PCM-3PCM-3END OF LIFEEND OF LIFE

Session 1Session 1

December 2, 2009December 2, 2009

Session ObjectivesSession Objectives

At the conclusion of this PCM-3 session, At the conclusion of this PCM-3 session, students will be able to students will be able to State and apply the key steps in delivering bad newsState and apply the key steps in delivering bad news Develop an effective oral analgesic regimen Develop an effective oral analgesic regimen Define “Advance Directive” Define “Advance Directive” Begin the process of establishing the overall goals of Begin the process of establishing the overall goals of

care with a patient with a life-limiting illnesscare with a patient with a life-limiting illness Discuss preferences regarding resuscitation with a Discuss preferences regarding resuscitation with a

patientpatient

Session AgendaSession Agenda

Introduction/Case Introduction/Case 9:45- 10:00am9:45- 10:00am

Giving Bad News Giving Bad News 10:00-10:5010:00-10:50

Shelly Lo, MDShelly Lo, MD

Developing an Oral Analgesic Regimen Developing an Oral Analgesic Regimen 10:55-11:3010:55-11:30

Theresa Kristopaitis, MDTheresa Kristopaitis, MD

Goals of Care, Advance Directives Goals of Care, Advance Directives 11:40 – 12:2011:40 – 12:20

John Hardt, PhDJohn Hardt, PhD

DNR Role Play DNR Role Play 12:30-1:1512:30-1:15

Small groupsSmall groups

““End of Life”End of Life”“Death”“Death”

Death is the final Death is the final stage stage of lifeof life

Death is less an event, than a Death is less an event, than a processprocess

Death is a Death is a journeyjourney

Sudden death,unexpected causeSudden death,unexpected cause

l < 10%, MI, accident, etcll < 10%, MI, accident, etc< 10%, MI, accident, etc

Death

Time

Healt

h S

tatu

s

Steady decline, shortterminal phaseSteady decline, shortterminal phase

Slow decline, periodiccrises, sudden deathSlow decline, periodiccrises, sudden death

EPEC

Physician’s Role in Physician’s Role in “Life Limiting Illness”“Life Limiting Illness”

Understand Understand physiologic changesphysiologic changes

Manage symptomsManage symptoms

Honest Honest communicationcommunication

Non-abandonmentNon-abandonment

EducationEducation

Willingess to work Willingess to work with a teamwith a team

CaseCase

HPIHPI 72-year-old woman presents to primary care 72-year-old woman presents to primary care

physician to establish care physician to establish care Chief concern - shortness of breath Chief concern - shortness of breath

progressing for the past monthprogressing for the past month Has intermittent sharp right sided chest pain Has intermittent sharp right sided chest pain

unrelated to activity unrelated to activity Nagging dry cough for the past several Nagging dry cough for the past several

months. months.

CaseCase

PMHxPMHx HTNHTN HyperlipidemiaHyperlipidemia

MedicationsMedications Atenolol 50mg daily Atenolol 50mg daily Simvastatin 40mg daily Simvastatin 40mg daily

Drug allergiesDrug allergies NoneNone

CaseCase

Social HistorySocial History Active smoking, 1ppd x 50 yearsActive smoking, 1ppd x 50 years Drinks 1 glass of wine with dinnerDrinks 1 glass of wine with dinner Retired grade school teacherRetired grade school teacher Divorced x 10 yearsDivorced x 10 years Has 1 daughter Has 1 daughter

Pt recently moved to the area to be closer to her Pt recently moved to the area to be closer to her daughter and 3 month old grand-son. daughter and 3 month old grand-son.

