DNACPR DISCUSSION II

ELI WENDOR

46 YEARS MALE

Role-play cases simulate real clinical practice to guide how candidates respond to clinical scenarios and real life practice.

Name: Eli Wendor
Age: 46 years old

Background
Eli Wendor is a 46-year-old male with a diagnosis of squamous cell carcinoma of the throat, which has metastasized. He was diagnosed 4 months ago and underwent chemotherapy and radiotherapy. Unfortunately, these treatments were unsuccessful. The disease has been fast progressive and he does not have long to live. Currently, Eli is receiving palliative care aimed at managing his symptoms and improving his quality of life. He has a tracheotomy tube in place, and a palliative care nurse visits weekly to manage this and other aspects of his care. The nurse's most recent visit was two days ago.

This morning, Eli recently experienced a distressing choking episode, during which he felt that food was stuck in his throat. This was somewhat alleviated by drinking fluids, but he remains concerned about the possibility of future incidents. This episode has increased his anxiety about his condition and he wants further support.

Eli is fully aware that his disease is incurable and that any medical interventions would primarily managing symptoms rather than offering a cure. This understanding has led him to consider his end-of-life care options. He has expressed a strong desire to formalize an Advance Decision to Refuse Treatment (ADRT), establish a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order, and ensure that he does not undergo any future hospital admissions. Additionally, Eli is interested in setting up a Lasting Power of Attorney (LPA) to ensure that his healthcare decisions are respected and carried out according to his wishes.

However, Eli is upset upon discovering that a DNACPR order was completed and added to his online medical records without his knowledge or consent. He feels that this action was taken without proper communication or consideration of his wishes, leading to a sense of betrayal and a lack of trust in his healthcare providers. He would have wanted to discuss things before they were initiated. This incident has exacerbated his feelings of being unsupported and misunderstood by the medical team responsible for his care. You will say "you doctors just want to think your boxes without checking how I feel about things."

Despite having a supportive family, Eli feels that they are not fully informed about the details of his medical condition and the implications of his treatment options. He often feels alone in navigating his illness and making critical decisions about his care. Eli is married to Julie, they have a dog but no kids.

Ideas: Eli know he would die within a year, he has come to terms with it.
Concerns: Eli's primary concerns include managing the symptoms of his illness, particularly the risk of choking, and ensuring that his end-of-life care preferences are clearly documented and respected.
Expectation: He seeks reassurance and a more active role in the decision-making processes regarding his care to ensure that his wishes are honored.

You are a doctor in your routine clinic, ready to begin your day of consultations. A patient has been booked to see you,

Name: Eli Wendor

Age: 46 years old

Past Medical History

4 months ago, diagnosed with squamous cell carcinoma of the throat, advanced mets.
Underwent chemotherapy and radiotherapy with no success.
Currently receiving palliative care.
Nurse visits weekly for tracheotomy tube management.

Booking Notes:
Experienced choking episode today, struggling to swallow, relieved somewhat by fluids.

Data Gathering, Interpretation, and Diagnosis

Positive Indicators:

Interprets and uses patient's notes appropriately: Demonstrates understanding of Eli’s medical history, including his cancer diagnosis, treatment history, and recent symptoms.
Identifies appropriate differential diagnoses and sifting questions: Asks detailed questions about the choking episode, potential triggers, and other symptoms to differentiate between causes (e.g., mechanical obstruction, aspiration).
Explores patient’s wishes and understanding around end-of-life care: Discusses Eli’s understanding of his prognosis and his desires for ADRT, DNACPR, and no hospital admissions.
Acknowledges and addresses patient’s emotional and psychological state: Validates Eli’s feelings of being unsupported and his distress over the unauthorized DNACPR order.
Gathers comprehensive social and support history: Inquires about Eli’s support network and his family's involvement in his care.

Negative Indicators:

Incomplete Medical History: Fails to ask specific questions about the recent choking episode or potential contributing factors.
Limited Exploration of Symptoms: Does not inquire about other related symptoms such as difficulty swallowing, weight loss, or voice changes.
Failure to Address Concerns: Does not adequately address Eli’s concerns about future choking episodes or his distress over the DNACPR order.
Overlooks Psychosocial Aspects: Neglects to explore the emotional impact of Eli’s condition on his daily life and well-being.

Clinical Management and Managing Medical Complexity

Positive Indicators:

Symptom Management: Provides a clear explanation of potential causes for choking and offers strategies to manage and prevent future episodes.
End-of-Life Care Planning: Facilitates a thorough discussion about ADRT, DNACPR, no hospital admissions, and LPA, ensuring Eli’s wishes are documented and respected.
Coordination with Palliative Care: Ensures continued involvement of the palliative care team for regular follow-ups and symptom management.
Patient Education: Offers resources and information about palliative care options, advance directives, and legal aspects of LPA.
Holistic Approach: Considers both physical symptoms and emotional well-being, providing comprehensive support.

