Advance Directives Scenario 1 – Patient
Goals:
1. Develop skills in using a recent health event/death of family member to introduce the topic of establishing advance directives
2. Develop skills at clarifying a patient’s understanding of his or her prognosis in discussions of advance directives
Setting: outpatient clinic
Patient: Mrs. (or Mr.) Jenkins
You are a 75yo retired textile worker from rural North Carolina. You have smoked your entire life but quit 2 years ago when your brother died of lung cancer. You remember his death as a very trying event, because he was on a ventilator for several days and seemed to suffer unduly at the end of his life. In addition, his children argued for several days about withdrawing life support. In the end, he died of complications of medical procedure and pneumonia.
You have recently (two weeks ago) been hospitalized for several days with a flare of emphysema and required oxygen, nebulizers, steroids and antibiotics to improve your condition. At this point, your breathing has improved and you have just a few days left on your steroids. However, you are still quite weak from the hospitalization and have relied on your spouse to do most of the household tasks since discharge. You haven’t even really been able to enjoy the company of your grandchildren (ages 4 and 7) as you used to.
You are in the office today for follow-up with your primary care physician, Dr. Robinson. She knows all the details of your hospitalization. You expect her to listen to your lungs, write prescriptions, and check blood work.
Advance Directives Scenario 1 – Provider
Goals:
1. Develop skills in using a recent health event/death of family member to introduce the topic of establishing advance directives
2. Develop skills at clarifying a patient’s understanding of his or her prognosis in discussions of advance directives
Setting: outpatient clinic
Provider: Dr. Robinson
Mrs. (Mr.) Jenkins is returning to see you today. The patient is 75 yrs old and has a history of COPD with an FEV1 of 1.05 L. She has been largely asymptomatic until the last 12 months, over which time she has required several rounds of steroid tapers and antibiotics for bronchitic symptoms and wheezing. She is not yet requiring home oxygen, but you anticipate that the need will arise soon. She was hospitalized for the first time two weeks ago with a particularly severe flare. The hospitalist who cared for her commented on the severity of her disease and the fact that she was very weak on discharge. He also inquired about her advance directives. When asked on admission, she was not aware of having completed a living will or designated a health care power of attorney.
You have expanded Mrs. Jenkins appointment time to 30 minutes (from 20 min.) to include a discussion of advance directives. At this point, you have taken a brief history, examined her and have recommended a program in pulmonary rehabilitation. You are now ready to bring up the issue of advance directives. She is alone in the office today.
Advance Directives Scenario 2 – Patient
Goals:
1. Develop skills in discussing prognosis with family member of a patient who is seriously ill and unable to participate in conversations
2. Develop skills in resolving a “conflict” between a family member and the care team on whether to withdraw support
Setting: Medical intensive care unit.
Patient: Mr. Jenkins (You are his daughter (son), Mrs. (Mr.) Simmons)
Your father is an 80-year old gentleman with diabetes and heart disease. He is now suffering from pneumonia and congestive heart failure. Infection has complicated his course and he is now on a respirator in the medical intensive care unit. He is on medications to maintain his blood pressure. Originally, he agreed to the respirator for a “trial of aggressive therapy.” He has no living will but he had indicated “Please do what you think is best. I don’t want to be a vegetable.” You are his only living relative, have taken care of him in the past, and have seen him bounce back from serious illness after his bypass surgery 10 years ago. He has been limited in his ability to perform even mild physical activities but before hospitalization had made some improvements with home PT. You want the care team to continue aggressive measures but you also want what is best for your father. Your mother died of cancer 5 years ago and was cared for by Dr. Small, who did everything he could. She died in the intensive care unit, though, and it was not a pleasant experience. This had been a very difficult time for your father. You feel confused and isolated.
Provider: Dr. Evers. (Attending Physician in the Intensive Care Unit.)
Advance Directives Scenario 2 – Provider
Goals:
1. Develop skills in discussing prognosis with family member of a patient who is seriously ill and unable to participate in conversations
2. Develop skills in resolving a “conflict” between a family member and the care team on whether to withdraw support
Setting: Medical intensive care unit.
Patient: Dr. Evers (Attending Physician in the Intensive Care Unit)
Mr. Jenkins is an 80yoM with diabetes and coronary artery disease. He is now suffering from pneumonia and congestive heart failure. Gram negative septicemia has complicated his course and his is now intubated and on pressors in the medical intensive care unit. He has now been in the ICU for 5 days and is not showing any signs of improving. After an episode of prolonged hypotension, he is also suffering from renal insufficiency and, neurologically, is not responding to spoken commands. You have been rotating on the unit for 2 days. You read in the chart that he originally agreed to the ventilator for a “trial of aggressive therapy.” He has no living will or health care power of attorney, but his daughter (Ms. Simmons), his only living relative, ahs been keeping vigil alone in the waiting room. You have not met her, but understand that she is “difficult.” At this point, she wants “everything done.” Others on the team feel that she has unrealistic expectations and that the time has come to withdraw support. You agree that his prognosis is very poor. You have scheduled a meeting with the daughter to discuss her father’s current condition and to establish a plan for either continuing all aggressive measures (now possibly including dialysis) or writing a DNR and setting a time table for taking him off the ventilator.
Advance Directives Scenario 3 – Patient
Goals:
1. Develop skills in discussing advance directives with an otherwise healthy elderly person
2. Demonstrate ability to assist patient in deferred decision making with respect to advance directives
Setting: outpatient clinic
Patient: Mrs. (or Mr.) Oldham
You are a 79 year old woman with only very mild knee arthritis. You take an occasional Tylenol, but otherwise take no medications. You attend church twice a week, sing in the choir, attend a water aerobics class weekly, and pride yourself on your independence. Your husband died of a heart attack 12 years ago and you have been living alone since. You have many older friends, most of whom are widowed women. You have tow children (sons) who both live in a city about 2 hours away. One of them is married and has two children, whom you see about once a month. In general, you are content. You have a number of friends who suffer from chronic illness and a few who now have dementia and live in nursing homes. Your biggest fear is that you will develop Alzheimer’s disease and suffer the same fate, but you have never shared this with anyone. You hope that you are able to think clearly and remain physically active until the day you die. As far as you know, you are seeing Dr. Price for a routine visit today. You expect to have a brief exam and will remind him that you need your mammogram.
Provider: Dr. Price
Advance Directives Scenario 3 – Provider
Goals:
1. Develop skills in discussing advance directives with an otherwise healthy elderly person
2. Demonstrate ability to assist patient in deferred decision making with respect to advance directives
Setting: Outpatient clinic
Provider: Dr. Price
Mrs. Oldham is a very healthy almost 80 year old woman with osteoarthritis and a history of mild obesity. She is coming today for a routine visit. You have recently attended a conference on End of Life Care and have resolved to encourage all of you older patients to consider establishing advance directives. Although she is healthy, you think Mrs. Oldham needs to consider having a living will and you seem to remember that she has children who live locally. You plan to bring the subject up at the end of the visit.