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Created by Dr Brian Ng (FY3)
Visual summary created by Dr Brian Ng (FY3)

Introduction

• Breaking bad news is a crucial skill to practice for exams and clinical practice.
• At any stage in their training, doctors will find themselves conveying difficult information to patients and/or family members.
• To be able to communicate distressing news requires sufficient preparation and practice which we will cover in this article.
• A helpful acronym, SPIKES may be used to structure the consultation to ensure all tasks are met.

S – Setting the scene

Firstly, before you speak to the patient it is important to choose an appropriate setting to initiate the consultation. In a hospital this is normally a side room or an enclosed space where there is privacy. Aim to have both the patient and yourself sitting down with chairs at a 45 degree angle which would help to put them at ease. Ensure you have sufficient knowledge of the information you would like to deliver to the patient to be able to support the patient going forwards and answer any questions they may have. If appropriate, you can ask the patient if they would like anyone in the room with them, either a family member of a relevant healthcare professional.

Ensure you introduce yourself, check the patient’s details, explain the purpose of the consultation and gain consent to proceed.

P – Perception

It is a good idea to begin by discussing the patient’s level of understanding of why they are here and their current knowledge about their health journey. This will give you a good standpoint to know how to continue with the consultation.

I – Invitation

Ask the patient whether they wish to know the details of their medical condition/situation. In exams, the answer will always be yes but in reality patients may choose to not want to hear bad news until at a later stage when they are ready.

K – Knowledge

It is important to remember these things when delivering the bad news:

• Do not jump straight into the bad news, always prepare the patient by telling them you have unfortunate news. This can be best done by referring back to what the patient knows then transitioning into what you know now.
• Use simple language that the patient can understand, not medical jargon.
• Deliver the information in sizeable chunks as when patients are upset it can slow down rate of comprehension.
• Allow the patient time to grieve and make them comfortable with pauses so they have space to react.
• Do not give false hope that will make them feel better momentarily. This can be seen as lying and potentially be used against you in the future.

E – Emotion

Recognising and responding to the patient’s emotions is key. People react in a variety of ways, they may have an outburst of grief, become angry or fall silent to bad news. Being able to respond to these is important. 

Identifying the source of emotion will be important to know how to react effectively. Most of the time, allowing the patient to express their feelings and then giving an empathetic response will make them feel heard. Additionally, do not underestimate the importance of active listening. Most of the time patient’s want to feel listened to rather than being spoken to. 

It is important to respect the patient’s preferences and to involve them in the decision-making process. This includes discussing the options available for managing the situation, and emphasizing the importance of making a decision that feels right for the patient. 

S – Summary

Being prepared to close the consultation is just as important as opening the consultation. Remember to always ask them if they have any questions or want any further clarification. At this point the patient would have had some time to adjust to the bad news so may have many questions for you. 

Before you end, offer an agenda for the next meeting. This will make the patient feel safe knowing that there is a clear plan moving forward. This could be arranging another consultation, referring the patient onto a specialist and/or signposting them useful links/leaflets that will explain things in more depth. 

Breaking bad news can be a difficult and emotional experience for both the healthcare professional and the patient. Whether it is a diagnosis of a serious illness, a change in a patient’s condition or the loss of a pregnancy, delivering bad news requires sensitivity, empathy and a clear and concise approach. By following these steps, healthcare professionals can help to reduce the emotional impact of bad news and support the patient through the difficult process.

References

1. https://www.gmc-uk.org/education/standards-guidance-and-curricula/guidance/reflective-practice/breaking-bad-news

2. https://northyorkshireccg.nhs.uk/wp-content/uploads/2021/02/Top_tips.pdf

3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5578619/

Author – Mohona Sengupta  

Editor – James Mackintosh

Last updated 20/05/23

Introduction

Contraception is a critical aspect of reproductive health care. With a variety of methods available, it is important for healthcare providers to effectively counsel patients about the options available and help them choose a method that is suitable for their individual needs. In this article, we will discuss the key considerations for counselling patients about contraception.

It is important to explore the patient’s preferences during the consultation as well ask them general questions to better understand what method of contraception is best for them. Some examples of questions to ask are:

1. What do you know about contraception?

2. What are the different methods of contraception?

3. Have you used contraception before, and if so, what worked well and what did not?

4. Is there anything that concerns you regarding contraception?

5. Why do you want to take contraception?

Furthermore, there are some questions which you, as the healthcare professional, may want to ask the patient to understand which contraceptive method would suit them:

1. Are you currently sexually active and looking to prevent pregnancy?

2. Do you have any medical conditions or allergies? (this may impact choice of contraception)

3. Are there any religious or cultural considerations that we need to take into account?

The patient may have concerns and misconceptions about contraception, and it is important for healthcare providers to address these in a compassionate manner, avoiding medical jargon as much as possible. Some of the most common concerns include:

– The potential side effects of each method being considered

– The effectiveness rate of each method being considered

– The advantages and disadvantages of each method being considered

– The contraindications of each method being considered

Types of Contraception

There are many different methods of contraception available. Some of the most commonly used ones include:

1. Hormonal methods: this includes birth control pills, patches, injections, and vaginal rings.

2. Barrier methods: this includes condoms, diaphragms and cervical caps.

3. Long-acting methods: this includes intrauterine devices.

4. Natural family planning: this involves monitoring fertility signs such as basal body temperature and observation methods to determine the fertile window.