Negative Indicators:

Lack of Thorough Symptom Investigation: Fails to investigate the choking episode in depth, potentially missing important details.
Limited Treatment Options: Does not discuss a range of management strategies for preventing choking or addressing other symptoms.
Delayed Referrals: Does not consider referral to a speech and language therapist or other specialists for further assessment of swallowing difficulties.
Insufficient Support for Advance Care Planning: Does not provide adequate information or support for completing ADRT, DNACPR, or LPA.
Neglects Emotional Support: Fails to offer appropriate emotional and psychological support to Eli during the consultation.

Relating to Others

Positive Indicators:

Encourages Patient Contribution: Allows Eli to express his concerns and wishes freely, giving him time to speak without interruption.
Develops and Maintains Rapport: Builds a trusting relationship by showing genuine empathy and understanding of Eli’s situation.
Follows Cues Offered: Responds appropriately to Eli’s emotional cues and concerns, addressing them sensitively.
Flexible and Conversational Approach: Adopts a conversational tone, making Eli feel comfortable and respected.
Achieves a Shared Management Plan: Collaborates with Eli to create a care plan that aligns with his wishes and values.
Explains Diagnosis Sensitively: Discusses the prognosis and implications of Eli’s condition in a way that is clear, compassionate, and honest.

Negative Indicators:

Poor Empathy: Appears detached or clinical, failing to acknowledge Eli’s distress and frustration.
Poor Communication: Engages in one-sided communication, not actively listening to Eli’s concerns or preferences.
Insensitive Approach: Ignores Eli’s emotional state, focusing solely on clinical aspects without addressing the broader impact on his quality of life.
Dismissive of Patient’s Concerns: Does not adequately address or validate Eli’s feelings of being unsupported or his distress over the unauthorized DNACPR order.
Lack of Flexibility: Rigid in approach, not adapting to Eli’s emotional needs or preferences during the consultation.

This marking scheme ensures a comprehensive assessment of a GP's management of Eli Wendor’s case, emphasizing the importance of thorough data gathering, effective interpersonal skills, and holistic clinical management.

These are the key issues in this clinical scenario.

Addressing these key issues ensures a thorough, compassionate, and patient-centered approach to Eli Wendor’s care, aligning medical management with his personal values and preferences.

Symptom Management - Choking Episodes: Address Eli’s recent choking episode, assess the risk of recurrence, and provide strategies to manage and prevent future incidents. This includes reviewing his swallowing function and dietary adjustments.

Advance Care Planning:

ADRT (Advance Decision to Refuse Treatment): Discuss and document Eli's wishes regarding life-sustaining treatments he wants to refuse.
DNACPR (Do Not Attempt Cardiopulmonary Resuscitation): Ensure a clear and consensual DNACPR decision-making process. Revisit the DNACPR order already placed without his knowledge, and correct any misunderstandings.

No Hospital Admissions: Explore and respect Eli’s desire to avoid future hospital admissions, ensuring he understands the implications.

Lasting Power of Attorney (LPA): Assist Eli in setting up an LPA to ensure his healthcare decisions are respected and executed as per his wishes.

Emotional and Psychological Support:

Addressing Distress: Acknowledge and address Eli’s feelings of being unsupported and his distress over discovering the DNACPR order completed without his knowledge.
Providing Reassurance: Offer emotional support and reassurance, validating his concerns and ensuring he feels heard and involved in his care decisions.

Coordination with Palliative Care:

Palliative Care Involvement: Ensure ongoing coordination with the palliative care team for symptom management and holistic support. Regular communication with the palliative nurse to address Eli's needs and concerns.
Holistic Approach: Consider both Eli’s physical symptoms and emotional well-being, providing comprehensive support that encompasses all aspects of his care.

Family and Social Support

Engaging Family: Explore the role of Eli’s family in his care, ensuring they are informed and involved to the extent Eli wishes. Provide guidance and support to them as needed.
Support Networks: Identify additional support networks and resources that can provide Eli with the assistance and reassurance he needs, including counseling services and patient support groups

Data Gathering, Interpretation, and Diagnosis

Positive Indicators:

Interprets and uses patient's notes appropriately: Demonstrates understanding of Eli’s medical history, including his cancer diagnosis, treatment history, and recent symptoms.
Identifies appropriate differential diagnoses and sifting questions: Asks detailed questions about the choking episode, potential triggers, and other symptoms to differentiate between causes (e.g., mechanical obstruction, aspiration).
Explores patient’s wishes and understanding around end-of-life care: Discusses Eli’s understanding of his prognosis and his desires for ADRT, DNACPR, and no hospital admissions.
Acknowledges and addresses patient’s emotional and psychological state: Validates Eli’s feelings of being unsupported and his distress over the unauthorized DNACPR order.
Gathers comprehensive social and support history: Inquires about Eli’s support network and his family's involvement in his care.

Negative Indicators:

Incomplete Medical History: Fails to ask specific questions about the recent choking episode or potential contributing factors.
Limited Exploration of Symptoms: Does not inquire about other related symptoms such as difficulty swallowing, weight loss, or voice changes.
Failure to Address Concerns: Does not adequately address Eli’s concerns about future choking episodes or his distress over the DNACPR order.
Overlooks Psychosocial Aspects: Neglects to explore the emotional impact of Eli’s condition on his daily life and well-being.

