Lecturer Psychiatry, Mansoura Faculty of Medicine Case scenarios BY Ibtihal M.A. Ibrahim Lecturer Psychiatry, Mansoura Faculty of Medicine

Case Number 1

Mrs. A is a previously healthy 50-year-old school teacher who initially presented a seizure. A CT scan showed an enhancing mass and she was referred to a neurosurgeon for a biopsy. Mrs. A’s biopsy showed a high-grade glioblastoma multiforme and she has now returned for follow-up accompanied by her husband.

1. How should a clinician prepare to break bad news to the patient and her family? 2. How can we help the patient or her family to determine the goals of care?

Mrs. A’s glioblastoma was treated with surgical resection and a course of radiation therapy. She went home and comes in for a routine follow-up visit. She would like to return to work as a teacher and get back to normal. You realize the value of discussing the goals of care while she is feeling well, but are not sure how to start. Several months later, Mrs. A has become increasingly tired and has lost 20 pounds. She subsequently has a seizure and is admitted to the hospital. A head CT shows tumor recurrence. Her oncologist believes her current performance status makes her a poor candidate for further disease-modifying therapy. You agree that her prognosis is less than 6 months. You visit her in the hospital to discuss next steps.

At the end of your conversation, Mrs At the end of your conversation, Mrs. A’s husband asks, “How long do you think she has to live?” How do you answer him? Mrs. A is being cared for at home. However, in the last several days, she has become increasingly agitated. Because of concern that this was due to increasing edema around her tumor, the dexamethasone was increased but the agitation continued. Haldol was both added with minimal improvement. After extensive discussion with her family, a decision was made to admit her to inpatient level of care with the treatment goal of tapering of her steroids and symptomatically treating her agitation, with an understanding that she might die during the admission.

What would you do in such case? That night, the covering physician found Mrs. A to be agitated with right-sided hemiparesis and an expressive aphasia. Given her known glioblastoma, an additional 20 mg of IV dexamethasone was given and the patient’s condition began to improve such that she was more alert and less agitated. The next morning, her family appeared and said, “we think that she is dying and we want to take her home to let her die in peace!.” What would you do in such case?

Case Number 2

Mr. M is 55 years old engineer Mr. M is 55 years old engineer. He is married and he has 2 boys and 2 girls. He had diabetes 20 years ago. He developed also hypertension 15 years ago. Several months ago, Mr. M has become increasingly tired. he subsequently began to complain from morning nausea and swelling of both feet. When he consulted his doctor he examined him and told him that he had to do some investigations.

How would you deliver this bad news? His son took the results of the investigation to the doctor who found that Mr. M serum creatinine is 12 How would you deliver this bad news? What is next?

The patient started haemodialysis (3 sessions/ week). Mr. M began to suffer from a lot of complications related to dialysis starting from bleeding from the fistula, hypotension after session and sometimes hypoglycemia

Due to repeated fainting attacks which resulted in fracture of his leg he had to be accompanied by one of his family members whenever he wants to go out He became frustrated, irritable and angry. He gave his family hard time as he refused to go to dialysis sessions and refused also to take his meds.

His family members came to you annoyed from his behavior and attitude His family members came to you annoyed from his behavior and attitude. They felt stressed by his illness (repeated complications) and his uncooperativeness What would you do?