5. Sterilisation: this includes female sterilisation (tubal ligation) and male sterilisation (vasectomy).

For a full overview of contraception-specific contraindications see UKMEC guidance: https://www.cosrh.org/Public/Public/Standards-and-Guidance/Method-Specific.aspx?hkey=245db426-eea3-4aa6-9bdf-d455d7ea6ab3.

After providing the relevant information about the different methods of contraception, the patient is better informed to choose a method that works for them. It is important to note that a healthcare professional’s discretion is needed in these scenarios, taking into account the preference, medical history, current medical problems, allergies and past contraceptive efficacy.

References
 
1. https://bnf.nice.org.uk/treatment-summaries/contraceptives-hormonal/ 

2. https://bnf.nice.org.uk/treatment-summaries/contraceptives-non-hormonal/ 

3. https://www.nhs.uk/conditions/contraception/

4. https://www.cosrh.org/Public/Public/Standards-and-Guidance/Method-Specific.aspx?hkey=245db426-eea3-4aa6-9bdf-d455d7ea6ab3

Author – Mohona Sengupta  

Editor – James Mackintosh

Last updated 16/06/26

Introduction

Breastfeeding is often regarded as vital component of baby and maternal bonding, yet many new mothers may face challenges in establishing breastfeeding due to various reasons. As healthcare professionals, it is imperative to understand the underlying causes of breastfeeding difficulties, employ effective assessment techniques, and provide comprehensive management strategies to support both mother and child.

Reasons for breastfeeding issues

1. Latch Issues: Improper latch is one of the most common reasons for breastfeeding difficulties. This may result from factors such as tongue-tie, palate abnormalities, or positional problems.
2. Insufficient Milk Supply: Some mothers may experience challenges in producing an adequate milk supply due to use of certain medications, lack of sleep, alcohol use or recent breast surgery.
3. Engorgement and Mastitis: Painful engorgement or infections like mastitis can make breastfeeding uncomfortable or even painful for the mother.
4. Nipple Pain or Damage: Sore, cracked, or bleeding nipples can deter mothers from continuing to breastfeed.
5. Medical Conditions in Mother or Infant: Certain medical conditions, such as hormonal imbalances or congenital issues in the infant, may hinder successful breastfeeding

Approach as a medical professional

As a healthcare professional, you are likely to encounter this problem in primary care. As a GP or doctor in foundation training, it is important to begin by obtaining a detailed history, including prenatal, birthing, and postnatal experiences. Alongside this, gathering a full past medical history, drug history and social history will ensure you are able to better understand the patient, who is the mother in this scenario.

Next, it is a good idea to examine the patient, focusing on the breasts and nipple conditions as well as the infant’s oral anatomy. If it is possible, observation of a feeding session would be very useful to evaluate latch, positioning and infant behaviour.

One of the main concerns with breastfeeding difficulties, is adequate growth and nutrition the infant. Therefore, at the appointment ensure baby’s height, weight and diaper output is recorded and plotted in the Red Book.

Management

Management will be guided by the underlying cause; however we will explain general management for new mothers experiencing non-pathological breastfeeding difficulties.

1. Education and Support: Provide thorough education on breastfeeding techniques. This can be in the form of educational resources, helplines and signposting to midwives or health visitors who would be in a better position to assess and offer advice on techniques. If you feel that the mother may benefit from emotional encouragement, it would be appropriate to share resources on support groups if they need it.
2. Addressing Latch and Positioning: Every new mother is offered health visits and a personal midwifery contact. They are available to offer goal-orientated breastfeeding advice and as they will likely meet you more often throughout your breastfeeding journey than doctors, they would be the best point of contact to offer practical demonstrations and gentle corrections to ensure correct technique.
3. Monitoring Milk Supply: Implement a plan to monitor milk production, which may include regular weighing of the infant and assessing diaper output. As a safety net, scheduling a future appointment with mother and baby would be appropriate.

Conclusion

By understanding the potential causes of breastfeeding difficulties and employing a comprehensive assessment approach, healthcare professionals can play a pivotal role in supporting mothers and infants on their breastfeeding journey. Providing empathetic, individualized care and collaborating with relevant experts can make a significant difference in the success and satisfaction of breastfeeding experiences for both mother and child.

References
 
1. https://www.nhs.uk/conditions/baby/breastfeeding-and-bottle-feeding/breastfeeding-problems/

2. https://cks.nice.org.uk/topics/breastfeeding-problems/

3. https://www.nhs.uk/conditions/baby/breastfeeding-and-bottle-feeding/breastfeeding/

4. https://www.laleche.org.uk/supporting-a-breastfeeding-mother/

Author – Mohona Sengupta  

Editor – James Mackintosh

Last updated 10/10/23

“Is there a doctor on board?”  

