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Breaking Bad news

6 steps – SPIKES

STEP 1: S—SETTING UP the Interview

Mental rehearsal is a useful way for preparing for stressful tasks. This can be accomplished by
reviewing the plan for telling the patient and how one will respond to patients' emotional
reactions or difficult questions. As the messenger of bad news, one should expect to have
negative feelings and to feel frustration or responsibility. It is helpful to be reminded that,
although bad news may be very sad for the patients, the information may be important in
allowing them to plan for the future.
Sometimes the physical setting causes interviews about sensitive topics to flounder. Unless
there is a semblance of privacy and the setting is conducive to undistracted and focused
discussion, the goals of the interview may not be met. Some helpful guidelines:
• Arrange for some privacy. An interview room is ideal, but, if one is not available,
draw the curtains around the patient's bed. Have tissues ready in case the patient
becomes upset.
• Involve significant others. Most patients want to have someone else with them but this
should be the patient's choice. When there are many family members, ask the patient
to choose one or two family representatives.
• Sit down. Sitting down relaxes the patient and is also a sign that you will not rush.
When you sit, try not to have barriers between you and the patient. If you have recently
examined the patient, allow them to dress before the discussion.
• Make connection with the patient. Maintaining eye contact may be uncomfortable but
it is an important way of establishing rapport. Touching the patient on the arm or
holding a hand (if the patient is comfortable with this) is another way to accomplish
this.
• Manage time constraints and interruptions. Inform the patient of any time constraints
you may have or interruptions you expect. Set your pager on silent or ask a colleague
to respond to your pages.

STEP 2: P—ASSESSING THE PATIENT'S PERCEPTION

Steps 2 and 3 of SPIKES are points in the interview where you implement the axiom “before
you tell, ask.” That is, before discussing the medical findings, the clinician uses open-ended
questions to create a reasonably accurate picture of how the patient perceives the medical
situation—what it is and whether it is serious or not. For example, “What have you been told
about your medical situation so far?” or “What is your understanding of the reasons we did the
MRI?”. Based on this information you can correct misinformation and tailor the bad news to
what the patient understands. It can also accomplish the important task of determining if the
patient is engaging in any variation of illness denial: wishful thinking, omission of essential
but unfavorable medical details of the illness, or unrealistic expectations of treatment.
STEP 3: I—OBTAINING THE PATIENT'S INVITATION
While a majority of patients express a desire for full information about their diagnosis,
prognosis, and details of their illness, some patients do not. When a clinician hears a patient
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express explicitly a desire for information, it may lessen the anxiety associated with divulging
the bad news. However, shunning information is a valid psychological coping mechanism and
may be more likely to be manifested as the illness becomes more severe. Discussing
information disclosure at the time of ordering tests can cue the physician to plan the next
discussion with the patient. Examples of questions asked the patient would be, “How would
you like me to give the information about the test results? Would you like me to give you all
the information or sketch out the results and spend more time discussing the treatment plan?”.
If patients do not want to know details, offer to answer any questions they may have in the
future or to talk to a relative or friend.

STEP 4: K—GIVING KNOWLEDGE AND INFORMATION TO THE PATIENT

Warning the patient that bad news is coming may lessen the shock that can follow the disclosure
of bad news and may facilitate information processing. Examples of phrases that can be used
include, “Unfortunately I've got some bad news to tell you” or “I'm sorry to tell you that…”.
Giving medical facts, the one-way part of the physician-patient dialogue, may be improved by
a few simple guidelines. First, start at the level of comprehension and vocabulary of the patient.
Second, try to use nontechnical words such as “spread” instead of “metastasized” and “sample
of tissue” instead of “biopsy.” Third, avoid excessive bluntness (e.g., “You have very bad
cancer and unless you get treatment immediately you are going to die.”) as it is likely to leave
the patient isolated and later angry, with a tendency to blame the messenger of the bad news.
Fourth, give information in small chunks and check periodically as to the patient's
understanding. Fifth, when the prognosis is poor, avoid using phrases such as “There is nothing
more we can do for you.” This attitude is inconsistent with the fact that patients often have
other important therapeutic goals such as good pain control and symptom relief.

