1. PCM-3 END OF LIFE Session 1 December 2, 2009

2. Session Objectives At the conclusion of this PCM-3 session, students will be able to State and apply the key steps in delivering bad news State 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 care with a patient with a life-limiting illness Begin the process of establishing the overall goals of care with a patient with a life-limiting illness Discuss preferences regarding resuscitation with a patient Discuss preferences regarding resuscitation with a patient

3. Session Agenda Introduction/Case 9:45- 10:00am Giving Bad News 10:00-10:50 Shelly Lo, MD Shelly Lo, MD Developing an Oral Analgesic Regimen 10:55-11:30 Theresa Kristopaitis, MD Theresa Kristopaitis, MD Goals of Care, Advance Directives 11:40 – 12:20 John Hardt, PhD John Hardt, PhD DNR Role Play 12:30-1:15 Small groups Small groups

4. “End of Life” “Death” Death is the final stage of life Death is less an event, than a process Death is a journey

5. EPEC

6. Physician’s Role in “Life Limiting Illness” Understand physiologic changes Manage symptoms Honest communication Non-abandonmentEducation Willingess to work with a team

7. Case HPI 72-year-old woman presents to primary care physician to establish care 72-year-old woman presents to primary care physician to establish care Chief concern - shortness of breath progressing for the past month Chief concern - shortness of breath progressing for the past month Has intermittent sharp right sided chest pain unrelated to activity Has intermittent sharp right sided chest pain unrelated to activity Nagging dry cough for the past several months. Nagging dry cough for the past several months.

8. Case PMHx HTN HTN Hyperlipidemia HyperlipidemiaMedications Atenolol 50mg daily Atenolol 50mg daily Simvastatin 40mg daily Simvastatin 40mg daily Drug allergies None

9. Case Social History Active smoking, 1ppd x 50 years Active smoking, 1ppd x 50 years Drinks 1 glass of wine with dinner Drinks 1 glass of wine with dinner Retired grade school teacher Retired grade school teacher Divorced x 10 years Divorced x 10 years Has 1 daughter Has 1 daughter Pt recently moved to the area to be closer to her daughter and 3 month old grand-son.

10. Case Family hx Mother – died age 49 – motor vehicle accident, no known chronic medical problems Mother – died age 49 – motor vehicle accident, no known chronic medical problems Father - died age 62 of MI Father - died age 62 of MI 1 brother – alive and well 1 brother – alive and well Son – committed suicide 5 years ago Son – committed suicide 5 years ago

11. Case ROS General – 10# weight loss over past 2 months “I guess I was too busy to eat with the move” General – 10# weight loss over past 2 months “I guess I was too busy to eat with the move” Otherwise review of systems negative Otherwise review of systems negative

12. Case Physical Exam BP 120/72 Pulse 82 RR 12 Temp 98.7 O F BP 120/72 Pulse 82 RR 12 Temp 98.7 O F She appears thin She appears thin Pertinent finding of decreased breath sounds right upper lung field Pertinent finding of decreased breath sounds right upper lung field No lymphadenopthy No lymphadenopthy

13. Work-up CXR Right upper lobe lung mass Right upper lobe lung mass

14. Work-Up CT scan chest 5.7 x 5.2 cm mass in the right upper lobe 5.7 x 5.2 cm mass in the right upper lobe Scattered subcentimeter nodules throughout both lungs Scattered subcentimeter nodules throughout both lungs Mediastinal and right hilar adenopathy Mediastinal 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

15. CT guided biopsy of lung mass Squamous cell carcinoma

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

17. Giving “Bad News” Shelly Lo, MD Department of Internal Medicine, Division of Hematology/Oncology Associate Medical Director, Loyola Hospice

19. Case Continued Oncology evaluation Diagnosis of lung cancer reviewed Diagnosis of lung cancer reviewed Implications of metastatic disease reviewed Implications of metastatic disease reviewed including Inability to eradicate disease In light of performance status, pt was believed to be a candidate for systemic chemotherapy Pt consents to therapy

20. Case Continued Chest pain getting worseChest pain getting worse Constant ache 5-6/10Constant ache 5-6/10 Worsens (sharp) with cough, laugh to 10/10 Prescribed percocet 5/325Prescribed percocet 5/325 1-2 tabs every 6 hours as needed 1-2 tabs every 6 hours as needed

21. Few days later Epic in-boxEpic in-box Still having pain. What to do? Still having pain. What to do?

22. Developing an Effective Oral Analgesic Regimen Theresa Kristopaitis, MD Department of Internal Medicine, Division of General Medicine Associate Medical Director, Loyola Hospice

24. Back to Case 6 months later Patient’s status declines Increased sleepiness Increased sleepiness Increased shortness of breath Increased shortness of breath Poor appetite Poor appetite Daughter finds pt lying on the floor after a fall Calls 911

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

26. Goals of Care Advance Directives John Hardt, PhD Neiswanger Institute for Bioethics and Health Policy at the Stritch School of Medicine Loyola University Chicago, Assistant to the President for Mission and Identify

28. DNR Role Play Small groups