In-flight medical emergencies (IMEs) are relatively common events, occurring in approximately 1 in 600 commercial flights. With increasing air travel, healthcare professionals are more likely to be called upon to assist during a flight. It is a uniquely challenging pre-hospital experience in an unfamiliar environment, with limited resources and altered physiology of cabin pressure. It is therefore useful to have a systematic approach to differentiate the various common presentations in an IME.  

Medico-legal Concern

You heard the request and felt compelled to help. As you are going to volunteer, you remember you’ve just enthusiastically gurgled down a generous serving of in-flight wine (or was it two?) After a brief reflection, you deem yourself unfit and decide your skills are better redirected to enjoying the in-flight entertainment.  

You are absolutely right, as you are at risk of misconduct! The best practice of medicine does not differ from in-land practice. You should always act within your competence and capabilities.

Legal liability is often the main concern for healthcare professionals when volunteering in an IME. The legal consideration varies across different airlines and their respective jurisdiction. Here are the key principles to note according to the General Medical Council and the International Civil Aviation Organisation:  

• There is no legal obligation to respond to an IME in the UK, only an ethical expectation.  

• Airlines generally welcome any medical help – physicians, physician assistants, nurses, advanced nurse practitioners, and paramedics.  

• Act within your competence and identify with your real name and profession. No further personal information is needed.  

• Always seek patient consent and document clearly using the resources available.  

• You do not lead a decision to make an emergency landing – the final decision is made collaboratively between the captain, cabin crew, and ground-based medical support.  

• Most countries have Good Samaritan protections, and litigation against help is very rare if the person acted in good faith, within competence, and with no resultant gross negligence.  

Tip: If you are travelling on a US-operated airline, the Aviation Medical Assistance Act will cover you from any medicolegal issues if you volunteer to assist during an in-flight medical emergency.  

The In-Flight Environment: What makes it different?

Understanding the unique physiology and logistics of flight is essential before addressing specific conditions. Cabin pressure is equivalent to an altitude of 6,000 to 8,000 feet. As such, arterial oxygen saturation is expected to fall to around 90-93% in healthy individuals. The difference in pressure causes expansion of trapped air due to barotrauma, eventually worsening some conditions such as pneumothorax, bowel obstruction, sinus or ear diseases. Most commercial aircraft carry a basic first aid kit, an enhanced emergency medical kit, an automated external defibrillator, and supplemental oxygen. However, content may vary by jurisdiction. Due to the limitations in physical space and resources, all airline medical emergencies are communicated to ground-based medical services, who will liaise with the pilot and the crew and assist the clinician in real time.  

Common In-Flight Medical Emergencies

The following is a list of the most common in-flight medical presentations according to the literature:  

Syncope and Presyncope 

In-flight syncope and pre-syncope are the most common presentations. They are usually benign, often resulting from dehydration, prolonged immobility, or a vasovagal response. Passengers may report dizziness, nausea, sweating, or visual dimming before a transient loss of consciousness. Causes include vasovagal, dehydration, orthostatic hypotension, hypoxia, and alcohol. Management includes lying supine with leg elevation, loosening of tight clothes, administration of supplemental oxygen (if indicated), encouraging fluid intake if alert, and monitoring blood glucose level.  

Gastrointestinal  

In-flight gastrointestinal conditions commonly include nausea, vomiting, diarrhoea, and abdominal pain, often related to motion, anxiety, or foodborne illness. More serious causes, such as gastroenteritis, peptic ulcer disease, or even early appendicitis, should be considered. Management usually comprises antiemetics, oral hydration and supplemental oxygen if indicated. It is important to consider red flag symptoms such as fever, persistent vomiting, localised or severe abdominal pain, peritoneal signs and gastrointestinal bleed as they may influence the decision to divert the flight.  

Chest Pain and suspected cardiac event  

In-flight chest pain may arise from benign causes such as musculoskeletal strain or reflux, but serious conditions like acute coronary syndrome (ACS), arrhythmia or pulmonary embolism must be considered. It is therefore essential to take a focused history and examination to ascertain the likely cause of chest pain and communicate promptly with the ground-based medical team. Consider initiating treatment such as aspirin in suspected ACS, glyceryl trinitrate (if blood pressure permissible), oxygen supplement and analgesia.  

Respiratory  

In-flight respiratory conditions commonly include pulmonary embolism, exacerbations of asthma and chronic obstructive pulmonary disease, hypoxia related to reduced cabin pressure, and anxiety-induced hyperventilation. Initial management focuses on reassurance, positioning the patient upright, and administering supplemental oxygen if available. Beware of any underlying medical conditions and encourage passengers to self-administer their own bronchodilator where possible. In more severe cases, diversion may be required.  

Neurological  

In-flight neurological conditions include syncope, seizures, and acute events such as stroke. Syncope is often related to dehydration, immobility, or vasovagal episodes, while seizures may occur in individuals with known epilepsy or be provoked by hypoxia or fatigue. Initial management involves ensuring patient safety, maintaining airway patency, and placing the individual in the recovery position if unconscious. Supplemental oxygen should be administered if available, and check blood glucose if equipment is available. For suspected strokes, early recognition is crucial, and flight diversion may be necessary. Passengers with known neurological conditions should carry medications and relevant medical information when travelling. 

A Systematic Approach

Remember, you are the extra hand, the clinical assessor – a translator of medical to human language. 

