Topic Title: End of Life Care



FACILITATOR GUIDE:

M4 ICE SEMINAR: End of Life Care

JAN/FEB 2012

APRIL 2012

Bolded text is information to guide you through the course. The students generally don’t have it in their packets. It is fine to paraphrase or use your own words.

List of Documents for M4 ICE SEMINAR: End of Life Care

Day 1 Facilitator Packet:

1. Facilitator Guide

2. Sign-In Sheet for students

3. Two pocket cards:





4. “Ideal Orders” for Case 1: to be handed out to the students after they have completed writing their orders for the case.

5. Optional Handout - Fast Facts #082 and 087 on Hospice:





Day 1 Student Packets:

1. Student Guide: There is a student guide for Medical Students and a student guide for Pharmacy Students.

2. Case 1: Mr. /Mrs. Bond: The students will read the case and develop a pertinent and comprehensive problem list.

3. Two pocket cards:





4. Standard 2 ply Order Form for writing orders from your institution. The M4s will use these to write their orders for Case 1.

5. Pain Cases: Students will work through these cases on their own using the equianalgesic table.

6. Equianalgesic Table: pdf/equianalgesictable.pdf for use with pain cases.

Day 2 Facilitator Packet:

1. “Communication in End of Life Care” PowerPoint.

2. “Suggested Order Set” for the Final Case: to be handed out to the students after they have completed writing their orders for the case.

Day 2 Student Packets (only Medical Students on Day 2):

1. Paper copies of the “Communication in End of Life Care” Power Point. The facilitator may use these slides to assist in reviewing the S-P-I-K-E-S protocol for breaking bad news.

2. Fish Bowl Cases: The students will play the role of physician with the facilitator and other students as observers. The student is able to immerse him/herself in a typical case getting experience with common discussions about goals of care, code status, etc. The facilitator and other students contribute with their observations and suggestions.

3. Final Case: Mr. /Mrs. Bronte: Similar to Day 1, students will work through a paper case-identifying a problem list or working differential, and write initial orders for management.

4. Standard 2 ply Order Form for writing orders from your institution.

TOPIC TITLE: END OF LIFE CARE

Date Published: May 2009 (11/2009, 3/2010, 12/2010, 2/2011, 1/2012)

Authors: Christina Cassel M4, Catherine Eberle, MD

FACULTY

LEADER: Catherine Eberle M.D. Travis Weyant Linda Farho, PharmD

Contact Information: Catherine.Eberle@ tweyant@unmc.edu Lfarho@unmc.edu

402-995-3287 402-559-3964 402-559-4374

Associated Faculty: Drs. Vandenberg, Lyons, Morgan, Rodabaugh, Sauer, Lavedan, Wester,

BACKGROUND and OBJECTIVES:

BACKGROUND:

This seminar is designed to refine the student’s skills in communication and management of common symptoms in dying patients. At the end of this seminar, students will be able to accurately describe hospice services, identify patients who are candidates for the service, know when to refer a patient for hospice care. The student will improve his/her skills in the area of communicating bad news, identifying goals of care and advance planning with patient(s) and family members. The student will improve his/her ability to manage common symptoms encountered in hospice and end-of-life care. Medical and Pharmacy students will work together on day 1 to improve their knowledge of each other’s discipline and their ability to work collaboratively to ensure excellent patient care and patient safety.

OBJECTIVES:

Upon completion, the student will be able to:

1. Formulate and write orders for management of key non-pain and pain symptoms based on patient goals of care.

2. Describe hospice; know services provided, by hospice; be able to identify appropriate patients, and indications for referral.

3. Demonstrate communication skills including breaking bad news, assisting patients and/or surrogates in discerning goals of care, advance care planning.

(Pharmacy students: #1 and #2 only)

EVALUATION/GRADES:

A passing grade is based upon attendance and participation. Student participation as evidenced by interacting with other students and facilitator will be the major basis for grading. Written assignments during the session will be taken into account as well.

ASSIGNMENTS

Given in class.

SEMINAR SCHEDULE:

Day One: Symptom Assessment and Management.

