‘physical or psychological harm’ to discuss it (Life on the wards p. [link] and Box 2.8 p. [link]).

Investigations

These may be unnecessary. This includes routine blood tests, where the outcome will not influence clinical management, but will also extend to the taking of nursing observations in the final stages of illness.

Food and fluid

A loss of appetite in the terminal stages of disease is common and at this stage nutrition should not be forced. The intake of oral fluids should be supported as long as tolerated, even if this incurs a risk of aspiration. Beyond this stage, artificial hydration (IV or SC) should be used only where it increases comfort, although regular mouth care may continue. Bear in mind that studies have shown no clear benefit to length or quality of life in a palliative setting.9

Analgesia

Not all dying patients are in pain, and overuse of syringe drivers is inappropriate. However, where present, it is vital to control pain while avoiding oversedation (Life on the wards p. [link]). Always exclude a treatable cause, eg urinary retention, constipation. If the patient is currently in pain give an immediate diamorphine bolus (2.5–5mg sc max 1hrly if not currently on diamorphine or give 1/6th of 24h dose 1hrly if already on diamorphine). Where pain is regular and predictable, discuss starting a syringe driver with a SC diamorphine infusion giving a total 24h dose equivalent to current cumulative opioid requirements (use Table 2.5 (Life on the wards p. [link]) to convert between opioids).

Agitation

This may be a sign of pain. Try prn doses initially; add a syringe driver (with additional prn dose) if regular doses are required:

PRN

Levomepromazine 12.5–25mg sc 6–12hrly, or

PRN

Midazolam 2.5–5mg/4h sc max 4hrly

Syringe driver

Levomepromazine 50–150mg/24h and/or midazolam 10–20mg/24h sc (higher doses up to 60mg/24h may be required).

Nausea and vomiting

Continue existing antiemetics in a syringe driver if they are controlling the symptoms; if there is no nausea then prescribe prn cyclizine and add a syringe driver if it is needed regularly. If further antiemetics are required use a 5HT3 antagonist (eg ondansetron).

PRN

Cyclizine 50mg/8h sc

Syringe driver

Levomepromazine 5–12.5mg/24h sc.

Secretions

The patient’s breathing may become rattly due to the build-up of secretions with a poor cough/swallow reflex. Sitting the patient up slightly may help; medication improves the symptoms if started promptly. Start with a prn dose and add a syringe driver if regular doses are required:

PRN

Glycopyrronium 200–400micrograms sc 6hrly or hyoscine butylbromide 20mg sc 6hrly.

Syringe driver

Glycopyrronium 1.2–2mg/24h SC or hyoscine butylbromide 90–120mg/24h sc.

Further care

Review the patient regularly. Ask the patient and/or relatives if there are any new symptoms and adjust medications accordingly. If you are unable to control symptoms, ask for a palliative care review.

Death

Declaring death

You will often be asked to declare that a patient has died. This is not an urgent request, but the patient cannot be transferred to the mortuary until it is done. There may be other members of staff who can do this if you are busy and unable to attend in a timely fashion. If you are uncomfortable doing this alone, or are doing it for the first time, ask another member of staff to accompany you.

The Academy of Medical Royal Colleges has guidance on the diagnosis and confirmation of death from which the following advice is adapted,10 but your hospital may have specific guidelines which you should follow.

1. Confirming cardiorespiratory arrest

You should observe the patient for a minimum of five minutes to confirm irreversible cardiorespiratory arrest has occurred:

  • Listen for heart sounds in two places, for one minute in each place (total two minutes), then

  • Palpate over a central artery (carotid/femoral) for one minute, then

  • Listen for breath sounds in two places, for one minute in each place (total two minutes).

It is common to hear transmitted gastrointestinal sounds when auscultating the chest, which should be ignored. However, in a very recently deceased patient it is also not uncommon for a lone complex to appear on the ECG, or for them to take a ‘last’ (agonal) breath. This or any other spontaneous return of cardiac or respiratory activity during your period of observation should prompt a further five-minute observation from the next point of cardiorespiratory arrest, unless the patient is for active resuscitation.

2. Confirming the absence of motor response

After five minutes of continued cardiorespiratory arrest confirm the absence of motor response in the patient:

  • Absence of the pupillary response to light; the pupils will often be dilated and they should not change when exposed to a bright light source (eg pen torch)

  • Absence of the corneal reflex; passing rolled up cotton wool over the edge of the cornea should not elicit a blinking response

  • Absence of any motor response to supra-orbital pressure; applying firm supra-orbital pressure should not elicit any motor response.

3. Documentation

The time of death is recorded as the time at which these criteria are fulfilled (Fig. 2.9). Remember to sign and print your name and bleep number.


Fig. 2.9 Example of what to write in the notes when a patient dies.

Fig. 2.9 Example of what to write in the notes when a patient dies.

What happens to the patient after death?

When a patient dies the nurses prepare the body,11 including: closing the curtains, lying the body flat with one pillow, closing the eyes and closing the jaw (this may need to be propped closed with a rolled towel under the chin), washing the body, using pads to absorb any leakage from the urethra, vagina, or rectum, and removing attachments (eg fluids, pumps). Lines and tubes are not removed since these will be inspected if a post-mortem examination is undertaken. The patient is completely covered with a sheet.

Once they have been declared dead and the body has been prepared, they are taken to the mortuary in a portable coffin. Curtains and portable partitions are used to try and screen this from other patients.

Communication around death

On occasion, it will be your duty to inform others of the death of a loved one. This will produce strong emotions, even when the news is expected, and calls for skilful and sensitive communication (Life on the wards p. [link]). Ensure you are mentally ready to break this news (ask a nurse to accompany you wherever possible), know the identity of everyone in the room, and that the environment is appropriate. Study the notes beforehand so that you can answer questions relating to events leading up to the death—if you are still unsure of details, be honest and offer to check. Ask if they would like to see the body at that time, and be clear that there will be later opportunities too. The most important element is to give those receiving the news time—both silence and emotion are completely acceptable and to be expected and should not be talked over or hurried. You will not be able to remove sorrow, but your empathy and professionalism may just help to soften a painful memory that will be mentally revisited many times in the coming months and years.

Always remember to inform the gp of the patient’s death, especially if it was unexpected. This is both courteous and prevents any unfortunate phone calls from the gp enquiring about the patient’s health.

Medical Certificate of Cause of Death

Life on the wards All deaths in the United Kingdom must be registered with a local registrar’s office. In order for this to happen, a doctor may issue a‘medical certificate of cause of death’(MCCD), confusingly often referred to as a‘death certificate’. Alternatively, where the cause of death is not clear or there are any circumstances requiring clarification, the coroner’s office must be informed (Life on the wardsp. [link]). In Scotland, different legislation applies and a slightly different MCCD is used and the procurator fiscal takes the coroner’s role.