• Approach the cabin crew in a calm and confident manner.  

• Start by identifying yourself to the cabin crew – stating your name and medical profession. 

• Gain the passenger’s consent and proceed to identify the passenger’s name and date of birth. If unconscious, seek collateral history wherever possible. If they are a minor, speak to their guardian if available.  

• Follow the aviation protocol and ensure the patient is in a safe position – well strapped to the seat or rested on the floor.  

• Ask the flight attendants for the first aid kit, emergency medical kit and automated external defibrillator (AED)  if indicated. Flight attendants are certified in cardiopulmonary resuscitation and the use of an AED.  

• Obtain a medical history and assess the ill passenger using the ABCDE approach (airway, breathing, circulation, disability, exposure) as per ALS protocol. Auscultation may be difficult due to aircraft noise, but aim to continuously monitor the vital signs.  

• With the passenger’s consent, communicate findings with the crew member and pilot. Follow the airline protocol and ask for ground-based medical consultation for advice.  

• Inquire about any available medications, especially in passengers with a known medical background.  

• If it can be done safely, consider moving the ill person to an area with more space and privacy 

• Notify the crew immediately if the passenger is suspected of having a communicable disease or is severely ill.  

• Further decisions in management and flight diversion are made by the pilot and the ground-based emergency medical services.  

• It is important to document your clinical encounter on specific airline forms if available and keep a copy for your own record.  

A common question revolves around DNACPR. If a passenger has a DNACPR form with them, should the medical responder heed the DNACPR at the time of an in-flight emergency? The answer varies depending on which airline and territory you are in. Different airlines have different protocols for such matters. It is therefore imperative to follow the respective airline’s protocol and communicate with ground medical support for advice. 

References & Further Reading

CDC Yellow Book [Internet]. Perspectives: Responding to Medical Emergencies When Flying; 2025 Apr [cited 2026 May 1]. Available from: https://www.cdc.gov/yellow-book/hcp/travel-air-sea/perspectives-responding-to-medical-emergencies-when-flying.html#cdc_report_pub_study_section_4-disclaimer

CDC Yellow Book [Internet]. Air Travel; 2025 Apr [cited 2026 May 1]. Available from: https://www.cdc.gov/yellow-book/hcp/travel-air-sea/air-travel.html

Chandra A, Conry S. In-flight Medical Emergencies. West J Emerg Med [Internet]. 2013 Sep 17 [cited 2026 May 14];14(5):499-504. Available from: https://doi.org/10.5811/westjem.2013.4.16052

FPnotebook [Internet]. In-Flight Medical Emergency; 2026 Jan [cited 2026 May 14]. Available from: https://mobile.fpnotebook.com/ID/Travel/InFlghtMdclEmrgncy.htm

Isakov A. UpToDate [Internet]. Management of inflight medical events on commercial airlines; 2025 Oct [cited 2026 May 14]. Available from: https://www.uptodate.com/contents/management-of-inflight-medical-events-on-commercial-airlines

If you liked this article, consider checking out: Pre-Hospital Management of Hypothermia

Written by: Dr Yun Yan Wong (FY2)
Reviewed by: Dr Callum Carruthers (GP with a special interest in Emergency Medicine, and responder with BASICS Scotland)

Hypothermia is defined as a core body temperature below 35°C. It may sound like a condition reserved for mountaineers or explorers stranded in Antarctica, but in the wrong circumstances, even the British climate can be life-threatening. Consider a student in Aberdeen who passes out drunk in a garden after a night out, or an elderly neighbour left without heating during a winter cold snap. When the body loses heat faster than it can produce it, core temperature begins to fall, triggering a cascade of physiological changes that can rapidly become fatal if left untreated. Understanding how hypothermia develops, how the body responds, and how to recognise its signs is essential for anyone working in pre-hospital medicine.

Physiology of Thermoregulation

Body temperature is regulated by the hypothalamus, which receives signals through central and peripheral thermoreceptors. When the body loses heat, the hypothalamus attempts to generate heat and reduce heat loss through several mechanisms:

1. Peripheral vasoconstriction

Blood vessels in the periphery constrict to reduce blood flow to these areas, thereby preventing heat loss and redirecting blood to vital organs.

2. Shivering

Shivering is the rapid, involuntary contraction of skeletal muscles, designed to generate heat through increased metabolic activity.

3. Piloerection

The sympathetic nervous system activates arrector pili muscles attached to hair follicles in the skin. Contraction of these muscles results in “goosebumps”, trapping air to act as insulation.

4. Secretion of hormones and catecholamines

Thyroid hormones are secreted to increase the basal metabolic rate, and catecholamines such as adrenaline increase the heart rate and blood pressure, improving the delivery of warm blood to tissues.

The body’s compensatory mechanisms for a low body temperature cannot last long. Without quick correction, these mechanisms fail, and the patient can quickly become critically unwell. Untreated hypothermia can lead to multiple organ failure and can be fatal.

Classification

Hypothermia can be classified as follows:

It is worth noting that most standard thermometers only measure down to 34°C, so low-reading thermometers would be required to accurately stage the severity of hypothermia.

