Scenario Example :  The Terminal Care Pathway

 Setting : Elderly Medicine Ward

 The following information will be provided in clerking notes:

 95 yr old female – Mrs Smith

 Past Medical History:

 Known CCF, DM, CKD, HTN, PVD, IHD, OA and poor mobility, memory impairment.

 Social History:

 Nursing home resident.

 Functional status:

 Hoisted to wheel chair. Incontinent of urine. Needs help washing and dressing. Pleasantly confused. Frail.

 History of presenting complaint:

 Admitted 8 days ago with severe community acquired pneumonia, type 1 respiratory failure and sepsis with acute kidney injury. Given IVABx, IVI, O2 therapy for 48 hours but little improvement and remained drowsy (GCS 10)...MAU decision was LCP. Family agreeable at the time. Her daughter has been by Mrs Smith’s bed side every day since admission.

Scenario Details

 This case explores the challenges in communication that can arise when a patient is started on the LCP and has a slower than anticipated deterioration. Relatives often find this time very difficult emotionally and difficult ethical dilemmas regarding nutrition and hydration etc may arise.

Equipment

LCP document

MAU clerking and old obs chart old abg/bloods

Drug card - with LCP meds

CXR

ECG

Tissues

 Mannequin Settings / Signs

Cool peripherally dry mucus membranes and reduced skin turgor

 NB – no recent obs on obs chart as patient on LCP.

If asked the nurse will do a set of observations as follows:

 RR 24 .

HR 95 

BP 90/50

Sa02 90% on nasal cannula

Temp 36.5

 Examination findings:

 breathing sounds ‘rattly’

Chest - bilateral crackles to mid zones

Legs - bilateral leg oedema

Abdo SNT

GCS-E:2 M:4 V:2

 Instructions for Trainee

 You have just come back from a week on annual leave. You are doing a ward round.One of your new patients is 95 yr old Mrs Smith. She was admitted 8 days ago with pneumonia and type 1 respiratory failure. She failed to respond to treatment and due to multiple co morbidities, it was decided after discussion with family to start her on the LCP 6 days ago.

 The nurse has asked you to consider prescribing a syringe driver when you see Mrs Smith as she sounds quite ‘ruttly’ despite being given “PRN medications”

 Please review Mrs Smith as you would normally on your regular ward round

 The daughter also has some concerns, please address these as you feel is appropriate.

 Information for Debriefer

  Trainee should briefly assess clinical condition of patient without causing distress or discomfort, maintaining dignity.

·            Trainee should listen to relatives concerns, picking up on cues and offering empathy.

·           Trainee should display effective communication skills in discussing sensitive issue of end of life care offering reassurance when appropriate.

·          Trainee should agree on sensible course of action with daughters support.

 Information for SP

 Overview of case:

 This case raises the difficult communication challenges that may arise when a patient has been put on the care of the dying pathway – and anticipated to pass away in 24-48 hours, but then does not deteriorate as predicted, sometimes 3 or 4 days can pass, sometimes longer, and the patients’ clinical condition may plateau but there is no significant improvement. At this stage the family may start to doubt if the correct decision about starting the LCP was made initially. In particular, they may feel anxious and confused at this stage, and concerned that too much time has passed and their family member is now being deprived of fluid (as no drip up) or nutrition (too drowsy to eat) – and that this may be causing their loved one distress. They can often perceive it as their loved one ‘fighting’ to stay alive and can express feelings of guilt that despite them ‘hanging on’ treatment has been withdrawn.

 The doctors’ role should be to assess each case on an individual basis and review the patients’ clinical condition. If there are no significant objective signs of improvement and the clinical opinion is still that the patient is in their end stages of life then this should be communicated effectively and sensitively to the relative.

 Background of Case

 You are an only child and live in Sheffield with your husband and two children and visit your Mum every 3-4 weeks. You work as a primary school teacher.

 Your mother’s illness

Your mum was living independently until 18 months ago, when following 2 falls (due to bad arthritis), she was unsafe to live on her own.

 Initially she moved in to residential care but then needed nursing care due to worsening mobility and breathlessness (you think she lost her confidence following the falls and was scared to mobilise but also you felt she had ‘given up’).

 A few months ago she was transferring with help of two nurses into a wheel chair but over the last 6 weeks there have been many days when she has often been reluctant to out of bed at all.

 She has outlived all her friends and often said she has had a good life …she still has a reasonable appetite but you have noticed she is a lot weaker than 6 months ago.

