pcm-3 end of life session 1 december 2, 2009. session objectives at the conclusion of this pcm-3...
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PCM-3PCM-3END OF LIFEEND OF LIFE
Session 1Session 1
December 2, 2009December 2, 2009
Session ObjectivesSession Objectives
At the conclusion of this PCM-3 session, At the conclusion of this PCM-3 session, students will be able to students will be able to State and apply the key steps in delivering bad newsState and apply the key steps in delivering bad news Develop an effective oral analgesic regimen Develop an effective oral analgesic regimen Define “Advance Directive” Define “Advance Directive” Begin the process of establishing the overall goals of Begin the process of establishing the overall goals of
care with a patient with a life-limiting illnesscare with a patient with a life-limiting illness Discuss preferences regarding resuscitation with a Discuss preferences regarding resuscitation with a
patientpatient
Session AgendaSession Agenda
Introduction/Case Introduction/Case 9:45- 10:00am9:45- 10:00am
Giving Bad News Giving Bad News 10:00-10:5010:00-10:50
Shelly Lo, MDShelly Lo, MD
Developing an Oral Analgesic Regimen Developing an Oral Analgesic Regimen 10:55-11:3010:55-11:30
Theresa Kristopaitis, MDTheresa Kristopaitis, MD
Goals of Care, Advance Directives Goals of Care, Advance Directives 11:40 – 12:2011:40 – 12:20
John Hardt, PhDJohn Hardt, PhD
DNR Role Play DNR Role Play 12:30-1:1512:30-1:15
Small groupsSmall groups
““End of Life”End of Life”“Death”“Death”
Death is the final Death is the final stage stage of lifeof life
Death is less an event, than a Death is less an event, than a processprocess
Death is a Death is a journeyjourney
Sudden death,unexpected causeSudden death,unexpected cause
l < 10%, MI, accident, etcll < 10%, MI, accident, etc< 10%, MI, accident, etc
Death
Time
Healt
h S
tatu
s
Steady decline, shortterminal phaseSteady decline, shortterminal phase
Slow decline, periodiccrises, sudden deathSlow decline, periodiccrises, sudden death
EPEC
Physician’s Role in Physician’s Role in “Life Limiting Illness”“Life Limiting Illness”
Understand Understand physiologic changesphysiologic changes
Manage symptomsManage symptoms
Honest Honest communicationcommunication
Non-abandonmentNon-abandonment
EducationEducation
Willingess to work Willingess to work with a teamwith a team
CaseCase
HPIHPI 72-year-old woman presents to primary care 72-year-old woman presents to primary care
physician to establish care physician to establish care Chief concern - shortness of breath Chief concern - shortness of breath
progressing for the past monthprogressing for the past month Has intermittent sharp right sided chest pain Has intermittent sharp right sided chest pain
unrelated to activity unrelated to activity Nagging dry cough for the past several Nagging dry cough for the past several
months. months.
CaseCase
PMHxPMHx HTNHTN HyperlipidemiaHyperlipidemia
MedicationsMedications Atenolol 50mg daily Atenolol 50mg daily Simvastatin 40mg daily Simvastatin 40mg daily
Drug allergiesDrug allergies NoneNone
CaseCase
Social HistorySocial History Active smoking, 1ppd x 50 yearsActive smoking, 1ppd x 50 years Drinks 1 glass of wine with dinnerDrinks 1 glass of wine with dinner Retired grade school teacherRetired grade school teacher Divorced x 10 yearsDivorced x 10 years Has 1 daughter Has 1 daughter
Pt recently moved to the area to be closer to her Pt recently moved to the area to be closer to her daughter and 3 month old grand-son. daughter and 3 month old grand-son.