Causes of Hypothermia

The causes of hypothermia can be broadly divided into increased heat loss, reduced heat production, and impaired thermoregulation. The most common reason for increased heat loss is environmental exposure to the cold. Exposure to wind and rain can accelerate heat loss. Some conditions that limit the body’s ability to generate heat include malnutrition, frailty, hypoglycaemia, hypothyroidism, and hypoadrenalism. Normal thermoregulatory mechanisms can be impacted by drug intoxication, stroke, dementia, and head injuries. Alcohol, in particular, is a common contributing factor, as it causes peripheral vasodilation, causing a false sense of warmth. Finally, hypothermia may develop secondary to sepsis, burns or major trauma.

Clinical Features & Assessment

Symptoms of hypothermia may include fatigue, nausea, vomiting, and confusion. The patient may present with cold and pale skin, slurred speech, or altered conscious level, such as agitation or reduced consciousness. Infants may present with a lack of response to stimuli or refusal to feed. It is worth noting that newborn babies lack the shivering mechanism and so are more vulnerable to the cold.

As for all pre-hospital scenarios, ensuring the area is safe and calling for help are the priorities. If the patient is unconscious, check for signs of life. In severe hypothermia, pulse and respiratory rate can be extremely low, so checks should be prolonged for up to 60 seconds if necessary. In cardiac arrest, CPR should be initiated.

In the absence of cardiac arrest, continue to assess as per usual in the ABCDE approach:

There are characteristic 12-lead ECG findings in hypothermia. Most commonly, it will show bradyarrhythmias, including marked bradycardia, atrial fibrillation with slow ventricular response, slow junctional rhythms, or AV block. The Osborne or J wave is a positive deflection at the J point (or negative in aVR and V1). It is usually most prominent in the precordial leads, and the height corresponds with the severity of hypothermia. QT prolongation and cardiac arrest can occur.

Frostbite is caused by ice crystals forming within tissues, usually the extremities. Signs include erythema, oedema, waxy appearance of skin, cyanosis, gangrene and reduced sensation.

Management of Hypothermia

The goal of treatment is to safely increase the patient’s core body temperature by preventing further heat loss and gentle rewarming. 

Preventing further heat loss is essential. The patient should be removed from the cold environment where possible, protected from wind and moisture, and insulated from the ground. Wet clothing should be removed when practical and replaced with dry insulation. Patients should be moved carefully, as excessive movement may precipitate ventricular arrhythmias. The patient should be kept horizontal where possible.

External rewarming can be passive or active. Passive rewarming is appropriate for mild hypothermia in patients who remain conscious and are shivering effectively. Measures include providing dry clothing, warm shelter, and blankets. Shivering generates significant endogenous heat and is often sufficient if further heat loss is prevented. Conscious patients may be offered warm, high-calorie food or drinks.

Patients with moderate or severe hypothermia require active rewarming. Heat should be applied to the trunk, particularly the chest, back, and axillae. Suitable methods include chemical heat packs, warming blankets, and other external heat sources. Avoid warming the limbs, as this can promote peripheral vasodilation and “afterdrop”, where cold peripheral blood returns to the core and further lowers core temperature. Warmed intravenous normal saline can prevent further cooling and support intravascular volume.

Other active internal warming methods that can be provided in hospital include arteriovenous rewarming, haemodialysis, warm saline lavage of pleura and peritoneum, cardiopulmonary bypass and extracorporeal membrane oxygenation (ECMO).

Complications of Hypothermia

Complications of hypothermia and subsequent rewarming include:

Key Learning Points

1. Hypothermia is defined as core body temperature below 35°C.
2. Causes of hypothermia include environmental exposure, sepsis, metabolic disorders, alcohol, and CNS disorders.
3. Patients should be assessed using the ABCDE approach.
4. Classical ECG features of hypothermia include bradyarrhythmias and Osborne waves.
5. The goal of treatment is to prevent further heat loss and encourage gentle rewarming.

References & Further Reading

1. Osilla EV, Marsidi JL, Shumway KR, et al. Physiology, Temperature Regulation. [Updated 2023 Jul 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507838/
2. Kuht J, Farmery AD. Body temperature and its regulation. Anaesth Amp Intensive Care Med [Internet]. 2021 Aug [cited 2026 Jun 13]. Available from: https://doi.org/10.1016/j.mpaic.2021.07.004
3. Burns E, Buttner R, Hypothermia [Updated 2024 Oct 28] Life in The Fast Lane. Available from: https://litfl.com/hypothermia-ecg-library/
4. Basit H, Wallen TJ, Dudley C. Frostbite. [Updated 2023 Jun 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK536914/
5. Haverkamp FJ, Giesbrecht GG, Tan EC. The prehospital management of hypothermia — An up-to-date overview. Injury [Internet]. 2018 Feb [cited 2026 Jun 13];49(2):149-64. Available from: https://doi.org/10.1016/j.injury.2017.11.001
6. Dow J, Giesbrecht GG, Danzl DF, Brugger H, Sagalyn EB, Walpoth B, Auerbach PS, McIntosh SE, Némethy M, McDevitt M, Schoene RB, Rodway GW, Hackett PH, Zafren K, Bennett BL, Grissom CK. Wilderness Medical Society Clinical Practice Guidelines for the Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia: 2019 Update. Wilderness Amp Environ Med [Internet]. 2019 Dec [cited 2026 Jun 13];30(4):S47—S69. Available from: https://doi.org/10.1016/j.wem.2019.10.002