Room setup:

1. Please write Goals and Objectives on the white board (page 2, above) if not already done.

2. Day One Student Packets will be available in the room or the facilitator can bring the packets.

|Clock Time |ACTIVITY |Time |

|8:00-8:45 |INTRODUCTIONS | |

|8:00-8:25 |Remind students to sign in! |15 min |

| |Introduce yourself to students and provide some background information about yourself, your interest and expertise | |

| |in end-of-life care, its importance and the rewards you receive doing end-of-life care. | |

| |Ask students to introduce themselves to you. (They will discuss their clinical experiences with death and dying | |

| |patients tomorrow morning. Knowing their interests and pending career choices is helpful in working through the |5 min |

| |sessions. It is ok to make changes in a case to make it more real for the group.) Pharmacy students may need | |

| |encouraging words for their participation, complicated seriously ill patients and symptom management medications. | |

|8:25-8:45 |REVIEW THE GOALS AND OBJECTIVES OF THE COURSE AND SCHEDULE | |

| |Refer to the Goals and Objectives on the white board (If not already written on the board, write them now.) |10 min |

| |Ask why students are taking this course, and do they want to add anything to the Goals & Objectives? (e.g., ‘this | |

| |seminar will be worthwhile if I get to learn about writing pain meds or happens or is learned.’) This is | |

| |meant to help you as the facilitator in addressing/ meeting the students’ goals. | |

| | | |

| |Hand out the student packet and review the following information: | |

| |Grading is based on attendance and participation. In essence the only way to fail this portion is to fail to | |

| |attend, participate or turn in work. | |

| |Broadly, the agenda is: | |

| |Day 1 – Symptom assessment and management by working through a case. | |

| |Day 2 – Communication skills commonly used in managing seriously ill patients. | |

| | | |

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| | | |

|8:45-10:00 |CASE 1 Mr./Mrs. Bond | |

| |The purpose of this paper case is to introduce a clinical approach in anticipating, assessing and managing common | |

| |symptoms. | |

| | | |

| |The case is in the “Day 1 Packet” for all students along with a pneumonic for writing orders. Two pocket cards are| |

|8:45-8:50 |also in the “Day 1 Packet”. They can be found at: | |

| | | |

| |These cards give information on writing orders and managing symptoms for patients. Take a few minutes to look | |

| |these over with the students. Facilitator’s copy of the case begins on the page below. (Facilitators have an Ideal| |

| |Order Set Guide, but the students do not.) | |

| | | |

| |Explain the process for the case which will take the next 60-90 minutes. | |

| | | |

| |Tell the students the following: | |

| |First, they are to read the case. They may ask the facilitator for additional information they want. | |

| |(3-5minutes/8:50-8:55) | |

| |Then, as a group, they will develop a pertinent and comprehensive problem list. They will need a student to scribe| |

| |this onto the white board. (10 minutes/8:55-9:05) | |

| |After the problem list is established, each student will write orders for this patient ON THEIR OWN and turn in a | |

| |copy. Students may use any resource they wish, but are expected to write orders ON THEIR OWN. PHARMACY students | |

| |are to act as consultants to the medical students in writing orders, BUT M4s must write their own orders. The | |

| |pocket cards in the handout should be helpful here. (15 minutes/9:05-9:20) | |

| |After everyone has turned in their orders, the group will then review orders and develop an “ideal” order set. (40| |

| |minutes/ 9:25-10:05) | |

| |At this time, the students should refer to the case of Mr. /Mrs. Bond that can be found in the “Day One Packet”. | |

| |Students should also be able to look at the two pocket cards that are referenced above. | |

| | | |

| | | |

| | | |

| |CASE 1: Mr./Mrs. Bond | |

| |Grey shaded area is case material. When you leave the grey, back in the schedule. | |

| | | |

| |Tasks and Time allotted: | |

| |15 minutes history, “examination”, and develop a PROBLEM LIST. (GROUP) | |

| |One student scribes the problem list onto the room’s white board as the group identifies problems. | |

| |Students need to consider the problem list in writing the admission orders. Each student works alone in writing | |

| |these orders. | |

| | | |

| |20 minutes to write orders. (INDIVIDUAL) | |

| |30 minutes to review content of orders and reasoning. (GROUP) | |

| | | |

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| | | |

| |Case One: Mr./Mrs. Bond | |

| | | |

| | | |

| |Medical History: Mrs. Bond is 54 year old with squamous anal cancer previously treated with surgery and | |

| |chemo-radiation with known liver metastasis, hypertension, depression, anxiety, cervical dysplasia, and history of | |

| |smoking. Patient was last seen three days ago for increased pain. She is taking acetaminophen/oxycodone 325mg/5mg| |

| |1 tablet by mouth every 6 hours as needed for pain. In addition to the acetaminophen/ oxycodone, she takes paxil| |

| |and metoprolol. | |

| |Her oncologist wants her admitted for better pain management, so she can continue with her experimental | |

| |chemo-radiation treatments. | |

| | | |

| |Social history: Patient is married with 3 grown children. Spouse works as an accountant downtown. Quit tobacco | |

| |and alcohol over 20 years ago. | |

| | | |

| |Physical examination findings | |

| |Vitals: Temp 36.0 deg. C, Pulse 75 regular, Resp 12, BP 135/80, Wt 135lbs (up 6 lbs from last visit) | |

