Patient Scenarios Flashcards
Your patient says that she does not want to be treated today, but the husband says you must treat the patient. What is your plan of action?
(1) recognise the patient has refused treatment (i.e., verbally withdrawn consent to treatment) and do not treat *relates to Domain 2 (professional and ethical practitioner)
(2) assess the patient’s decision-making capacity *relates to Domain 1 (medical radiation practitioner)
- if patient has capacity…
- if the patient does not have capacity… *relates to Domain 2 (professional and ethical practitioner) + Domain 3 (communicator and collaborator)
(3) report the incident to the RO and the relevant staff (i.e., RTs involved in direct care and senior RT) *relates to Domain 3 (communicator and collaborator)
One of your patients with prostate cancer wishes to stop his radiation after 3 fractions because he has heard of proton beam radiation, and he wants this new treatment. Discuss your plan of action.
(1) recognise the patient has refused treatment (i.e., verbally withdrawn consent to treatment) and do not treat *relates to Domain 2 (professional and ethical practitioner)
(2) explore the reason for the patient’s withdrawal *relates to Domain 3 (communicator and collaborator)
- consider criteria for valid consent (i.e., patient must have capacity to consent, consent must be made freely and voluntarily and consent must apply to treatment) *relates to Domain 2 (professional and ethical practitioner)
- consider socio-cultural factors (i.e., education level) *relates to Domain 2 (professional and ethical practitioner)
(3) refer patient to RO *relates to Domain 2 (professional and ethical practitioner)
(4) report incident to RO and relevant staff (i.e., RTs involved in direct care and senior RT) *relates to Domain 3 (communicator and collaborator)
A Rad Onc gives you telephone instructions to treat a patient but consents have not been completed and although everything is good, the paperwork is not. What can you do, the patient has arrive.
(1) recognise consent has not been completed and do not treat *relates to Domain 2 (professional and ethical practitioner)
(2) inform RO that we are unable to treat patient without consent due to departmental procedures/protocols
- RO could be unaware consent has not been completed
- If RO is aware, inform the RO that departmental procedures/protocols will not allow us to treat the patient without the consent but that you can relay the request to the senior RT to come up with a solution that ensures the patient is treated as soon as possible *relates to Domain 3 (communicator and collaborator)
(3) relay the information to the senior RT and relevant staff, and secure the next CT appointment which coincides with the RO
- consider when the RO is returning to the facility
- consider whether the RO is at another facility and whether the patient can be transported there for consents and CT
(4) inform patient that we are unable to treat without the RO present *relates to Domain 3 (communicator and collaborator)
A child (person < 18 years of age) arrives for his first day of treatment, but does not wish to radiation therapy treatment. Their parents demand you to treat him.
(1) recognise the child has refused treatment and do not treat *relates to Domain 2 (professional and ethical practitioner)
(2) explore reason for refusal *relates to Domain 3 (communicator and collaborator)
(3) assess patient’s capacity to refuse treatment (i.e., Gillick-competent) A parent’s right to consent to treatment on their child’s behalf is not absolute. A child is Gillick-competent is they have achieved sufficient understanding, intelligence and maturity to fully understand the nature of the proposed treatment, alternatives to treatment and risks/consequences of proposed and alternative treatment options, including no treatment. *relates to Domain 1 (medical radiation practitioner)
- if patient is Gillick-competent… *relates to Domain 2 + Domain 3
- if patient is not Gillick-competent… *relates to Domain 2 + Domain 3
(4) report incident to RO and relevant staff (i.e., RTs involved in direct care and senior RT) *relates to Domain 3
One of your patients is receiving breast irradiation with a standard dose prescription of 50 Gy in 25 fractions. After one week of treatment, she presents with severe erythema, similar to what you might expect for someone who has received 25 fractions. The reaction is within the radiation field and looks like an acute radiation reaction. Discuss actions you should take.
