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Palliative Care Experience

for

THIRD YEAR MEDICAL STUDENTS

Medical College of Wisconsin

Authors

David E. Weissman, MD

Linda Blust, MD

Palliative Care Center

Froedtert Hospital/Medical College of Wisconsin

Milwaukee, WI 53226

Copyright 2005, Medical College of Wisconsin, Inc.

M3 Palliative Care Experience

Introduction

At the Medical College of Wisconsin, all 3rd year students participate in a Palliative Care Experience during their one-month required Internal Medicine Ambulatory rotation. The Palliative Care experience is modeled after, but uses original material, a similar program at the University of Maryland (D Ross, MD).

1. Global Learning Objectives

• Understand the meaning of the clinical domain, Palliative Care, and its relationship to Hospice Care.

• Learn five components of a palliative care assessment.

• Complete a self-assessment of palliative care knowledge.

• Improve knowledge in core domains of palliative care: pain and symptom management, communication skills, ethics, hospice and goal setting.

• Understand your personal values surrounding care of the dying that impact upon decision-making.

Educational Plan and Specific Learning Objectives

All students complete the five activities listed below.

A. Clinical Experience/Patient care assessment—½a day supervised experience at a clinical sites: Inpatient/outpatient palliative care service or Home visit with Home Hospice program or Visit to Residential Hospice. During this ½ day, students are assigned one patient to interview and then to complete a written patient assessment (see template below).

Objectives

• Learn the roles and responsibilities of the primary care physician for the hospice patient.

• Attend an Interdisciplinary Team Meeting

• Demonstrate completion of a written palliative care patient assessment.

1 Self-study material—Booklet of resource information

Objective

• Improve fund of knowledge re: core domains of palliative care through self-study (e.g. pain, communication, ethics)

C. Complete Knowledge, Self Confidence and Concerns survey (Take Home Examination)

Objective

• Review personal strengths and weaknesses in knowledge concerning core domains of palliative care (e.g. pain, communication, ethics).

• Review personal fears and concerns concerning ethically challenging patient scenarios.

D. Small group workshop (1.5 hours with 8-10 students)—led by Palliative Care faculty;

Objectives

• Review Take-Home Examination and Patient Care Assessments

• Explore personal feelings and past experiences regarding caring for dying patients.

• Review communication skills of giving bad news and goal setting

Self-Reflection essay

Objective

• Self reflect on personal feelings and meaning of caring for dying patients.

2. Resource Material provided to students

• Palliative care resource guide for 3rd year medical students (Self-study guide)

• Take Home Examination

• Pain Management, Pocket Card

• Running a Family Meeting, Pocket Card

• Communication Phrases for End-of-life Care, Pocket Card

4. Student evaluation

The palliative care experience is one aspect of a month long ambulatory care experience in Internal Medicine. Preceptors for the Clinical Experience (see 1. above) complete a written evaluation (see last page of this document). The Take-Home examination and the Personal Essay are NOT used for evaluation purposes.

PATIENT ASSESSMENT (student information)

During the two-week ambulatory rotation, you will be instructed to report to a clinical care site involved with palliative or hospice care. At the site, you will meet with an on-site clinician (nurse and/or physician), who will introduce you to one patient to interview.

Expectations of students:

1. Students will report promptly to the assigned site on their assigned date;

2. Upon arrival, a palliative care/hospice health care provider will be assigned to the student and accompany the student to supervise the experience;

3. Students will meet with one patient, discuss care issues with the palliative care/hospice team and complete a palliative care assessment;

4. Students will submit the completed workup to the course director by the final day of the Ambulatory Care experience;

5. Students will complete an evaluation form of the experience and return the evaluation to the Course Director.

MEDICAL STUDENT ½ DAY VISIT

(Information for hospice/palliative care site coordinator)

Palliative Care or Hospice health care provider role:

1. Meet the student at the arranged date/time place;

2. Select one patient for the student to interview. Provide pertinent information about the patient that is necessary for the home visit or inpatient interview;

3. Provide the student access to the patient's chart for aid in assessing and interviewing;

4. Act as a resource for the student when assessing and interviewing the patient; serve as a role model;

5. Provide emotional support to the student as this is a new experience for most students;

6. Discuss with the student any follow up care, referrals or other interventions needed by the patient and/or family as well as the role the primary care physician played in the care of the client;

7. Explain the function and invite the student to attend your Interdisciplinary team meeting (if timing permits).

8. Provide verbal feedback to the student regarding student’s behaviors and complete a written Student Evaluation form, to be faxed to the Course Director;

9. Communicate with course director, as needed, regarding the student and/or experience.

PERSONAL ESSAY

This Palliative Care experience is an opportunity for you to consciously examine your own reactions to dying patients and their families. Write a short essay (200-500 words) after your hospice or palliative care patient visit, describing your personal experience.

