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Medicine year 2 semester 1 > Case 19- SAP > Flashcards

Case 19- SAP Flashcards

1
Q

Bad news in medicine

A

Any information that will likely alter drastically a patients view of his or her future

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2
Q

Breaking bad news

A

Breaking bad news is likely to produce strong emotional responses, the way bad news is shared affects how the patient will cope. There may be a range of emotional responses- anger, distress, shock and hopelessness. Try and find something positive for a patient to hold onto- positive framing. Consider leaflets and other sources of information.

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3
Q

How to establish empathy

A

1) Respect
2) Open questions
3) Giving your patient time
4) Showing interest in the patient
5) Active listening
6) Watching for verbal and non-verbal cues
7) Effective sincere empathic statements
8) Empathic facial expression
9) Eye contact
10) Mirroring and use of touch

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4
Q

How to prepare for breaking bad news

A
  • Prepare you yourself- know any results, know as much as you can about the patient and the illness, know what options are available, who can help and what happens next
  • Prepare the setting- private with no interruptions and adequate time, prepare the room layout
  • Prepare the patient- who else needs to be present- family members, HCP who knows the patient or family. Advanced warning that there is news to hear
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5
Q

Initiating breaking bad news

A
  • Establishing initial rapport- introduction and initiating the interview
  • Check out patient perceptions- ideas, concerns and expectations
  • Give a warning shot that there is news to hear
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6
Q

Breaking bad news- giving the information

A
  • Assess prior knowledge- what do they want to know
  • Listen to the patient to assess informational needs and level of language
  • Give clear information in direct chunks and check understanding and invite questions
  • Allow news to settle- use silence
  • Prepare for different emotional responses
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7
Q

Responding to patients reactions after breaking bad news

A
  • Possibility of strong emotional responses and new concerns
  • What are their reactions/feelings/immediate concerns
  • Respond to their emotional reactions with empathy
  • Do they have questions- answer honestly and realistically
  • Are they ready to consider options/making shared decisions/plan?
  • Offer emotional support and hopefulness
  • Be sensitive to cues - if patient has had enough
  • Be clear about definite next step
  • Arrange a follow up
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8
Q

Physiological signs of death

A
  • Irreversible cardiorespiratory arrest (no heart sounds or central pulse for a minimum of 5 minutes)
  • No breath sounds
  • Pupils dilated and unreactive to light
  • No response to pain
  • Cloudiness of the cornea
  • Rigor mortis (~3 hours after death)
  • Decreased body temperature
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9
Q

Physiological signs of dying

A
  • Loss of appetite
  • Excessive fatigue or sleep
  • Physical weakness
  • Mental confusion
  • Laboured breathing
  • Decrease urinary output
  • Cold, cyanosis extremities and mottled skin
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10
Q

Definition of death

A

An unresponsive patient, with a body temperature under 35 degrees who has not been taking drugs of alcohol
- no spontaneous movement
- no respiratory effort
- no heart sounds or pulses
- absence of reflexes
- pupils are fixed and dilated
There is no legal deviation in the UK, just assessed as the irreversible loss of capacity for consciousness and to breathe

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11
Q

GMC guidance for doctors on their role at the end of life

A

Doctors should:

  • discuss adaptation to major life changes such as bereavement
  • contribute to the care of patients and their families e.g. managing symptoms, team working, effective communication and practical issues of law and certification
  • communicate appropriately
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12
Q

Responding to dying

A
  • People face the possibility of their own deaths in unique ways.
  • There is a range of emotional responses and coping strategies – these mostly help people to continue functioning.
  • It is important to listen to peoples stories
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13
Q

What is Spirituality

A
  • Meaning in life
  • Interrelatedness
  • Wholeness
  • Morality
  • Awareness of God
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14
Q

What influences Spirituality

A
  • Understanding of their condition/mortality
  • Decision-making
  • Coping strategies
  • Adherence
  • Relationships with healthcare team
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15
Q

Advance refusal of treatment

A

In some circumstances, a competent patient can have an advance statement - they can make choices about what they wish or do not wish to happen to them in particular situations (valid for the future, when they are no longer competent to make decisions)
Competent patient can withdraw their advance refusal at any time and this does not need to be in writing

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16
Q

When can a health professional go against an advanced refusal

A

If the healthcare professional has reasonable grounds to think that there are circumstances that the patient didn’t anticipate when they made the decisions which could have impacted their decision, it could be a valid reason not to act on an advance refusal

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17
Q

Role of the doctor in death

A
  • Legal duty for the doctors to notify the cause of death
  • Doctor who attended deceased last should issue this certificate detailing cause of death
  • Doctors, nurses or ambulance clinicians should confirm death has taken place
  • GPs visit a patient home/residence in an expected death to issue the certificate
  • Unexpected deaths recommend a visit but this is not a requirement
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18
Q

