Transcript PCM-3 END OF LIFE Session 1

PCM-3
END OF LIFE
Session 1
December 2, 2009
Session Objectives
At the conclusion of this PCM-3 session,
students will be able to





State and apply the key steps in delivering bad news
Develop an effective oral analgesic regimen
Define “Advance Directive”
Begin the process of establishing the overall goals of
care with a patient with a life-limiting illness
Discuss preferences regarding resuscitation with a
patient
Session Agenda
Introduction/Case 9:45- 10:00am
Giving Bad News 10:00-10:50

Shelly Lo, MD
Developing an Oral Analgesic Regimen

10:55-11:30
Theresa Kristopaitis, MD
Goals of Care, Advance Directives 11:40 – 12:20

John Hardt, PhD
DNR Role Play 12:30-1:15

Small groups
“End of Life”
“Death”
Death is the final stage of life
Death is less an event, than a
process
Death is a journey
Sudden death,
unexpected cause
<
< 10%,
10%, MI,
MI, accident,
accident, etc
etc
Health Status
l
l
Death
Time
EPEC
Physician’s Role in
“Life Limiting Illness”
Understand
physiologic changes
Manage symptoms
Honest
communication
Non-abandonment
Education
Willingess to work
with a team
Case
HPI




72-year-old woman presents to primary care
physician to establish care
Chief concern - shortness of breath
progressing for the past month
Has intermittent sharp right sided chest pain
unrelated to activity
Nagging dry cough for the past several
months.
Case
PMHx


HTN
Hyperlipidemia
Medications


Atenolol 50mg daily
Simvastatin 40mg daily
Drug allergies

None
Case
Social History





Active smoking, 1ppd x 50 years
Drinks 1 glass of wine with dinner
Retired grade school teacher
Divorced x 10 years
Has 1 daughter
Pt recently moved to the area to be closer to her
daughter and 3 month old grand-son.
Case
Family hx




Mother – died age 49 – motor vehicle
accident, no known chronic medical problems
Father - died age 62 of MI
1 brother – alive and well
Son – committed suicide 5 years ago
Case
ROS


General – 10# weight loss over past 2 months
“I guess I was too busy to eat with the move”
Otherwise review of systems negative
Case
Physical Exam




BP 120/72 Pulse 82 RR 12 Temp 98.7OF
She appears thin
Pertinent finding of decreased breath sounds
right upper lung field
No lymphadenopthy
Work-up
CXR

Right upper lobe lung mass
Work-Up
CT scan chest




5.7 x 5.2 cm mass in the right upper lobe
Scattered subcentimeter nodules throughout
both lungs
Mediastinal and right hilar adenopathy
2.8 x 2.1 cm lesion in the dome of the liver
CT guided biopsy of lung mass
Squamous cell carcinoma
She has returned to her doctor’s office to
for the test results/diagnosis
Giving “Bad News”
Shelly Lo, MD
Department of Internal Medicine, Division of
Hematology/Oncology
Associate Medical Director, Loyola Hospice
Case Continued
Oncology evaluation


Diagnosis of lung cancer reviewed
Implications of metastatic disease reviewed
including Inability to eradicate disease
In light of performance status, pt was
believed to be a candidate for systemic
chemotherapy
Pt consents to therapy
Case Continued
• Chest pain getting worse
• Constant ache 5-6/10
Worsens (sharp) with cough, laugh to 10/10
• Prescribed percocet 5/325
•
1-2 tabs every 6 hours as needed
Few days later
• Epic in-box
•
Still having pain. What to do?
Developing an Effective
Oral Analgesic Regimen
Theresa Kristopaitis, MD
Department of Internal Medicine, Division of
General Medicine
Associate Medical Director, Loyola Hospice
Back to Case
6 months later
Patient’s status declines



Increased sleepiness
Increased shortness of breath
Poor appetite
Daughter finds pt lying on the floor after a
fall
Calls 911
Case
Hospitalized
Inpatient physician believes he/she must
address (review?) goals of care, advance
directives and “code status” with the
patient
Goals of Care
Advance Directives
John Hardt, PhD
Neiswanger Institute for Bioethics and Health
Policy at the Stritch School of Medicine
Loyola University Chicago, Assistant to the
President for Mission and Identify
DNR Role Play
Small groups