1. Your attitude, mood, or feelings before meeting the patients.

2. Your thoughts and feelings during your initial contacts with patients and the setting in which you found them.

3. Whether this changed in any way over the course of your time with patients.

4. To what degree were you able to empathize with the patients or was it too hard to imagine being in their situation?

5. What was the most challenging characteristic of the patients for you? (e.g., physical debility, appearance, having to think about death, uncertainty about what to do or say?)

6. What did you learn about yourself from this experience that you can use to enhance your relationship with patients in the future?

Clearly, there is no right answer; this will be of value only if you can honestly reflect on the experience. Complete your essay and turn into the Course Director’s office; you will have an opportunity to discuss your essay during the small group workshop.

TAKE-HOME EXAMINATION

A 33 item Palliative Care multiple-choice examination will be distributed on the first day of the rotation; along with self-study guide materials. Complete the examination on your own, using the self-study guide resources; you are free to use any other sources of information available to you. Included with the exam is a self assessment of your concerns of pertinent legal, malpractice and ethical issues common to end of life care; plan to discuss your concerns during the small group workshop. The examination will be reviewed as a group during the small group workshop.

SELF-STUDY MATERIAL

A packet of Palliative Care Self-Study material will be made available to you.

SMALL GROUP WORKSHOP

There will a 1.5 hour small-group Palliative Care teaching workshop as part of the Ambulatory rotation This time is for you to bring up any topics of concern, discuss patient care issues, and review the Palliative Care examination.

PALLIATIVE CARE PATIENT WORK-UP

DIRECTIONS: Complete the Palliative Care Assessment below; seek assistance from palliative care/hospice staff as needed to complete the assignment.

Student’s Name::

Name of Site Visit Site:

Name of Site Visit Staff:

Date of Patient visit:

Patient’s Primary Diagnosis:

Pertinent Secondary Diagnoses:

1. Narrative of Current Condition

A one-paragraph discussion of the terminal illness.

2. Physical Symptom assessment:

List individual physical symptoms (e.g. pain, nausea); provide pertinent information about each symptom (onset, duration, location, exacerbating/relieving factors, treatments and their effects and impact of symptoms on activities of daily living):

Symptom # 1

Symptom # 2

Symptom # 3

Symptom # 4 (use back for additional symptoms)

3. Psychosocial/Spiritual Assessment; Support System

Complete a psychosocial and spiritual assessment; list key family members and other support individuals; report current areas of psychological/spiritual distress; explore spiritual care issues: examples of questions to ask include:

• Who does the patient identify as “family”?

• Who does the patient rely upon in times of stress?

• How does the patient usually deal with stress?

• What role does faith play in the patient’s life?

• Does the patient participate in an organized religion?

• Does the patient have someone in the faith community to talk with? Has that person been contacted?

• Does the patient need to get in touch with any family or friends? Can the staff help in contacting them?

4. Assessment and communication of estimated survival

Explore the patients/family understanding of their prognosis—have they asked?, have they been told? Review the chart and talk to the staff to get opinions on the patients prognosis. Use the ECOG Performance Status Scale to establish the patient’s current score. Key questions to ask include assessment of :

• Degree of nutritional intake: full, partial, minimal, none.

• Percentage of time spent in bed or lying down each day: none, 25-50%; 50-75%; All.

• The temporal patter on energy loss—what has happened over the proceeding weeks, months.

Patient and Family Goals

Explore the patient/family goals. Key questions to ask include:

• Does the patient have any goals that need to be accomplished in the time left?

• Is there anything preventing the patient from accomplishing these goals?

• Can the patient identify anything that would make this time especially meaningful to him/her?

Goals:

1.

2.

3.