STEP 5: E—ADDRESSING THE PATIENT'S EMOTIONS WITH EMPATHIC RESPONSES

Responding to the patient's emotions is one of the most difficult challenges of breaking bad
news. Patients' emotional reactions may vary from silence to disbelief, crying, denial, or anger.
When patients get bad news their emotional reaction is often an expression of shock, isolation,
and grief. In this situation the physician can offer support and solidarity to the patient by
making an empathic response. An empathic response consists of four steps:
• First, observe for any emotion on the part of the patient. This may be tearfulness, a
look of sadness, silence, or shock.
• Second, identify the emotion experienced by the patient by naming it to oneself. If a
patient appears sad but is silent, use open questions to query the patient as to what
they are thinking or feeling.
• Third, identify the reason for the emotion. This is usually connected to the bad news.
However, if you are not sure, again, ask the patient.
• Fourth, after you have given the patient a brief period of time to express his or her
feelings, let the patient know that you have connected the emotion with the reason for
the emotion by making a connecting statement. An example:
1. Doctor: I'm sorry to say that the x-ray shows that the chemotherapy doesn't seem to
be working [pause]. Unfortunately, the tumor has grown somewhat.
2. Patient: I've been afraid of this! [Cries]
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3. Doctor: [Moves his chair closer, offers the patient a tissue, and pauses.] I know that
this isn't what you wanted to hear. I wish the news were better.
In the above dialogue, the physician observed the patient crying and realized that the patient
was tearful because of the bad news. He moved closer to the patient. At this point he might
have also touched the patient's arm or hand if they were both comfortable and paused a moment
to allow her to get her composure. He let the patient know that he understood why she was
upset by making a statement that reflected his understanding. Other examples of empathic
responses can be seen in Table 2⇓.

Table 2.

Examples of empathic, exploratory, and validating responses

Until an emotion is cleared, it will be difficult to go on to discuss other issues. If the emotion
does not diminish shortly, it is helpful to continue to make empathic responses until the patient
becomes calm. Clinicians can also use empathic responses to acknowledge their own sadness
or other emotions (“I also wish the news were better”). It can be a show of support to follow
the empathic response with a validating statement, which lets the patient know that their
feelings are legitimate (Table 3⇓).
Table 3.

Changes in confidence levels among participants in workshops on communicating bad news

Again, when emotions are not clearly expressed, such as when the patient is silent, the
physician should ask an exploratory question before he makes an empathic response. When
emotions are subtle or indirectly expressed or disguised as in thinly veiled disappointment or
anger (“I guess this means I'll have to suffer through chemotherapy again”) you can still use an
empathic response (“I can see that this is upsetting news for you”). Patients regard their
oncologist as one of their most important sources of psychological support, and combining
empathic, exploratory, and validating statements is one of the most powerful ways of providing
that support (Table 2⇑). It reduces the patient's isolation, expresses solidarity, and validates
the patient's feelings or thoughts as normal and to be expected.