 You don’t think she is depressed, but she has always been quite pragmatic (she is a retired head mistress) and used to say to you that when she was not able to look after herself that was the time she should go.

 Your dad died 30 yrs ago and mum has always been used to her independence.

 Your feelings / perceptions / concerns

If trainee builds good rapport and offers a lot of empathy then volunteer the following information:

 You feel guilty you couldn't care for your mum at your own home, but the house is not big enough to have her move in. Also as a working mum you didn’t think you would be able to manage her care properly. Your Mum also said she would never want to be a ‘burden’. You wish you had tried to convince her to live with you and you could have converted study into a bedroom for her.

 You have been with your mum over 12 hours a day whilst she has been in hospital, you don't want her to dye on her own, you missed your dad passing away because it all happened very quickly (he had a brain haemorrhage) and you lived 2 hours drive away.

 You feel exhausted right now but don't want to leave your mum. You are feeling very anxious that things haven’t changed over last few days and that your mum is suffering and not getting any treatment.

 You are worried that the wrong decision has been made about withdrawing treatment. You had not envisaged that she would still be here 6 days after withdrawing treatment. You are finding it really hard to see her like this every day. You do not think she is in pain, she seems to have been asleep most of the time, her breathing is quite noisy and the medications the nurses give seem only to help transiently.

 Compared to 6 days ago, your mum is more drowsy and her breathing is more shallow if anything.

 You are on your own as your husband is at home looking after children. His parents both died when he was young. Your Aunty lives in Oz and didn't think she would get back in time but now is thinking of booking a flight back to Uk.

 Your questions are:

 Is it normal that your mum has been on the LCP for 6 days now with little change in condition?

 Was it the right decision that the ‘pathway’ was started in the first place? You are beginning to have doubts…. Do you think she should be given another trial of treatment incase she responds better this time?

 Your Mum hasn't had anything to eat or drink for days now, won't she feel hungry /thirsty? Shouldn’t she at least have a drip?

 Progression of Scenario:

 If trainee communicates well, allow yourself to be reassured - if they sound unsure or do not adequately address your concerns then become more upset and demand to speak to the consultant.

 You believe that deep down, this is what she would have wanted - she would not have wanted a fuss, or to be kept alive to live in a nursing home dependant on others.

 Ultimately, the doctor should recognise that Mrs Smith is still in the end stages of life and it is appropriate to continue the LCP with a syringe driver to control symptoms. If the doctor is in doubt they should discuss with the consultant.

 Learning Outcomes

After participating in this scenario you should be able to:

Effectively assess patients on the Liverpool Care Pathway and make appropriate decisions regarding continued suitability for LCP

 Effectively and sensitively communicate with relatives issues relating to end of life care and LCP

Example of Curriculum Mapping:

Geriatric Curriculum Items Covered in this Scenario:

1,2,5,6,7,12,13,17,27,28,29,37,44 See appendix for details.

GIM Curriculum items : Includes items up to no.17 outlined above as common competencies. Also:

·       Breathlessness

·       Management of Patients requiring Palliative and End of Life Care

 Appendix : Geriatric Curriculum 2010 (see www.jrctb.org.uk)

 Common Competencies

1.History Taking

To progressively develop the ability to obtain a relevant focussed history from increasingly complex patients and challenging circumstances

To record accurately and synthesise history with clinical examination and formulation of management plan according to likely clinical evolution

 2.Clinical Examination

To progressively develop the ability to perform focussed and accurate clinical examination in increasingly complex patients and challenging circumstances

To relate physical findings to history in order to establish diagnosis and formulate a management plan

 3.Therapeutics and Safe Prescribing

To progressively develop your ability to prescribe, review and monitor appropriate medication relevant to clinical practice including therapeutic and preventative indications

 4.Time Management and Decision Making

To become increasingly able to prioritise and organise clinical and clerical duties in order to optimise patient care

To become increasingly able to make appropriate clinical and clerical decisions in order to optimise the effectiveness of the clinical team resource

 5. Decision Making and Clinical Reasoning

To progressively develop the ability to formulate a diagnostic and therapeutic plan for a patient according to the clinical information available

To progressively develop the ability to prioritise the diagnostic and therapeutic plan To be able to communicate the diagnostic and therapeutic plan appropriately

 6. The Patient as Central focus of care

To be able to prioritise the patient’s wishes encompassing their beliefs, concerns expectations and needs