CaseCase

Family hxFamily hx Mother – died age 49 – motor vehicle Mother – died age 49 – motor vehicle

accident, no known chronic medical problemsaccident, no known chronic medical problems Father - died age 62 of MIFather - died age 62 of MI 1 brother – alive and well1 brother – alive and well Son – committed suicide 5 years agoSon – committed suicide 5 years ago

CaseCase

ROSROS General – 10# weight loss over past 2 months General – 10# weight loss over past 2 months

“I guess I was too busy to eat with the move”“I guess I was too busy to eat with the move” Otherwise review of systems negativeOtherwise review of systems negative

CaseCase

Physical ExamPhysical Exam BP 120/72 Pulse 82 RR 12 Temp 98.7BP 120/72 Pulse 82 RR 12 Temp 98.7OOFF She appears thinShe appears thin Pertinent finding of decreased breath sounds Pertinent finding of decreased breath sounds

right upper lung fieldright upper lung field No lymphadenopthyNo lymphadenopthy

Work-upWork-up

CXRCXR Right upper lobe lung massRight upper lobe lung mass

Work-UpWork-Up

CT scan chestCT scan chest 5.7 x 5.2 cm mass in the right upper lobe5.7 x 5.2 cm mass in the right upper lobe Scattered subcentimeter nodules throughout Scattered subcentimeter nodules throughout

both lungsboth lungs Mediastinal and right hilar adenopathyMediastinal and right hilar adenopathy 2.8 x 2.1 cm lesion in the dome of the liver 2.8 x 2.1 cm lesion in the dome of the liver

CT guided biopsy of lung massCT guided biopsy of lung mass

Squamous cell carcinomaSquamous cell carcinoma

She has returned to her doctor’s office to She has returned to her doctor’s office to for the test results/diagnosisfor the test results/diagnosis

Giving “Bad News”Giving “Bad News”

Shelly Lo, MDShelly Lo, MDDepartment of Internal Medicine, Division of Department of Internal Medicine, Division of

Hematology/OncologyHematology/OncologyAssociate Medical Director, Loyola HospiceAssociate Medical Director, Loyola Hospice

Case ContinuedCase Continued

Oncology evaluationOncology evaluation Diagnosis of lung cancer reviewedDiagnosis of lung cancer reviewed Implications of metastatic disease reviewedImplications of metastatic disease reviewed

including Inability to eradicate diseaseincluding Inability to eradicate disease

In light of performance status, pt was In light of performance status, pt was believed to be a candidate for systemic believed to be a candidate for systemic chemotherapy chemotherapy

Pt consents to therapyPt consents to therapy

Case ContinuedCase Continued

• Chest pain getting worseChest pain getting worse

• Constant ache 5-6/10Constant ache 5-6/10Worsens (sharp) with cough, laugh to 10/10Worsens (sharp) with cough, laugh to 10/10

• Prescribed percocet 5/325 Prescribed percocet 5/325 • 1-2 tabs every 6 hours as needed1-2 tabs every 6 hours as needed

Few days laterFew days later

• Epic in-boxEpic in-box• Still having pain. What to do?Still having pain. What to do?

Developing an Effective Developing an Effective Oral Analgesic RegimenOral Analgesic Regimen

Theresa Kristopaitis, MDTheresa Kristopaitis, MDDepartment of Internal Medicine, Division of Department of Internal Medicine, Division of

General MedicineGeneral MedicineAssociate Medical Director, Loyola HospiceAssociate Medical Director, Loyola Hospice

Back to CaseBack to Case6 months later6 months later

Patient’s status declines Patient’s status declines Increased sleepinessIncreased sleepiness Increased shortness of breathIncreased shortness of breath Poor appetitePoor appetite

Daughter finds pt lying on the floor after a Daughter finds pt lying on the floor after a fallfall

Calls 911Calls 911

CaseCase

HospitalizedHospitalized

Inpatient physician believes he/she must Inpatient physician believes he/she must address (review?) goals of care, advance address (review?) goals of care, advance directives and “code status” with the directives and “code status” with the patientpatient

Goals of CareGoals of CareAdvance DirectivesAdvance Directives

John Hardt, PhDJohn Hardt, PhD

Neiswanger Institute for Bioethics and Health Neiswanger Institute for Bioethics and Health Policy at the Stritch School of MedicinePolicy at the Stritch School of Medicine

Loyola University Chicago, Assistant to the Loyola University Chicago, Assistant to the President for Mission and IdentifyPresident for Mission and Identify

DNR Role PlayDNR Role Play

Small groupsSmall groups