5. Assessment of discharge/disposition issues

Note: for some patients, particularly those in a hospice residence facility, they are well established in that setting with the expectation they will stay there until the time of death. For other residents, the issue of disposition is unsettled. For these patients, key questions to answer include:

• What is the most appropriate setting for the patient to be in, up until the time of death (e.g. inpatient or home hospice, nursing home, hospital)?

• Is the patient and family comfortable with their current setting?

• What special needs to patients have that will impact on care setting? (e.g. need frequent nurse assessment for pain management or dressing changes)

SUMMARY / PROBLEM LIST

Write a one paragraph, or bulleted problem list of the current assessment and your recommendations; taking into account all the above information.

PALLIATIVE CARE PATIENT WORK-UP (example)

DIRECTIONS: Complete the Palliative Care Assessment below; seek assistance from palliative care/hospice staff as needed to complete the assignment.

Student’s Name: John Smith

Name of Site Visit Site: Froedtert Hospital Palliative Care Inpatient Unit

Name of Site Visit Staff: Julie Griffie, RN

Date of Patient visit: 10/4/01

Patient’s Primary Diagnosis: Metastatic lung cancer: bone, liver metastases

Pertinent Secondary Diagnoses: CHF, Diabetes

Patient’s Age 74 Ethnicity Caucasian

1. Narrative of Current Condition

This is a 74 y/o man with metastatic lung cancer; originally diagnosed in March 2001 following cough and chest pain. He has known metastases to liver and spine. He has had radiation treatments to the lung primary and the spine metastases. He had two courses of chemotherapy, but there was tumor progression with increasing liver metastases; he decided not to have any further chemotherapy. He was admitted to the hospital two days ago for pain control.

2. Physical Symptom assessment:

List individual physical symptoms (e.g. pain, nausea); provide pertinent information about each symptom (onset, duration, location, exacerbating/relieving factors, treatments and their effects and impact of symptoms on activities of daily living:

Symptom # 1 Back Pain

Constant, dull, achy, well localized to lower mid back; no radiation. Made worse by sitting up or coughing. Currently pain rated at 8/10; drops to 5/10 after PCA bolus dose-lasts for 60 minutes. Pain awakens patient from sleep. Currently on MS 2 mg/hr infusion with 5 mg q 10min PCA bolus dose. Also on Decadron 4 mg q 12. Uses heating pad and distraction.

Symptom # 2 Anorexia

No appetite x six weeks, food tastes bad, 30 pound weight loss over past three months. No nausea, vomiting, abdominal pain.

Symptom # 3 Constipation

Bowel movements very hard; roughly every 4-5 days, but only small amount; using Senekot 2 bid; no past history of constipation. No abdominal swelling, nausea or vomiting.

3. Psychosocial/Spiritual Assessment; Support System

Complete a psychosocial and spiritual assessment; list key family members and other support individuals; report current areas of psychological/spiritual distress; explore spiritual care issues: examples of questions to ask include:

Second marriage—lives with current wife; two children by past marriage—both live in region. 1st wife deceased (breast cancer). Children and wife very supportive, visit frequently. Patient has two sibs, both live >100 miles away. Wife is primary caregiver, is healthy.

Patient is a non-practicing Lutheran; not affiliated with a church, has no particular spiritual care person. Patient desires to re-connect with faith prior to death. Wife is practicing Catholic.

4. Assessment and communication of estimated survival

Patient says that the doctors told him, “no one can tell for sure”. He states that he believes his time is short, maybe only a few weeks, but no one has said anything. Over the past month he has had a dramatic decrease in energy; he spends >75% of the time in bed or laying down. His appetite is non-existent.

Estimated ECOG Performance Score: 3 Estimated survival: < 3 months

5. Patient and Family Goals

Explore the patient/family goals. Key questions to ask include:

1. Patient wants to re-connect with his fait

2. Patient has personal affairs to complete; will, funeral arrangements

3. Patient wants to see his siblings again before he dies.

4. Patient wants to be at home and be kept comfortable

5. Patient does not want any further medical tests or procedures

6. Assessment of discharge/disposition issues

The patient wants to go home; his wife is concerned about her ability to provide care. Home is a two-story condominium. They are aware of the concept of “Hospice”, but they do not know any details. Both patient and wife express concerns about disrupting their children’s lives—they don’t want to be a burden. The wife is particularly fearful of managing pain, she doesn’t want her husband to suffer. The only active medical intervention currently being used is the morphine infusion; the patient asks if he would need this at home.

