Counseling

Question 1

Smoking: Assessing readiness to quit smoking

Answer 1

2 Models:

• 5 As:
  - Ask about tobacco use
  - Advise to quit
  - Assess willingness to make a quit attempt
  - Assist in quit attempt
  - Arrange follow-up
• Stages of change model
  - Precontemplation:
  - Preparation
  - Contemplation
  - Action
  - Maintenance

Question 2

Breaking Bad news: SPIKES

Answer 2

S - Setting
P - Perception
I - Invitation
K - Knowledge
E - Empathy
S - Strategy, summary, and SAFETY!!

Question 3

HIV counselling: HIV positive

Answer 3

S - Setting

• How did you come in today?
• I have some important news, would you like me to call someone to be there?

P - Perception: “Since this is the 1st time I am seeing you…”

• What happened that made you request HIV test?
• Why?
• Anything in particular?
• And what did you discuss last time?

I - patients’ Invitation
* “Would you like me to give you further details as to why the importance of the test, and the reason to order it?”

K - giving Knowledge

• As you know, this test was performed to rule out…
• “I am really sorry to tell you that the results came back positive”

E - Empathy

• Normalize their feelings
• Leave a 5-sec pause
• “What thoughts are going through your mind?, or What concerns you the most? “ The patient will give you clues as to what to address.
• R/O suicide: “Some of my patients, when they go through these situations have thoughts of harming themselves or others? Do you? or did you?
• *** “Do you consider yourself someone who would like all the details or just the minimum?”
• If so, give details about the disease, causes, etc.

S - Summary and safety

• As discussed, even though this is a lot of information, I want to assure you that you will not be alone in the process.
• There are options we have and that we can use. Again, I know this too much to process, so I would understand if you would like to come back in 2 days to discuss all these options.
• Safety
  
  • FU in 2 days
  • HIV specialist
  • Suicide: “Mr…., some people going through a lot of stress have thoughts that life is not worth living and that it would be better without them. Do you? If so, some have thoughts of harming themselves? Do you? If so, have you ever planned it or attempted?
  • Local support: I will make sure to contact you, in the meanwhile, I will give you some pamphlets with interesting and important information.
  • Safe sex counselling: Education

Question 4

Counselling: Needlestick injury

Answer 4

1. Concerns
2. History
   * What happened?
   * Immunization record
   * Previous occupational exposure
   * Intravenous drug abuse
   * Sexual history
3. Inform the patient about concern (HIV/diseases)
   * What it is
   * Transmission rates
   * Advancement in disease treatment
   * If pregnant: Address pregnancy concerns
4. Plan
   * “I will speak with the patient, explain, and ask for consent to perform test”
   
   • If he agrees:
     - If positive: We will know the possible tx.
     - If negative: No post-exposure prophylaxis is needed.
   • If he doesn’t agree or we know he is HIV+: Assess the “exposure code” and match it with the “HIV status code” -> To simplify, guidelines state we assume you were exposed and give prophylaxis tx:
     - HIV: 4 weeks of 2 anti-virals.
     - Hep B: HepB vaccination 3 doses + Ig (STAT)
5. Workup
   * Blood tests for patient and for the exposed
   
   • Repeated in 3 weeks, 6 weeks, and 12 weeks
     
     • I am going to speak to the patient now and come back
     • Any other question or concern?
     • Safety: Suicide, safety driving

Question 5

Seizure counselling

Answer 5

1. Introduction
2. Hx:
   * When
   * Who
   * How
   * Why
3. What is your understanding of seizure?
   * Definition + usually, does not cause learning disability or brain damage
   * Dx: 2 unprovoked seizures 24 hours apart
   * Cause: Idiopatic, or structural brain damage (post-meningitis)
   * Prognosis: Depens on the type and the epilectic syndrome.
   
   • Morbidity: Trauma is not uncommon
   • Mortality: small proportion (most due to impaired consciousness).
4. Dangerous activities: Safety!!! What do you do for living?
   * Restrictions until we control them and you are seizures-free:
   
   • Report for satefy precautions to the ministry of transportation
   • Diving, swimming, hiking, mountain climbing
   • Taking unsupervised baths, better take shower not bath, with open door
   • Working at significant heights, operating machines and the use of fire and power tools.
5. Avoid triggers
   
   • Chronic alcohol: ↓ blood level of anti-epileptics due to ↑ metabolism
   • Excess alcohol: ↓ seizure threshold
   • Stress!!!: Counsel and offer support
   • Sleep deprivation
   • Head trauma
   • Not compliant with medications or interactions!!!
6. Recommendations:
   
   • Treatment all your life
   • Talk with you physician about any new medication
   • Seizure meds are teratogenic, females to take proper contraceptive measures
   • Bracelet
   • If seizure: Go to ER
   • Regular FU visits and monitoring of anti-convulsion levels
7. Treatment
   
   • Mainstay of therapy: Anticonvulsivant -> If > than 1. Avoidance of typical precipitants as SOC for single, unprovoked seizures
   • Meds: Long term. Start with 1, if not better, increase dose and/or add another
   • Side effects: Movement disorders, liver, kidney, teratogenicity, drowsiness, concentration.