If you enjoyed this article, consider checking out: Spooktacular Scenarios: When the Vampire Strikes (Pre-Hospital Haemorrhage Management)

Written by: Dr Tze Chien Low (FY1)
Edited by: Dr Maria Kent (FY2, MTB Pre-Hospital Medicine Lead)
Reviewed by: Dr Callum Carruthers (GP with a special interest in Emergency Medicine, and responder with BASICS Scotland)

Introduction

You may be asked to explain a procedure or investigation to a patient. These will include endoscopic tests. You would not be expected to know how to perform the procedure. However, you should be able to provide a basic explanation, give them information in a patient-centred way, and signpost the patient to other resources if you do not know the answer to their specific questions.

These are common types of scope procedures that you may be asked to explain:

Gastroscopy

Bronchoscopy

Colonoscopy

Cystoscopy

Approach

When explaining a procedure to a patient it is important that demonstrate a patient centred approach. You should find out what they already know, regularly check their understanding, and encourage them to ask questions. It is more important to address the patient’s agenda and concerns, than ensuring that you provide specific information. (In contrast to consenting for a procedure where you must ensure that the patient understands the potential risks, benefits, and complications.)

As a doctor or medical student, you should not consent a patient for a procedure that you cannot perform yourself.

We recommend a ‘chunk and check’ approach. This is where you give a short ‘chunk’ of information, pause to let the patient process it, and then check that they understand what you have told them.

General Structure

1. What does the patient understand so far?

2. Explain what the procedure is.

3. Why are they having this test?

4. Before the procedure.

5. During the procedure.

6. After the procedure.

7. Risks/complications.

8. Any further questions?

It is not essential that you stick to this structure. In your OSCEs the patients/actors should prompt you for any information that you may not have mentioned. They want to give the best opportunity to demonstrate your knowledge and skill. If you do not know the answer to a question, be honest and offer to find out from a senior colleague and/or offer them a patient information leaflet.

Quick Summary Table

References
 
1. https://www.nhs.uk/conditions/gastroscopy/

2. https://patient.info/chest-lungs/chest-infection/bronchoscopy 

3. https://www.nhs.uk/conditions/colonoscopy/ 

4. https://www.bupa.co.uk/health-information/cancer/sigmoidoscopy 

5. https://www.nhs.uk/conditions/cystoscopy/

Author – James Mackintosh  

Editor – Mohona Sengupta

Last updated 10/10/23

Introduction

As future healthcare providers, medical students bear a responsibility to respect and safeguard the rights of their patients, especially when it comes to sensitive matters such as consent for medical treatment. Fraser guidelines, established in 1985, serves as a crucial ethical framework that outlines the principles guiding the assessment of a young person’s capacity to provide consent for medical treatment, including contraception and abortion.

In the UK, adults, defined as patients over the age of 18 are legally regarded as competent therefore able to make decisions regarding their health. For a patient between 16 and 18 years old, consent can be obtained from themselves or a legal guardian. It is important to note that these rules only apply to acceptance of a medical treatment, and generally only individuals over the age of 18 can deny treatment.

How to assessing capacity

Children under the age of 16 can consent to medical treatment if they are deemed to have sufficient judgement to thoroughly understand the terms to what is proposed. In making this judgement, there are a set of criteria which must be fulfilled:

1. Sufficient Age and Maturity: The individual must be of an age and maturity level where they can fully understand the information and implications related to the proposed medical treatment or intervention.

2. Understanding of the Information: They must have a clear understanding of the nature, purpose, and potential risks and benefits of the treatment, as well as the likely consequences of not undergoing the treatment.

3. Ability to Retain Information: The person must be able to retain the information provided to them and use it to make a rational decision. This implies that they can remember and consider the relevant details over a reasonable period of time.

4. Ability to Weigh Options: The individual should demonstrate an ability to weigh the potential benefits against the potential risks and make a reasoned decision based on this assessment.

5. Freedom from External Pressure or Coercion: It must be evident that the person’s decision is made freely, without any undue pressure or influence from external parties, including parents, guardians, or healthcare providers.

6. Capacity to Communicate Decision: The person should be able to effectively communicate their decision, whether it be consent or refusal, to the healthcare provider.

Conclusion

It is important to note that Gillick competence is specific to each individual and the context of the proposed medical treatment. A person may be deemed Gillick

competent for one type of treatment but not for another, depending on their level of understanding and maturity regarding each specific situation.

As healthcare professionals, it is important to keep accurate records of the discussions with patients, including documentation of capacity at given points in time. As the capacity for informed consent may evolve over time, healthcare professionals should re-assess the young person’s ability to make decisions about their health, which underlies the core principles of medical practice.