Eligibility

In hospital, it is ultimately the consultant’s responsibility to ensure the MCCD is properly completed but it can be delegated to a member of the team who ‘attended’ the patient in the last 14d of life (28d in Northern Ireland). This applies to those involved in the patient’s care and who reliably know the history and course of in-patient stay. Where circumstances require involvement of the coroner’s office/procurator fiscal (Life on the wards p. [link]), do not complete the MCCD unless they instruct you to do so.

Completing the MCCD

Most of the entries are self-explanatory:

  • Name of deceased: full name of the deceased

  • Date of death as stated to me: eg fifteenth day of August 2016

  • Age as stated to me: eg 92 years

  • Place of death: ward, hospital, and city where they died

  • Last seen alive by me: eg fourteenth day of August 2016

Then circle just one of these (most commonly option ‘3’):

  1. 1. The certified cause of death takes account of information obtained from post-mortem.

  2. 2. Information from post-mortem may be available later.

  3. 3. Post-mortem not being held.

  4. 4. I have reported this death to the Coroner for further action.

Then circle just one of these (most commonly option ‘a’):

  1. a. Seen after death by me.

  2. b. Seen after death by another medical practitioner but not by me.

  3. c. Not seen after death by a medical practitioner.

Cause of death

This can be difficult: it is important to take advice from the consultant the patient was under.12 It is important to think of this as a sequence of events leading up to the death of the patient. The pathology listed in I(a) is whatever ultimately resulted in the patient dying (eg intraventricular haemorrhage, myocardial infarction, meningococcal septicaemia); avoid using modes of death (Table 2.7) as this may lead to delays later in the process. The I(b) and I(c) entries should be the pathology/sequence of events which led up to I(a). Include pathology in II which likely contributed to death but might not have necessarily been part of the main sequence of events leading up to the death. It is not compulsory to have entries in I(b), I(c) or II and these can be left blank. Avoid abbreviations.

Table 2.7 Causes and modes of death

Causes of death (use these terms)

Modes of death (avoid these terms)

Myocardial infarction, cardiac arrhythmia

Cardiac arrest, syncope

Sepsis, hypovolaemia, haemorrhage, anaphylaxis

Hypotension, shock, off legs

Congestive cardiac failure, pulmonary oedema

Heart failure, cardiac failure, ventricular failure

Bronchopneumonia, pulmonary embolism, asthma, chronic obstructive pulmonary disease

Respiratory failure, respiratory arrest

Cerebrovascular accident

Collapse

Cirrhosis, glomerulonephritis, diabetic nephropathy

Liver failure, renal failure, uraemia

Carcinomatosis, carcinoma of the …

Cachexia, exhaustion

Approximate interval between onset and death

This gives the sequence of events a time frame.

An example

I(a)

Pulmonary embolism

6 hours

    (b)

Fractured femur

7 days

    (c)

Osteoporosis

30 years

II

Ischaemic heart disease

30 years

The death might have been due to or contributed to by the employment followed at some time by the deceased

If you think the death was in any way related to their employment or an industrial disease you should refer the case to the coroner/procurator fiscal for their consideration.

Signing the certificate

This requires your signature and medical qualifications, alongside which your local office will usually ask you to print your name and often your GMC number. For Residence it is acceptable to enter the name of the hospital and the city. For deaths in hospital: you also need to enter the name of the patient’s consultant at the time of death.

Completing the sides

Make sure you complete the stubs on either side of the main form, copying exactly your entries off the main form.

Completing the back

If you have spoken to the coroner’s or procurator fiscal’s office, and they have decided it is appropriate for you to complete the MCCD, they may ask you to circle one of the options and initial in box A on the reverse of the MCCD.

Post-mortem

There are two types of post-mortem (PM): those mandated by the coroner or procurator fiscal, and those undertaken after a medical request (a ‘hospital PM’).

The coroner’s PM

(Procurator fiscal in Scotland.) Undertaken to find out how someone died and to inform the decision on whether an inquest is needed or not. The next of kin is informed, but not asked for permission, as the law requires a PM to be performed.

A hospital PM

This is usually undertaken at a doctor’s request to provide more information about an illness or the cause of death. Consent must be given by the patient before they died, or by the next of kin after their death. The hospital bereavement office can assist with this should you be asked to gain consent.

Cremation forms

Statute

While individual crematoria or regions may have slightly different looking cremation forms, they all follow a similar pattern and ask very similar questions.13 Guidance on how to complete cremation forms is freely available online,14 though the bereavement office will also be able to guide you and answer your questions.

Cremation form nomenclature

The main form to be completed for adult cremation is ‘Cremation 4’ (Form B in Northern Ireland)—see ‘Completing Cremation 4’ Life on the wards p. [link]. The senior doctor (who must be fully registered for >5 years) who checks and verifies the details in Cremation 4 subsequently completes ‘Cremation 5’ (Form C in Northern Ireland). Other cremation forms are available for stillbirths, and for the cremation of body parts.

Eligibility

For deaths in hospital, it is expected that the person completing Cremation 4 treated the deceased during their last illness and to have seen the deceased within 14 days of death. Medical practitioners completing Cremation 4 must hold a licence to practise with the GMC, which includes temporary or provisional registration.

Examining the body

If you are completing a cremation form you were previously required to see the body to check the patient’s identity (wrist band and physical appearance) and examine them to see if they have any implant which may cause a problem during cremation (see Box 2.10). Under the proposed reforms, this responsibility will transfer to the Medical Examiners. If you are required to view the body, check the notes, ECGs, and X-rays for possible implants, but also examine the patient for scars or palpable implants (pacemakers are usually, but not always, on the anterior chest wall). If you believe there is an implant, talk to the mortuary staff who will be able to remove it.

Remuneration

Under prior arrangements junior doctors were paid around £70 for completing the form (Life on the wards p. [link]); this fee is under review as part of the new reforms. Any fee comes from the patient’s relatives via the funeral director who keeps the money if you fail to take it. The reason you are paid is because this is not a standard NHS service and you are taking responsibility for the fact the body will not be able to be exhumed for evidence if there is any doubt in the future as to the cause of death.

Death certification, registrars, examiners, and the coroner

Steps involved in registering a death

If a medical practitioner completes the MCCD, this is given to the next of kin, usually by the bereavement office; if the doctor cannot complete a MCCD, the coroner sends the relevant paperwork directly to the registrar after establishing a cause of death to the best of his/her satisfaction, through a post-mortem and/or investigation and/or inquest. Only once the registrar has the relevant paperwork can the death be entered into the register and a death certificate issued to the next of kin, permitting a burial or cremation to take place.

