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PCM > Communicating Bad News > Flashcards

Communicating Bad News Flashcards

1
Q
  1. Know Yourself
A

Physicians communicate their own emotional responses
Be aware of own responses
Process your feelings with others

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2
Q
  1. Create a Plan
A 
Allot adequate time
- Prevent interruptions
Determine who else the patient would like to present
- If child, patient's parents
Plan what you will say
- Confirm medical facts
- Don't delegate
Create a conducive environment
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3
Q
  1. What Does the Patient Know?
A

Establish what the patient knows
Assess ability to comprehend new bad news
Reschedule if unprepared

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4
Q
  1. How Much Does the Patient Want to Know?
A

Recognize, support various patient preferences

  • decline voluntarily to receive information
  • designate someone to communicate on his/her behalf

People handle information differently

  • race, ethnicity, culture, religion, socioeconomic status
  • age and developmental level
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5
Q
  1. Sharing the Information
A

Say it, then stop

  • avoid monologue, promote dialogue
  • avoid jargon, euphemisms
  • pause frequently
  • check for understanding
  • use silence, body language

Don’t minimize severity
- avoid vagueness, confusion

Implications of “I’m sorry”

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6
Q
  1. Responding to Feelings
A

Affective response
- tears, anger, sadness, love, anxiety, relief

Cognitive response
- denial, blame, guilt, disbelief, fear, loss, shame, intellectualization

Basic psychophysiologic response
- fight-flight

Be prepared for

  • outburst of strong emotion
  • broad range of reactions

Give time to react
Listen quietly, attentively
Encourage descriptions of feelings
Use nonverbal communication

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7
Q
  1. Planning, Follow-Up
A

Plan for the next steps

  • additional information, tests
  • treat symptoms, referrals as needed

Discuss potential sources of support
Give contact information, set next appointment
Before leaving assess: safety of patient, supports at home
Repeat news at future visits

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8
Q

Preparing for the Last Hours of Life

A

Time course unpredictable
Any setting that permits privacy, intimacy
Anticipate needs for medications, equipment, supplies
Regularly review the plan of care
Caregivers
- awareness of patient choices
- knowledgeable, skilled, confident
- rapid response
Likely events, signs, symptoms of the dying process

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9
Q

Physiologic Changes During the Dying Process

A 
Increasing weakness, fatigue
Decreasing appetite/fluid intake
Decreasing blood perfusion
Neurologic dysfunction
Loss of ability to close eyes
Pain
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10
Q

Weakness/Fatigue

A 
Decreased ability to move
Joint position fatigue
Increased risk of pressure ulcers
Increased need for care
- activities of daily living
- turning, movement, massage, OMT
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11
Q

Decreasing Appetite/Food Intake

A

Fear: “giving in”, starvation
Reminders
- food may be nauseating
- anorexia may be protective
- risk of aspiration
- clenched teeth express desires, control
Help family find alternative ways to care

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12
Q

Decreasing Fluid Intake

A 
Oral rehydrating fluids
Fears: dehydration, thirst
Remind family, caregivers
- dehydration does not cause distress
- dehydration may be protective
Parenteral fluids may be harmful
- fluid overload, breathlessness, cough, secretions
Mucosa/conjunctiva care
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13
Q

Decreased Blood Perfusion

A 
Tachycardia, hypotension
Peripheral cooling, cyanosis
Mottling of skin
Diminished urine output
Parenteral fluids will not reverse
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14
Q

Neurologic Dysfunction

A

Decreasing level of consciousness
Communication with the unconscious patient
Terminal delirium
Changes in respiration
Loss of ability to swallow, sphincter control

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15
Q

Frequency of Symptoms Last Two Weeks of Life

A 
Pain 51-100%
Dyspnea 22-46%
Athenians 80%
Anorexia 80%
Dry mouth 70%
Mental confusion 68%
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16
Q

Signs of Active Dying

A

Retained audible respiratory secretions - death rattle (24-60 hrs)
Respiration with mandibular movement - jaw movement increases with breathing (2-5.8 hrs)
Cyanosis of extremities (1-5 hrs)
No radial pulse (1-3 hrs)

17
Q

“The usual road to death”

A

Decreasing level of consciousness
Progression
Eyelash reflex

18
Q

“The difficult road to death”

A 
Terminal delirium
Medical management
- benzodiazepines (lorazepam, midazolam)
- neuroleptics (haloperidol, chlorpromazine)
Seizures
19
Q

Changes in Respiration

A

Altered breathing patterns

  • dismissed tidal volume
  • apnea
  • Cheyne-Stokes respiration a
  • accessory muscle use
  • last reflex breaths

Fears
- suffocation

Management

  • family support
  • oxygen may prolong dying process
  • breathlessness
20
Q

Loss of Ability to Swallow

A 
Loss of gag reflex
Buildup of saliva, secretions
- scopolamine or glycopyrrolate to dry secretions
- postural drainage
- positioning
- suctioning
21
Q

Loss of Sphincter Control

A

Incontinence of urine, stool
Cleaning, skin care
Urinary catheters
Absorbent pads, surfaces

22
Q

Pain

A 
Fear of increased pain
Assessment of the unconscious patient
- persistent vs fleeting expression
- grimace or physiologic signs
- incident vs rest pain
- distinction from terminal delirium
Management when no urine output
- stop routine dosing, infusion of morphine
- breakthrough dosing as needed
- least invasive route of administration
23
Q

Loss of Ability to Close Eyes

A 
Loss of retro-orbital fat pad
Insufficient eyelid length
Conjunctival exposure
- increased risk of dryness, pain
- maintain moisture
24
Q

Medications

A

Limit to essential medications
Choose less invasive route of administration
- buccal mucosal or oral first, then consider rectal
- subcutaneous occasionally
- intravenous rarely
- intramuscular almost never

25
Q

As Expected Death Approaches

A 
Discuss
- patient/family wishes
- status of patient
- realistic care goals
- role of physician/interdisciplinary team
Reinforce signs, events of dying process
Personal, cultural, religious, rituals, funeral planning
Family support throughout the process
26
Q

Signs that Death has Occured

A 
Absence of heartbeat, respirations
Pupils fixed
Color turns to a waxen pallor as blood settles
Body temperature drops
Muscles, sphincter so relax
- release of stool, urine
- eyes can remain open
- jaw falls open
- body fluids may trickle internally
27
Q

Loss, Grief with Life-Threatening Illness

A 
Highly vulnerable
Frequently losses:
- function/control/independence
- image of self/sense of dignity
- relationships
- sense of future
Confront end of life
- high emotions
- multiple coping responses
28
Q

Loss, Grief, Coping

A

Grief = emotional response to loss

Coping strategies

  • conscious, unconscious
  • avoidance
  • destructive
  • suicidal ideation
29
Q

Normal Grief

A

Physical

  • hollowness in stomach
  • tightness in chest
  • heart palpitations

Emotional

  • numbness
  • relief
  • sadness
  • fear
  • anger
  • guilt

Cognitive

  • disbelief
  • confusion
  • inability to concentrate
30
Q

Complicated Grief

A

Chronic grief
- normal grief reactions over very long periods of time

Delayed grief
- normal grief reactions are suppressed or postponed

Exaggerated grief
- self-destructive behaviors (eg, suicide)

Masked grief
- unaware that behaviors are a result of the loss

31
Q

7 Step Protocol

A
  1. Know yourself
  2. Create a plan
  3. What does the patient know?
  4. How much does the patient want to know?
  5. Sharing the information
  6. Responding to patient, family feelings
  7. Planning and follow-up

PCM (26 decks)

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