References

1. https://learning.nspcc.org.uk/child-protection-system/gillick-competence-fraser-guidelines

2. https://www.nhs.uk/conditions/consent-to-treatment/children/

3. https://www.bing.com/search?q=gillick+competence&cvid

Author – Mohona Sengupta  

Editor – James Mackintosh

Last updated 10/10/23

Introduction

Human Immunodeficiency Virus (HIV) is a virus that attacks the body’s immune system which makes it more vulnerable to infections and diseases which can be life threatening. HIV is primarily spread through sexual contact, sharing of needles and from mother to child during pregnancy, childbirth, or breastfeeding. Diagnosis can be from a simple blood test that screens for antibodies to the virus.

Setting up the consultation

Telling a patient they have been diagnosed with HIV can be devastating and can cause a range of emotions. It is important for healthcare professionals to approach the situation with empathy and sensitivity to ensure the patient receives the support they need during this difficult time.

The first step in telling a patient they have been diagnosed with HIV is to prepare for the conversation. This may involve reviewing the patient’s medical history, planning what you want to say and having support services readily available for the patient. This can be a complex and emotional topic so keep sufficient time for the conversation.

Explaining the diagnosis

When explaining the diagnosis, explain what HIV is and how it is transmitted. It may also be helpful to provide information about the stages of HIV and what this means for the patient’s health. Following this, the patient will need to be told the treatment options.

Patients with a new diagnosis, who are well otherwise, will need to be seen by a specialist HIV team preferably within 48 hours of testing positive. Whilst it is important to reiterate that there is currently no cure for HIV, antiretroviral therapy (ART) can effectively manage the virus and slow the progression of the disease, irrespective of their CD4 count. ART involved taking a combination of antiviral drugs that work to reduce the amount of virus in the body, prevent the virus from replications and strengthen the immune system.

With early diagnosis and treatment, people with HIV can live long and healthy lives. Monitoring of HIV infection is carried out in specialist clinics using the CD4 count and viral load. This is crucial to ensure that effectiveness of treatment and any side effects are monitored continually.

Side effects of ART:

As with any treatment, ART can cause side effects which range from mild to more severe. These include appetite loss, lipodystrophy, diarrhoea, mood changes and trouble sleeping. More severe but rarer side effects include diabetes, lactic acidosis, kidney damage or numbness in hands or feet. However, the patient must be told that they should NOT suddenly discontinue or adjust the dose of ART without specialist advice as this can cause treatment resistance.

Support and Prevention

People living with HIV should take steps to prevent the transmission of the virus to others. This may include using condoms during sexual activity, avoiding sharing needles and other injecting equipment.

A large part of the initial consultation will involve discussing the support and resources available to the patient. This may include support groups, counselling services and further advice. Ensure the patient understands that they are not alone and there are many people and organisations that can help them through this difficult time.

Conclusion

Finally, it is important to end the conversation by reiterating your support for the patient. Let them know that you are available to answer any questions that they may have in the future, and you will continue to be there for them as they navigate this difficult time.

HIV Counselling Checklist

• Preparation: choose a private setting for the consultation and ensure you have all information to hand before approaching the patient.
• Introduction: explain the purpose of the appointment and that you have received the results of their HIV test.
• Delivery of the diagnoses: clearly and accurately inform the patient of their HIV diagnosis.
• Explanation of the virus: provide a brief explanation of what HIV is and how it affects the body.
• Discussion of treatment options: explain the standard treatment for HIV, which is antiretroviral therapy, and how it works to manage the virus.
• Discussion of potential side effects: this is important so the patient is fully informed, including problems with discontinuing treatment.
• Prevention of transmission: discuss the steps the patient can take to prevent the transmission of HIV to others, such as using condoms and avoiding sharing needles.
• Availability of support: discuss the range of support services available to the patient, including counselling, support groups and financial assistance programs.
• Follow-up appointment: schedule a follow-up appointment to monitor the patient’s progress and ensure that their treatment is working effectively.
• Offer of support: remind the patient you are there for them and will continue with providing long term support.

References
 
1. https://www.nhs.uk/conditions/hiv-and-aids/

2. https://www.who.int/health-topics/hiv-aids#tab=tab_1

3. https://www.hiv.gov/hiv-basics/overview/about-hiv-and-aids/what-are-hiv-and-aids/

Author – Mohona Sengupta  

Editor – James Mackintosh

Last updated 04/02/24

Introduction

Consent is an important aspect of medical practice. It is a requirement in everyday practice as part of examining patients, performing investigations and procedures as well as overall health decisions.

Types of Consent

Consent may be given in different forms, which are deemed acceptable depending on what the consent is used for. There are certain requirements for each type of consent, so it is important to be aware of this before asking for consent from the patient

Overall, if verbal consent is acceptable, then it is considered just as valid as written consent. This is because some individuals may not be able to read or write (for example, those whose first language is not English, any disorder affecting movement e.g muscular dystrophy)

Verbal consent 

• This is consent 
• Examples of when it is permissible to give verbal consent include:
  • Medication such an painkillers, antibiotics 
  • An abdominal examination
  • Investigations such as a chest x-ray

Written consent 

• This is consent 
• Examples of when written consent is required:
  • Any surgical procedure 
  • Storage and use of gametes and embryos in fertility treatment.

What makes consent valid?

