Intern Survival Series Lecture #5 Dying, Death and Breaking Bad News Shaping the Future of Healthcare | www.thewrightcenter.org
Objectives – Be able to identify the internists role in palliative care – Become familiar with the S-P-I-K-E-S protocol – Have an understanding of the process of pronouncing someone as deceased – Identify the most common causes of death in the USA Shaping the Future of Healthcare | www.thewrightcenter.org
A Brief Note • This lecture series is not meant to be all inclusive or totally comprehensive to all of medicine • It is not meant to supersede clinical judgment • It is not meant to replace daily reading or bedside teaching • It is meant to act as a starting point for which to grow from as new primary care physicians • It is a tool to help you survive the your new job Shaping the Future of Healthcare | www.thewrightcenter.org
Questions? • Who are you? • Who do you want to be? • What do you see in your future? • What are your goals? – Short term? – Long Term? • What is the likely hood you accomplish what you set out to? • What are your barriers to will you face? – Personal? – Financial? – Educational? – National? Shaping the Future of Healthcare | www.thewrightcenter.org
What if…. • You became sick…. • Would you have more questions – Diagnosis? – Prognosis? – Treatment? Shaping the Future of Healthcare | www.thewrightcenter.org
What if…. • Your diagnosis was terminal? • Who would you want to tell you? • How would you want to be told? • What would you want to know? Shaping the Future of Healthcare | www.thewrightcenter.org
What if… • It wasn’t you, but a member of your family – Wife – Mother – Brother – Sister – Child Would that change your answers? Shaping the Future of Healthcare | www.thewrightcenter.org
The Challenge As physicians we are faced with difficult tasks and decisions everyday • Telling someone that there is no cure/life prolonging treatment options • left is: – Difficult • the nature of the conversation is tense • most people aren’t ready to die and most def don’t want to hear it from a resident – Variable • each patient handles the news differently – Denial, Angry, Bargaining, Depression, Acceptance – Complicated • family dynamics you are no longer just dealing with Mr. Y, but Mrs. Y, John Y, Sally Y, etc Shaping the Future of Healthcare | www.thewrightcenter.org
How do you tell someone they have a terminal diagnosis? • ???? • As a busy resident, seeing many patient’s in one morning, constricted by time, pressure, fatigue how do you tell someone they have terminal disease? • Most times you don’t know they have one initially. • The diagnosis comes through in the course of the investigation Shaping the Future of Healthcare | www.thewrightcenter.org
Case Presentation • Mr. Y, 50 y.o. male, former 30y 2PPD smoker comes to the office c/o SOB despite quitting smoking 2 yrs ago. He has had an OP stress test which was negative, he had PFTs which showed moderate COPD and started on appropriate inhalers. Despite this his SOB has worsened from moderate with exertion to mod to severe with minimal exertion and is present at rest. He reports a 10lbs weight loss over the last 6 weeks and this am coughed up a ¼ cup of dark red, bloody sputum. Shaping the Future of Healthcare | www.thewrightcenter.org
Case Presentation PMHx: HTN, COPD • PSxHx: none • Allergies: NKDA • Medications: • HCTZ 12.5mg PO Daily – Spiriva 18mcg, 2 puffs daily – Advair Disckus 50/100mcg 1 puff PO BID – Family Hx: • Mother, deceased 81, Alzheimer's Disease – Brother: 39, no PMHX – Father: Estranged – Social Hx: • Former 2PPD x 30y cigarette smoker, quit May of 2010 – 20 cans of beer/week, mostly on weekends – Works as a Computer programmer for a local hospital – Shaping the Future of Healthcare | www.thewrightcenter.org
Case Presentation • ROS (+)SOB, +hemoptysis, +worsening productive cough, +10lbs weight loss, +3 pillow orthopnea, +anorexia, (-)Chest pain, -dysphagia -dizziness, -confusion, -N/V/D, -hematemsis, -Abd pain, Remainder of ROS is negative Shaping the Future of Healthcare | www.thewrightcenter.org
Case Presentation PE: VS: 98.9, 96, 20, 122/74, O2sats 90% RA G: NAD, anxious CV: RRR, +s1/s2, no m/c/g/r R: Decreased BS at bases, faint wheezes throughout B/L lung fields, (+) Right sided rhonchi in mid lung field, palpable R subclavicular LN present A: +BS, s/nt/nd, no organomegally, no pain with deep palpation Ex: + peripheral pulses intact and equal in U&LE B/L, -edema, -cyanosis, +clubbing HEENT: EOMI, PERRLA, Normal Sclera, no thyromegally, No appreciable lesions lesions on upper or lower lip or buccal mucosa, TM visualized and clear B/L Shaping the Future of Healthcare | www.thewrightcenter.org