Death Certification Reforms

In response to the Shipman Inquiry and more recently the Francis Inquiry, a new system is being introduced. All MCCDs will be scrutinized by a Medical Examiner, who will be able to make certain changes to the MCCD after examining the case notes or talking to staff involved in the patients care and to the individual who initially completed the MCCD, if the cause of death is inaccurate. Junior doctors may speak to their local Medical Examiner before completing the MCCD for guidance. Any case which would normally have been referred to the coroner will still be referred to the coroner, but if not accepted by the coroner will then be subsequently scrutinized by the Medical Examiner. The purpose of the Medical Examiner system is to: ensure more accurate reporting of disease processes; to better identify unusual patterns of death which may have public health or local clinical governance implications; to ensure the individual completing the MCCD understands the cause of death; and to provide an opportunity to raise other matters which might require the death to be reported to the coroner.

Medical Examiner

These are medical practitioners from any speciality background who are licensed to practise by the GMC and with at least 5 years’ experience. As well as scrutinizing MCCD and guiding doctors to complete these, they will also discuss the cause of death with the family and act on any additional information the family provides. They will work closely with the coroner’s service and registrations services, and feed information back to clinical governance structures to aid in future healthcare planning and provision.

The Coroner

The coroner15 is a government official and is usually a lawyer but may have joint degrees in law and medicine; their job is to investigate a death when the cause of death is unknown or cannot readily be certified as being due to natural causes (see Life on the wards ‘A death should be referred to HM Coroner if:’ p. [link]).

This note is for guidance only, it is not exhaustive and in part may represent desired local practice rather than the statutory requirements. If in any doubt, contact the coroner’s office for further advice.

The Coroner’s Office

This is staffed by Coroner’s Officers. They are not usually medically or legally qualified and are often serving, or ex-police officers. They take the majority of enquiries, and will filter which cases are escalated to the coroner.

Making a referral to the coroner

Any case which meets the criteria in the box should be referred to the coroner’s office for their consideration; after discussing the case, the coroner’s officer may suggest it is appropriate for the referring doctor to complete the MCCD. Occasionally the coroner’s officer will either take over the case, or wish to discuss it directly with the coroner first, and in these situations the MCCD should not be completed by the referring doctor unless instructed to do so.

To refer, or not to refer?

If you are in any doubt about whether to refer to the coroner or not, speak first to your seniors, or the local Medical Examiner for advice.

Nutrition

A patient’s nutritional state has a huge effect on their well-being, mood, compliance with treatment, and ability to heal. You should consider alternative nutrition for all patients without a normal oral diet for over 48h. iv fluids are only for hydration, they are not nutrition. See Table 2.8 (Life on the wards p. [link]) for nutritional requirements.

Table 2.8 Nutritional requirements

Name

Sources

Daily requirement

Deficiency

Carbohydrate

Almost all foods

300g

Malnutrition

Protein

Meat, dairy, vegetables, grain

50g

Kwashiorkor

Fat

Nuts, meat, dairy, oily foods

56g

Malnutrition

Calcium

Dairy, leafy vegetables

1g

Osteoporosis

Iodine

Fish, seafood, enriched salt

150micrograms

Hypothyroid

Iron

Meat, vegetables, grains

15mg

Anaemia

Magnesium

Dairy, leafy vegetables, meat

420mg

Cramps

Potassium

Fruits, vegetables

3.5g

Hypokalaemia

Selenium

Meat, fish, vegetables

55micrograms

Keshan disease

Sodium

Processed foods, salt

2.4g

Hyponatraemia

Zinc

Cereals, meat

11mg

Hair/skin problems

Vitamin A (retinoid)

Dairy, yellow or green leafy vegetables, liver, fish

900micrograms

Night blindness

Vitamin B1 (thiamine)

Bread, cereals

1.2mg

Beriberi

Vitamin B2 (riboflavin)

Meat, dairy, bread

1.3mg

Ariboflavinosis

Vitamin B3 (niacin)

Meat, fish, bread

16mg

Pellagra

Vitamin B5 (pantothenic acid)

Meat, egg, grains, potato, vegetables

5mg

Neurological problems, paraesthesia

Vitamin B6 (pyridoxine)

Meat, fortified cereals

1.7mg

Anaemia

Vitamin B7 (biotin)

Liver, fruit, meat

30micrograms

Dermatitis

Vitamin B9 (folate)

Bread, leafy vegetables, cereals

400micrograms

Anaemia

Vitamin B12 (cobalamin)

Meat, fish, fortified cereals

2.4micrograms

Anaemia

Vitamin C (ascorbic acid)

Citrus fruits, tomato, green vegetables

200mg

Scurvy

Vitamin D

Fish, liver, fortified cereals

5–15micrograms

Rickets/osteomalacia

Vitamin E

Vegetables, nuts, fruits, cereals

15mg

None

Vitamin K

Green vegetables, cereals

120micrograms

↑PT

Enteral feeding (via the gut)

Oral

Most patients manage to consume sufficient quantities of hospital food to stay healthy. If not (eg due to inability to feed self, increased demand due to malnutrition) consider simple remedies, eg assisted feeding, favourite foods from home, medications for reflux/heartburn (Life on the wards p. [link]) or nausea (Life on the wards p. [link]). If they are still not consuming adequate nutrition then discuss with the dietician who can advise on nutritional supplements and high-energy drinks.

Nasogastric (NG)

(Life on the wards p. [link] for insertion procedure) This is a good short-term measure, however placing the tube may be uncomfortable and some people find the sensation of the tube uncomfortable once it is in. Liquid foods and most oral medicines (except slow-release and enteric-coated preparations) can be given via NG tube; advice regarding medications via this route may be required from a pharmacist. Tubes can also be endoscopically placed naso-jejunally if required, eg gastric outlet obstruction.

Gastrostomy

Often called ‘PEGs’ (percutaneous endoscopic gastrostomy), these are a good long-term method of feeding for patients who cannot feed orally. They are typically sited endoscopically, though surgical and radiological approaches are possible (a radiologically inserted gastrostomy is referred to as a RIG). It is also possible to place a jejunostomy if required.

Parenteral feeding (via the blood)

Parenteral nutrition (PN) or total parenteral nutrition (tpn) requires central access because extravasation of the feed causes severe skin irritation. Central access can be via a long-line (eg peripherally inserted central catheter) or central line (eg Hickman). It is used when the patient cannot tolerate sufficient enteral feeds (eg short gut syndrome) or when gut rest is required.

There is significant risk associated with PN use including line insertion, line infection, embolism/thrombosis, and electrolyte abnormalities. It is essential to monitor blood electrolytes regularly including Ca2+, PO43–, Mg2+, zinc, and trace elements, particularly in those starting PN after a period of malnutrition (see next paragraph).