The trends surrounding death and dying

A
  • 70% of people prefer to die at home
  • 68% of people are comfortable talking about death
  • 29% have discussed their wishes
  • 4% have advanced care plans
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19
Q

Models to understand reaction to dying and bereavement/experience of loss

A
  • Kubler-Ross
  • Worden’s stage of grief
  • Dual-process model
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20
Q

Kubler ross model of death and bereavement

A
  • Denial- avoidance, confusion, shock, fear
  • Anger- frustration, irritation, anxiety
  • Depression- overwhelmed, helplessness, hostility, flight
  • Bargaining- struggling to find meaning, reaching out to others
  • Acceptance- exploring options, new plan in place, moving on
    This is not a linear process. The sequence of feeling a patient from knowledge they are terminally ill to actually dying. Sequential with some overlap.
    Shock and hope are also responses which occur alongside
21
Q

Coping styles model of death and bereavement

A

Psychological adjustment to terminal illness, the 5 different modes of adjustment
• Fighting spirit - tries to keep going
• Fatalism - life happens, need to accept what comes your way
• Hopelessness- dependent on others for physical and psychological needs, wants other people to do things for them
• Anxious preoccupation - cant focus on anything other than death
• Avoidance/denial- not wanting to know information about the disease, going on as if it didn’t happen

22
Q

William Worden tasks of grief

A
  1. To accept reality of the loss
  2. To experience the pain of the loss
  3. To adjust to an environment in which the deceased is missing
  4. To emotionally relocate the deceased to an important but not central place in life in order to move on
23
Q

Experiencing the pain of loss

A 
Pining, goes in a circle. Conflict between trying to search and avoid reminders
• Sense of loss
• Searching for reminders
• Grief when they are found
• Avoidance of reminders
24
Q

Dual process model for coping with loss

A

Two separate but related processes. The restoration orientation is about getting your life back and becoming a whole person again.
• Loss orientated- grief work, inclusion of grief, breaking bonds/ties, denial/avoidance of restoration changes
• Restoration orientated- attending to life changes, distraction from grief, denial of grief, doing new things, new roles/identity/relationships

25
Q

How has death changed over time?

A
  • Cause of death
  • Familiarity of people with death
  • The role of the doctor in death and bereavement
  • Life expectancy
  • Practises around death and bereavement
26
Q

Death moving from a quick death to a slow death

A

• Higher levels of medical technology
• Earlier detection of disease
• An increase in complexity of definitions of death
• Higher levels of chronic disease mortality
• Lower levels of fatal injuries
• A greater activist and curative response towards a person who is dying - aims to prolong their life
• Modern era- social changes
Over time there has been a reduction in death rates and an increase in life expectancy. Infant mortality rates has gone down.

27
Q

Death- Geography and culture

A
  • Different causes of death around the world
  • Different religious and cultural practises
  • Doctor’s role in different cultures
28
Q

Customs around dying/death

A

Customs - burials, cremations and other preferences will vary due to influences
- culture
- religion
- legal requirements- may have to be reported to the coroner
- climate
- family traditions
- cause of death
= access to burial/cremation/support services

29
Q

How different cultures respond to death

A
  • Catholics: believe in heaven, some pray with a priest when person is close to death, burials or cremations
  • Greek Orthodox: believe in eternal life so burials only as we need to return to earth, candle lit by priest after death for 40 days as they believe the soul roams on earth for 40 days
  • Hindu: believe in reincarnation- cremating releases the spirit, avoid touching the dead body as not to contaminate it and make it unclean
  • Buddhists: believe in rebirthing, buried or cremated depending on tradition, gravestones important
30
Q

Resilience in medical students

A

1) The capacity to thrive in difficult/demanding situations at work
2) Important for medical students because to effectively support patients, we need to be able to respond to, reflect on and cope with challenging situations
3) Reflection will help medical students to understand a situation and know how something could be improved - can make them a better doctor and won’t make the same mistakes twice

31
Q

How to engineer regeneration of the spinal cord (8)

A
  1. Degrade the glial scar- Chondroitinase
  2. Olfactory ensheathing cells
  3. Stem cells- may also be useful for other neurodegenerative diseases such as replacing motor neurones in MND
  4. Neuromodulation- enabling weak signals
  5. Microelectrode array recording- brain signals are amplified and filtered. The low frequency signal is called the local field potential. The high frequency signal contains action potentials from nearby neurons
  6. Encoding- cosine tuning of movement direction
  7. Decoding- population vectors
  8. Brain spine interfaces
32
Q

Neuromodulation

A

A form of psychiatric neurosurgery in which permanently implanted electrodes trigger responses in specific brain circuits
Pathways by themselves not strong enough to reach threshold but when they are stimulated, increase excitability so closer to threshold. This means that weakened signal can still generate movement because weak connections are now enabled