STEP 6: S—STRATEGY AND SUMMARY

Patients who have a clear plan for the future are less likely to feel anxious and uncertain. Before
discussing a treatment plan, it is important to ask patients if they are ready at that time for such
a discussion. Presenting treatment options to patients when they are available is not only a legal
mandate in some cases, but it will establish the perception that the physician regards their
wishes as important. Sharing responsibility for decision-making with the patient may also
reduce any sense of failure on the part of the physician when treatment is not successful.
Checking the patient's misunderstanding of the discussion can prevent the documented
tendency of patients to overestimate the efficacy or misunderstand the purpose of treatment.
Clinicians are often very uncomfortable when they must discuss prognosis and treatment
options with the patient, if the information is unfavorable. Based on our own observations and
those of others we believe that the discomfort is based on a number of concerns that physicians
experience. These include uncertainty about the patient's expectations, fear of destroying the
patient's hope, fear of their own inadequacy in the face of uncontrollable disease, not feeling
prepared to manage the patient's anticipated emotional reactions, and sometimes
embarrassment at having previously painted too optimistic a picture for the patient.
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These difficult discussions can be greatly facilitated by using several strategies. First, many
patients already have some idea of the seriousness of their illness and of the limitations of
treatment but are afraid to bring it up or ask about outcomes. Exploring the patient's knowledge,
expectations, and hopes (step 2 of SPIKES) will allow the physician to understand where the
patient is and to start the discussion from that point. When patients have unrealistic
expectations (e.g., “They told me that you work miracles.”), asking the patient to describe the
history of the illness will usually reveal fears, concerns, and emotions that lie behind the
expectation. Patients may see cure as a global solution to several different problems that are
significant for them. These may include loss of a job, inability to care for the family, pain and
suffering, hardship on others, or impaired mobility. Expressing these fears and concerns will
often allow the patient to acknowledge the seriousness of their condition. If patients become
emotionally upset in discussing their concerns, it would be appropriate to use the strategies
outlined in step 5 of SPIKES. Second, understanding the important specific goals that many
patients have, such as symptom control, and making sure that they receive the best possible
treatment and continuity of care will allow the physician to frame hope in terms of what it is
possible to accomplish. This can be very reassuring to patients.

Extradural Heamatoma in child

You are the FY 2 doctor in the Paediatric department
10 year old boy Joshua Pilmore was brought into the hospital by the ambulance
because he met with the Road traffic accident.
CT scan of the head showed he had extra dural heamatoma.
Seniors are getting ready to take him to the theatre. He is in a critical condition.
You have not seen the child.
Talk to his parents and address their concern.

Dr: Hello Mr and Mrs Pilmore ? ….. I am Dr ….. one of the junior doctor in the
Paediatric department. Are you the parents of Joshua ? Parents: Yes doc
Dr: I am one of the team of doctors looking after your son.
Parent: Oh, How is he doctor ?
Dr: Joshua is in the resuscitation room now. Our team is taking care of him.
I have come here to talk to you about him. Before that – Mr Pilmore, I was told that he
met with an accident. Can you please tell me more about ii?
Parent: Doctor we were about to go to a restaurant and Joshua suddenly ran to cross the
road and the next thing I heard he was calling me Papa Papa. When we saw him he was
under the car. We called the ambulance immediately. They brought him here.
Dr: I am very sorry to hear that. When did this happen ?
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Parent: About half an hour ago.

Dr: Mr and Mrs Pilmore, I have not seen him as yet. I will be seeing him soon after I
talk to you. I do have some news about him. I wish I could give you some good news
but unfortunately Joshua is in a very critical condition now ?
Parent: What happened why do you say that?
Dr: Mr and Mrs Pilmore, we examined him and did a CT scan of his head which
showed he had head injury and has bleeding inside the head.
Parent: Is it serious ?
Dr: This is a very serious condition. I am very sorry to say this.
Parent: Don’t you have any treatment for this?
Dr: We can do surgery and try to remove the blood clot from the brain. That is what our
team is trying to do. We do have the best surgical team to deal with such problems. We
are doing our best to save him. Most of the time surgery is very successful and they
recover from the condition. However sometimes it can be very serious. In fact
sometimes it can be even life threatening.
Parent: Is he going to die doctor ?

