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END OF LIFE DISCUSSIONS
1. How are you feeling today?
Are you having much pain?
How about shortness of breath?
Are you comfortable with the treatment you are receiving?
2. I got something that is quite important that I need to ask.
It is one of these hospital regulations.
I find it awkward to talk about it but I need to address them.
3. The problem is there is not much treatment available to us because the breast cancer has
progressed to other parts of your body.
What I’d like to talk to you about today are some decisions for the future.
4. Is this something that you are comfortable to talk about now or is there someone you want to
be here with you?
Issues:
1. I would like to know if there is someone you want to make decisions for you if you are too
sick to tell me directly.
If you become too sick for me to talk to you directly, who is it you would like me to talk to
about your healthcare?
If you want to make that decision legal, you can sign a dual power of attorney for healthcare.
2. I’d also like to talk to you about the focus of your treatment.
This doesn’t mean stopping treatment altogether but changing it.
From one that is meant to cure the cancer that we now know is not possible to one that is
focused on treating your symptoms to keep you feeling more comfortable and free from pain.
This is really hard to face but there isn’t anything else to treat your cancer.
But there is a lot of things to treat your symptoms.
There is a lot of things that we can do to make you more comfortable in order that you will
not suffer unnecessarily.
3. Now, when you think about the progression of your disease, what is it that scares you most.
What is important to you now?
What sort of things have been hard to you with your illness?
What sort of things are important for you to do before you die?
How is this treatment affecting you?
-
4.
If in my medical judgement, I thought that you were close to death, I would do my
best to make sure you are free from pain and try to make sure that you are at home
and at the hospital. Does that sound like what you mean?
One of the other things I would like to talk to you about today is what we sometimes do
when a person’s heart stops beating or they stop breathing.
It’s called resuscitation.
On an otherwise healthy person, this can sometimes bring them back to life.
It is very dramatic and very harsh treatment.
It would involve pressing or pounding on your chest.
We will administer an electrical charge to your heart, put a tube to your mouth
into your lungs to enable you to breathe.
It’s very traumatic and very uncomfortable.
In a person with a disease like yours its doubtful that resuscitation will even
work.
In your case where cancer has already spread to so many parts of the body, there’s a
less than 1% chance that we can bring you back to life.
That means that even if we attempted resuscitation, there’s a > 99% chance that it
will fail.
Now even if we got your heart started again it will only last a couple of days and you
may be unconscious for that whole time. Do you understand this?
Now, I want to get your feelings on this. Whether you want to take that small chance
that the resuscitation will make a difference or if you want to take the opportunity to slip
away peacefully.
I want to get your thoughts on this kind of choice.
If your heart were to stop beating, would you want us to do some very
aggressive techniques to get it going again?
I hear you. I’ll record that in the chart that we had this conversation.
That if your heart stops we will not attempt to restart it.
5. I would like to reassure you that even if you decide that you will not have any resuscitation
that does not mean that we will withhold treatment from now on.
I would like you to know that I will take care of you whatever you decide.
Closing:
1. Do you want some time to think about this and discuss it in the next visit?
2. We’ll keep on talking about this and if there are some changes you make sure to let me know.
3. Next time, I think it’s important to bring your husband in so we can discuss about this
together.
4. Do please call me if you have any questions and I’ll call you next month.
WIFE ASSAULT
Screening Questions
How are you and your partner getting along?
What happens when you disagree about something?
Have you been physically hurt by anybody in the last year?
Have you ever been pressured or forced into a sexual situation against your will?
OR
S = Do you feel safe or stressed in your relationship?
A = Have you ever been abused or afraid in a relationship?
F = Are your friends and family aware of your relationship problems?
E = Do you have an emergency plan if needed?
Hx of physical abuse
How did it happen?
When did it happen?
Has there been any problems at work or at home to make them happen?
How long has this been going on?
Do you have any other injuries? Does it hurt anywhere else?
Have you ever been hospitalized for physical injuries?
Do you have any medical problems? Are you taking any medications?
Is there a history of abuse in your family or your husband’s family?
Ask husband to leave the room so you talk to the patient.
Ask an explanation for other injuries that may be present.
Does any of your family or friends know about this?
Do you get in touch with them easily?
Husband
How is your husband?
Is he working? What type of work does he do?
Do you have arguments often? Does he shout at you?
Does he have any drinking or drug problems?
Are things particularly bad between you and your husband when he drinks?
Forgive me for asking but it is important that I ask.
Has your husband ever hit you? How many times?
Did your husband ever threaten you with physical harm?
Potential Danger
Did your husband ever threaten you with physical harm/death threats?