| |General: Cooperative. No acute distress, but does look in pain. | |

| |Skin: Moist. | |

| |HEENT: NC/AT. EOMI symmetric bilateral. PERRLA. TMs clear bilaterally. | |

| |Heart: Normal S1/S2 without murmur. | |

| |Lungs: Clear to auscultation bilaterally. | |

| |Abdomen: +Bowel sounds. Protuberant, dull to percussion, tender to palpation. Nonlocalizable. Hepatomegaly. | |

| |Rectal exam produces stool in vault with normal tone, hemoccult negative. | |

| |Extremities: +2 pedal pulses bilaterally. | |

| |Hematologic: No bruising on extremities. | |

| |Neurologic: CNS II-XII grossly intact, no nystagmus, gait normal. Romberg normal. | |

| |Psychiatric: Depressed mood with decreased concentration, sleep and energy. Also feels guilty. Lot of family | |

| |social support. Less friends around than before cancer diagnosis. Possible spiritual distress. | |

| | | |

| |Labs: | |

| |CBC: Within normal limits | |

| |CMP: Within normal limits except Ca 15.2. | |

| |Intact PTH: Within normal limits | |

| |Parathyroid hormone-related protein level: 13.0 (normal May go through orders using ADCA VANDIMLS pneumonic (have a student reveal his/her order | |

| |for that item and then discuss alternate approaches) but may use any approach that results in identifying an | |

| |‘ideal’ order set. | |

| |We now have pharmacy students in the room, include them in the discussion. What is their approach to med choice | |

| |and dose; clarify as needed. | |

| | | |

| |Hand out the Case 1 “Ideal Order Set” after completing discussion. (In facilitator envelope as student handout) | |

|10:00-10:15 |BREAK |15 min |

|10:15-10:35 |INTRODUCTION TO HOSPICE: |20 min |

| |Using white board to record responses, ask students to identify their understanding of hospice. You may either | |

| |take questions and answer them; OR ask the following questions: 1. Who qualifies for hospice? 2. What services | |

| |does hospice agency provide? 3. What services does the hospice agency not provide? 4. What questions does the | |

| |group know about hospice? 5. What is referring physician’s responsibility? Identify truths and correct myths; OR | |

| |Hand out the Fast Facts #082 and review with them. | |

| | | |

| |At the end of time, point out the Fast Facts #082 and 087 on Hospice. | |

| | | |

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| | | |

|10:35-11:30 |PAIN CASES: |60 min |

| |WRITING ORDERS AND TITRATING OPIATES | |

| |Students will learn how to initiate and titrate opiates for pain management and how to use an equianalgesic table | |

| |when changes in opiates are needed. | |

| | | |

| |The pain cases are in the student’s packet. BEFORE they start their work, please ask students if they know how to | |

| |use the equianalgesic table. Clarify and correct as needed. Make sure that all students know how to use the table. | |

| |(You may have to work 1:1 with an individual student.) Have they ever used one? Seen staff in hospital or clinics | |

| |use one? The table can be found at: pdf/equianalgesictable.pdf | |

| |Pharmacy students are available in 2012 sessions, make use of them. | |

| | | |

| |**It is OK to work through case A in order to teach students how to use the equianalgesic table. ** | |

| | | |

| | | |

| |Once they know how to use the table, students | |

| |will work through the cases on their own. If help is needed, they may ask the pharmacy students for assistance. | |

| | | |

| |When students have finished the cases, have the group review their answers and calculations. Explain and make | |

| |corrections as needed. | |

| | | |

| |**Pain cases start on the next page. ** | |

| |(Facilitators have calculations/answers) | |

| | | |

| | | |

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CASE A:

Mrs. Danish is a 45 years old female with breast cancer. She has known metastases to bone. She was admitted to the hospital earlier in the week because of a pain crisis; i.e., failure to control her pain as an outpatient. She was taking 2 tabs of acetaminophen/hydrocodone (500/7.5) Q4 hour around- the- clock. She has had nausea and constipation and is having difficulty keeping medications down.

How much acetaminophen is she taking in 24 hours?

• 1,000mg X 6 = 6,000mg acetaminophen

1. How much hydrocodone is she taking in 24 hours?

• 15mg x 6 = 90mg hydrocodone

2. How much oral morphine would be the equivalent of this amount of hydrocodone?

• 30mg hydrocodone = 30mg morphine

X 3 X3 ___

• 90mg hydrocodone = 90mg morphine

3. How much IV morphine would be its equivalent?

• 90mg ORAL morphine (3mg oral morphine = 1mg IV)

X0.33_____

• 30mg IV morphine

4. Using the information from above to write orders to manage her pain. (Don’t forget to write for breakthrough pain control and laxative to treat/prevent constipation.)

