View Log: Out of Hours Session - HOME - Bradford VTS



View Log: Out of Hours SessionCurrent Selections2.02 Patient Safety and Quality of Care2.03 The GP in the Wider Professional Environment3.09 End-of-Life CareCommunication and consultation skillsPractising holisticallyData gathering and interpretationMaking a diagnosis/decisionsClinical managementWorking with colleagues and in teamsMaintaining performance, learning and teachingMaintaining an ethical approachDate: 09/02/2019Subject title: Elderly lady with tingling and numbness in her hand and elderly lady not eating and drinkingType of OOH session:Mobile VisitVenue: Leicester Time: 14:00 – 19:00 (5 hours)PATIENT 1.65 year old lady seen in her house with numbness in the left handDATA GATHERINGThe left hand numbness had been going on for a long time. It comes and goes. This episode started today. She had tingling sensation on the fingers. Symptoms were restricted to the hand. The arm and forearm were spared. She had no limb weakness or problems with speech (trying to rule out stroke). She was eating and drinking ok. Past medical history : AF on apixaban, dementia, previous strokes and social issues.? Obs were stable, apyrexial. No facial asymmetry. Tinnel and Phalen signs were positive. No bruises on her arm (trying to look for evidence of physical abuse).DECISION MAKING/MANAGEMENTI made a diagnosis of carpal tunnel syndrome based on bits of the history and examination - because of the positive Tinnel and Phalen signs and the sensation were on the lateral digits along the median nerve distribution. Also, carpal tunnel has been suspected in the past. I prescribed gabapentin for her because of the neuropathic pain.?DATA GATHERINGHer house was noticed to be in so much disorder and squalor. Youngest son met during the visit claimed that the eldest son had lasting power of attorney to her funds but that she was not being released enough money. Carer said she is having sausage only for teatime today which is clearly not enough and there is no money to purchase food for her.DECISION MAKINGI concluded that this was a financial safeguarding issue and potential neglect because the patient is vulnerable and incapable of making independent decision about her finances due to her dementia and lack of direct access to her funds. Also, the level of squalor in the house suggested a likelihood of neglect and lack of proper personal care for the patient.IMT/WORKING WITH TEAMSI looked up into SystmOne and noticed that safeguarding alert had been raised previously. However, I was not certain what has been done so far and what is currently being done. My OOH Clinical Supervisor entered additional safeguarding information on SystmOne and he called the LCD manager (LCD is the organisation overseeing OOH duties) and he advised us to raise a significant event raised on LCD website. And the plan was for social services to investigate further on Monday.ETHICSAs doctors, we have a duty to protect our patient from situations that can harm them or at risk of harming them. Raising safeguarding concerns is a way of doctors ensuring that they do no harm (NON-MALEFICIENCE) and do all they can to make patient’s well-being of utmost priority (BENEFICIENCE). I learnt that I don’t have to face the clinical presentations of patients alone, I need to quickly identify safeguarding issues where there is one, raise my concerns and channel them appropriately through working with others. We called the eldest son because he had the LPA to update him of our concerns and the referral to social services. We explained to him that we were doing all we can to ensure that his mother is safe and free of harm and he was happy with the plan.?PATIENT 2.99 year old lady on palliative care, not eating and drinking today. Also, she was not responding to conversation.?DATA GATHERINGShe had multiple co-morbidities (CLD, CKD etc) and already had anticipatories in place but has not started this. She had been placed on the Goldline (a local service for patients on the Palliative register who coordinate care and can be a first contact for queries etc). She had been not been taking her medications because she was unable to eat or drink anything. She had been aggressive and shouting over the last few days and has not been lying quietly and peacefully.She was looking generally icteric, not in any acute painful or respiratory distress, her observations was stable. She was unconscious (U on the AVPU scale) and there were no abnormal findings on chest and abdominal examination.ETHICS & DECISION-MAKINGShe had a DNACPR in place. Conversations and decisions about resuscitation should be made early enough before patients get poorly and preferably when the patient is able to contribute to the decision-making process (PATIENT AUTONOMY). It is important to know resuscitation status of patients in palliative care and to make it clear in their records – because it can help with ethical decision making – in this case, the dilemma of whether to resuscitate or not if she suffers a cardiac arrest.?MAKING A DECISIONI had an impression that she was nearing her last days of life because of her symptoms and signs - she had multiple long-term illnesses, unconscious, not eating and drinking any longer, not taking her meds and had no acute medical condition that can reversed (CKS outlines symptoms and signs of last few days of life). So, we decided to stop all her meds and for her anticipatories to be administered by the district nurses when needed. At this moment, she was lying calm and peaceful, did not appear to be in pain and was not vomiting and had no secretions, hence, there was no indication for starting the anticipatories at the moment. COMMUNICATION SKILLS/PRACTISING HOLISTICALLYI tried to explore her daughter’s ideas about what was going on with her mum. I asked her daughter what her thoughts were about her mum's state. She said she believes her mum is nearing the end of her life as she has been deteriorating over the last few weeks. She said at her mum's last admission, she clearly stated that she didn’t want any further admissions and would like to be kept comfortable in her last days. She said her mum has had a good life and did not wish to resuscitated.I demonstrated empathy by telling her that “I am sorry that is quite difficult to for you to take in but she you are right, your mum is nearing the end of life and the inevitable may happen any time soon. She does not appear to be in painful or breathing distress. However, you can be reassured that we had prescribed some medications to help her keep comfortable and pain free in her last days.” I also demonstrated empathy by using a soft tone of voice and tried to show that I was willing to be of help.I explored her concerns by asking her “if she had any concerns”. She asked if how the medications would be given and I told her that when she shows signs of pain or distress, the residential home care workers will inform the district nurses to come and administer the anticipatories.?I know that sometimes there can be carer’s stress in a relative taking care of a palliative patient or someone whose loved is nearing end of life. So, I told the daughter that if she has any concerns or require any support personally, she should not hesitate to speak to staff of the residential care home and they will channel it to the appropriate people so that we all can help her. She was grateful for the explanation.MORE ON ETHICSEnd of life care and comfort is important for patients and relatives. Patients need to kept comfortable in their last days to prevent any further harm or distress (non-maleficience). Their dignity also needs to be preserved. Relatives have this psychological relief when they realise that that their loved is pain free, treated with love and care, and respect shown for maintaining their dignity.PLT/WORKING WITH TEAM/COMMUNITY ORIENTATIONI Googled and read up more about the GOLD LINE. And I realised that they are the team involved in looking after patients on palliative or end of life care in the community. This group of patients have their phone number and can contact them at any time they need medical help if they are unable to contact their GP surgery or during out of hours. This service is run by nurses who triage patient’s needs and channels them to the right staff e.g OOH GP or district nurses. With the efforts of the Gold Line, I read that most patients have been able to die in their preferred place of death which is usually their home. And this means a lot to them and their families. I am now aware of the existing channel of communication between Gold Line and GPs to achieve better care, support and prompt medical consultations to palliative or end of life patients.What will you do differently in future?:What further learning needs did you identify?:How will you address these in future:Shared?:CommentsThere are no learning log comments to display.AttachmentsThere are no library items to display. ................
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