Social

Question 1

Establishing Advanced Care / discussing goals of care?

Answer 1

If the patient has a good understanding of their prognosis:

• I believe that it is a reasonable time to begin discussing Advanced Care with him/her as he/she has a reasonable understanding of his/her prognosis.
• I would focus initially on building rapport in order to gain trust.

If the patient has poor insight into their prognosis:

• Given that patient has relatively limited insight into their prognosis, attempting to discuss Advanced Care too abruptly may have a negative impact.
• For this reason, I would focus initially on building rapport in order to gain trust.
• Then I would focus on improving his insight into his disease and how it can impact on his/her prognosis, in a sensitive manner
• Only once I am confident that he has a reasonable understanding of their prognosis, I would begin goals of care discussion

Then…

This conversation can be emotionally difficult for the patient.

• Build Rapport & gain his trust
• Check with patient who she/he wants to be involved in discussion
• Organise a family meeting
• In a sensitive manner, I’d layout information on the current disease state & prognosis
• I’d like to spend more time to understand his belief & values
• Based on my discussion with the patient, the most important thing for him/her is …… (e.g. QOL, living to son’s 1st school day…etc)
• Therefore I would ensure that this patient’s Advanced care planning is in line with these priorities
• And I would document this so that it is clearly communicated to other healthcare professionals

Question 2

Monitoring & Surveillance for Psychological Impact of Advanced Comorbidities

Answer 2

I am concerned about his/her psychological well-being in the future.

Why is it happening? (Risk factors)

I feel that this patient is at risk because…(describe risk factors)

• Can’t do what they enjoyed the most due to disease
• Progressively losing their independence
• Previous depression
• Social isolation
• Other reasons

Why is this important?

• Reduce self-efficacy
• Impact on adherence to therapy and follow-up
• Increased risk of suboptimal disease control & complications

What am I going to do?

• Screen for depressive symptoms every 3-6 monthly using DSM-5 criteria
• Non-pharm
  
  • Enlist family & friend’s support
  • Encourage healthy lifestyle: ETOH moderation, exercise, good sleep hygiene, balanced diet, mild-body programs (e.g. yoga)
  • Increase social interaction: community groups, support groups
  • Resources: Black dog institute (MH support), Lifeline (crisis support)
  • CBT - medicare subside 10 sessions. Identify, challenge and modify mal-adaptive behaviours
  • Counseling
• Pharm
  
  • Mirtazapine (if under-weight) - improves sleep and appetite (15mg start, max 45mg)
  • SNRI (e.g. Venlafaxine, Duloxetine 20mg) - better for fat people
  • Start low and gradual increase
  • _Monitor for side effect_s
    
    • Sedation, Insomnia, Seizure
    • GI side effects
    • Hyponatremia
    • Sexual dysfunction
    • Anti-cholinergic
    • Prolonged QT

Question 3

Addressing Health Literacy / Lack of Insight

Answer 3

Why is it happening (state risk factors for this patient)

• The complexity of medical issues
• Lack of explanation
• Limited education - “next thing is education. He is educated up to…he should/may have difficulty understanding with only one off explanation. I’d really like to spend some time explaining things clearly…”
• Mood disorders / Cognitive impairment (unlikely in long case) - “There might be an another aspect of his health literacy” - “I’d like to ensure that mood is not a playing a role”
• Lack of taking ownership of their own health

Why is it important (Impact)

• Adherence
• Foster self-efficacy
• Long-term outcome

Plan

• Dedicated session
• Speak slowly in moderate pace
• Prioritise content to discuss - limit to 3
• Repeat & confirm that they understand
  
  • Seek GP & family support
  • Website
  • Community groups
• Written information
• Visual aids
• Encourage patient participation: encourage patient to ask questions - have 2-3 questions ready for next appointment

Question 4

Addressing Compliance/Adherence issues?

Answer 4

Why is it happening? (list risk factors for this patient)

• Patient: busy life (forgets), insight, level of education, lack of belief in the treatment, simply forgets, cannot afford
• Disease: asymptomatic / patient used to symptoms
• Doctor: inadequate follow-up, poor relationship
• Medications: cost, dosing, pill burden, the barrier to obtaining medications, side effects

Why is it important?