7. Prioritisation of Patient Safety in Clinical Practice

To understand that patient safety depends on the organisation of care and health care staff working well together

To never compromise patient safety

To understand the risks of treatments and to discuss these honestly and openly with patients so that patients are able to make decisions about risks

To ensure that all staff are aware of risks and work together to minimise risk

9.Principles of Quality and Safety Improvement

To recognise the desirability of monitoring performance, learning from mistakes and adopting no blame culture in order to ensure high standards of care and optimise patient safety

12.Relationships with Patients and Communication within a consultation

To communicate effectively and sensitively with patients, relatives and carers

13. Breaking Bad News

To recognise the fundamental importance of breaking bad news. To develop strategies for skilled delivery of bad news according to the needs of individual patients and their relatives / carers

 14. Complaints and Medical Error

To know how to respond appropriately to complaints and medical errors

 17. Principles of medical ethics and confidentiality

To know, understand and apply appropriately the principles, guidance and laws regarding medical ethics and confidentiality

19. Legal Framework for Practice

To understand the legal framework within which healthcare is provided in the UK in order to ensure that personal clinical practice is always provided in line with this legal framework

 21. Evidence and Guidelines

To progressively develop the ability to make the optimal use of current best evidence in making decisions about the care of patients

To progressively develop the ability to construct evidence based guidelines in relation to medical practise

27. Comprehensive Geriatric Assessment

To be able to perform a comprehensive geriatric assessment (CGA)

 28. Diagnosis and Management of Acute Illness

To be able to diagnose and manage acute illness in older patients in a variety of settings

 29. Diagnosis and Management of Chronic Disease and Disability

To be able to diagnose and manage chronic disease and disability in older patients in both hospital and community settings

To understand the process in which health beliefs, socio-economic circumstances and culture impact on health, and vice-versa

To understand that as doctors we have the opportunity and ability to address inequalities in healthcare

 32. Delirium

To be able to recognise, diagnose and manage a state of delirium presenting both acutely or sub-acutely in patients in hospital, in the community and in other settings

33. Dementia

To be able to assess and manage patients who present with dementia and also to assess and manage patients with dementia who present with other illnesses in acute and intermediate care

37. Nutrition

To know how to assess the nutritional status of older people in different care settings and in conjunction with other relevant health professionals be able to devise an appropriate nutritional support strategy for patients

44. Palliative Care

To have the knowledge and skills required to assess and manage patients with life-limiting diseases (malignant and non-malignant) across all health care settings, in conjunction with other health care professionals

49. Dementia and Psychogeriatric Services

To be able to assess and manage patients who present acutely with cognitive impairment
To be able to assess and manage patients who present non-acutely with cognitive impairment

To be able to assess and manage patients who present with cognitive impairment incidental to other co-morbidities

To be able to assess and manage patients who present with pre-existing intellectual disability presenting with cognitive decline

Some reflective feedback quotes:

"Certainly very realistic"

 "Can identify barriers to communication more effectively"

"The Scenarios were very realistic! The mix of a clinical situation with communications skills made multi tasking necessary which was good"

-         "The simulation settings were very realistic and well thought through.  Having the simulated patient present brought the scenarios into context and set the scene for realistic experiential learning. "

        "Extremely useful day bringing focus to a neglected area of curriculum. Very well planned and thought through training day and would propose is repeated annually."

        "These scenarios are ones we commonly encounter in real life but with minimal observation – this allowed for constructive feedback on performance.'         

       ' The scenario allowed us to appreciate the more subtle but important intangible aspects of communication that can not easily be taught or identified from reading text books or didactic teaching methods"

       " HPS was able to bring the emotional component to life within the scenario and due to this a lot of non verbal communication skills became apparent ...bending down to patient level etc."

      "The simulation was very useful formatively for the person doing it as well as for facilitating reflective and assimilation of learning for the spectators and person participating afterwards"

 "Practicing dealing with angry patients – learned some techniques to use to diffuse the situation"

'In future I will try to follow the patients / relatives agenda more than my own'

"Helpful to see how different specialties approach the same problem from different view points with differing actions'

 Suggestions for Improvement:

-       "More knowledge base improvement – short lecture on the facts of the case scenarios just performed eg opiate toxicity, PEG feeding in dementia to reinforce the facts and learning points as well as the key communication skills."

        "Expand this further into more scenarios in end of life situations"

        " More conversation / interaction with patient"