Several options possible- Breakthrough-

• 1.25mg/hour IV morphine 0.25mgQ15min or 0.5Q20min

• 2.5mg Q 2 hours

• 5mg Q 4 hours 3mg Q2hours PRN (5mg more likely)

Theses would give approximately same analgesia, but pain was NOT controlled on this so may want to increase by 25 to 100%!

6. Since her pain wasn’t controlled, how do you decide how much to increase her morphine to?

The rule of thumb is to increase by 25-50% for mild-moderate pain (generally 4-6/10) and by 50-100% for moderate to severe pain (7-10/10).

For above case:

+50% (45mg) +100% (60mg)

2mg/hour(48mg/d) 2.5mg/hour(60mg/d)

PCA: 0.5mgQ 15minutes PRN

The equianalgesic table can be found at:

CASE B: (Continuing case above)

After titration, Mrs. Danish is now comfortable on IV morphine 6 mg / h. She is now tolerating oral food and fluids. You will now convert her pain regimen to oral medications before discharge.

1. How much parenteral (IV) morphine is she receiving in 24 hours?

• 6mg/h x 24h/d = 144mg/d

2. What is the oral equivalence of this amount of morphine?

• 144mg x3mg oral/1mg IV = 432mg/day

• When converting, may decrease by 25% because of cross-tolerance-

This would be 324mg/day.

Oral Dosing options:

--100mgMSContin Q8hours

--150mgMSContinQ12hours

3. What is an appropriate breakthrough (PRN) dose of morphine?

• Breakthrough should be 10-15% of total daily dose. (q4hours)

• This is 40-60mg oral morphine Q4hours PRN pain not controlled. (@ 432mg/day)

• This is 30-45mg oral morphine Q4hours PRN (@ 324mg/day)

CASE C:

Use the prior case of Mrs. Danish for this case. Her pain is controlled on the 6 mg/hour of morphine as previously stated. However, she is still unable to take oral medications. She wishes to go home, but family is unwilling to manage IV, so you have agreed to convert to transdermal fentanyl so that she can go home.

1. Bring forward the morphine equivalence calculated from Case B.

• IV= 144mg/day PO=432mg/day

2. Use the table below to convert to transdermal fentanyl using both conversions.

• PO(125mcg/hour patch Q72hours (I)

• PO(216mcg/hour(200mcg/hour patch Q72hours.(II)

The point of this is to show that equianalgesic tables are not perfect and there may be wide range depending on method you use. Clearly need to monitor patient response and adjust accordingly. Also, that it may be OK to start low if you are unsure, AS LONG AS you are willing to re-evaluate and titrate based on response.

I- II-

I-

Total PO Morphine (mg) Transdermal Fenatnyl (mcg/hr) ▪

45-134 25

135-224 50

225-314 75

315-404 100

405-494 125

495-584 150

585-674 175

675-764 200

AND

II-

2mg oral morphine = 1ug of transdermal fentanyl (i.e. 50mg oral morphine = 25mcg fentanyl )

Reference:

Weissman, D., Ambuel, B., Hallenbeck, J. (2004). Improving End-of-Life Care A

Resource Guide for Physician Education. (3rd ed.). Retrieved from



| | | |

| | | |

|11:30-11:50 |WRAP UP: |20 min |

| |This is “fudge” time if needed. | |

| |Field questions from the morning; | |

| |Identify what students have learned, what they did well! | |

| | | |

| |TELL STUDENTS: | |

| |Remind the medical students to read the brief articles that can be found online. | |

| |Communication: Fast Facts and Concepts #38 | |

| |Two readings on important palliative emergencies: | |

| | | |

| | Meet same room at 8am Tuesday morning. | |

| |They should bring any reference materials (PDA, laptop, books, etc) that will assist them in managing patients. | |

| |PHARMACY STUDENTS WILL NOT BE PRESENT ON DAY 2. | |

Facilitators: PLEASE LEAVE SIGN IN SHEET AND STUDENTS’ COMPLETED WORK IN ENVELOPE

--DAY 2 STARTS NEXT PAGE—

Day Two: Communication: Giving Bad News & Advance Planning

Students should bring any reference materials (PDA, laptop, books, etc) that will assist them in managing patients.