Do you think that your current living arrangements is safe?
Is your partner presently at home?
Does your husband have a criminal history? Did he ever serve time in jail?
Did you ever think of inflicting harm on yourself?
Did you ever push through with it?
Is there a gun in the house?
Children
How many children do you have? What are their ages?
Were your children ever abused?
Violence in a home affects the future behavior of children.
Counselling
I’m glad you told me.
I am concerned for your safety.
I assure you that this conversation will remain confidential.
Wife abuse is a criminal offence.
It is not your fault that this happened. You do not deserve to be abused.
Plan of Action
Have you ever tried counseling?
Do you think your husband might come along to a marriage counselor?
I can arrange an appointment for you so that you can talk to someone who
Specializes in these things so that you can know your options.
There are community resources that can help.
I will give you their phone numbers and location.
You can also move temporarily to a “safe house” where you can review
Your options carefully without the threat of violence.
You have the right for protection. Involving the police helps prevent further
abuse. It is your choice. Nobody can force you to do anything.
If you decide to go back, I strongly suggest that you create a plan of escape in the
event that you feel that you and your children’s lives are threatened.
Have a suitcase ready and leave it with a friend or relative. Pack essential
Clothing, medications, car keys, driver’s license, money, social security no., birth
certificates and special toys for the children.
I would like to see you again in the next 24 hours to see how you are doing.
TRUTH TELLING – ALZHEIMER’S DISEASE
Introduction
So how are things going along?
Before I tell you the results, a couple of things I need to ask:
When this began did you think that the memory is leading to something serious
or something temporary?
If it turns out that it is something serious, are you the kind of person who wants
me to tell you what the exact diagnosis is?
The brain scan showed that the substance of the brain, the cortex, is a little bit thinner
than we would expect in a man of your age. So that alerted us that something is going
on.
And then you did the other test where you did some arranging things and memory test.
The test showed a memory problem.
From these information the tests indicate a strong possibility of Alzheimer’s.
What comes to mind when you hear Alzheimer’s disease?
What happens to me?
Alzheirmer’s is a disease that does not get better, it does not get healed with time.
It is a disease that happens over a long period of time. Almost always it steadily
gets worse. However, we cannot predict how fast the disease will progress.
In most situations, Alzheimer’s get progressively serious and produce problems over a
period of years. In a small number of patients, it can happen quickly in a period of
months or 2 years or less. But generally, it’s a fairly slow and progressive condition.
Due to the unpredictable course of the illness, you need to come for follow-up
Visits so we can see how the diagnosis is affecting your everyday life in order
That we can make the necessary changes.
Treatment for Cure
Cure is not available at this moment. There are several medications being used but they
are still in the investigational stage. It is an option available to you.
Social Supports
Who stays home with you at the moment?
Children, friends and relatives that may help?
If you want, I can set up a meeting with you and your family so that I can tell them the
diagnosis.
I’d like you to come back in a few weeks with your wife.
I want us all to sit together and start making plans for how we can help if and
when your memory problems become worse.
We need to discuss at what stage of your illness do you feel you would
prefer to be in an institution and not your home, who should make decisions for you
about your healthcare when you are not able to make these decisions on your own.
I also advise you to start having your financial affairs in order.
I would also want you to get in touch with some local support groups to help you learn
more about Alzheimer’s and get more information on what help is available in your
community. I will provide you with some informational brochures including phone
numbers of organizations that can help.
What I’ll do now is make an appointment. And I will see you with your wife and
we will pick it up from there.
REFUSAL OF TREATMENT
1. Ask about px’s mental or emotional state.
- Could you manage your own affairs?
- Are you feeling blue?
2. Ascertain that patient understands disease and the treatment.
- What’s your understanding of what’s going on?
- Do you know how we treat that condition? Can you describe what doctors have
done in the past?
- Are the drugs and oxygen OK with you?
- Are you having any adverse reactions from the treatment you’re getting?
3. Ascertain that patient understands the consequences of decision.
- Do you know what would happen if we didn’t put the tube in?
- Do you want to die?
- What would you like to do if this happens again?
- Why do you want to make that decision? What’s your concern?
4. Ask about the presence of other potential decision makers/involved persons.
- Do you have family or friends who know about your decision?
5. Ask whether patient wants other life-sustaining treatments/alternative treatments.
6. Agrees to respect patient’s request or state that people have the right to make such
decisions.
- I will respect your wishes.
- I think it’s certainly your right.
7. Describe plan to act on patient’s request while patient is still in hospital.
- Note in the patient’s chart
- Discussion with nurses or housestaff
- Describe what will happen in terms of medications and keeping patient
comfortable.