(1) recognise abnormal severity and onset of skin reaction and do not treat until reason for skin reaction is found *relates to Domain 1 (medical radiation practitioner)
(2) ask patient whether and when they first noticed the skin reaction to determine duration and physical symptoms
(3) ask patient how they have been caring for their skin since starting treatment and whether they have changed their skin care recently - reaction could be due to change in product or inappropriate care *relates to Domain 1 (medical radiation practitioner)
- ask patient which products she has been recommend/prescribed - reaction could be due to allergy/hypersensitivity to product
- ask patient whether and how she has been using the recommended/prescribed products - reaction could be due to no or inappropriate use of product
(4) consider patient factors, pre-existing conditions, chemotherapy or other agents which could have exacerbated skin reaction
- consider patient factors (i.e., allergy, older age (increased presence of skin folds), chronic sun exposure or previous treatment to same area)
- consider pre-existing conditions (i.e., connective tissue disorder or radiosensitivity disorder)
- consider chemotherapy (i.e., dermatitis)
- consider other agents which should have been ceased prior to treatment (i.e., ADT, immunotherapy, CDK inhibitors, or complementary and alternative medicines)
(5) report incident to nurses and refer patient to nurses - to recommend alternative product/s or refer to RO to prescribe alternative product/s or antibiotics, re-enforce importance of skin care and instructions for skin care, suggest additional support and monitoring of skin reaction (i.e., daily nursing before and after treatment and weekly treatment review with RO) *relates to Domain 3 (communicator and collaborator)
(6) report incident to senior RT - re-check treatment and machine out-put
(7) report incident to physics - determine whether other patients have experienced similar reaction or whether isolated incident
(8) record incident in patient’s chart for continued management purposes
One of your patients attends for treatment and they appear vague, and their condition seems to have deteriorated compared to previous days. Discuss your plan of action?
(1) recognise patient’s condition has deteriorated and do not treat until reason for acute deterioration is found *relates to Domain 1 (medical radiation practitioner)
(2) explore reason for acute deterioration
- ask patient how they are feeling today in comparison to previous days and why they think they are feeling that way
- ask patient whether they are experiencing any side effects, or if it is known that they are experiencing side effects, ask patient if the side effects have gotten worse recently
- if the patient is still vague, ask how they got to treatment to determine if they came with someone who could provide further information about their condition
(3) if not explored, consider factors which could have exacerbated the patient’s condition (i.e., chemotherapy, nausea/vomiting medication such as ondansetron or granisetron which causes QT-prolongation, anxiety medication such as lorazepam, systemic pain relief such as morphine which causes drowsiness)
(4) report patient’s condition to nurses and refer patient to nurses *relates to Domain 3 (communicator and collaborator)
- nurses can monitor condition and perform vital signs/observations for baseline comparison to determine severity of deterioration
- if patient’s condition does not improve or worsens, RO should be notified and can decide to admit patient to hospital for further testing and continued monitoring
(5) report incident to RO and relevant staff (i.e., RTs involved in direct care, senior RT and nurses)
(6) record incident in the patient’s chart
Your patient with lung cancer feels short of breath when they lie down for treatment. You are running late on the machine. What can you do?
(1) recognise that they are experiencing shortness of breath which could impact patient’s safety and accuracy of treatment and do not continue to set-up until it is determined whether the patient can undergo treatment without shortness of breath *relates to Domain 1 (medical radiation practitioner)
(2) explore reason for shortness of breath
- ask the patient if they would like to sit up on the treatment couch to improve breathing (if physical) or alleviate anxiety (if psychosocial)
- consider factors which could have exacerbated shortness of breath to determine if (1) physical due to symptoms of lung cancer, side effects of treatment, adverse reaction to medicine, lung or heart co-morbidity or other condition or if (2) psychosocial due to anxiety *relates to Domain 1 (medical radiation practitioner) + Domain 2 (professional and ethical practitioner)
- ask patient if it is normal for them to feel short of breath when they lie down to determine if it is an existing or new condition - if it is a new condition, refer the patient to the nurse and RO
(3) - inform patient of risks/consequences of non-compliance and explain to patient we do not want to force him to lie down and be treated when he is short of breath, especially where, if he were to cough or sit up suddenly during treatment it could jeopardise his safety and the accuracy of treatment
- ask the patient if he would like to see the nurses to give him some more time to regain his breath, drink some water and come up with some strategies for shortness of breath before treatment or whether he feels that he can lie down without shortness of breath for the duration of the set-up and the treatment
(3a) if yes, report incident to nurses and refer to nurses - nurses can take vital signs/observations for baseline comparison and monitor condition - if condition does not improve or worsens, nurses can refer patient to RO who can decide to admit patient (i.e., for oxygen, monitoring or further radiology/lung function testing) *relates to Domain 3 (communicator and collaborator)
(3b) if no, and i patient is able to lie down after having the short time to regain his breath and drink some water, i would continue with the patient-set up - if no issues, i would let the patient know we can see/hear them outside of the room and to signal if needed - i would monitor patient from outside of room when delivering treatment - i would check how the patient felt after treatment was delivered and if any concerns refer to nurses as a precaution *relates to Domain 5 (radiation safety and risk manager)
(4) report incident to relevant staff (i.e., RTs involved in direct care and senior RT) and record incident in patient’s chart
(5) if possible, apologise and inform and next patient machine is running late and notify administration team to inform the following patients upon check-in, and thank the patients for their patience when they present for treatment
Your patient with brain mets receiving WBRT says the shell/mask is not fitting even though it was perfect last week. What can the problem be and what is the solution?