Refeeding syndrome

After a prolonged period of malnutrition or parenteral nutrition, feeds must be reintroduced slowly (over a few days) to prevent electrolyte imbalance, particularly ↓PO43–. It can be fatal but is entirely avoidable if blood tests are checked daily during the at-risk period (for 3–5d, until full feeding rate established) and any electrolyte abnormalities are corrected promptly.

Nutritional requirements

Difficult patients

Alcoholism

Patients with excessive alcohol consumption can present with a range of problems, either directly related to their alcohol abuse or to unmasking of alcohol dependency during enforced abstinence during their admission for unrelated medical problems. The assessment and management of these patients is discussed on Life on the wards p. [link].

Elderly patients

They often take many medications, making interactions and side effects more common. Declining renal function means lower doses may be needed for renally excreted drugs. Likewise, elderly patients are more prone to heart failure from fluid boluses/excessive iv fluids. Other problems include: increased susceptibility to infections; higher pain threshold (can mask fractures or other acute pathology); atypical disease presentations; poor thermoregulation (easily develop hypothermia); malnourishment (if unable to obtain/prepare food); history taking can be difficult if hard of hearing. Elderly patients can suffer with depression and other psychiatric illness (Life on the wards p. [link]) and social circumstances must always be considered prior to discharge—liaise with ot, physiotherapy, and social services.

Aggression and violence

The majority of patients have respect for NHS staff; however, under certain circumstances anyone can become aggressive:

  • Pain (Life on the wards pp. [link][link])

  • Reversible confusion or delirium, eg hypoglycaemia (Life on the wards pp. [link][link])

  • Dementia (Life on the wards pp. [link][link])

  • Inadequate communication/fear/frustration (Life on the wards p. [link])

  • Intoxication (medications, alcohol, recreational drugs)

  • Mental illness or personality disorder (Life on the wards pp. [link][link]).

The aggressive patient

Ask a nurse to accompany you when assessing aggressive patients. Position yourselves between the exit and the patient and ensure that other staff know where you are. The majority of patients can be calmed simply by talking; try to elicit why they are angry and ask specifically about pain and worry. Be calm but firm and do not shout or make threats. If this does not help, offer an oral sedative or give emergency IV sedation (Life on the wards p. [link]) or call hospital security.

The aggressive relative

Relatives may be aggressive through fear, frustration, and/or intoxication. They usually respond to talking, though make sure you obtain consent from the patient before discussing their medical details. Consider offering to arrange a meeting with a senior doctor. If the relative continues to be aggressive, remember that your duty of care to patients does not extend to their relatives; you do not have to tell them anything or listen to threats/abuse. In extreme cases you can ask security or police to remove the relative from the hospital.

Violence

Assault (the attempt or threat of causing harm) and battery (physical contact without consent) by a patient or relative is a criminal offence. If you witness an assault or are assaulted yourself, inform your seniors and fill in an incident form including the name and contact details of any witnesses. If no action is taken on your behalf, inform the police yourself.

Abuse

Abuse is a violation of an individual’s human and civil rights and may consist of a single act or repeated actions. It may be physical, sexual, financial, psychological, or through neglect. Patients of any age can be abused. Do not be afraid of asking patients how they sustained injuries or asking directly if someone caused them. Inform a senior if you suspect a patient has been abused (see Box 2.11).

Needle-stick injuries

Many doctors have received needle-stick injuries without serious consequences (see Table 2.9). However, if you have just been exposed, get advice as soon as possible.

Table 2.9 Viruses associated with needle-stick injuries

Hepatitis B

Hepatitis C

HIV

UK prevalence

<0.5%

<0.5%

<0.1%

Transmission risk

1 in 3 (without vaccine)

1 in 50

1 in 300

Vaccination

Vaccines at 1, 2, + 12mth

None

None

Post-exposure

Immunoglobulin or booster

None

Triple therapy

Immediately

Stop what you are doing. If it is urgent, phone your senior/colleague to do it. Your future health is your top priority.

Percutaneous exposure

(needle or sharp) Squeeze around the wound so that blood comes out and wash with soap and water; avoid scrubbing or pressing the wound directly.

Mucocutaneous exposure

(eyes, nose, mouth) Rinse with water (or 1L of 0.9% saline through a giving set for eyes/nose).

Within an hour

A colleague should:

  • Talk to the patient alone, explain what has happened and ask about risk factors:

    • injecting drugs, blood transfusions, tattoos or piercings in foreign countries, unprotected sex (particularly in last 3mth, in a developing country or, if male, with a man), prior testing for hepatitis B+C or hiv and the results

  • Ask to take a blood sample for testing for hepatitis B+C and hiv.

You should:

  • Phone occupational health if during office hours or go to the ED and follow their advice exactly

  • Document the event in the patient’s notes and complete an incident form.

Post-exposure prophylaxis

You may be prescribed antiretrovirals (triple therapy, within 1h), hepatitis B immunoglobulin (within 24h), or hepatitis B booster (within 24h) according to the significance of the exposure. There is currently no post-exposure prophylaxis for hepatitis C.

Over the next few weeks

The patient’s blood tests should take <2d for hiv and hepatitis b+c results. Following high-risk exposure you may be advised to have a blood test in the future (2–6mth); during this time you should practise safe sex (condoms) and not donate blood. You cannot be forced to have an HIV test. Discuss with occupational health about involvement in surgery.

Pre-op assessment

Elective patients attend pre-op clinics well before their operation to:

  • Assess the patient’s problem (ie do they still need the operation?)

  • Gauge their medical fitness for an anaesthetic and surgery

  • Request any pre-op investigations (see nice guidelines, Table 2.10)

  • Check consent (this should only be obtained by the surgeon performing the procedure or a person competent to undertake it, Life on the wards p. [link])

  • Answer any questions the patient may have.

Table 2.10 Preoperative investigations*

Ix

Indication

fbc

All major surgery, or intermediate surgery if CVS or renal disease.

Sickle-cell

All patients with a positive family history of sickle cell disease

u+e

If at risk of AKI plus (i) ASA 1 and major surgery, (ii) ASA 2 and intermediate surgery or (iii) ASA 3/4 and minor surgery

Clotting

(i) intermediate/major surgery if ASA 3/4 with liver failure, or (ii) in a patient taking an oral anticoagulant

HbA1c

All patients with diabetes and no HbA1c in last 3mth

β‎-hcg

Urine β‎-hCG if any doubt whether a patient may be pregnant

ecg

If (i) minor surgery, ASA 3/4 and none in last 12mth, (ii) intermediate surgery and cardiovascular, renal or diabetic disease and ASA 2 or (iii) major surgery, >65yr, and none in last 12mth

Echo

Any patient with a either (i) signs/symptoms of heart failure or (ii) a murmur with SOB, presyncope, syncope, or chest pain

PFT/ABG

Discuss with anaesthetist if intermediate or major surgery and ASA 3/4 due to known or suspected respiratory disease.