SUMMARY / PROBLEM LIST

1. Pain—somatic pain syndrome, partially controlled; needs more aggressive pain management; issue of route of analgesic delivery needs to be simplified if possible to reduce family anxiety re: home care.

2. Anorexia—severe; likely secondary to progressive cancer. Role of appetite stimulants can be addressed.

3. Constipation—patient needs more aggressive management.

4. Spiritual—patient wants to reconnect with faith; needs connection to spiritual caregiver.

5. Prognosis—patient would like an open discussion of prognosis so he can make plans regarding will, meeting with family members, etc..

6. Disposition—patient and wife need information about home hospice option including description of home care services.

INTERNAL MEDICINE AMBULATORY CARE

PALLIATIVE CARE EXPERIENCE

TAKE-HOME EXAMINATION and CONCERNS SURVEY 1

Name: ______________________________

Date: __________________

Instructions:

Complete the Take Home examination and Concerns Survey; all questions on the knowledge test have only one best answer. Return to the Course Director by the last day of the rotation.

1. This examination is adapted from a validated survey instrument used as part of the National Residency End-of-life Training Project. Mullan P, Weissman DE, Ambuel PB, von Gunten CF. End-of-life care education in internal medicine residency programs: inter-institutional study. Journal of Palliative Medicine 2002; 5:487-496.

A 72 y/o man with lung cancer and bone metastases has increasingly severe pain over the Left hip. The pain began 6-8 weeks ago and was initially controlled with acetaminophen/oxycodone tablets (Percocet), using 4-6 tablets/day. Over the past two weeks [‘the pain has worsened; he now takes 12 tablets per day with only partial pain relief. The pain is constant, aching and well localized; there is no referred pain. (questions 1-6)

1. Increasing pain in this patient most likely represents:

1) new onset depression

2) opioid addiction

3) opioid tolerance

4) worsening metastatic cancer

2. This man’s pain is best described as:

1) neuropathic pain

2) somatic pain

3) vascular pain

4) visceral pain

3. When would you expect a patient to report the maximal analgesic effect after taking a dose of acetaminophen/oxycodone (Percocet):

1) 30--45 minutes

2) 60--90 minutes

3) 120-150 minutes

4) 180-210 minutes

4. The most appropriate next step in drug therapy for this patient would be to discontinue Percocet, and start:

1) oral hydrocodone (e.g. Vicodin, Lortab)

2) oral hydromorphone (Dilaudid)

3) oral long-acting morphine (e.g. MS Contin, Oramorph SR)

4) oral meperidine (Demerol)

5. The single most appropriate adjuvant analgesic for this patient is:

1) amytriptyline (Elavil)

2) neurontin (Gabapentin)

3) ibuprofen (Motrin)

4) lorazepam (Ativan)

6. For this patient, choose the single most appropriate first drug to prescribe to prevent constipation:

1) docusate (Colace)

2) bisacodyl (Ducolax)

3) lactulose (Chronulac)

4) senna concentrate (Senokot) with/or without docusate (Colace)

A 27 y/o woman with AIDS notes burning pain along the bottom of both feet. The pain has been present for 4 months and is getting worse. There is often a numbing sensation; the pain limits her ability to walk. She recently began taking acetaminophen with codeine, 2 tabs q4H. She says the medicine provides no relief and it makes her feel sleepy. (questions 7-8)

7. This woman’s pain is best be described as:

1) neuropathic pain

2) somatic pain

3) vascular pain

4) visceral pain

8. The most appropriate next step in drug therapy for this patient would be to prescribe:

1) amytriptyline (Elavil)

2) ibuprofen (e.g. Motrin)

3) long-acting opioid (e.g. MS Contin, or fentanyl patch (Duragesic))

4) lorazepam (Ativan)

A 54 y/o woman is hospitalized for an exacerbation of rheumatoid arthritis. She has chronic mid and low back pain from corticosteroid-induced compression fractures of the spine. You prescribe a long-acting oral morphine preparation (e.g. MS Contin) and short-acting oral morphine (e.g. MSIR) for breakthrough pain. (questions 9-13)

9. The patient asks you how often she can take the short-acting oral morphine for pain. Your best response would be to say, “as often as:

1) every 2 hours”

2) every 4 hours”

3) every 6 hours”

4) every 8 hours”