Room setup:

1. Please write Goals and Objectives on the white board (page 2, above) if not already done.

2. Day 2 Student Packets will be available in the room or the facilitator can bring them to the seminar.

|Clock Time |Activity | |

|8:00-8:45 |INTRODUCTION: | |

| |Introduction to the day. | |

| |Any questions from yesterday? | |

| |Look at agenda: | |

| |Main goal today is to get practice having discussions that are often difficult. Facilitator will give brief | |

| |lecture, followed by the opportunity for the students to practice in small groups among themselves. | |

| |For the next 30-45 minutes engage the students in their experiences and concerns when taking care of seriously | |

| |ill and/or dying patients. | |

| |Ask the students to identify cases they experienced/observed in which communication was a challenge; or that | |

| |didn’t go well or as expected. What made it difficult? How would they handle the situation now? Another | |

| |question may be: “When you look ahead to next year, do you feel prepared to have Code status (or DNR) | |

| |discussions? OR What situations are you most worried about having to do on your own as an intern? | |

|8:45-9:30 |COMMUNICATION DIDACTIC | |

| |There is not enough time to cover in great detail but goal is to make sure students have a systematic way to | |

| |approach communication with patients and families. Facilitator should think of themselves as a senior resident | |

| |prepping an intern before going into a family meeting. | |

| | | |

| |**See next Page** | |

| | | |

COMMUNICATION DIDACTIC (continued)

The students were assigned reading last evening to help prepare them for improved communication.

--Facilitator should review the S-P-I-K-E-S protocol for breaking bad news.

Available at:

You may use any of the following methods.

• The “Communication in End of Life Care” PowerPoint.

o This slide set will be available on the computer in your room. If you make changes, please bring it on a thumb drive to load today.

o Hard copy is below is in your appendix. (Students have in their Day 2 Student Packet.)

• You may also simply use the white board and review SPIKES Protocol.

-- PROCEED TO NEXT PAGE AND ROLE PLAY INSTRUCTIONS --

|9:30-10:30 |ROLE PLAY AND COMMUNICATION PRACTICE: | |

| |Goal is for student to practice communications that physicians often find difficult. | |

| |Use FishBowl technique explained below. | |

| | | |

| |** See next Page for cases*** | |

Fish Bowl

In a Fish Bowl, a student playing the role of physician becomes a ‘fish’ in a fishbowl, with the facilitator and other students as observers. The student is able to immerse him/her-self in a typical case getting experience with common discussions about goals of care, code status, etc. The facilitator and other students contribute with their observations and suggestions.

In this session, each student will play the role of a ‘physician’ and practice having a code status discussion with a patient being admitted to the hospital. A second student plays the role of the patient. All other members of the group provide feedback. Roles rotate every 5-7 minutes, so that everyone has a turn.

“Time outs” may be used to ask for input from the group before, or during an interview.

Tasks: Using Fish Bowl technique, students will gain experience in having discussions common in palliative care/end-of-life by interviewing each other given several scenarios.

Three cases are available. Pick one and repeat, so that students learn from each other. May use a different case if group gets “stale.”

-Mr. Williams: Code status and Goals of Care.

-Mr. McNully: Breaking bad news

-Mr. Church: Code status, Goals of Care and/or Hospice discussions.

Facilitator should always find a positive note to end on.

Recommendation:

1. Once a student role plays as the physician, (s) he should then role play as the patient.

2. Facilitator may role play initially to show an example versus a brave student volunteer.

FISHBOWL CASE- Mr. Williams BACKGROUND:

HPI: Mr. Williams is 50 y/o, diagnosed with pancreatic carcinoma 5 months ago after presenting with a locally advanced, unresectable, pancreatic mass and painless jaundice. He underwent surgery to relieve the biliary obstruction and then received radiation and two months of chemotherapy. The chemotherapy was very hard on him, causing severe nausea and fatigue. He called you one week ago saying that over the past 3 weeks there was a decline in energy, generalized fatigue and little appetite. You ordered an abdominal CT scan which showed new liver metastases. You met the patient last week to review treatment options; the patient elected not to pursue any further chemotherapy; that his goal was to remain at home and be as comfortable as possible.

However, yesterday he called and said the pain was much worse and he was vomiting and unable to keep food down. He was admitted yesterday for pain, dehydration and nausea management. The primary team has asked you to come talk to him, because at admission he was so agitated about his pain, he wouldn’t discuss code status. Overnight he has improved and seems more approachable.

PAST HISTORY

Mild hypertension controlled with medication; one episode of renal colic 3 years ago.

SOCIAL HISTORY

Patient is married with two daughters, ages 28 and 24, both live in the area The patient is an elementary school special education teacher, on extended leave since the cancer surgery. The patient has never smoked and uses alcohol rarely.

TASK:

1. Discuss CPR/DNR orders

2. Re-affirm the patient’s goals for future care

(One student role plays the oncologist and enters the “hospital” room with a 2nd & 3rd student playing the parts of Mr. Williams and his wife. Rotate roles after 5-7 minutes with feedback).