Clinical Management and Managing Medical Complexity

Positive Indicators:

Symptom Management: Provides a clear explanation of potential causes for choking and offers strategies to manage and prevent future episodes.
End-of-Life Care Planning: Facilitates a thorough discussion about ADRT, DNACPR, no hospital admissions, and LPA, ensuring Eli’s wishes are documented and respected.
Coordination with Palliative Care: Ensures continued involvement of the palliative care team for regular follow-ups and symptom management.
Patient Education: Offers resources and information about palliative care options, advance directives, and legal aspects of LPA.
Holistic Approach: Considers both physical symptoms and emotional well-being, providing comprehensive support.

Negative Indicators:

Lack of Thorough Symptom Investigation: Fails to investigate the choking episode in depth, potentially missing important details.
Limited Treatment Options: Does not discuss a range of management strategies for preventing choking or addressing other symptoms.
Delayed Referrals: Does not consider referral to a speech and language therapist or other specialists for further assessment of swallowing difficulties.
Insufficient Support for Advance Care Planning: Does not provide adequate information or support for completing ADRT, DNACPR, or LPA.
Neglects Emotional Support: Fails to offer appropriate emotional and psychological support to Eli during the consultation.

Relating to Others

Positive Indicators:

Encourages Patient Contribution: Allows Eli to express his concerns and wishes freely, giving him time to speak without interruption.
Develops and Maintains Rapport: Builds a trusting relationship by showing genuine empathy and understanding of Eli’s situation.
Follows Cues Offered: Responds appropriately to Eli’s emotional cues and concerns, addressing them sensitively.
Flexible and Conversational Approach: Adopts a conversational tone, making Eli feel comfortable and respected.
Achieves a Shared Management Plan: Collaborates with Eli to create a care plan that aligns with his wishes and values.
Explains Diagnosis Sensitively: Discusses the prognosis and implications of Eli’s condition in a way that is clear, compassionate, and honest.

Negative Indicators:

Poor Empathy: Appears detached or clinical, failing to acknowledge Eli’s distress and frustration.
Poor Communication: Engages in one-sided communication, not actively listening to Eli’s concerns or preferences.
Insensitive Approach: Ignores Eli’s emotional state, focusing solely on clinical aspects without addressing the broader impact on his quality of life.
Dismissive of Patient’s Concerns: Does not adequately address or validate Eli’s feelings of being unsupported or his distress over the unauthorized DNACPR order.
Lack of Flexibility: Rigid in approach, not adapting to Eli’s emotional needs or preferences during the consultation.

Resuscitation Decisions - Medical Ethics
https://youtu.be/oLfFR5qTOuc?si=9AYR8Hw5Az5MP579
Matthew Smith: CSA case DNR form (Must watch!)
https://youtu.be/1kXHhZK_lv0?si=0lhBU_MCcmClxz7B
Angry Relative - DNACPR Discussion (Must watch!)
https://youtu.be/UoVuBeHPGYo?si=xSWpDIwC5fXRQWih
DNACPR Discussion – Communication
https://youtu.be/rKY2qkf0jM4?si=_NNNxtT9HfL2kcrG
Resuscitation (CPR) Counselling
https://youtu.be/KowT-7aEoZA?si=SMKo4YpFPbwH_rFS
Making decisions on behalf of adults lacking capacity
https://www.theddu.com/guidance-and-advice/guides/making-decisions-on-behalf-of-adults-lacking-capacity

Tips and Strategies to Pass Eli Wendor's Case

To successfully manage Eli Wendor's case, a GP should focus on thorough data gathering, compassionate communication, and comprehensive clinical management. Here are some key tips and strategies:
Data Gathering, Interpretation, and Diagnosis

Detailed History Taking:Ask about the choking episode and any other recent symptoms.
Explore Eli’s understanding of his prognosis and current treatment.

Assess Understanding and Wishes:Discuss Eli’s wishes regarding ADRT, DNACPR, no hospital admissions, and LPA.
Clarify and document his preferences and ensure they are respected.

Emotional and Psychosocial Inquiry:Validate Eli’s feelings about being unsupported and his distress over the DNACPR order.

Clinical Management and Managing Medical Complexity

Symptom Management:Provide strategies to prevent and manage choking episodes.
Ensure regular review and adjustment of palliative care measures.

Advance Care Planning:Facilitate discussions around ADRT, DNACPR, and LPA.
Correct the unauthorized DNACPR order and involve Eli in the decision-making process.

Coordination with Palliative Care:Maintain regular communication with the palliative care team.
Ensure holistic support addressing both physical and emotional needs.

Relating to Others

Build Rapport and Trust:Show genuine empathy and actively listen to Eli’s concerns.
Allow Eli to express his feelings and provide reassurance.

Clear and Sensitive Communication:Explain medical terms and procedures in a way that Eli can understand.
Discuss prognosis and end-of-life options with sensitivity and honesty.

Engage Family and Support Networks:Involve Eli’s family in discussions as per his wishes.
Provide information about additional support resources and counseling