Chapter 6 The Therapeutic Approach to the Patient with a Life-threatening Illness

Life-threatening Illness Cultural perspective on life-threatening illness How you live, think, speak, and behave Viewed differently by different cultures Family strongest influence Work with family and belief system

Choices in Life-threatening Illness Urgency of decisions depend on possible life expectancy Patients have right to choose or refuse treatment Palliative care focuses on quality of life, relieving symptoms of pain and suffering

Choices in Life-threatening Illness VSED (voluntarily stop eating and drinking) Total sedation; medication causes unconsciousness and eventually death In a few states, option to seek aid in dying

Choices in Life-threatening Illness Issues appropriate to discuss with patients facing life-threatening illnesses: Alternative methods of treatment Pain management and treatment Loss of self image and independence Legal protection Durable power of attorney for health care or health care proxy Health care directives Patient Self-Determination Act

Choices in Life-threatening Illness Issues appropriate to discuss with patients facing life-threatening illnesses: Finances; insurance coverage Emotional needs of patient and family Life-threatening illnesses are family illnesses Primary patients (the one with the illness) Secondary patients (family and friends of patient) Helping patients live their last days is important

The Range of Psychological Suffering Often leads to physical symptoms Help patients understand that relationships change Encourage patients to set goals for themselves Listen carefully and seek clues to nonverbal communication

The Patient with HIV/AIDS Patients will have great stress when diagnosed with HIV or AIDS May have fairly good health for a period or very serious near-death illness Recent developments in treatment of HIV infection and AIDS help patients to live longer Lives greatly compromised because of suppressed immune system

The Patient with HIV/AIDS HIV affects mostly individuals who are relatively young Treating HIV expensive Many patients have little or no insurance coverage

The Patient with HIV/AIDS May experience central nervous system involvement AIDS when patients’ CD4 counts decline to less than 200 Particular type of opportunistic infection or tumor, AIDS-related brain or lung illness, severe body wasting

The Patient with Cancer Patients believe cancer and death equated Choosing treatment complicated and has many facets Treatments are surgery, radiation, chemotherapy or combination

The Patient with Cancer Patients can experience serious side effects from both radiation and chemotherapy Even when there is “nothing more to do” related to the cancer, there is still “much to do” to maintain comfort

The Patient with ESRD Loss of kidney (renal) function leads to end-stage renal disease (ESRD) Patients cannot live long unless they receive dialysis or kidney transplant Dialysis is filtering blood to remove wastes and can sustain life for years Some patients will opt not to have dialysis and to let death come from kidney failure

The Stages of Grief Dr. Elisabeth Kübler-Ross determined stages of grief Denial Anger Bargaining Depression Acceptance

The Stages of Grief Not all patients go through all five stages Some patients go through all five stages over and over again, each time with a little less stress; others get stuck in one stage No two patients follow the same pattern Family members also suffer grief and are often in different stages

The Stages of Grief The acronym TEAR To accept the reality of the loss Experience the pain of the loss Adjust to what was lost Reinvest in a new reality

The Challenge for the Medical Assistant Be sensitive and respectful Must be comfortable treating all patients Nonmedical forms of assistance Referrals to community-based organizations Recommend support systems Spiritual support