1. FIRST TIME role play: Have a code status discussion.

Variations may include:

2. Mr. Williams states he is fighter and won’t give up.

3. Mr. Williams and his wife disagree on what the code status should be.

4. Ages of children are younger, and Mr Williams wants to see them grow up.

Fishbowl Case- Mr. McNully (optional)

Medical History: Mr. McNully is a 27-year-old whom you saw for the first time 5 days ago. He came in to see you for a dry cough and sweats, which had been present over the last month. When you examined him you felt multiple enlarge cervical and supraclavicular lymph nodes. At the time, you were concerned about infection or cancer, but were not certain. You told him that he had enlarged lymph nodes, that you were not sure what it was, and that he should see Dr. Stein a surgeon, for further tests and probably a biopsy. You asked him at the time if he had any questions and he had none. He did make it clear; however, that he is the kind of person who likes to know what is going on with his health.

He saw the surgeon, Dr. Stein, the next day and a lymph node biopsy was performed. The surgeon ordered a chest and abdomen CT scan done while the biopsy results were pending.

The pathology showed Hodgkin’s disease. Chest CT revealed multiple enlarged hilar lymph nodes. The abdominal CT showed multiple enlarged retroperitoneal lymph nodes. You spoke to an oncologist about the results. He explained that this is a “good prognosis” tumor. There is a 70% chance of a significant response, and a 50% chance of a “long-term” survival with chemotherapy. The oncologist indicated he could see the patient within the next three days for an initial evaluation.

Mr. McNully is a graphic artist living with a significant other. His parents are alive, they live 500 miles away; there are no siblings.

The visit today was scheduled for you to go over the test results.

Task: To give Mr. McNully the results of the biopsy and CT scans.

(A student role plays the physician with a2nd & 3rd student playing the parts of Mr. McNully and his SO. Rotate roles after 5-7 minutes).

Variations:

1. Mr. McNully is very discouraged about his prognosis and begins to cry.

FISHBOWL CASE-Mr. Church (Optional)

HPI: Mr. Church is 70 year old with COPD with 50 pk-yr smoking history, Hypertension, Diabetes, Peripheral artery disease, and Osteoarthritis coming in today at spouse’s insistence. Mr. Church has had a harder time getting around than usual; he can walk up fewer stairs without getting short of breath or dizzy. He has some improvement with using his albuterol inhaler the maximum times per day but it seems to be not working as well now. Current medications include albuterol rescue inhaler, Advair, ipratropium, Claritin, metoprolol succinate 100mg per day, metformin 1g twice a day, and ibuprofen as needed.

Spouse is worried because patient cannot do his usual activities and can barely get to bathroom and back to his chair. Previously Mr. and Mrs. Church were very realistic about his COPD. Now they are thinking about hospice. This is one of their questions today. Physician recalls that he has had 3 hospital admissions in the past 6 months and 4 ER visits.

Social history: Patient is married. Patient is retired & on disability. He lives in a 2 bedroom home. Mr. Church does not believe in god. Spouse works as an electrician. Son lives nearby and Mr. Church’s parents live 5 hours away.

Physical examination findings

Vitals: Temp 36.0 deg. C, Pulse 102 regular, Resp 22, BP 135/80, Wt 135lbs (down 5 lbs.)

General: Cooperative, breathing through pursed lips. Alert and oriented to person and place only.

Skin: Moist.

HEENT: WNL

Heart: RRR without murmur.

Lungs: Diminished, soft wheezing heart throughout bilaterally.

Abdomen: +Bowel sounds. Soft/nontender/nondistended to palpation.

Extremities: +2 pedal pulses bilaterally. Finger and toe nails slightly blue tint.

Hematologic: No bruising on extremities.

Neurologic: CNS II-XII grossly intact, no nystagmus, gait normal. Romberg normal.

Psychiatric: Only slight insight into problems. Denies anhedonia and depressed mood.

Labs/Imaging:

SaO2: 86% at rest on room air, 80% with mild exercise/movement on room air.

CBC: Within normal limits (Hct and Hgb upper end of normal)

CMP: Within normal limits except CO2 35. UA: Normal.

CXR: Unchanged emphysema, cardiomegaly. No infiltrate. Otherwise normal.

TASK: Initiate and lead a “code status discussion.”

(A student role plays the physician with a2nd & 3rd student playing the parts of Mr and Mrs. Church. Rotate roles after 5-7 minutes).