CaseCase
Family hxFamily hx Mother – died age 49 – motor vehicle Mother – died age 49 – motor vehicle
accident, no known chronic medical problemsaccident, no known chronic medical problems Father - died age 62 of MIFather - died age 62 of MI 1 brother – alive and well1 brother – alive and well Son – committed suicide 5 years agoSon – committed suicide 5 years ago
CaseCase
ROSROS General – 10# weight loss over past 2 months General – 10# weight loss over past 2 months
“I guess I was too busy to eat with the move”“I guess I was too busy to eat with the move” Otherwise review of systems negativeOtherwise review of systems negative
CaseCase
Physical ExamPhysical Exam BP 120/72 Pulse 82 RR 12 Temp 98.7BP 120/72 Pulse 82 RR 12 Temp 98.7OOFF She appears thinShe appears thin Pertinent finding of decreased breath sounds Pertinent finding of decreased breath sounds
right upper lung fieldright upper lung field No lymphadenopthyNo lymphadenopthy
Work-upWork-up
CXRCXR Right upper lobe lung massRight upper lobe lung mass
Work-UpWork-Up
CT scan chestCT scan chest 5.7 x 5.2 cm mass in the right upper lobe5.7 x 5.2 cm mass in the right upper lobe Scattered subcentimeter nodules throughout Scattered subcentimeter nodules throughout
both lungsboth lungs Mediastinal and right hilar adenopathyMediastinal and right hilar adenopathy 2.8 x 2.1 cm lesion in the dome of the liver 2.8 x 2.1 cm lesion in the dome of the liver
CT guided biopsy of lung massCT guided biopsy of lung mass
Squamous cell carcinomaSquamous cell carcinoma
She has returned to her doctor’s office to She has returned to her doctor’s office to for the test results/diagnosisfor the test results/diagnosis
Giving “Bad News”Giving “Bad News”
Shelly Lo, MDShelly Lo, MDDepartment of Internal Medicine, Division of Department of Internal Medicine, Division of
Hematology/OncologyHematology/OncologyAssociate Medical Director, Loyola HospiceAssociate Medical Director, Loyola Hospice
Case ContinuedCase Continued
Oncology evaluationOncology evaluation Diagnosis of lung cancer reviewedDiagnosis of lung cancer reviewed Implications of metastatic disease reviewedImplications of metastatic disease reviewed
including Inability to eradicate diseaseincluding Inability to eradicate disease
In light of performance status, pt was In light of performance status, pt was believed to be a candidate for systemic believed to be a candidate for systemic chemotherapy chemotherapy
Pt consents to therapyPt consents to therapy
Case ContinuedCase Continued
• Chest pain getting worseChest pain getting worse
• Constant ache 5-6/10Constant ache 5-6/10Worsens (sharp) with cough, laugh to 10/10Worsens (sharp) with cough, laugh to 10/10
• Prescribed percocet 5/325 Prescribed percocet 5/325 • 1-2 tabs every 6 hours as needed1-2 tabs every 6 hours as needed
Few days laterFew days later
• Epic in-boxEpic in-box• Still having pain. What to do?Still having pain. What to do?
Developing an Effective Developing an Effective Oral Analgesic RegimenOral Analgesic Regimen
Theresa Kristopaitis, MDTheresa Kristopaitis, MDDepartment of Internal Medicine, Division of Department of Internal Medicine, Division of
General MedicineGeneral MedicineAssociate Medical Director, Loyola HospiceAssociate Medical Director, Loyola Hospice
Back to CaseBack to Case6 months later6 months later
Patient’s status declines Patient’s status declines Increased sleepinessIncreased sleepiness Increased shortness of breathIncreased shortness of breath Poor appetitePoor appetite
Daughter finds pt lying on the floor after a Daughter finds pt lying on the floor after a fallfall
Calls 911Calls 911
CaseCase
HospitalizedHospitalized
Inpatient physician believes he/she must Inpatient physician believes he/she must address (review?) goals of care, advance address (review?) goals of care, advance directives and “code status” with the directives and “code status” with the patientpatient
Goals of CareGoals of CareAdvance DirectivesAdvance Directives
John Hardt, PhDJohn Hardt, PhD
Neiswanger Institute for Bioethics and Health Neiswanger Institute for Bioethics and Health Policy at the Stritch School of MedicinePolicy at the Stritch School of Medicine
Loyola University Chicago, Assistant to the Loyola University Chicago, Assistant to the President for Mission and IdentifyPresident for Mission and Identify
DNR Role PlayDNR Role Play
Small groupsSmall groups