10. Following the first dose of morphine the patient develops nausea. Which one of the following statements concerning nausea while taking opioids is true:

1) nausea to opioids is due to bowel distention and stimulation of the vagus nerve

2) nausea to opioids is usually accompanied with itching

3) nausea to opioids represents a drug allergy

4) nausea to opioids resolves in most patients within 7 days

11. The first night after this patient starts morphine the nurse calls you to report that her respiratory rate has dropped to 6-8 breaths/min. Your advice is to:

1) administer 0.2 mg naloxone (1/2 amp of Narcan)

2) administer 0.4 mg naloxone (1 amp of Narcan)

3) assess level of consciousness

4) assess level of pupillary response

12. On the third hospital day a decision is made to discontinue the long-acting morphine and begin using a fentanyl (Duragesic) patch. Therapeutic analgesic levels should not be expected after the first application of a fentanyl patch until:

1) 2 - 6 hours

2) 7-12 hours

3) 13-24 hours

4) 25-36 hours

13. Compared to morphine, which one of the following opioids more frequently results in clinically significant respiratory depression:

1) hydrocodone (e.g. Vicodin or Lortab)

2) hydromorphone (Dilaudid)

3) methadone (Dolophine)

4) oxycodone (e.g. Percocet)

A 63 y/o woman is hospitalized with advanced peripheral vascular disease and gangrene of several toes. She has had chronic pain in her feet, maintained with good pain control on an outpatient regimen of long-acting oral morphine 180 mg q 12 and rare use of oral hydromorphone for breakthrough pain. The patient needs to be NPO for a surgical procedure. (questions 14-16)

14. When converting from oral morphine to intravenous morphine, at an equianalgesic dose, the most appropriate dose conversion is:

1) 3 mg oral = 9 mg intravenous

2) 3 mg oral = 3 mg intravenous

3) 3 mg oral = 1 mg intravenous

4) 3 mg oral = 0.3 mg intravenous

15. In converting IV morphine to an equianalgesic dose of IV hydromorphone (Dilaudid), the most appropriate dose conversion would be:

1) 1 mg morphine = 4 mg hydromorphone

2) 1 mg morphine = 1 mg hydromorphone

3) 1 mg morphine = 0.50 mg hydromorphone

4) 1 mg morphine = 0.25 mg hydromorphone

A 67 y/o woman with pancreatic cancer metastatic to liver comes to your clinic together with her husband. Over the past four weeks she has lost her appetite and experienced steady weight loss. She spends >75% of the day in bed or lying on a couch because of fatigue. Her oncologist has indicated that there is no role for further chemotherapy. (questions 16-21)

16. Outside the examination room the patient’s husband stops you and says, “if you have more bad news, please do not tell my wife—she will fall to pieces”. How should you manage the husband’s request to limit “bad news”?

1) ask the husband if family/friends/clergy might be better at transmitting bad news

2) ask the husband if he understands the principle of ‘patient autonomy‘

3) ask the husband to define the type of information he feels you can present

4) ask the husband to tell you more about his concerns

17. The single best predictive factor in determining prognosis in patients with metastatic cancer is:

1) functional ability

2) number of metastatic lesions

3) serum albumin

4) severity of pain

18. The patient asks you: “so how much time do you think I have?” After further discussion with the patient and her husband you confirm that they want to talk about her prognosis. The best approach is to tell them that:

1) on average patients with her condition live for about six-nine months

2) only God can determine how long someone has to live

3) you believe her time is short, only a few weeks to a few months

4) you really can’t tell how much time she has left

19. The patient asks you, “Is there anything I can take to improve my appetite?” Which of the following drugs has been shown to improve appetite in advanced cancer patients:

1) conjugated estrogen (e.g. Premarin)

2) haloperidol (Haldol)

3) lorazepam (Ativan)

4) megesterol acetate (Megace)

20. As you talk to the patient, you decide this would be a good time to discuss referral for home hospice care. Under the Medicare Hospice Benefit, which one of the following admission criteria is not required:

1) a physician-of-record is identified

2) DNR (no code) status

3) expected prognosis of 6 months or less

4) the approach is limited to a palliative, symptom-oriented approach

21. The husband asks about hospice support services. As part of the Medicare Hospice Benefit which of the following is not provided:

1) bereavement program for surviving families

2) night-time custodial care

3) payment for all medications related to the terminal illness

4) skilled nursing visits

A 74 y/o anuric, end-stage renal failure patient has been receiving hemodialysis three-times per week for seven years. She is considering stopping dialysis as it is increasingly a burden due to infections, vascular access problems and fatigue. (questions 22-24)

22. The patient wants to know how long she would likely survive if she stops dialysis. The best response would be to say:

1) “about 2-3 days”

2) “about one week”

3) “only God can determine how long someone has to live”

4) “there is no way to tell for sure”

23. The patient tells you she would like to be at home when she dies. Her son asks about intravenous fluids—“will we need intravenous fluids at home?” Which one of the following statements about intravenous (IV) hydration in the last week of life is true:

1) maintaining IV hydration will improve pain management

2) maintaining IV hydration will prevent dry mouth

3) stopping IV hydration will lead to painful muscle cramps

4) stopping IV hydration will lessen dyspnea associated with renal failure

24. Four days after going home a visiting nurse calls you and says the patient was awake most the night, is very fidgety, and keeps trying to get out of bed. Her speech is garbled, she is only oriented to person. She is afebrile and has no focal neurological signs. Which one of the following statements about treating this symptom complex (terminal delirium) is true:

1) family members should leave the room to help decrease the agitation

2) paradoxical worsening of this condition may occur after administration of a minor tranquilizer (e.g. Ativan or Valium)

3) placing the patient in a dark room will help decrease sensory input and reduce the agitation

4) the drug treatment of choice is an anti-cholinergic medication

A 40 y/o man is in the outpatient clinic with increasing dyspnea. He was diagnosed HIV positive 12 years ago and now has skin and pulmonary Kaposi sarcoma (KS). The patient stopped taking anti-retroviral medications 9 months ago because of intolerable side effects. On exam he has a respiratory rate of 20-24; chest x-ray shows multiple pulmonary metastases. Following the exam, the patient says “lets just get this over with, put me to sleep and let me die”. (questions 25-27)

25. Which one of the following statements about depression at end-of-life is true:

1) Clinical depression is a normal stage of the dying process

2) Depression associated with HIV is more difficult to treat than in cancer patients

3) Feelings of hopelessness/worthlessness are indicators of a clinical depression

4) The degree of appetite and sleep disturbance is predictive of response to anti-depressant medication

26. Which one of the following statements, that concern patients with a terminally illness, is closest to the definition of "physician assisted suicide":

1) discontinuing intravenous fluid administration in a patient who can no longer take oral medication

2) writing a prescription for a lethal dose of a medication that the patient can use at the time of their choice

3) raising the dose of intravenous morphine with the intent of depressing respiration to the point of death

4) removing a respirator at the request of a decisional patient

27. The best drug choice to treat dyspnea in this patient is an:

1) anti-cholinergic/anti-muscarinic (e.g. scopolamine)

2) anti-depressant (e.g. amytriptyline (Elavil))

3) anti-histamine (e.g. diphenhydramine (Benadryl))

4) opioid analgesic (e.g. morphine)

A 75y/o man is transferred to your inpatient ward from a nursing home because of cough, fever and headache. Chest x-ray shows a large pulmonary infiltrate and moderate sized pleural effusion. The patient has the capacity to make decisions for himself. Your initial management plan includes starting IV antibiotics, performing a lumbar puncture and a thoracentesis. (Questions 28-29)

28. Which of the following should be discussed with the patient prior to initiation of therapy to ensure patient consent?

1) None, consent is implied when patients are transferred from a nursing home

2) Only the lumbar puncture

3) Only the lumbar puncture and the thoracentesis

4) Pleurocentesis, lumbar puncture and IV antibiotics

29. All of the following must be present to establish that this patient has decision-making capacity

except:

1) able to reason, to weigh treatment options

2) can express a choice among treatment options

3) is oriented to place and time

4) understands the significance of information relative to personal circumstances

A 60 y/o woman has metastatic breast cancer with bone and pleural metastases. Her husband brings her to clinic stating that over the past week she has noted fatigue, thirst and frequent need to urinate. On examination she is dehydrated and lethargic but arousable, there are no focal neurological findings. (questions 30-33)