*nice guidelines: Life on the wardsguidance.nice.org.uk/NG45

†Surgeries are either minor (eg skin excision, breast abscess), intermediate (eg inguinal hernia, varicose vein excision, tonsillectomy, knee arthroscopy), or major (eg hysterectomy, discectomy, prostate resection, joint replacement, lung operations, colonic resection). American Society of Anaesthesiologists Physical Status Classification. ASA 1 (healthy), ASA 2 (mild systemic disease), ASA 3 (severe disease) or ASA 4 (life-threatening severe disease).

Pre-op investigations

See Table 2.10.

Requesting blood pre-op

Each hospital will have guidelines on the transfusion requirements for most elective operations; become familiar with these. Blood for transfusion is in limited supply and should only be cross-matched when necessary. Table 2.11 shows common blood requirements for elective surgery.

Table 2.11 Summary of operations and blood requirements

Blood request

Operation

No request

Minor day-case surgery (carpal tunnel, peripheral lipoma)

Group and save

Laparoscopy, appendicectomy, cholecystectomy, hernia, hysterectomy, liver biopsy, mastectomy, varicosity, thyroid

X-match 2units

Colectomy, arthroplasty, laparotomy, TURP, hip replacement

X-match 4units

Abdominoperineal resection, hepatic/pancreatic surgery

X-match 6units

Aneurysm repair (book iCu bed post-op)

Patients with medical problems

DM

(Life on the wards pp. [link][link]) Put the patient first on the operating list.

CVS

Inform the anaesthetist if patients have had recent chest pain, an undiagnosed murmur, or symptoms of heart failure. The anaesthetist may want you to request an Echo or may see the patient personally.

Rheumatoid arthritis/ankylosing spondylitis

Inform the anaesthetist as these patients may be difficult to intubate or have an unstable C-spine—the anaesthetist may want to see the patient or request radiological imaging.

Contacting the anaesthetist/ICU

Find out the anaesthetist for your patient’s list and tell them about any patients who may need further investigations or a review preoperatively. If your patient will need an ICU bed post-op inform ICU well in advance (contact details available from the anaesthetic department office) and confirm with ICU on the day that the bed is still available.

Special circumstances

Steroids

(Life on the wards p. [link]) Patients taking regular steroids must have extra steroid cover during surgery and be converted to iv preparations if nbm. Discuss each patient’s needs with your team and the anaesthetist.

Anticoagulants

Warfarin should be stopped at least 5d preoperatively, with a target INR of <1.5 for most surgery; those with prosthetic heart valves may need IV/SC heparin cover instead (Life on the wards pp. [link][link]). Stop DOACs 1d before low bleeding risk surgery or 2d before high bleeding risk surgery, except in CKD patients (CrCl <50mL/min) on dabigatran who need it holding for 2d (low bleeding risk surgery) or 4d (high bleeding risk surgery). Seek haematology advice if unsure. Those needing spinal/epidural anaesthetics may have different rules—discuss with the anaesthetist.

Antiplatelets

Clopidogrel must be stopped 7–10d before surgery; aspirin is usually continued unless otherwise instructed by senior surgeon (if in doubt check with the operating surgeon/consultant).

Oestrogens and progestogens

hrt can be continued as long as dvt/pe prophylaxis is undertaken. Progestogen-only contraceptives can be continued, but combined oral contraceptives should be stopped 4wk prior to surgery and alternative means of contraception used.

Bowel preparation

See Table 2.12 Life on the wards p. [link].

Table 2.12 Procedures and the potential need for bowel preparation

Bowel preparation

Procedure

None

OGD, ERCP, closure (reversal) ileostomy

Phosphate enema (on day of surgery)

Anal fissure, haemorrhoidectomy, examination under anaesthetic (sigmoid colon/rectum/perianal area), flexible sigmoidoscopy

Full bowel prep (see Box 2.12)

Colonoscopy, rectopexy, right hemi-/left hemi-/ sigmoid/pancolectomy, anterior resection, abdominoperineal resection, Hartmann’s reversal

Writing the drug chart

Try and do this at pre-admission clinic to save yourself time later. Document any allergies. Things to check include:

Prophylactic anticoagulation

(Life on the wards pp. [link][link]).

Antibiotics

Consider pre-op antibiotics (check local guidelines).

Bowel preparation and IV fluid

(Life on the wards p. [link]).

Regular drugs

Review these and write up those which should be continued in hospital (stop cocp, clopidogrel as above, etc).

TED stockings

Prescribe these for all patients.

Analgesia and antiemetics

(Life on the wards pp. [link][link] and Life on the wards pp. [link][link]) The anaesthetist will usually write these up during the operation.

Instructions for the patient

  • Where and when to go for admission (write this down for them)

  • If they are to have bowel prep, they should usually be on clear fluids at least 24h before the operation (Life on the wards p. [link])

  • Tell the patient about any drains, ng tubes or catheters which may be inserted during the operation

  • Tell them if they are being admitted to iCu post-op.

Bowel preparation

Before endoscopy and some gi surgery procedures, patients are given laxatives to clear the bowel (Table 2.12). For surgery, the aim is to reduce the risk of post-op anastomotic leak and infections. Accumulating evidence suggests that it does not improve complication rates and may even be harmful,17 hence use of bowel preparation prior to surgery is declining. Check your local policy for guidance. Where bowel preparation is required, it is vital that patients are instructed properly and the importance of good compliance is stressed. For example, during colonoscopy inadequate bowel preparation can lead to pathology being missed or the procedure being aborted (see Box 2.12).