Consent can only be valid if it fulfills 3 criteria:

• It must be voluntary
  • The patient must decide freely. There must be no element of coercion or pressure involved from friends, family or medical practitioners. 

• It must be informed
  • The patient must have sufficient knowledge on the topic to be able to make a competent decision. 
  • For example, this may involve an explanation of a procedure with its associated risks, benefits, complications and recovery. Alternatives to the procedure must also be explained and how the outcome may vary.  

• The person giving consent must have capacity
  • Capacity involves being able to understand the information, retain it long enough to weigh up the options and then communicate their final decision. 
  • It is important to note that capacity is situation-specific, and several factors can affect someone’s capacity to consent. 
  • You should always assume that a patient has the capacity to consent until proven otherwise.

Mental health and Consent

The Mental Capacity Act (MCA) is designed to protect people who may lack the mental capacity to make their own decisions about their care. It applies to people aged 16 and over.

If a patient is held under the Mental Health Act, they can be treated against their will. This is due to the fact that they are deemed to not have sufficient capacity to make a decision on their healthcare. 

How is mental capacity assessed?

The MCA sets out a 2-stage test of capacity:

• Does the person have an impairment of their mind or brain, whether as a result of an illness, or external factors such as alcohol or drug use?
• Does the impairment mean the person is unable to make a specific decision when they need to? 

The MCA says a person is unable to decide if they cannot do 1 or more of these things:

• understand the information relevant to the decision
• retain that information for long enough to make the decision
• use or weigh up that information as part of the process of making the decision
• communicate their decision

Sectioning

A person may be sectioned, which means they are kept in hospital under the Mental Health Act. This may be voluntary or involuntary. 

Sectioning may be necessary for a number of reasons including certain mental disorders and the health and safety of the patient or others. 

There are many different sections to be aware about. The most commonly used ones include:

• Section 2 – Detained for up to 28 days
• Section 3 – Detained for up to 6 months 
• Section 5 (2) – Detained for up to 72 hours
• Section 5 (4) – Detained for up to 6 hours or until a doctor or clinician with authority to detain arrives.

What to do if consent is not valid?

If the consent provided does not meet the 3 criteria listed above, it is important to think about the next steps you can take to continue patient care. 

Importantly, a patient lacking capacity should not be denied necessary treatment.

Options include: 

• Lasting power of attorney (LPA)
  • This is a legal document that allows a patient to decide who can make future decisions for them should they lose the capacity to consent. An example of this includes a stroke, where the patient may lose the ability to understand the information relayed to them.
  • There are 2 types of LPA
    • health and welfare
    • property and financial affairs
  • An attorney can be anyone aged 18 and above and does not need to live in the UK. 
  • Patients can have more than one attorney
  • It can take up to 20 weeks to process this form, therefore alternative measures may need to be explored if an LPA has not yet been finalised. 

• Advanced directive
  • A decision made by the patient, whilst they still have the capacity to consent, to refuse certain types of treatment in the future. It takes precedence over any other decision. 
  • A common example of this is a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR). 
  • Advanced directives are legally binding. This must be written and signed by the patient with a witness involved. 

• Advanced statement
  • This statement described the patient’s wishes, beliefs and feelings about their care and management but is not considered legally binding.
  • It can be used alongside other factors to help healthcare professionals and family members come up with a plan.

• Acting in the patient’s best interest
  • Normally a multidisciplinary team (MDT) is required to make a decision on a patient’s management if a lasting power of attorney and advanced directive are not present. 
  • This can also used when patients are presenting in a life-threatening situation. 
  • This may also be the most sensible option if you suspect the LPA is abusing their position or the patient. 

• Appointment of healthcare proxy
  • For incapacitated adults, the Mental Capacity Act 2005 has set guidelines for the appointment of a proxy decision maker. 
  • A proxy can have access to their health information. 

• Court – The Court of Protection’s Practice Direction states that some matters should be dealt by the court. Cases that would necessitate court intervention include
  • Decisions about the proposed withholding or withdrawal of artificial nutrition and hydration from a person in a permanent vegetative state or a minimally conscious state
  • Cases involving organ or bone marrow donation by a person who lacks capacity to consent
  • Cases involving non-therapeutic sterilisation of a person who lacks capacity to consent.

Conclusion

Consent is seen in everyday practice, and it is important to be familiar with the ethico-legal factors associated with it. A person may be capacitous to consent for some decisions and not others depending on the complexity of the situation.

It is important as healthcare professionals to not abuse the power of making decisions on behalf of patients who are unable to consent and instead endeavour to involve as many people as possible, including family and other members of the team, when making life-changing decisions. 

References
 
1. https://www.nhs.uk/tests-and-treatments/consent-to-treatment/

2. https://www.medicalprotection.org/uk/advice-centre-articles/eng-consent-the-basics

3. https://www.nhs.uk/tests-and-treatments/end-of-life-care/planning-ahead/advance-decision-to-refuse-treatment/

4. https://www.mentalhealth.org.uk/explore-mental-health/a-z-topics/mental-capacity

5. https://www.mind.org.uk/information-support/legal-rights/sectioning/about-sectioning/

Author – Salma Salem  

Editor – Mohona Sengupta

Last updated 26/03/24