8. States that patient can change mind.
PATIENT’S RELATIVE’S REFUSAL OF TREATMENT
1. Ask about patient’s mental status
2. Patient’s preference
- Is this what the patient want?
- Have you ever discussed with the patient what their feelings are towards lifesustaining procedures?
- Did she ever leave any advance directives or living will?
- Do any of her other relatives or friends have any information about the patient’s
previously expressed wishes?
- Sometimes our own preferences towards this procedures differ from the
patients.
- It is the patient’s right to make this decision.
- If you were in the same situation as your mother (patient), you would want to
be involved in a decision about your own life.
3. Substitute Decision Maker
- How are you related to the patient?
- Do you feel you are well informed about her wishes?
- Do have legal power of attorney for her?
- How about the other members of her family, do they share the same views
as yours? Has there been a family meeting about this issue?
4. Patient’s consent
- The patient may not be frightened by, or may even welcome, discussion
of her illness and the DNR order.
- The discussion can be handled in a sensitive way.
- You may be present during the discussion.
- Offer counseling or support.
5. Refuse to write the DNR order without the mother’s consent.
- I will only write the DNR order with the patient’s consent.
- Describe what other care will be given when DNR order is given (e.g. mouth will be
kept moist, patient will not be neglected)
DECISION TO FOREGO TREATMENT – JEHOVAH’S WITNESS
1. Explain the seriousness of the patient’s condition and what has been done medically:
e.g. patient is unconscious, losing blood, suffering incipient shock,
given intravenous saline
2. Is there anyone else who should be here to help make the decision?
3. What do you know about your mother’s prior wishes?
4. Does she still believe in J.W. teachings?
5. Is the card a valid reflection of her true wishes?
6. How do we proceed from here?
7. Do you know what may happen if we don’t give her any blood?
8. Do you think your mother would still choose “no blood” if she knew she could die?
9. States that the patient’s wishes will be respected.
BRAIN DEATH
1.
explains meaning of brain death (e.g. no
neurological function, diffuse brain damage, brain tissue destroyed).
2.
assures wife of certainty of diagnosis.
(i.e. two neurologists/neurosurgeons agree)
3.
assures wife of certainty of prognosis.
(i.e. brain damage is irreversible, no
chance of recovery)
4.
states clearly that husband is dead now.
5.
states that brain death is legal definition of death.
6.
states that life support should be stopped.
7.
mentions that husband is candidate for organ donation.
8.
asks about organ donation card or previous discussions about organ
donation.
9.
asks wife for her views regarding donation of husband's organs.
10.
states that organ donation will not affect burial. (i.e. can use an open
casket)
BIRTH CONTROL PILL
You started doing a locum for Dr. Hardy a few weeks ago. He will be on educational
leave for 6 months.
You are about to see Beverley Carter, who has been Dr. Hardy's patient for several years.
Her 16 year old daughter, Linda, is also a patient of Dr. Hardy. A few months ago, Dr. Hardy
prescribed the birth control pill for Linda because she was sexually active. Linda asked several
informed questions and was fully aware of the risks and benefits of taking the pill. Dr. Hardy
wrote in his notes that he felt she was fully competent to make that decision. Linda told Dr. Hardy
in no uncertain terms that she did not want her mother to know she was on the pill or why she
was being prescribed the pill. Last week you saw Linda to renew her prescription for the pill. You
agree with Dr. Hardy's assessment of her competence.
The mother, Beverley, has subsequently become suspicious about Linda's visits to the
doctor's office and has made this appointment to discuss the issue. You have a very busy office
today and only have 10 minutes to see her.
1.
refuses to discuss nature of daughter's visit.
2.
states that information about daughter's medical condition is confidential.
3.
states that nature of present visit between mother and doctor is also
confidential.
4.
checks if mother has asked daughter about reason for visit.
5.
addresses nature of mother-daughter communication.
6.
offers practical strategies for
improving communication with daughter
(e.g. counsel them together).
7.
states that competent people (like
Linda) are treated like adults and allowed to make their own medical
decisions.
8.
addresses consequences of breaking
confidentiality: e.g. patients will lose trust or not discuss personal matters
which may have bearing on physical health.
HIV INFECTION
You started doing a locum for Dr. Lang a few days ago. Dr. Lang will be gone for several
months.
You are about to see David Plant, who has been Dr. Lang's patient for several years.
Generally he has been very healthy and has not needed much medical care except for the
occasional health check up. A few weeks ago he confided to Dr. Lang that he had unprotected
anal intercourse with a homosexual lover on at least 5 occasions about 4 years ago. He expressed
fear of having AIDS and requested an HIV test. Sandy, his wife of 3 years, is also a patient of Dr.