Surgical terminology

Prefix/suffix

Meaning and example

Angio-

  • Relating to a vessel

  • Angioplasty—reconstruction of a blood vessel

Chol-

  • Relating to the biliary system

  • Cholecystitis—inflammation of the gallbladder

Hemi-

  • Meaning half of something

  • Hemicolectomy—excising half the colon

Hystero-

  • Relating to the uterus

  • Hysterectomy—removal of the uterus

Lapar-

  • Relating to the abdomen

  • Laparotomy—opening the abdomen

Nephr-

  • Relating to the kidney

  • Nephrotoxic—damaging to the kidney

Pan-

  • Total/every

  • Pancolectomy—complete removal of the colon

Per-

  • Going through a structure

  • Percutaneous—going through the skin

Peri-

  • Near or around a structure

  • Perianal—near the anus/around the anus

Proct-

  • Relating to the rectum

  • Proctoscopy—examination of the rectum

Pyelo-

  • Relating to the renal pelvis

  • Pyelonephritis—inflammation of the renal pelvis

Thoraco-

  • Relating to the thorax

  • Thoracotomy—opening the thorax

Trans-

  • Going across a structure

  • Transoesophageal—across the oesophagus

-ectomy

  • Surgical excision

  • Nephrectomy—removal of a kidney

-gram

  • A radiological image often using contrast medium

  • Angiogram—contrast study of arteries

-itis

  • Inflammation of an organ

  • Pyelonephritis—inflammation of the renal pelvis

-olith

  • Stone-like

  • Faecolith—solid, stone-like stool

-oscope

  • A device for looking inside the body

  • Sigmoidoscope—device for looking into the distal colon

-ostomy

  • An artificial opening between two cavities or to the outside

  • Colostomy—opening of the colon to the skin

-otomy

  • Cutting something open

  • Craniotomy—opening the cranium (skull)

-plasty

  • Reconstruction of a structure

  • Myringoplasty—repair of the tympanic membrane

Preparing in-patients for surgery

Checklist

Before your patient goes to theatre, you have a responsibility to check the following have been done:

  • The consent form has been signed by the patient and surgeon

  • The patient has been seen by the anaesthetist

  • The operation site has been marked by the surgeon (imperative if the operation could be bilateral, eg inguinal hernia repair)

  • The preoperative blood results are in the notes

  • The preoperative ecg and/or cxr are available

  • Prophylactic lmwh, ted stockings, and antibiotics have been prescribed where relevant (do not give heparin <12h pre-op if having spinal/epidural)

  • The patient has received bowel preparation if necessary

  • The patient has been adequately fasted (see next section)

  • Blood has been crossmatched and is available if required (Life on the wards pp. [link][link])

  • Check if the patient has any last-minute questions or concerns and is still happy to proceed with the operation.

Oral fluids pre- and post-op

In general, patients should not eat for at least 6h before going to theatre but can have clear fluids until 2h. In emergencies this rule may be overruled, but the risk of aspiration of gastric contents will be increased.

If patients are having an operation which requires bowel preparation, check local guidelines as to what oral intake the patient is allowed while taking the laxatives, usually it is either clear fluids only or a low-residue diet (Life on the wards p. [link]).

Nil by mouth (NBM)

Patients cannot have any oral food or significant fluid intake; hydration must be maintained with iv fluids. However, oral medication (eg antiarrhythmics) may be taken with a sip of water, if not taking them would put the patient at more risk. Non-essential medication such as vitamin supplements may be omitted; check with your seniors.

Clear fluids

Include non-carbonated drinks such as black tea, black coffee, water, squash drinks (not milk or fruit juice).

Sips

30mL water/hour orally, usually given for the first day after major abdominal surgery involving bowel anastomoses.

Soft diet

This includes food such as soup and jelly. Once patients have been tolerating clear fluids postoperatively for at least 24h, they may be allowed to start a soft diet.

Most patients can safely drink clear fluids up to 2h before surgery. The following increase the risk of aspiration:

  • Pregnancy

  • Being elderly

  • Obesity

  • Stomach disorders, eg hiatus hernia, reflux

  • Pain (+ opioids).

Booking theatre lists

The operating theatre

Theatre design

Operating theatres include an operating area, a scrubbing-up area, a preparation room, a sluice (area for dirty equipment and dirty laundry), and an anaesthetic room. There will also be a whiteboard (to document date, operation, and number of swabs/blades/sutures used), a display system for viewing radiology, and an area to write up the operation notes and histopathology forms. Above the operating table, there are usually main sets of lights, as well as smaller, more mobile units (satellites).

Theatre staff

Each operating theatre has a team of assistants who clean and maintain the theatre. The ‘scrub nurse’ scrubs for each operation to select instruments as requested by the surgical team. One other trained nurse and an auxiliary nurse act as ‘runners’ to fetch equipment for the scrub nurse and to monitor the number of swabs and sutures used (displayed on the whiteboard). An operating departmental assistant (oda) maintains the anaesthetic equipment and assists the anaesthetist. Each operation is logged, with details of the patient, name of the operating surgeon, patient’s consultant, and anaesthetist.

Theatre clothing

Fresh scrubs should be worn for each operating list and should be changed between lists, or between cases if they become dirty or potentially infected with mrsa. Theatre shoes are essential for safety purposes and you will not be allowed to enter without them. Theatre scrubs and shoes should not be worn uncovered outside of theatres except in an emergency.

Scrubbing up

Scrubbing up is an art and a key part of minimizing infection risk to the patient. If in doubt, a theatre nurse can show you how to do it.

  • Prior to scrubbing, remove jewellery and put your mask and a theatre hat on

  • Open a gown pack and drop a pair of sterile gloves on top

  • When scrubbing up for the first patient, scrub under your nails using a brush with iodine or chlorhexidine. Wash hands for a further 5min

  • Unravel your gown; ensure that it does not touch the floor

  • Touching its inner aspects only, put it on with the end of the sleeves covering your hands

  • Put on your gloves. Do not touch the outside of your gloves with your bare hands

  • For high-risk operations (eg Caesarean, hiv +ve) double-glove and protect your eyes with a visor or safety spectacles

  • Wait for an assistant to tie your scrub gown from behind

  • If your hand becomes non-sterile, change your glove. If your gown becomes non-sterile you need to rescrub; change your gown and gloves.

Theatre etiquette

  • If you are scrubbed up:

    • ask someone not scrubbed to adjust the lights for you

    • do not pick up instruments which fall to the ground

    • if you are handed an instrument by someone who is not scrubbed, check that you can touch it before accepting it

  • In operations involving the abdomen and the perineum, if you are asked to move from the perineum to the abdomen you must rescrub. This is not necessary when swapping from abdomen to perineum

  • If you sustain a needle-stick injury, leave the operation and report to occupational health (Life on the wards p. [link])

  • Always eat/drink and go to the toilet before going to an operating list.

Watching an operation

Make sure you can see; get a stool or stand at the patient’s head if the anaesthetist allows. Although you are not actively participating in the operation, use the time to learn surgical techniques. If you can’t follow what’s going on, ask. As the operation finishes, fill in any histology forms or ttos if appropriate. Check histology samples are labelled accurately.

WHO Surgical Safety Checklist

In 2009, the NPSA released guidance on the WHO Surgical Safety Checklist, a process by which all members of the theatre team have a discussion about the operation and the patient in advance of undertaking the procedure. The aim of this is to improve patient safety and prevent errors such as wrong-site surgery, retained throat-packs, avoidable delays in obtaining blood products, or senior help should an unexpected incident arise. Most trusts have devised their own checklist so these vary between hospitals, but are all based on the NPSA guidance.18

The checklist is read out loud before the anaesthetic is given, before the operation starts, and after the operation is completed. Before the operation everyone in theatre introduces themselves, the patient’s details, the procedure about to take place, and the site are confirmed, relevant equipment is checked to be present, and VTE prophylaxis measures are declared. At the checkout after the operation, swab counts, instrument and sharps counts are checked, the operation note is confirmed, and specimens labelled. Plans for postoperative management are also confirmed.