33
Q

Engineering regeneration of the spinal cord

A
  1. Degrade the glial scar - chondroitinase and promote growth of nerve fibres
  2. Olfactory ensheathing cells - promote nerve regrowth, growth factors transplanted into spinal cord and promote growth of right type of cells
  3. Stem cells
34
Q

Microelectrode array recording

A

• Electrode array = 100 spikes on a small square (4mm2), implanted into the cortex and top of spikes close to cell bodies. Record extracellular voltage close to neurones to see brain signals, brain signals are amplified and filtered
• Low frequency- local field potential
• High frequency- action potentials from nearby neurons
The spinal cord injury prevents movement but the motor circuits in the brain are still working

35
Q

The concept of spirituality at the end of life for some patients

A

1) When someone approaches the end of their life, they may feel isolated which may create longing for connection both with human beings as well as with non human things
2) May be appropriate to ask a patient about their personal beliefs and engage with their views (even if you don’t agree with them)
3) Some patients may feel stress and may experience feelings of guilt about things they have (not) done in their lives

36
Q

The Argumemts for and against pulmonary resuscitation in the patient

A

FOR

  • patient may not want CPR
  • there could be serious damage done by CPR - not the quality of life they want to live
  • the patient has the right to choose
  • outcome may be worse than withholding CPR

AGAINST
- patient could survive and make a full recovery

37
Q

Criminal negligence

A

Liability that can occur when a doctors carelessness or anattentive actions cause harm. Doctors have a duty of care

38
Q

What to consider with regards to assisted suicide

A
  • Intensity of encouragement or assistance
  • Intent to encourage or assist
  • Personal or professional capacity
  • Honest/accuracy/account keeping
  • Under 18?
  • Capacity of patient
  • Knowingly prescribing the means
  • Clear, voluntary, settled and informed decision to commit suicide OR threatened/pressured?
39
Q

MCA code of practise- end of life care:

A
  • All the reasonable steps that are in the patients best interests should be taken to prolong their life
  • BUT
  • If a treatment is futile, overburdening for the patient or there is no prospect for recovery, then it may be best to withdraw or withhold life sustaining treatment, even if it results in death
40
Q

Ethical issues surrounding end of life care

A
  • Communication breakdowns
  • Patient autonomy being compromised
  • Ineffective symptom management
  • Non-beneficial care
  • Issues with shared decision making
41
Q

Legal issues surrounding end of life care

A
  • Physician assisted suicide is illegal
  • Mental capacity of patient who has decided to make an advanced decision to refuse treatment
  • The patient has the right to chose
42
Q

Doctrine of double effect``

A
  • When an act that produces a morally good effects and a morally bad effect is considered ethically okay, as long as the bad effect wasn’t intended.
  • It is acceptable to cause a foreseen bad effect that is not intended when the good effect cannot be obtained without the risk of the bad effect and where there is good reason to allow the risk of the bad effect
43
Q

The 4 conditions for the doctrine of double effect

A
  1. The action intended must be good or at least indifferent
  2. The good not the bad was intended
  3. The good effect is not produced by the bad effect
  4. There is a proportionally grave reason for producing the bad effect
44
Q

The Cardinal symptoms relating to neurological disease

A

1) Headaches
2) Nausea and vomiting
3) Blurred/double vision/ loss of vision
4) Hearing difficulties and tinnitus
5) Vertigo and dizziness
6) Speech or language difficulty
7) Swallowing difficulties
8) Altered consciousness, fits or faints
9) Psychological changes
10) Gait changes
11) Tremor and loss of co-ordination
12) Weakness
13) Sphincter disturbances- bladder, bowel and sexual dysfunction
14) Rigidity
15) Numbness, pins and needles

45
Q

Signs of motor neurone disease

A
  • Upper motor neurone and lower motor neurone signs
  • Upper motor neurone- spasticity, brisk reflexes and upward plantar reflex
  • Lower motor neurone- wasting, vesiculations
  • No pain or sensory symptoms
46
Q

Symptoms in ALS motor neurone disease (most common type)

A

Over 40, stumbling spastic walk, foot drop, proximal myopathy, weak grip (struggle opening doors), weak shoulder abduction (difficulty washing hair), frontal temporal dementia.

47
Q

Progressive cerebral palsy

A

Only affects cranial nerves 9-12. Muscles affected are used for talking, chewing and swallowing

48
Q

Progressive muscular atrophy

A

Only the anterior horn is affected. No upper motor neurone signs. Small muscles of the hands and feet are affected first. No muscle spasisity

49
Q

Primary lateral sclerosis

A

Mainly upper motor neurone signs. Muscle spasticity in the legs causing weakness, speech problems

Medicine year 2 semester 1 (53 decks)

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