Case Presentation A/P 1) Worsening SOB with, weight loss, hemoptysis palpable LN -Sent for CXR, has OP appointment with pulm in 3 Days. -Pt offered admission, denied, called pulm and made earliest appointment possible -Advair dose increased Shaping the Future of Healthcare | www.thewrightcenter.org
Case Presentation 3 Days later pt presents to a local hospital in severe respiratory distress • Day 1 (Monday): Requires BiPAP, high dose steroids • Day 2 (T): Titrated off BiPAP, CXR ordered & reviewed showed R sided pulm nodules, Chest CT ordered but delayed due to difficulty lying flat • Day 3(W): CT shows Right sided hilar mass with liver nodules Consult Pulm • Day 5 (F): subsequent bronch performed, mass seen and Bxs taken . Shaping the Future of Healthcare | www.thewrightcenter.org
Case Presentation • Day 6 (S):Awaiting results, meet with pt’s wife and brother, long discussion had about possible diagnosis, treatment options and pt wishes. • Day 7 (Su): Awaiting results…… • Day 8(M): preliminary report from pathology indicated SCLC, hem/onc consulted, patient made aware • Day 9 (T) Final path confirms SCLC, Hem/onc recommends palliative radiation, does not tell patient what palliative means, glance over cell type, do not spend much time with patient. Pt’s wife states she is relieved that treatment is available and that he will be ok……….. Shaping the Future of Healthcare | www.thewrightcenter.org
Case Presentation How do you fill the patient-provider knowledge gap? • Recap: At this point you know pt has a terminal disease, but patient and family do not, despite meeting with sub-specialist. • Who’s responsibility is it to ensure they have better understanding of what is going on. • Interesting fact: It takes the average adult learner hearing something 8 (EIGHT) times before they are able to retain 75% of what they are told (and that is not including all the medical terminology) • On first pass through, patients retain <25% Shaping the Future of Healthcare | www.thewrightcenter.org
S-P-I-K-E-S Protocol for Breaking Bad News • S ETTING and Listening Skills • P erception by the patient of the medical problem • I nvitation from patient for medical information • K nowledge - giving medical facts • E xplore emotions and empathize as the patient responds • S trategy & Summary Shaping the Future of Healthcare | www.thewrightcenter.org
S ETTING and Listening Skills Ensure Adequate Physical space • Try to ensure privacy • Sit down! with eyes on same level as patient's • Arrange about 2 feet of space and no physical barriers between you • Have a box of tissues nearby if likely to be needed • Seat relative/friend next to patient (not between you and patient) • Body language and eye contact • Try to look relaxed and unhurried • Maintain eye contact (except during patient's distress) Shaping the Future of Healthcare | www.thewrightcenter.org
S ETTING and Listening Skills • Touch may also be helpful during the interview: • if a non-threatening area is touched (e.g., hand or forearm) • if you are comfortable with touch • if the patient appreciates touch and does not withdraw • Switch on your listening skills to show that you are an effective listener • Use open questions that elicit information from the patient • "how are you” • "what did that make you feel? Shaping the Future of Healthcare | www.thewrightcenter.org
S ETTING and Listening Skills • Facilitate, by pausing when the patient speaks • by nodding, smiling, • saying "tell me more about that” • by repeating one key work from the patient's last sentence in your first sentence • Clarify, by making any ambiguous or awkward topic obvious • Handle telephone/pager interruptions sensitively • tell the patient about any time constraints • clarify when discussion will resume Shaping the Future of Healthcare | www.thewrightcenter.org
P erception by the patient of the medical problem • Ask the patient to tell you what he or she knows or suspects about the current medical problem • for example • "What did you think when . . .“, • "Did you think it might be serious . . . " • As the patient replies: • Listen to the level of comprehension and vocabulary. • Notice any mismatch between the actual medical information and the patient's perception of it (including denial) Shaping the Future of Healthcare | www.thewrightcenter.org
Recommend
More recommend