Post-op care

As well as seeing patients preoperatively, you should review them after the operation. This means you can review and discharge day cases with your team, as well as making sure the in-patients are stable after the operation.

Discharging day cases

(This may be done by nursing staff.)

Before

sending day surgery patients home, you should make sure they are alert, have eaten and had fluids without vomiting, have passed urine, are mobilizing without fainting, and have adequate pain relief. Inspect the operation site and check their observations. Go through the operation procedure, findings, and follow-up with the patient.

Organize

appropriate follow-up care and clarify if they need dressing changes, suture removal dates, and where this can be done (gp surgery, ed, or ward). If the patient develops any post-op temperatures, pain, or bleeding, they should contact their gp or come to the ed.

Common questions about discharge

  • Patients can self-certify as unfit for work for up to a total of 7d (including time spent as in-patient); if you anticipate required time off work will routinely be longer than this, issue a Fitness to Work/Med 3 note (Life on the wards p. [link]) for the total expected time; this is the responsibility of the hospital team, not the patient’s GP. Unanticipated extensions to the recovery period can be handled by the GP

  • Patients requiring proof of hospital admission (for sick pay or social security payments) should be issued with a Form Med 10 (Life on the wards p. [link])

  • Tell the patient if their sutures are dissolvable or if they need to return to have them removed (give dates; often GP practice nurses will do this)

  • Patients can shower and commence driving again 48h after minor surgery (as long they can perform an emergency stop; Life on the wards p. [link])

  • Advise patients not to fly for 6wk following major surgery.

In-patient post-op care

Post-op

patients are at risk of complications associated with the operation, either directly (eg haemorrhage) or indirectly (eg pe).

When reviewing

post-op patients, document the number of days since the operation and the operation they underwent (eg 2d post left mastectomy).

Ask about

pain, ability to eat and drink, nausea/vomiting, urinary output and colour, bowel movements/flatus, mobilization.

Examine

wound site, chest, abdomen, legs, drains, stoma bags, iv cannulae, catheter bag, drain entry site, amount drained, colour of any fluid being drained.

Look at the observations:

pyrexia, hr, bp, RR, 24h fluid balance (total input and output (including drains) and net balance); document all findings.

Review the drug chart

for analgesia, antibiotics, fluids.

Check

postoperative Hb; transfuse if necessary (Life on the wards pp. [link][link]).

Involve

other members of the MDT if necessary, eg stoma nurse, pain team, physiotherapists, social worker, occupational therapist.

Post-op problems

Hypotension

(Life on the wards pp. [link][link])

Ask about

Pre-op bp, fluid input, epidural, drugs, pain.

Look for

Repeat bp, hr, fluid input/urine output, temperature, gcs, orientation, skin temp, cap-refill, signs of hypovolaemia/sepsis, wounds, drain, abdomen, any signs of active bleeding.

Management

Hypotension is common post-op and does not always require intervention. Tachycardia is a worrying feature suggesting shock. If this or other adverse features are present do 15min obs and monitor hourly urine output (catheterize bladder). Lie the patient flat, and give oxygen. Get iv access, consider fluid challenge (eg 500mL crystalloid STAT, Life on the wards p. [link]). Send bloods for fbc and crossmatch (blood cultures if you suspect sepsis). Apply pressure to any obvious bleeding points. Call for senior review early.

Pyrexia

Temp 37.5°C, investigate if this persists/increases after the first 24h post-op (Life on the wards pp. [link][link]; see Box 2.16).

Ask about

Cough/sob, wound, dysuria/frequency, abdo pain, diarrhoea.

Look for

bp, hr, temp, wound, catheter, iv cannulae, chest, abdomen.

Management Urine

M,C+S;

blds

fbc, u+e, crp, blood cultures;

Imaging

cxr, consider abdominal uss or ct, echo if new-onset murmur.

Shortness of breath/↓O2 sats

(Life on the wards pp. [link][link])

Ask about

Chronic lung/cvs disease, previous pe, chest pain, ankle swelling, new-onset cough.

Look for

bp, hr, temp, pallor, lungs (consolidation, crackles, air entry), signs of fluid overload, leg oedema/calf swelling.

Management

Sit up and give O2;

blds

fbc, abg;

cxr, ecg.

Consider 0.9% saline nebs, antibiotics and regular chest physiotherapy. If you suspect a pe (Life on the wards p. [link]) call for senior help and specialist advice (medical registrar on-call). See also Box 2.17.

Wound management

Types of wound healing

Primary closure

This is most common in surgery, where wound edges are opposed soon after the time of injury and held in place by sutures, Steri-Strips™, or staples. The aim is to minimize the risk of wound infection with minimal scar tissue formation (Table 2.13).

Table 2.13 Abdominal wound complications

Ask about

Examine

Management

Superficial dehiscence

Pink serous discharge, burst sutures

Skin and fat cavity exposed (rectus sheath closed)

Not an emergency but ask for senior review—wound may need packing ± antibiotics

Deep dehiscence

Pink serous discharge, haematoma, bowel protrusion

Separation of wound edges with bowel exposed

Call for senior help urgently. Cover the bowel with a large sterile swab soaked in 0.9% saline. Check analgesia and fluid replacement, give antibiotics

Infection

Pyrexia, pain, erythema, white, yellow or bloody exudate from wound site

Tenderness, odorous discharge, swelling

Wound swab, broad-spectrum antibiotics initially (Life on the wards p. [link]), discuss with your senior

Delayed primary closure

This is more commonly used in ‘dirty’ or traumatic wounds. The wound is cleaned, debrided, and then initially left open for 2–5d. Antibiotic cover may be given until the wound is reviewed for closure.

Secondary closure

This is much less commonly encountered in surgery. Healing by secondary intention happens when the wound is left open and heals slowly by granulation. This is used in the presence of large areas of excised tissue, infection, or significant trauma, where closing the wound would be impossible or would give rise to significant complications.

Common elective operations

Laparoscopic cholecystectomy

Operation to remove the gallbladder.

Indications

Symptomatic gallbladder stones, asymptomatic patients at risk of complications (diabetics, history of pancreatitis, immunosuppressed).

Pre-op

No bowel prep required, 6h fasting pre-anaesthetic (Life on the wards p. [link]).

Procedure

This involves insufflating the abdomen with CO2, inserting 3 or 4 ports through the anterior abdominal wall to enable laparoscopy and the use of operating instruments to remove the gallbladder.