.

|10:30-10:40 |BREAK |

|10:40-11:30 |FINAL CASE - Mr./Mrs. Bronte |

| |Similar to yesterday, students will work through a paper case—identifying a problem list or working |

| |differential, and write initial orders for management. The case is in their student packet. Facilitator copy |

| |is on next page. |

| |Instruct the students to read the case, if additional information is needed, they may ask you. (There is no |

| |hidden information or additional information needed.) |

| |Similar to day 1, but no pharmacy students. Still each should work on their own today. |

|11:30-11:40 |FINAL CASE: Debriefing |

| |Collect a copy of their orders and hand out the suggested order set and discuss with group |

|11:40-11:50 |WRAP UP |

| |Thank students and answer any final questions |

Facilitators: Remember to turn student work in by placing the sign-in sheet and student order sheets in the provided envelope and leave in your room.

Final Case: Mr. /Mrs. Bronte

Purpose of case: Check clinical assessment and treatment skills for palliative care emergencies.

Patient name: Mr. /Ms. Bronte

Diagnosis: Metastatic colon cancer, Hypertension, Diabetes, Osteoarthritis

Setting: In ER.

Reason for visit: Pain

Time allotted: 10 minutes for reading and data collection.

15 minutes for documentation( write problem list and orders

30 minutes for review and discussion

Tasks: The group will obtain additional history, but each student will write his or her own orders to be turned in prior to the discussion and review.

1. Individually, write orders that address diagnostic evaluation and patient’s pain and other symptoms. ( Additional history is provided in italics in the facilitator guide)

2. Evaluate candidacy for hospice.

3. Note, or anticipate, other issues that this patient is likely to develop in the near future and include in orders.

BACKGROUND: Mrs. Bronte is 69 year old hospice patient with Metastatic colon cancer previously treated with surgery and FOLFOX and known liver metastasis, Hypertension, Diabetes, Osteoarthritis coming in today with increased pain.

Two days ago, Mrs. Bronte was seen by her PCP with some increasing back pain. At that time, pain was associated with cramping pain adjacent on the right to the lower spinal column; rated 5/10. She stated she would be happy if her pain was at 2-3/10. It had been increasing slowly, for at least 1 day before the visit. No associated symptoms were noted. Mrs. Bronte falls asleep best on the left side. Walking is okay despite the pain. Her PCP changed her pain regimen to acetaminophen/oxycodone 325mg/5mg 1 tablet by mouth every 6 hours and cyclobenzaprine 5mg p.o. TID.

HPI: (Her words in italics)

I have been taking the medications and I am anything but better. It has been doing nothing but getting worse. My pain is through the roof. I just want something for the pain! My stomach is so large right now I almost cannot fit in my “vacation/holiday” pants. My pain is currently 9/10. My stomach and back aches pain shoots down into my legs. I have a hard time walking around without tripping. I just cannot make it to the bathroom in time. Nothing seems to help. I did not sleep more than 2 hours last night. I wish that I could just rest easier….is that too much to ask in my position?

I am so frustrated it has not gotten better. I do not know if there would be quicker ways to die, but sometimes I wonder when I hurt this much.

I know this will kill me. I just don’t want it to kill my spirit and not do as much as I can. I need better pain control.

Meds:

Citalopram 20mg po QHS, Metoprolol 50mg po BID, acetaminophen/oxycodone 325/5mg po Q6hours, cyclobenzaprine 5mg po TID.

ROS:

GU: Yes I have been losing both urine and stool, but I thought it was because I do not make it to the bathroom as fast as I used to.”

PAIN: When asked where she thinks the pain is from, “I do not know what it is….it cannot be my cancer, can it?

Social history: Patient is married with 3 children, a 49-year old married daughter, 46-year old married son, and 44 year old divorced son. All children still live in town. Mrs. Bronte’s parents and two sisters live 5 hours away. The spouse’s parents live in a nursing home in town. They live in a 2 bedroom home close to downtown. She does believe in god but does not currently attend a church. Her spouse works as an architect downtown.

She has not completed Advance Directive paperwork . . . but indicates she would want her husband to be dpoa, and she is not sure about “code status”.

Physical Examination findings

Vitals: Temp 37.2 deg. C, Pulse 99 regular, Resp 20, BP 145/80, Wt 135lbs (up 6 lbs from last visit), SaO2 98%

General: Cooperative, but distressed. Looks to be in pain.

Skin: Moist. Reddened 3.0 cm area on the sacrum currently covered with a hydrocolloid dressing.

HEENT: NC/AT. EOMI symmetric bilateral. PERRLA. TMs clear bilaterally.

Heart: Normal S1/S2 without murmur.

Lungs: Clear to auscultation bilaterally.

Abdomen: +Bowel sounds. Protuberant. Dull to percussion and tender to palpation suprapubically. Hepatomegaly +. Rectal exam produces loose stool in vault with decreased sphincter tone.

Back: Tenderness to palpation in low back over spine. Some bilateral muscle spasms around same area.

Extremities: +2 pedal pulses bilaterally. Trace pedal edema bilaterally.

Hematologic: No bruising on extremities.

