Block 9 Flashcards
Clinical reasoning =
the ability to sort through a cluster of features presented by a patient and accurately add a diagnostic label/treatment strategy
Health literacy =
the cognitive and social skills which determine an individuals ability to gain access to, understand and use information in a way to maintain good health
Bad news is…
Any news that drastically and negatively alters the patient’s view of his/her future
What does ‘bad news’ depend on?
Context:
- Social life
- Hobbies
- Occupation
- financial circumstances
- Age
What may clinicians worry about giving bad news?
- Not being prepared for patients emotional reaction
- Feeling inadequate
- Embarrassed they may have previously given too optimistic a picture
- Fears of destroying hopes
- Uncertainty about patient’s expectations
Distancing strategies that are used in breaking bad news:
Avoidance False reassurance Premature reassurance Normalization Switching/focusing on something else
2 strategies for breaking bad news:
ABCDE
SPIKES
ABCDE =
Advanced preparation Building relationship Communicate well Deal with reactions Encourage and validate emotions
Ways to advance prep =
Location
Turing off distractors
Mentally preparing
Reading notes
Ways to communicate when breaking bad news:
Allow silences
Validate feelings
Ask patient to describe their understanding
Allow time for questions
SPIKES =
Setting up Perception Invitation Knowledge Emotions Summary and strategy
Ways to prepare patient for bad news =
Right setting
Inviting in family members
Find out what patient already knows
Find out what patient wants to know
Ways to disclose bad news =
Warning shot
Short chunks
Clarify understanding
Ways to follow-up the disclosure of bad news =
Respond to emotions
Answer questions
Plan a follow up
Distress and acute grief can last for
up to 6 months
Period of adjustment is between
6-12 months
Ways to deal with a patient’s anger =
- Recognise it
- Don’t dismiss
- Remain calm
- Make a plan
lifetime incidence of cancer
1:3
Incidence of cancer mortality
1:4
How many people in England are diagnosed with cancer each year?
> 250,000
How many people in England die from cancer each year
> 130,000
Most common cancer for mortality =
Lung cancer
Most common cancer in prevalence for women and men
Women = breast Men = prostate
3rd most common cancer =
Colorectal
Most common cancers in young people =
- Leukemia
- Brain: astrocytoma, medulloblastoma
- Lymphoma (hodkins and non-hodkins)
Eurocare study was conduted in the
1980s
What did the eurocare study find?
UK was last in Europe for cancer mortality rates
Potential causes of UKs poor performance in eurocare study:
Difference in data collection Difference in stage presentation Delay in diagnosis Social class Access Age
What report was a consequence of the Eurocare study?
Calman-Hine report
Calman-hine report decided that:
- All patients need uniform access to high quality care
- Better awareness of early cancer signs
- More information to cancer patients and their families
- Psychosocial support
- Primary care should be central to cancer care
Solutions suggested by the Calman-Hine report:
- 3 levels of care: primary, cancer units, cancer centers
- MDT approach
Functions of the 3 levels of care identifies in the Calman-Hine report
- Primary care
- Cancer units - common, diagnosis, non complex chemo and surgery
- Cancer centers - rare, complex chemo, radiotherapy
What does the cancer MDT do?
- Discuss new diagnosis
- Management plan
- Inform primary care
- Designate key worker
- Develop guidelines
- Audit
First every comprehensive strategy to tackle cancer provision was:
NHS cancer plan (2000)
6 key areas for action in the cancer reform strategy (2007):
- Prevention
- Early diagnosis
- Better treatment
- Life after cancer
- Reduce inequalities
- Provide care in right setting
Name something which helps with life after cancer
National survivorship initiative
NAEDI hypothesis decribes =
Why people present late/avoidable cancer deaths
Why might people present late with cancer:
- Lack of awareness
- Negative perception
- Age, sex, SES, past experience, co-morbidities
Medical functions of the clinical record:
- Aide memory for effective communication
- Support Hx and examination
- Clarity of diagnosis
- Continuity of care
- Treatment is followed
- Explanation for patient
Non-medical functions of clinical records =
Audit Financial planning Resource usage Research Legal - provide info to third party, act as evidence Medical education
What should you record on a clinical record?
Presenting symptoms and reason for seeking care
Relevant clinical findings
Diagnosis and differentials
Options for care and treatment
Safety netting and discussions with patient about risks vs benefits of treatment
Investigations ordered
Decisions made
How should you record on a clinical record?
Professionally
Comprehensively
Contemporaneously
When can info be removed from a clinical record?
Valueless
Duplicated
Even if a patient requests it, when can info not be removed from a patient record?
Will later harm patient
Medically relevant
What can a computerised system have that a paper based one doesnt?
Clinical decision support tools
What is included in a ‘summary care record’
Name, address, DOB, NHS number
Mediations
Allergies
When can you break confidentiality?
Required by law
Health and social care act
Court order
Public interest
What act sets out that data should be processed lawfully, fairly, for adequate reason, up to date and not longer than necessary?
Data protection act
What are the Caldicott principles of data protection?