Post-op

Patients can eat as soon as they recover from the anaesthetic, can usually go home later in the day or the following morning. Not all patients are followed up; some consultants like to review patients in clinic after 6–8wk.

Complications

Haemorrhage, wound infections, bile leakage, bile duct stricture, retained stones; may require conversion to more major open surgery.

Colectomy

Operation to remove part or all of the colon (Fig. 2.11).


Fig. 2.11 Common large bowel resections (the shaded area represents the section of colon removed during the operation).

Fig. 2.11 Common large bowel resections (the shaded area represents the section of colon removed during the operation).

Indications

Malignancy, perforation, ibd which can no longer be managed medically.

Pre-op

Full bowel prep rarely required, 6h fasting pre-anaesthetic (Life on the wards p. [link]).

Procedure

This involves a midline longitudinal laparotomy incision and resection of the diseased bowel if done open, can be done laparoscopically. A stoma may or may not be formed.

Post-op

Sips of fluid orally for 24h post-op, gradually built up to free fluids and then light diet. Hospital stay 3–7d (‘enhanced recovery pathways’ used to streamline post-op recovery). All patients followed up in clinic.

Complications

Haemorrhage, wound infection, wound dehiscence, anastomotic leak.

Anterior resection

Operation to resect the rectum with a sufficient margin (usually 5cm) and anastomose the left side of the colon with the rectal stump. See Fig. 2.12.

Indications

Rectal carcinoma.

Pre-op

Full bowel prep rarely required, phosphate enema 1h pre-op, 6h fasting pre-anaesthetic (Life on the wards p. [link]).

Procedure

This involves a midline longitudinal laparotomy incision and resection of the diseased rectum if done open. Can be done laparoscopically.

Post-op

Sips of fluid orally for 24h post-op, gradually built up to free fluids and then light diet. Hospital stay 4–10d. All patients followed up in clinic.

Complications

Haemorrhage, wound infection, wound dehiscence, anastomotic leak.

Abdominoperineal resection (AP resection)

Operation to resect the rectum/anus and form a permanent colostomy. See Fig. 2.13.

Indications

Low rectal carcinoma where it would be impossible to resect the tumour without removing the anus, can also be performed as part of a panproctocolectomy for ulcerative colitis.

Pre-op

Full bowel prep rarely required, phosphate enema 1h pre-op, 6h fasting pre-anaesthetic (Life on the wards p. [link]), stoma nurses to be involved.

Procedure

This involves a midline longitudinal laparotomy incision and resection of the diseased rectum and anus.

Post-op

Sips of fluid orally for 24h post-op, gradually built up to free fluids and then light diet. Hospital stay 4–10d. All patients followed up in clinic.

Complications

Haemorrhage, wound infection, wound dehiscence, stoma retraction.

Stomas

Colostomy

Common locations

LIF or right hypochondrium.

Features

May be permanent or planned for subsequent reversal; mucosa sutured directly to skin.

Output

Soft/solid stool; intermittently passed.

Indications

Colorectal cancer, diverticular disease, trauma, radiation enteritis, bowel ischaemia, obstruction, Crohn’s disease.

Ileostomy

Common locations

RIF.

Features

May be permanent or planned for subsequent reversal; bowel mucosa sutured to form a ‘spout’ to avoid skin contact with bowel contents which are irritating (not flush with skin).

Output

Liquid stool (may be bile-stained); passed continuously.

Indications

GI tract cancer, IBD, trauma, radiation enteritis, bowel ischaemia, obstruction.

Urostomy

Sometimes referred to as a nephrostomy if originating in renal pelvis.

Common locations

Left or right flank, lower anterior abdominal wall.

Features

A ureteric catheter may be protruding from the skin into the stoma.

Output

Clear urine passed continuously.

Indications

Renal tract cancer, urinary tract obstruction, spinal column disorders, hydronephrosis, urinary fistulae.

Common complications

  • Electrolyte/fluid imbalance (Life on the wards pp. [link][link])

  • Ischaemia/necrosis shortly after formation

  • Obstruction/prolapse/parastomal hernia

  • Skin erosion/infection

  • Psychosocial implications.

It is important to refer patients who are likely to need stomas to the stoma care nurse prior to the operation. Patients with stomas also need to alter their diet to avoid excess flatulence or overly watery stool, so should also be referred to the dietician. Troublesome ‘high-output’ stomas leading to fluid balance problems or excessive need for bag emptying require specialist gastroenterologist advice.

Notes:

2 Non-urgent outpatient referrals to other specialties should go through the patient’s GP, since payment comes from their budget. If this is required, a note should be made on the discharge summary with specific details of why this referral is being recommended. Urgent referrals (especially for suspected malignancies) can still be made directly. Check with the consultant recommending the referral.

3 Converting low-dose radiation exposure to cancer risk is fraught with difficulty; attempts to extrapolate from cancer rates in those exposed to very high dose radiation are unsound. The general principle must be to keep exposure As Low As Reasonably Possible (ALARP).

4 NICE guidelines available at Life on the wardsguidance.nice.org.uk/CG173

9 Good P, et al. Medically assisted hydration to assist palliative care patients. Cochrane Database Syst Rev 2014;4:CD006273. Life on the wardswww.cochrane.org/CD006273/SYMPT_medically-assisted-hydration-to-assist-palliative-care-patients

10 Academy of Medical Royal Colleges ‘A Code of Practice for the Diagnosis and Confirmation of Death’, 2010. Life on the wardshttp://www.aomrc.org.uk/publications/reports-guidance/ukdec-reports-and-guidance/code-practice-diagnosis-confirmation-death/

11 Henry C, Wilson J. Personal care at the end of life and after death. Nursing Times 8 May 2012, available free online at: Life on the wardswww.nursingtimes.net/Journals/2012/05/08/h/i/z/120805-Innov-endoflife.pdf

12 As part of the reforms to death certification that are being proposed, the new role of Medical Examiner (Medical Reviewer in Scotland) will provide an additional source of advice (Life on the wards p. [link]).

13 In Scotland, the information previously contained on the cremation form will be included on the revised MCCD. Arrangements in the rest of the UK are under review.

15 The term ‘coroner’ as used here applies to the coronial service in use in England and Wales and Northern Ireland, as well as the role of the Procurator Fiscal in Scotland. Although these are all covered by different legislation, the same basic roles and rules apply. Likewise the new role of ‘Medical Examiner’ in England and Wales is equivalent to ‘Medical Reviewer’ in Scotland.

16 Taken from: Dorries, C.Coroners’ Courts: A Guide to Law and Practice, 3rd edition, Oxford University Press, 2014.

17 Guenaga K, et al. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev 2005;1:CD001544.