Dr: As I mentioned our team will try to do the best for Joshua. As I told you before, most
of the time children do recover from the problem once we do the operation and remove
the blood clot from inside his head. However, there is slight chance that he may not
make it. I am sorry to say this.
Mother may cry – console her and dad. ( tissues – glass of water to drink).
Parent: Doctor I can’t believe this !
Dr: I can’t even imagine how you are feeling now. We will do everything possible from
our side.
Parent: Thank you doctor
Parent: Can we see him?
Dr: I can understand you want to see him. As you know at the moment we are
resuscitating him. You may not be able to see him for long time because we need to
operate on him as soon as possible. May be you can have a quick look at him now
and you can see him properly after the operation, is that OK Mr and Mrs Pilmore.
Parent: Ok doctor. Will there be any damage to the brain after the operation ?
Dr: Hopefully he will not have any brain damages. However, we can’t say much about it
now. We may know that only after the surgery.
Dr: Any other concerns Mr and Mrs Pilmore? Parents : No doctor.
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Dr: Are you Ok for us to go ahead with the operation?

Parents: Sure doctor, if you think that it is necessary. Please do whatever is best
for him.

Dr: Thank you. I need to ask you few questions about his health ? Is that OK?
Parents : OK
Dr: Can I ask you how was Joshua’s health before this happened
? Parent: He was completely fine.
Dr: Did he have any medical conditions at all ? Parents: No
Dr: Is he on any medications? Parent: No
Dr: Is he allergic to anything you know? Parent: Strawberries
doctor.
Dr: I see. It is good that you told me about it. I will make a note of
this in his notes and let everyone know about this so that no one
gives him strawberries here. Can I ask is he allergic to any
medications at all? Parents - No
Dr: Any medical conditions in the family members ? Parent: No
Dr: When did he last eat or drink? Parent: Just before this happened / in the morning.
Dr: How many hours ago is that? Parents … hours ago.

Dr: Thank you very much for the information. Is there any other questions? Parents:
No
Dr: Thank you very much Mr and Mrs Pilmore, once again I am very sorry to give this
news.

We will keep you informed about everything.

I will be around if you need any other help. I hope to come back with good news.
Thank you very much.

Fracture pelvis in child

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You are the FY 2 doctor in the Paediatric department

10 year old boy Joshua Martin was brought into the hospital by the ambulance
because he met with the Road traffic accident.
Investigations revealed that he has fracture pelvis.
Pulse – high. BP – very low. He is not stable.
Talk to his parents and address their concern.

Dr: Hello Mr and Mrs Martin ? ….. I am Dr ….. one of the junior doctor in the
Paediatric department. Are you the parents of Joshua ? Parents: Yes doc
Dr: I am one of the team of doctors looking after your son.
Parent: Oh, How is he doctor ?
Dr: Joshua is in the resuscitation room now. Our team is taking care of him.
I have come here to talk to you about him. Before that – Mr Martin, I was told that he
met with an accident. Can you please tell me more about ii?
Parent: Doctor we were about to go to a restaurant and Joshua suddenly ran to cross the
road and the next thing I heard he was calling me Papa Papa. When we saw him he was
under the car. We called the ambulance immediately. They brought him here.
Dr: I am very sorry to hear that. When did this happen ?

Parent: About half an hour ago.

Dr: Mr and Mrs Martin, I do have some news about him. I wish I could give you
some good news but unfortunately Joshua is in a very critical condition now.
Parent: What happened why do you say that?
Dr: Mr and Mrs Martin, we examined him and did some investigations. They show that
he has broken his hip bones. Because of that he is bleeding heavily inside in his hip
area.
Parent: Is it serious ?
Dr: This is a very serious condition. I am very sorry to say this.
Parent: Don’t you have any treatment for this?
Dr: We can do surgery and try to fix the fracture. That is what our team is trying to do.
We do have the best surgical team to deal with such problems. We are doing our best to
save him. Most of the time surgery is very successful and they recover from the
condition.
Usually that controls the bleeding. Also we may need to give him blood transfusion
because he would have lost lot of blood. Is that OK for us the give the blood
transfusion ?