Neurologic: CNS II-XII grossly intact, no nystagmus, unable to walk without two-person stand-by assist. Romberg normal. Biceps, triceps, patellar, and Achilles reflexes +2. MMSE 28/30 with serial 7’s (unchanged). Muscle strength bilateral legs 2/5.

Psychiatric: Depressed mood with decreased sleep and energy.

LABS:

CBC: WBCs 10,000; Hgb 13.0; Platelets 150,000

BMP: Within normal limits except Glucose 130.

UA: Unable to obtain with bedpan/urinal.

Imaging:

MRI of spine: Compression of spinal column at the level of the cauda equina. Other metastases present within lumbosacral vertebrae.

MRI abdomen: Multiple liver metastases.

ADDITIONAL INFORMATION:

Multiple liver nodules, has poor prognosis; (Occasionally single metastases can be resected,) but with both liver and spine metastases prognosis is poor. (Prognosis ranges from LESS than 5% to approx 20% 5-year survival in stage IV disease. Mrs. Brown probably only has months to live.)

SUGGESTED ORDER SET FOR FINAL CASE

ADMIT

DIAGNOSIS:

**Metastatic colon cancer

**Spinal cord compression

Diabetes mellitus

*Depression

Pressure ulcer-stage I

Osteoarthritis

CONDITION:

Stable. (Guarded ok)

(CODE STATUS: (must be included somewhere in orders)

(Different groups may have different results)

No Code Full Code Other: ______________

Allergies:

None known

VITALS:

Vitals Q shift. (per unit protocol is OK.)

Assess pain every hour until pain rated less than 5 (or patient’s “goal”), then every two hours** (May place here or in Nursing section)

Please record I/O

Notify MD for: (BP _______; P_________; RR ___________; PAIN __________)

ACTIVITY:

Up ad lib OR Up in the chair with assist

NURSING:

Record Pain assessment and response Q 1hours until pain less than 5;

Then q2hours until less than 4; Then q4 hours.

Accuchecks needed (since starting steroids)

DIET:

Diabetic diet OR Regular diet, consistency as tolerated.

IV fluids:

Not clearly needed. (OK basal rate (keep vein open) up to 50ml/hour)

MEDICATIONS:

Home meds which should be continued

Citalopram- 20 mg PO qHS

Metoprolol- 50 mg PO BID

Home med which should be changed:

Acetaminophen/oxycodone- 325/5 mg PO Q6hours PRN Pain

MEDICATIONS: (continued)

New meds:

PAIN: Pain regimen should include both routine and PRN medication:

she was taking 1 tab 4 times daily of acetaminophen/oxycodone (325/5 mg=20mg/day oxycodone and 1300mg APAP) then

THIS: Oxycodone 7.5 mg po QID (=30mg/day oxycodone)

OR: Oxycodone 5 mg po Q4hours ATC (=30mg/dayoxycodone)

OR: Morphine IV 2.5 mg Q4hours (=15 mg IVMorphine/day = 45mg PO Morphine =30mg/day of oxycodone)

(These all work out to be a 50% increase in opiate dosing.)

AND:

Oxycodone 5-10mg Q 4 hours PRN pain

OR: Morphine 1mg IV Q 1 hours PRN pain.

(Appropriate PRN is 15% of total opiate dose Q4hours)

BUT SHOULD ALSO START:

• DECADRON (multiple options available.)

Methylprednisolone 100mg IV over 15 minutes then 16mg PO QID on D#1, 8mg QID x1 day, 4mg QIDx1 day, 4mg BIDx3 days, then stop or continue per Oncologist.

• Sliding scale insulin. (steroids likely to lead to hyperglycemia)

CONSTIPATION might worsen with increase of opiates: IF DIARRHEA then PRN only.

--Docusate 100 mg PO BID (200 mg BID OK) AND

--Sennoside 17.2mg PO BID

--Add PRN agent(s): Lactulose/Sorbital or MOM or ______________

DVT Prevention: --Heparin 5000 units SQ Q8hours OR enoxaparin 40mg SQ daily

GI Protection: No indication

LABS:

AM lab: CMP, CBC

SPECIAL:

CODE STATUS: Could be here..

ADVANCE DIRECTIVE: Document if she has one OR what she would want. (may put in narrative note rather than orders)

Post void residual ( PVR)-to rule out urinary retention

CONSULTS:

--Radiation Oncology consult

--Neurosurgery consult.

--Consider Chaplain (give reason on consult(cancer patient, seriously ill, believes in god, and feels guilty)

Reference:

Weissman, D., Ambuel, B., Hallenbeck, J. (2004). Improving End-of-Life Care A

Resource Guide for Physician Education. (3rd ed.). Retrieved from



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