• *Pregnancy precautions:
  - Are you sexually active?
  - Do you take contraception?
  - If yes: There might be drug interaction, so for the time being you need to continue to use your pills and add another physical method such as condoms till you see your gynecologist
  - Planning on getting pregnant? If yes, Better to have seizure control first

Question 6

INR counselling

Answer 6

INR target for PE/DVT: 2 - 3
Mechanical valve -> 2.5 - 3.5

1. Intro
   * Why are you doing INR
   * Hx of disease: Previous ER? lungs? meds? TARGET INR!
2. Information and figure out why it increased/↓: “Do you have any idea why?”
   * Compliance
   * Forget
   * New medication
   * Diet: Spinach?
3. Impact: “I would like to ask you … to check if you have a relapse, and we will go from there:
   * DVT relapse:
   • DVT: Pain / swelling / redness in your calf muscles?
   • PE: SOB/chest pain/heart racing?
   • Stroke: Any confusion/Vision changes/Weakness?
     
     • Bleeding:
   • Any bleeding? Gums/nose/coughing/bruises/dark urine?
   • Weakness/numbness/difficulty finding words?

“Based on what you told me here, there are no obvious serious consequences. If it is ok with you, we can discuss your situation now”

4. Red flags (females): OCP, pregnancy (heparin instead), vaginal bleeding
5. What is your understanding about DVT
   
   • Causes: Prolonged immobility, medical condition
   • Complications:
     - Relapse (recurrence of DVT): 8%
     - Relapse with warfarin: 0.8%
     - Probability DVT (clots and PE): 3%
6. Blood thinners
   
   • Chances of having bleeding with warfarin: 1%
     - Chances of intra-craneal without having extra-cranial: near 0%
7. Decision- If patient agrees:
   * Low INR: We will do as we did the first time: Heparin and warfarin at the same time, and stop heparin after 3 days
   * High INR: Hold on, and then re-start with lower dosage.
   * INR measurements: daily until reaching target, then 2x/week, 1x/week, every 2-4 weeks.

Question 7

Cancer screening guidelines

Answer 7

• BRCA 1/BRCA 2
• Lung
• Gastric

Question 8

Serious Illness Conversation Guide

Answer 8

1. Set up conversation
۰ Introduce purpose
۰ Prepare for future decisions
۰ Ask permission
      -“I’d like to talk about what is ahead with your illness and do some thinking in advance about what is important to you so that I can make sure we provide you with the care you want — is this okay?”

2. Assess understanding and preferences
   
   • “What is your understanding now of where you are with your illness?”
   • “How much information about what is likely to be ahead with your illness would you like from me?”
3. Share prognosis
   ۰ Share prognosis
   -“I want to share with you my understanding of where things are with your illness…”
   ۰ Frame as a “wish…worry”, “hope…worry” statement
   -Uncertain: “It can be difficult to predict what will happen with your illness. I hope you will continue to live well for a long time but I’m worried that you could get sick quickly, and I think it is important to prepare for that possibility.”
   ۰ Allow silence, explore emotion
4. Explore key topics
   ۰ Goals
   -“What are your most important goals if your health situation worsens?”
   ۰ Fears and worries
   -“What are your biggest fears and worries about the future with your health?”
   ۰ Sources of strength
   -“What gives you strength as you think about the future with your illness?”
   ۰ Critical abilities
   -“What abilities are so critical to your life that you can’t imagine living without them?”
   ۰ Tradeoffs
   -“If you become sicker, how much are you willing to go through for the possibility of gaining more time?”
   ۰ Family
   -“How much does your family know about your priorities and wishes?”
5. Close the conversation
   
   • “I’ve heard you say that ___ is really important to you. Keeping that in mind, and what we know about your illness, I recommend that we ___. This will help us make sure that your treatment plans reflect what’s important to you.”
   • “How does this plan seem to you?”
   • “I will do everything I can to help you through this.”

Question 9

SPEAK: Patient’s advance care planning

Answer 9

S - Substitute decision-maker or representative

  - "If you were to ever become unable to direct your own medical care, tell us, whom would you want to help us make medical decisions for you?"
  - "Do you have a Representation Agreement? (Ask for a copy)"

P - Preferences for medical decision making

  - "How do you like to receive medical information?"
  - "How do you make medical decisions?"
  - "Who helps you make medical decisions?"

E - Expressed wishes or advance care plan

  - "Are there any medical treatments that you know of, that you’ve already thought about, and that you would never want to have?"
  - "Have you written anything down in a plan? My Voice Workbook perhaps?"
  - "Who have you talked to about what kinds of medical treatments you would or would not want if your health deteriorated?"

A - Advance directive
-“Have you written an advance directive? (Ask for a copy)”

K - Knowledge about medical condition (s)

  - "What is your understanding of your illness? Of what might happen in the future? Of what the options for treatment are and their risks & benefits?"
  - "What other medical information would you like to have in order to make further advance care plans?"