Parents: Yes doctor you can give blood transfusion.

Dr: Mr and Mrs Martin, As I told you before most of the time the operation is very
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successful and we will be able to control the bleeding. However sometimes it is be very
difficult to control the bleeding in that case it can still be very serious and it can be even
life threatening.
Parent: Is he going to die doctor ?

Dr: As I mentioned our team will try to do the best for Joshua. As I told you before, most
of the time children do recover from the problem once we do the operation and fix the
broken bones.
However, there is a very slight chance that he may not make it.
Mother may cry – console her and dad. ( tissues – glass of water to drink).
Parent: Doctor I can’t believe this !
Dr: I can’t even imagine how you are feeling now. We will do everything possible from
our side.
Parent: Thank you doctor
Can we see him?
Dr: I can understand you want to see him. As you know at the moment we are
resuscitating him. You may not be able to see him for long time because we need to
operate on him as soon as possible. May be you can have a quick look at him now
and you can see him properly after the operation, is that OK Mr and Mrs Martin.
Dr: Any other concerns Mr and Mrs Martin ? Parents : No doctor.

Dr: Are you Ok for us to go ahead with the operation?

Parents: Sure doctor, if you think that it is necessary. Please do whatever is best
for him.

Dr: Thank you. I need to ask you few questions about his health ? Is that OK?
Parents : OK
Dr: Can I ask you how was Joshua’s health before this happened
? Parent: He was completely fine.
Dr: Did he have any medical conditions at all ? Parents: No
Dr: Is he on any medications? Parent: No
Dr: Is he allergic to anything you know? Parent: Strawberries
doctor.
Dr: I see. It is good that you told me about it. I will make a note of
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this in his notes and let everyone know about this so that no one
gives him strawberries here. Can I ask is he allergic to any
medications at all? Parents - No
Dr: Any medical conditions in the family members ? Parent: No
Dr: When did he last eat or drink? Parent: Just before this happened / in the morning.
Dr: How many hours ago is that? Parents … hours ago.

Dr: Thank you very much for the information. Is there any other questions? Parents:
No
Dr: Thank you very much Mr and Mrs Pilmore, once again I am very sorry to give this
news.

We will keep you informed about everything.

I will be around if you need any other help. I hope to come back with good news.
Thank you very much.

Intracranial bleed in adult. BBN

You are the FY 2 doctor in the medical department.
62 year old man Mr Ali presented to the hospital with headache and the CT scan
of his head showed huge intracranial bleed due to berry aneurysm.
He is unconscious but breathing on his own.
Neurosurgeon has decided that active intervention is not useful.
Your Consultant has decided for Palliative treatment.
Talk to his wife Mrs Ali and address her concerns.

Dr: Hello Mrs….. I am Dr. …. How are you

doing? Wife: I am OK.
Dr: I am one of the junior doctors in the medical department looking after your
husband Mr Mohammed Ali. I am here to talk to you about his condition.
Dr: Do you know anything about his
condition? Wife: He had headache and he
collapsed at home. Then we brought him in
here doctor.
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Dr: I am sorry to hear about that.

Dr: Can I ask you few questions about his health? Wife: Yes doctor.
Dr : Did he have any medical conditions at all? Wife - No
Dr: Like High blood pressure ? Diabetes? Any heart conditions or kidney problems?
Wife : No
Dr: Any stroke or mini strokes before ? Wife: No

Dr: How was he before ? Was he very active ? Was he working?

Wife : He was very active.

Do you know what happened after you

brought him to the hospital ? Wife : No
doctor.

Dr: Mrs Ali, we did a CT scan of his head and we got the result. Did anyone discuss
the CT scan result with you ?
Wife: No doctor ?

