Where you are
You are an F2 in the Emergency departmentWho the patient is
Mr. Mohamad Ali, a 77 year old man who collapsed at home and was brought to hospital by an ambulance.Other information you have about the patient
The patient is unconscious but breathing independently. The neurosurgeons have assessed the patient and have classified his condition as terminal and feel that an operation would not resolve the problem. The CT scan of the head was done which showed massive intracerebral bleed. Surgeons believe that the patient had burst of Berry aneurysm.What you must do
Please speak to his wife mrs Ali and address her concerns.
Patient’s relative information: -
- You are Mrs. Ali, a 60-year old lady;
- You have come to the hospital to visit your husband who was brought to the hospital by the ambulance after collapsing at home.
- You and your husband were watching TV when he suddenly collapsed.
- You called the ambulance and he was brought to hospital.
- You have come on your own to hospital.
- You have 2 children: Your daughter lives in Australia and your son lives in London.
Concerns
- How is my husband doctor?
- What do you mean by terminal? (ask only if the doctor says it is terminal)
- Can you take him to ITU?
- How long will he live? / How long does he have remaining to live?
- Why did it happen to him?
- Are you doing anything for him while he is in hospital? Are you giving up on him?
- I have got two daughters who live in Australia. Do you think I need to call them?
Always keep normal facial expressions, avoid looking depressed and your task is to break the news in layers and the treatment here is palliative care. If the patient is about to expire, don’t be afraid, say it in a nice and expressive manner and look for support system
Doctor: Hello Mrs. Ali I am Dr (name) one of the junior doctors in the department. Could you confirm your husband’s name and age for me please?
(Confirm identity)
P: Mr Mohamad Ali, aged 77. Doctor, can you please tell me how my husband is?
Never say I will tell you later
D: I can see (always acknowledge) you are worried. I am here to answer all your questions. Before we start, Mrs. Ali, is there anyone you’d like to join us to support you for this discussion? (Look for support system)
P: No. Doctor can you tell me how my husband is?
D: Well, your husband is being looked after by an expert team of doctors. I can see that you are very concerned. Would it be all right if I ask you a few questions before I go on? (Try to know what happened to explain concerns later easily.)
P: Okay doctor.
P1- focused hx
D: Can you tell me what happened? (We need to know how much the other person knows, so ask)
P: Well, we were just sitting and all of a sudden he lost his consciousness.
D: Okay, so what did you do?
P: I called an ambulance and then brought him to the hospital immediately.
D: You did the right thing. I cannot imagine how you must have felt at that time.
(Appreciate what she did and reflect emotions)
Ask related questions: (Before, During, After)
- Did he have a fever or a headache or vomiting before he fainted?
- Was he unwell in any other way before he fainted?
- Did he experience any warning before the collapse?
- Was he conscious at that time?
- Did you notice any fits or any other problems?
- Did he lose consciousness when you collapsed?
- How did he feel after the collapse? Confused? Hallucinating? Amnesia?
P2- Past hx
D: Is it the first time that this has happened?
P: Yes/No
P3- Maftosa + desa
D: Has he been diagnosed with any medical conditions in the past?
P: High blood pressure (Pt may say hypertension/ kidney related problems, strokes, etc)
D: Was he under any medication? Blood thinners? Allergy?
D: Family hx of any sudden death? Kidney related problems?
Always check knowledge and idea before breaking the bad news-
(2 layers then break the news)
D: How much do you know about your husband’s condition? Do you have any idea what’s going on? Has anyone spoken to you before me?
P: No doctor I have no idea and you are the first one talking to me. Is he okay?
D: As you know your husband was brought to the hospital by the ambulance. When he came to the hospital, we performed some examinations and also a CT scan of the brain very quickly to find out why he collapsed.
P: Okay, what happened?
D: Do you have anybody with you today, or do you want anybody to be with you?
P: Please tell me?
D: So we assessed him, we did a CT scan on him. Unfortunately, it’s not what we were hoping for. PAUSE (just 1 to 2 seconds) 1st layer
P: What?
D: I’m afraid, we don’t have good news for you Mrs. Ali. PAUSE- 2nd layer
P: What? I don’t understand.
So break the news.
D: Unfortunately, the CT scan shows he has massive bleeding inside his brain.
PAUSE
See the response of the patient. The patients can respond in different ways. The patients can be shocked; they can be loud and start crying. They might just go into a quiet mode. So anything can happen. Whatever happens, give your response accordingly.
D: I can see that you are really shocked by all this. You were not expecting news like that.
(EVE protocol)
(So, just explain these things to the patient. Wait for 4 or 5 seconds till the patient is calm, looking at you again. If you think you need to offer a tissue, offer a tissue, offer a glass of water etc. Then ask her:
D: Do you want me to tell you more or do you want anyone to be with you?
(Offer support once again)
P: It is fine doctor.
D: I understand it would be really hard to talk at this moment, but do you have any questions at this point? (Ask concern and how much they want to know)
P: Why did it happen to him?
D: Most likely this could have happened because of his high blood pressure.
P: What are you going to do for him? Any surgery?
D: Usually if someone has suffered a bleed, the brain specialist would try to remove the clot in the brain but in your husband case, I’m sorry the expert team of doctors has assessed him and they feel surgery is not going to be helpful for him.
P: Why?
D: It is not a good option for him; it can in fact become more dangerous or fatal for him.
P: Can you take him to ICU?
D: Well, we keep patients in the ICU if they can’t breathe on their own or if we are expecting them to recover. But Mr Ali is unconscious but breathing on his own.
P: Are you going to keep him just like that?
D: Well, the experts think that palliative care is the best care that we can provide him now.
P: What is palliative care?
D: It is care that is given to patients when they are in a terminal condition. It is giving social, psychological and spiritual support to the patient and his family and we will try to relieve his pain and make him as comfortable as we can.
P: Did you say terminal condition? Is he going to die?
D: I am sorry to say it but I am afraid given the situation, it’s less likely that he is going to make it. (Don’t be afraid to say he is going to die, but wrap it in a nice manner.)
P: How long does he have?
D: It is really difficult to say how long he will last, it varies from patient to patient. As we monitor him more we will get a better idea of how long he has left.
P: Should I call my children?
D: Yes you should definitely inform them. Your husband’s condition is quite serious so it’s better that your children know about his condition so if they want to visit, they can visit him and also support you.
P: Can I take him home?
D: I need to speak to my seniors to see how that can be arranged.
Few other questions you can ask: (Talk about end of life care)
D: Do you feel that this is what he would want at this stage?
D: Do you know if he has ever expressed his wishes regarding where he would like to be if things come to this point?
D: Do things he would like to be done at this stage of his life.
D: I know this is very devastating news. If you need any kind of support please do let me know. I can be there or I will arrange any of my colleagues to be there to help you with whatever you need.