Lang and has an appointment with you next week. She does not know about her husband's
homosexual experience. Mr. Plant's test has come back HIV positive. A confirmatory test is also
positive. Please inform Mr. Plant of the test results and deal with his concerns.
Mr. Plant did not have an appointment. He walked in and insisted on seeing you today.
You have a very busy office and only have 10 minutes to see him.
1.
checks if patient talked with previous doctor about test,
or implications of test.
2.
assures patient he does not have AIDS.
3.
states that prognosis is variable.
4.
states that wife should be told/she has a right to know.
5.
states that wife could be HIV positive and should be tested.
6.
advises patient to use abstinence or safe sex with wife or other
partners to prevent transmission of HIV.
7.
encourages patient to tell wife.
8.
offers to help tell wife.
9.
advises patient that wife may find out
through public health contact tracing.
10.
offers follow up visit.
SEXUAL IMPROPRIETY
1.
inquires about how things "didn't work
out" and establishes that relationship
was sexual.
2.
informs the patient that sexual contact
is not part of the normal doctor/patient
relationship.
3.
informs patient that sexual contact
in context of doctor/patient
relationship is unethical.
4.
asks about how patient is feeling
currently (e.g. depression, anxiety).
5.
assures patient that she is not
responsible/it is not her fault.
6.
tells patient that filing a report in
front of the College is an option.
7.
understands that sexual impropriety
could lead to loss of physician's
licence.
8.
mentions that physician is obligated to
report the psychiatrist.
9.
asks for name of psychiatrist.
10.
offers ongoing counselling to patient
and/or referral to a psychiatrist.
11.
recognizes that patient may feel more
comfortable with a female psychiatrist.
Child Abuse
History
You probably have gone through a lot today.
I have to ask some questions about your family and how Junjun received his injuries.
It really is pretty worrying when a child gets hurt.
Can you tell me what happened?
When did you notice it? (time interval before seeking help)
What do you think did he fell on?
Height? What did he land on?
Did he have any previous injuries similar to this?
How did the others happen?
Past Medical Hx
How was your pregnancy with him? Labor and delivery?
Ht and wt at birth and at present?
Feeding difficulties? Problems with toilet training? Enuresis, encopresis?
School performance?
Medical illnesses? Medications?
Family Hx
History of parental child abuse.
Request husband to leave the room.
Social Setting
How many children do you have? What are their ages?
Who takes care of the children?
Who works? Who disciplines the children?
What is the usual pattern of discipline in the family?
How are the children punished?
Stressors at work or at home?
How is your financial situation?
How is your relationship with your husband? Do you feel that you and your
Husband can communicate effectively with each other?
Are friends or close relatives available for help? Are they easily accessible?
Does your husband have any drinking problem, does he lose his temper easily?
“ When we see children with these kind of injuries we are often concerned on what happens at
home.
What I am saying is that Junjun has some injuries and I would like to sort out with you how the
injuries happened.”
“ Children’s Aid Society” is there to help people. I will get in touch with someone who I think
will be able to help you. You have some problems and its not unusual. So why not let us have
the chance to help you out.”
Panic Disorder
History
Can you tell me what happened?
When did this happen?
Did this happen out of the blue without any warning?
Where were you at the time? Did it happen at home? During sleep?
Does it occur in a particular time of day?
How long did it last until things are at its peak?
Did you have similar attacks in the past? When was the last time? Frequency?
I’m going to ask you about some symptoms you may have experience during the
Attack. Did you….
S…sweat
T…tremble or shake
U…feel unsteady or light headed
D…feel like things around you were unreal, like you were in a dream, like
you were outside of yourself watching (depersonalization/derealization)
E…feel your heart racing, pounding, or skipping beats (elevated heart rate)
NTS…feel nausea
FEAR … fear you were going crazy or might lose control
… fear you might die
3C’s… chills or hot flashes
… choking or being smothered
… chest pains or pressure
Consequences
How do the attacks affected your mood? Does it make you feel sad or hopeless?
Some people who feel sad have these thoughts of harming themselves. Did you ever feel
like
you want to hurt yourself?
Are you afraid that the attack may happen again?
How has that affected your work?
How about your relationships?
What are you afraid of? How have you managed to cope?
Have you tried avoiding particular situations?
Rule out
Medical Illnesses
Hyperthyroidism, pheochromocytoma, heart disease, diabetes mellitus
Medications
Amphetamine, OTC, herbal, alcohol, street drugs
Psychiatric Illnesses
OCD, PTSD, Specific phobia, Anxiety