(1) incorrect patient - re-check patient identification (full name, DOB and address) *relates to Domain 5 (radiation safety and risk manager) to protect and enhance patient safety; enabling components require me to follow patient identification procedures to confirm correct patient, treatment and site
(2) incorrect equipment or indexing of equipment - re-check equipment and indexing of equipment
(3) radiation-induced side effects of acute oedema (swelling) in the treatment area
- remove 1-2 shims
- cut portion of shell at advice of RO
- re-scan, re-plan and re-treat at advice of RO
- refer to nurses/RO for pharmaceutical management (i.e., steroid to reduce oedema and any associated side effects) *relates to Domain 1 (medical radiation practitioner) + Domain 4 (evidence-informed practitioner) + Domain 3 (communicator and collaborator)
An angry patient swears at you and tells you that you are “ F.. Stupid”. How do you react to this?
Your patient with metastatic Cervix cancer tells the staff, and everyone that cares to listen that you are incompetent because you did not change her treatment time when she demanded it. Do you have options?
Your patient’s wife is furious because you won’t change the patient’s appointment schedule for the next day - she has a golf game, and she simply cannot miss it.
Mrs Smith wants to have treatment at a time that suits her, but it is not possible because there are hundreds of patients who also want their appointments when it suits them and it wont work. She is a friend of the Minister of Health and threatens you with dismissal. What can you do?
(1) understand the patient (i.e., normal patient in abnormal situation or abnormal patient in abnormal situation)
(2) understand the illness (i.e., prognosis, symptoms, side effects)
(3) understand the emotion (i.e., fear, anxiety or worry, absolute, irresponsible or mis-directed denial and shock, anger, sadness or depression)
(4) understand the context (i.e., age, gender, race/ethnicity, religion, socio-economic status, education level)
(5) build a bridge to care (i.e., communicate, be respectful, be professional, be empathetic and set boundaries)
- display appropriate behaviour when communicating
- remain calm and listen to what the patient has to say about the situation and validate what they are saying by stating “i understand that you are feeling frustrated” to remain respectful and empathetic
- although not my fault, i would apologise to the patient by stating “i understand that this could cause you to feel frustrated” to remain professional, and continue this with reasoning “but unfortunately the treatment schedules have been finalised and there are no patients at that time that can swap with you due to conflicting concurrent treatment, specialist appointment or work/family commitments” - reassure the patient that you will try your best to accomodate their appointment change in future
- if the patient continued to be aggressive or became more aggressive, i would set boundaries by stating “i have listened to what you have to say about the situation but i will not tolerate abusive behaviour such as swearing or threatening” and that if they continue i will take further action - i would re-direct their anger by suggesting they complete a feedback/complaint form or speak to the senior RT
- i would report the incident to the senior RT and site manager if required and record the incident in the patient’s chart
Your patient with advanced melanoma says that she is afraid of dying. What can you say or do?
(1) recognise that the patient has acknowledged that they are going to die and want to talk to someone about dying and their fears around dying
(2) validate what the patient is saying by acknowledging that it is normal to be afraid of dying but that you and the MDT are here to talk and help her through this difficult time
(3) explore the patient’s fears around dying and understand the the patient may express emotions of sadness or anger when speaking further about dying
- ask the patient what about dying makes them fearful to determine if her fear is (1) physical, (2) emotional or (3) spiritual
- ask the patient how long she has been feeling this way
- ask the patient if she spoken to anyone else about dying and her fears about dying
(4) encourage the patient to seek the appropriate physical, emotional or spiritual support by acknowledging although it may be difficult to talk about dying and your fears, it may help to talk to a counsellor/psychologist or even a friend/family member
(5) report the incident to the nurse/RO and refer the patient to the nurse/RO for a referral to counsellor/psychologist or other supports
(6) actively monitor the patient’s use of support services and her mental health as she comes for treatment each day
*relates to Domain 3 (communicator and collaborator)
Your favourite patient attends palliative radiation and brings you a gift every other day. It started with a small flower as a gift, but today it’ s a bottle of expensive whiskey. Should you share it?
