Who you are:
You are FY2 in medical departmentWho the patient is:
Mr. Jack Smith is 78 years old and was admitted yesterday with a chest infection. He has a history of COPD. 15 years ago, he had MI and 3 years ago he was diagnosed with heart failure. He is receiving IV antibiotics for chest infection. He doesn’t want to take the medication.What you should do
Talk to him and address his concern.
Approach
Doctor: I can see from my notes that you have been admitted with a chest infection, how are you right now?
Patient: I am ok doctor thank you.
D: I understand that you have some concerns and I am here to address your concerns, but before that can you walk me through your condition? Has anyone
explained your condition to you?
P: I know I have a condition called Pneumonia, which is a bug in my lung for which I am taking antibiotics.
Quick Hx
D: What brought you to the hospital in the first place?
P: I had a cough, fever and I haven’t been breathing well for the last 3 days.
P2
D: I can see from my notes that you have heart failure, it’s a quite a challenging condition, how are you coping?
P: The doctor gave me some medications for it.
D: Any other conditions?
Social history
D: Who do you live with?
P: I live alone, my wife died 5 years ago.
D: I am really sorry for your loss? Does any family member visit you?
P: Yes my daughter visits me every week, but she has rheumatoid arthritis.
D: I am really sorry to hear that, how is she doing?
P: She is fine.
D: Do you have any concerns?
P: Doctor, I don’t want to take my medications.
Refusal Structure:
D: Which medications don’t you want to take?
P: Heart failure medications.
D: May I know why you don’t want to take them? And do you know the name of these medications?
P: They make me drowsy and tired all the time, I can’t remember the name right now.
Address concern
D: OK, I totally appreciate your concern, but may I know why you think you are tired due to medications?
P: I started to get tired only after taking these medications, before that I was totally fine.
D: Tiredness may be due to many reasons, I would like to ask you some questions and run some tests and if we are sure that you are tired due to the medications, we can adjust the doses or replace them, how do you feel about that?
Tiredness could be also due to heart failure; I am afraid if we stopped the medications, it would be worse.
P: I don’t want to take the medications and I want to spend quality time with my daughter.
D: I appreciate how you are feeling, have you discussed your decision with her?
P: Not yet.
Warn him: Asses his capacity.
D: You have heart failure, that means your heart is unfortunately unable to pump blood around your body properly. Do you know that?
D: Do you know why we are giving you these medications?
To make it easier for your heart to work and bring your symptoms under control.
D: Do you know what could happen if you stop your medications?
I am afraid that your heart would not be able to pump your blood well, and that makes blood and fluids accumulate in your body and in your lung which is a life-
threatening condition.
Benefit
D: If you take your medication, you will have a better quality of life as you are concerned about your daughter, if your symptoms are controlled, you will be able
to enjoy the time you spend with her.
D: Do you mind If I speak to my senior, to have a chat with you about it?
Examination: Ideally, I would like to take your vitals and examine your heart and your chest. Is that OK with you?
Management
I will inform my senior.
You can also discuss your decision with your GP and he can tell you about the many options for end-of-life discussions.
Safety netting: At any time, if you change your mind, just let us know