Dr: Before I tell you the result MRs Ali can you please tell me - Do you have any
idea what may be happening to him ?
Wife: No doctor.
Dr: I am very sorry to say this - it is not a good news. He has a very serious
condition. Do you want to know about it?
Wife: Yes doctor.
Dr: Do you want any of your family members to be with you when we discuss this?
Wife: No it is OK doctor.
Dr: Mrs Ali, CT scan of his head showed there is massive bleeding inside his head.
This is a very serious condition.
Wife: But don’t you have any treatment for that?
Dr: Sometimes we can do surgery to treat this condition. We have discussed his
condition with the Neurosurgeon but he thinks the surgery or any other treatment
will not help for your husband’s condition because the bleeding is very huge.

Unfortunately, we will not be able to treat his condition. He is in a very critical

condition.
In fact it is a life threatening condition.

Wife: Do you mean to say he is going to die ?

Dr: I really wish I could say it is not true. But unfortunately Mrs Ali that is

true. She may cry – Pause, offer tissues and water.

Wife: Why did this happen doctor?

Dr: Mrs Ali There are various reasons this condition can happen. In his case he had
some abnormal blood vessels in his head which were kind of swollen and thin and that
blood vessel suddenly ruptured and caused this heavy bleeding. Also since he had
high blood pressure sometimes the high blood pressure can contribute to this problem.
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Sometimes this condition can run in the family members.

Wife: Are you not going to do anything?

Dr: I really wish we could do something to save his life. But Mrs Ali - unfortunately
we will not be able to save his life because the bleeding is very huge.
Wife: That means you are leaving him to die ?
Dr: I am really sorry if I made you feel that way. I can imagine why you are feeling
that way. Mrs Ali - If at all we could have done anything we would have definitely
done that for him. But our hands are tied because there is no such treatment available
to save his life.
Wife: Are you going to keep him in the Intensive therapy unit ?
Dr: Sometimes if they are not breathing on their own we keep patients in the ITU
and attach a machine which helps them in breathing.

Mrs Ali as you may know he is still unconscious but breathing on his own at the
moment.
I really wish we could keep him in the ITU and treat him. But we keep only such
patients in the ITU to treat - with whom we expect them to recover from the
condition. Unfortunately, we are not expecting that Mr Ali will recover from his
condition.
Keeping him in the ITU even if he stops breathing is not going to help him.

My consultant will discuss these things with you because your opinion is also
very important for us. What do you think Mrs Ali ?
Wife: I can understand. Are you not going to do anything at all for him ?

Dr: Mrs Ali, However we are going to do everything possible from our side to keep
him comfortable. We will provide him palliative care – that is we will be providing
all types of care to keep him comfortable.
Wife: When do you think he may die?
Dr: I really wish that I could say that he can live very long
and healthy life but Mrs Ali he may not live very long. He
may die any day.
Wife: I have 2 sons. Should I tell them to come here ?
Dr: Mrs Ali I think you should tell them to come here
because as I mentioned it is a very serious condition now.
Wife: Can I take him home doctor ?
Dr: Yes surely Mrs. Ali. We will make all the arrangements so that you can take
him home and we will provide all types of care and support you may need to look
after him as long as he lives.
Dr: Is there any other
concerns?
Wife: No doctor.
Dr: Once again I am very sorry to give you this bad news.
Wife: Thank you doctor
Dr: Thank you very much Mrs. Ali. If you need any help please do let us know.
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Aorto - Femoral bypass surgery. BBN

You are the FY 2 doctor in the surgery department.

Mrs. … 64 year lady had right sided Aorto-femoral bypass surgery. She developed
heavy bleeding in the brain after the operation. She has been transfused with 6 units
of blood.
She is taken to the theatre now. Your Consultant is in the theatre.
Talk to her husband Mr… and address his concerns.
This complication was not unexpected.