30. The most likely diagnosis of this new problem is:

1) brain metastases

2) hypercalcemia

3) hyperglycemia

4) sepsis

31. Over the next week she deteriorates and becomes unconscious, the family decides that no further aggressive care is warranted. The family notices that the patient has very loud, raspy breathing and asks you if there is any treatment. You determine the cause is retained oro-pharyngeal secretions (“the death rattle”). The best class of drugs to treat "death rattle" is a(n):

1) anti-cholinergic/anti-muscarinic (e.g. scopolamine)

2) benzodiazepine (e.g. lorazepam (Ativan))

3) butyrophenone (e.g. haloperidol (Haldol))

4) opioid analgesic (e.g. morphine)

32. Two days later the patient dies; you are called to “pronounce the patient”. As you enter the room there are four family members standing around the bed, each holding or touching the woman. Which of the following is not appropriate during this encounter:

1) ask the family to leave the room while you perform your examination.

2) offer to remove medical paraphernalia (e.g. oxygen mask, IV line).

3) stand quietly for a moment and offer consolation to the family

4) volunteer to contact family members not present.

33. Three months after the patients death her husband comes to your office. He says that he sometimes thinks that his wife is in the house talking with him, that he imagines he hears her voice, he has gained 10 pounds since her death, but otherwise feels well. He is concerned that he is “going crazy”. These symptoms are most consistent with a:

1) complicated grief reaction

2) major depression

3) normal grief reaction

4) psychotic disorder

Physicians often have concerns that certain medical decisions may either be contrary to accepted legal, ethical or professional standards or that they may be contrary to their own personal beliefs. For each of the situations listed below, please indicate the type and amount of concern you have, using the following scale:

4 = very concerned

3 = somewhat concerned

2 = somewhat unconcerned

1 = not concerned

A. Decision: Providing maximal pain relief throughout a cancer patient’s illness, even before the terminal phase. Concerns:

___This violates state law

___This violates medical practice standards and represents malpractice

___This violates accepted ethical norms

___This violates my personal religious or ethical beliefs

B. Decision: Withdrawing non-oral feedings (G-tube or NG tube) from a decisional terminal cancer patient who asks for such feeding to be discontinued. Concerns:

___This violates state law

___This violates medical practice standards and represents malpractice

___This violates accepted ethical norms

___This violates my personal religious or ethical beliefs

C. Decision: Withdrawing IV hydration from a terminal cancer patient, who can no longer take oral fluids and who is clearly dying. Concerns:

___This violates state law

___This violates medical practice standards and represents malpractice

___This violates accepted ethical norms

___This violates my personal religious or ethical beliefs

D. Decision: Withdrawing parenteral antibiotics from a non-decisional dementia patient with urosepsis, at the request of their Power for Attorney for Health Care or legal guardian. Concerns:

___This violates state law

___This violates medical practice standards and represents malpractice

___This violates accepted ethical norms

___This violates my personal religious or ethical beliefs

E. Decision: Withdrawing ventilator support from a non-decisional dementia patient at the request of their Power for Attorney for Health Care or legal guardian. Concerns:

___This violates state law

___This violates medical practice standards and represents malpractice

___This violates accepted ethical norms

___This violates my personal religious or ethical beliefs

THE END

HOSPICE AND PALLIATIVE CARE EXPERIENCE

MEDICAL STUDENT ACTIVITY SUMMARY

(TO BE COMPLETED BY THE AGENCY STAFF CONTACT)

AGENCY OR PALLIATIVE CARE UNIT NAME: ____________________________________

STUDENT NAME:____________________________________________________________

VISIT DATE:________________

ACTIVITY REPORT -- STUDENT PARTICIPATED IN WHAT ACTIVITIES (check all that apply):

____Patient home visit(s)

____Interdisciplinary team meeting attendance

____Inpatient or consultation palliative care unit—patient visit

____Outpatient palliative care clinic patient visit

____Student had an opportunity to interact with more than one interdisciplinary team member

Indicate Yes or No to the following:

____Student arrived on time for experience

____Participated with care team in a professional manner

____Collected information from patient chart and health provider

____Established a positive rapport with the patient and/or family

____Discussed with hospice staff how the terminal illness has affected the family, identifies

problems and interventions to meet patient and family needs.

COMMENTS: (use reverse side of page for additional space)

____Do you have any concerns about this students ability to compassionately care for dying

patients and families? If yes, please explain:

_____________________________________________ _________________

Signature and title of supervisory staff member Date

Please fax this form to the course director.

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