• Impact on disease outcome
• Complications

Plan

• Address specific cause for this patient
• General
  
  • Educate
  • Reminders: phone apps, sticky notes, keep the pills where patient goes for breakfast
  • Pillbox, webster pack
  • Generic medications (cost)
  • Rationalise medications
  • Simplify dosing regimes - slow release, once daily

Question 5

Addressing ETOH excess.

Answer 5

Goals:

• Encouraging Abstinence from ETOH / or decrease consumption
• Prevent complications

Cessation of ETOH / or decrease consumption

• Why are they drinking? Address psychosocial factors.
• Manage withdrawals
• Inpatient if high-risk of seizures or DT, otherwise outpatient
• BDZ based on AWS: regular diazepam or oxazepam if there is liver dysfunction​​
• eTG 2016 –> diazepam 20mg q2h max dose 60mg daily for withdrawal symptoms
• Thiamine 300mg TDS IV/IM for 5 - 7 days then 300mg daily thereafter
• FLAGS
  
  • Organise dedicated session
  • Feedback: educate on harms of alcohol, especially if has no insights
  • Listen to their concerns (e.g. are they afraid of withdrawals)
  • Advice on benefits (financial, social, medical)
  • G: set a specific goal
    
    • Avoiding friends who drinks too much
    • Not having ETOH at home
    • Spacing out drinks
  • S: set a Strategy based on what the patient is willing to try.
    
    • Reinforce patient - show belief that he/she can make a change
• Non-pharm
  
  • Involve family for support & psychology involvement
  • Motivational interviewing - to help resolve ambivalence about change
  • CBT: helping them to identify mal-adaptive thought process & encouraging positive adaptive behaviours
  • Mutual help groups such as AA
  • These can also be done via online
• Pharm (1st line = Naltrexone / Acamprosate)
  
  • Naltrexone > acamprosate: one tablet 1/day, more effective, however cannot be used in the advanced liver. Cannot be given to opioid users (since it is opioid antagonist)
    
    • Can be started while drinking
    • Monitor LFTs
  • Acamprosate: TT TDS, less effective, but safe in liver failure. Needs dose adjustment for renal impairment. Contraindicated in renal failure
  • Topiramate

Monitor complications

• History & exam: CCF, CLD, cerebellar dysfunction, PN, WKorsakoff’s, social
• Ix: ECG, LFTs, FBC (BM, macrocytic anaemia)

Question 6

Addressing Smoking

Answer 6

Goals

• Improve awareness of its harms
• Cessation
• Relapse prevention

Dedicated session to offer education & advice

• Feedback on harms of smoking
• Listen to their concerns
• Advice on benefits of quitting - financial & health
• Goal: set a quit date (not smoking less cigarette - ineffective)
• offer Strategies - pharmacological & non-pharmacological

Non-pharmacological

• Enlist the support of family & friends
• ***Warn potential AEs of quitting
  
  • Explain that these are short lasting: weight gain, irritability, depression
• Dealing with craving: _alternative activitie_s, e.g. exercise
• Written information packs: benefits, harm, side effects of quitting
• Address barriers as much as possible: ETOH, friends, social situation, Caffeine
• Refer to QUITLINE or smoking cessation clinic
• Relapse rate is highest in the 1st week (50%) - so I will follow-up weekly for the first 2 weeks (then GP f/u regularly)

Pharmacological

• NRT (14-21mcg/d): angina, arrhythmia, cardiac
• Varenicline (nicotine R partial agonist): abnormal dreams, epilepsy, psych
• Bupropion: Bulimia, Brain issues (insomnia, seizures)

Question 7

Addressing geographic isolation

Answer 7

Why is it happening?

• State patient-specific factors

Why is it important

• Difficulty attending appointments and getting medications
• Challenging emergency care
• Risk for social isolation + mental disorders

Management

• Screen and treat depression & cognitive impairment
• Ensure an Action plan is in place, including contact numbers
• Simplify: pool appointments together
• Home deliver meds
• Make use of Telehealth & skype
• Community transport
• Ensure patient is on eligible support scheme (e.g. NDIS)
• Engage outreach services