Dr: Hello Mr I am Dr…. one of the junior doctor in the surgical department.
How are you doing?
Pt: I am OK

Dr: I am one of the team of doctors looking after your wife Mrs.
I am here to talk to you about her condition. Do you know anything about how her
condition is now?
Pt: She had a surgery. I just came to see her now. I don’t know doctor how she is now.
How is she doctor?
Dr: I really wish I had a good news for you. But Mr..I am very sorry to say this she is in a
very critical condition now.
Pt: Why doctor what happened ?
Dr: After the surgery she was moved to the ward then we noticed that she started
bleeding heavily. We already transfused her 6 bags of blood. Unfortunately bleeding
has not stopped. So we have shifted her to the operation theatre again to try to stop
the bleeding. My Consultant is with her in the theatre. Our whole team is trying our
best to stop the bleeding.

Pt: OK. I need to go for my work now. Shall I come back after she is back from the
theatre?
Dr: Mr. I am very sorry to say that this condition is very serious because we may not
be able to stop the bleeding and it is a life threatening situation now.

Pt: What do you mean ? Do you mean she may not make it ?
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Dr: I really wish to I could say she is not in danger but unfortunately that is true Mr...
We are trying our best to stop the bleeding but it is very difficult to stop the bleeding in
such situation and if we do not succeed in stopping the bleeding she will not survive.

Pt: But why this happened?

Dr: Unfortunately sometimes this type of complications does happen after the surgery.
Pt: Didn’t you know this problem can happen before the surgery?
Dr: These types of problems are expected to happen after this type of surgery. Usually
we are prepared to handle this type of problems by operating again but in your wife’s
case it is very difficult to control the bleeding.
Pt: If you did expect this problem before then why did you do the surgery?
Dr: Unfortunately her condition was so serious that if we did not do the surgery she
would have lost her leg. That is why we did the surgery.
Husband: If you did not do that surgery she would have just lost her leg but now you
have put her life at risk.
Dr: Mr… It is true that it is a life threatening condition now but the risk of bleeding was
very low. Usually more than 95% of the people recover from this operation without any
complications at all.
We usually inform the patient all the benefits and the risks of the operation before we
do any operation. Since the risk was very low we did the surgery. It is very unfortunate
that this problem happened to her.

Pt: I think you did the operation unnecessarily and you are giving me my wife’s dead
body now.
Dr: I am really sorry if I made you feel that way. I can imagine why you are feeling that
way. It was essential at that time to do the surgery to save her leg.

Pt: Why is that you say it is difficult to stop the bleeding? Where is she bleeding from?
Dr: Let me explain her condition and what operation we did on her and you can
understand where she is bleeding and why it is difficult to stop the bleeding.
We all have a big blood vessel in our tummy called Aorta which branches out into
smaller branches and it continues in to the leg as femoral artery which supplies blood
to the leg. She had blockage in the femoral artery in the top part of her thigh so the
blood was not flowing into her leg.

We had to do an operation to restore the blood supply to her leg. So we connected an

artificial tube from the Aorta in her tummy to the femoral artery in the thigh so as to by
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pass the blockage. We have succeeded in restoring the blood supply to the leg but
unfortunately she has bleeding now. Bleeding is happening where we joined the
artificial tube to the original blood vessel. Because blood is under heavy pressure in
that area it is very difficult for us to stop the bleeding.
However my seniors are doing their best to stop the bleeding. Let us hope they will
succeed.
Pt: Doctor I have two sons. Do you think I should inform them?

Dr: Mr … Yes surely you can tell them that she is in a serious situation.
Pt: Should I tell them to come here ?
Dr: Yes, Unfortunately the condition is very serious Mr. I think you should tell them to
come here very soon.

Pt: One of my son is in London other one is in Australia.

Dr: You can tell your sons to come here as soon as possible as she is in a critical
condition. I think they need to be informed about it.
[ sometimes he may say one is in London and the other is in Somerset – both can come
here soon]

Pt: OK. Thank you doctor.

Dr: Once again I am very sorry to give this bad news. Let us hope that she will be fine. If
you need any kind of help please do let me know. Thank you very much.