- Justify purpose of collection
- Don’t share identifaible info
- Share minimum info
- Access on need to know basis
- Everyone with access should know their responsibilities
- Understand and comply with law
The body is:
Physical
Social
Discourses for bodies examples
- Good/bad bodies
- Particular bodies reflex disordered lifestyle
- Use of self-destructive language for autoimmune diseases
Why is the body social?
Seen as an external reflection of peoples attitudes, values and lifestyles
The civilized body (Elias) =
Markers for an adult citizen is that the body is under control
- Hide natural functions
- Control emotions
- Separate space between bodies
How is the civilized body disrupted in disease?
- Cannot hide natural functions (leaky bodies)
- May not control emotions
- Personal space: physical care
Male body image…
Language of power, neutral
Function
What the body can do
Female body image…
Negative
Language of control
Apperance
Social currency
Biographical distribution:
A reorganisation of life context
Ex am ‘age appropriate body’ going wrong in disease
Arthritis in young person
Body image impacts our
Perception of ourself
Confidence
The way we see our role
Interactions with other
Body image problem is a
existence of a marked discrepancy between the actual or perceived appearance/function and an individuals expressed ideal. Leading to interference with routine, occupational, social or relationship functioning.
Physcial impact of breast cancer =
Loss of breast Asymmetry Difficulties with bra/clothing Scarring Hair loss Weight gain Menopausal symptoms
Psychological impacts of breast cancer =
Loss anxiety greif Loss of confidence Lack of trust in body Depression Feeling incomplete Change of identity Reminder of cancer
Social impacts of breast cancer =
Change in role Sexuality Intimacy Forming new relationships Employment, leisure Social isolation
Concerns of people with a stoma =
work intimacy new relationships leaky smell sex
Why is hair important?
Identity
A way of doing gender
Demasculating
3 different vaccine strategies:
- Protect vulnerable
- Elimination
- Eradication
Who are ‘vulnerable’ and should be vaccinated
- Increased risk of exposure (IDUs, health workers)
- Increased risks of consequences
Elimination vs eradication
Elimination = reducing transmission R<1 Eradication = no infection, animal or environmental reservoirs.
Example of vaccines given to vulnerable people
Meningitis B
Pneumococcal
Influenza
Examples of vaccines for elimination
Mumps
Tetanus
Diptheria
Examples for vaccines for eradication
Smallpox
Polio
Examples of passive immunity:
Mother to child
Placental, breast milk
IV-Ig
Active immunity example:
Infection
Vaccine
R0 =
Basic reproductive number.
Number of 2ndry cases per 1mary case in a totally susceptible population
R0 is a factor of the
Microorganism
Population
R0 is proportionate to:
Length of time cases infectious
Number of contacts: population density, travel etc
Chance of transmitting infection during encounter with susceptible host (virulence factors)
R0 can differ in
Different pathogens
Different populations
R =
Effective productive number. Actual number of secondary cases per primary cas observed in a population
R0 is usually (smaller/larger) than R
Larger
Equation R =
R = R0 x s
s =
Population susceptible
R > 1
Number of cases increasing
Epidemic threshold is when
r = 1
R < 1
Number of cases decreasing
For elimination, R must be
< 1
S* =
critial population susceptible.
S* = 1/R0
H =
Herd immunity threshold
H = 1 = S*
If H = 95%. What does this mean?
Only 5% of population can be susceptible for R = 1.
S>5% then R>1
What is the only way to effectively eliminate an infection?
Herd immunity - <100% efficacy, <100% uptake, contraindications
What should you consider when deciding is a disease should be vaccinated against?
- Is it a public health issue?
- Is this the best way of dealing with it?
- Side effects, risks
- public acceptance
- Costs, resources, will is fit in with vaccine schedule
Communicable disease =
An illness due to an agent that arises through transmission of that agent from infected person/animal/reservoir to a susceptible host directly or indirectly.
How are communicable diseases controlled?
- Survellience from PHE
- Outbreak tracing
- Prevention: vaccine, food laws
- Shutting down/appropriate control
Outbreak vs epidemic vs pandemic
Outbreak - localised area
Epidemic - large area, threshold depends on microorganism
Pandemic - very large area, crosses international border, large population
Factors that increase risk of health-care associated infection:
- Reduced immunity/co-morbidities
- Extremes in age
- Virulence factors of hospital pathogens
- Antimicrobial resistance
- Breach of defence mechanisms: ventilators, catheters etc.
Policies and procedures to reduce HCAIs:
- Sharp disposal
- Sterilise instruments
- Isolation, barrier nursing
- Screening patients
- Don;t over prescribe antibiotics
- Vaccinate workers
An argument is sound when -
Premises are true
Conclusion logically follows premise
Deductive vs inductive reasoning
Deductive = arguing from logic Inductive = arguing from experience
Consequentilaism vs deontology vs virtue ethics
Consequentiliasm = Morally right if has a good outcome
Deontology = actions themselves are morally right or wrong, duty
Virtue ethics = depends on persons character