(1) recognise that repetitive and expensive gift-giving is inappropriate and do not accept the gift
- understand person, illness, emotion and context to build a bridge (i.e., bargaining)
- inform the patient that although it was a lovely gesture that departmental procedure and protocol will not allow you to accept a gift of such monetary value
- encourage patient to enjoy their own gift
- understand patient may feel embarrassed, angry or upset that you did not accept the gift
(2) if patient insists or continues in the coming days, explore reason for gift-giving and set boundaries
- ask patient why they feel the need to bring you gifts - this could determine if the gift-giving is inappropriate or seeking something in return
- if reason is inappropriate, inform patient that repetitive and expensive gift-giving is making you feel uncomfortable and to please stop bring you gifts - inform the patient if he continues to bring you gifts after telling him this that you will take further action (i.e., report behaviour and no longer be able to treat him)
(3) report incident to senior RT and site manager and record incident in the patient’s chart if required (i.e., if the patient became aggressive)
*relates to Domain 2 (professional and ethical practitioner) to provide each patient with dignity and care + Domain 3 (communicator and collaborator)
A patient tells you that another patient has been discussing complementary therapies while in the waiting room, and that they have said they will come for treatment but will not tell the doctor or RT about the complementary medicine. This patient then tries to sell their complementary medicines to other patients in the waiting room (e.g., radium weed). Discuss your plan of action.
(1) thank patient 1 for notifying you and reassure patient that it is not appropriate patient behaviour nor is it accepted in waiting room
- inform patient that failure to disclose CAM to RO has risks/consequences if CAM interferes with treatment or other recommended/prescribed medicines
- ask patient if it made them feel a certain way (i.e., uncomfortable, violated or doubtful)
- reassure patient they are receiving high-quality treatment and action will be taken to ensure they feel comfortable and safe in waiting room
- refer patient to RO if required
(2) pull patient 2 aside and inform patient it has been brought to your attention he is selling CAM in the wait room
- ensure patient understands departmental procedures and protocols do not tolerate selling CAM in wait room or in/around department
- ensure patient understands discussing other patient’s cancer and treatment in wait room in this way is a breach of privacy/confidentiality and makes other patients feel uncomfortable, violated and doubtful affecting their treatment experience
- ensure patient understands if he continues behaviour and tries to sell CAM after your conversation, further action will be taken and it will be reported to RO and site manager
(3) report incident to senior RT, RO and relevant staff (i.e., admin, nurses, RTs to monitor wait room interactions with other patients) and record incident in patient’s chart
(4) refer patient to nurse/RO to disclose CAM and discuss risks/consequences
*relates to Domain 3 (communicator and collaborator)
The departmental policy clearly states that all patients who attend radiation should wear shoes, but Mr Jones refuses to do so. What are your options?
Your least favourite patient Bob with prostate cancer, attends the treatment without clothes, only his gown and he does not mind exposing himself to the staff and unsuspecting patients. What can you do?
(1) pull patient aside and inform patient departmental procedures and protocols require all patients to wear shoes/socks
(2) explore reason for refusal to wear shoes/socks
- consider patient may have lost or does not have shoes/socks or patient may require assistance to dress shoes/socks - inform family/carer or nurses for assistance if required
- ensure patient understands function of shoes/socks is to prevent falls and maintain hygiene
- ensure patient understands shoes/socks and departmental procedures and protocols are for his safety and to minimise risk of incidents which have occurred in past
- ensure patient understands if, following our conversation, he continues to not wear shoes/socks further action will be taken and it will be reported to RO/site manager
- report incident to senior RT and relevant staff (i.e., admin, RTs and nurses to monitor in wait room) and record incident in patient’s chart
*relates to Domain 3 (communicator and collaborator)
Your 87-year-old patient with mild dementia, says that she is being beaten in the nursing home. What can you do?
(1) explore this further and do not let the patient leave facility without escalating the claim
- ask patient who in nursing home has beaten her
- ask patient if person is here with her today
- if no, ask patient who is here with her today and if you can talk to them (a family member or carer may have more information - it is possible patient has been beaten in another nursing home and has since moved but is unable to remember)
- if yes, ask patient if she will talk to nurse/RO about the issue further to come to a solution so she feels safe at nursing home
(2) report incident to nurse/RO and record incident in patient’s chart
- nurse/RO to physically examine patient and to refer to social worker
(3) actively monitor progress and patient’s physical/mental health
