DNACPR DISCUSSION

EUNICE FERBIN

82 YEARS, FEMALE

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

Name: Eunice Ferbin
Age: 85 years old

Background:

You are an 85-year-old woman with a significant medical history including COPD and a past stroke.
You live alone with support from carers, and your children live abroad.
You have had frequent hospital admissions for COPD exacerbations, which have significantly impacted your quality of life.

Current Situation:

You have a DNACPR order in place, established 4 months ago.
You are aware of the DNACPR decision and have discussed it with your family.
You are currently managing your symptoms with the prescribed medications but still experience significant breathlessness and fatigue.

Emotional State:

You may feel anxious or uncertain about your health and future.
You might have concerns about your quality of life and the implications of the DNACPR decision.

Response to Questions:

Be open about your symptoms and how they affect your daily life.
Express any concerns or questions about the DNACPR decision, your condition, and future care plans.
Show understanding of your medical situation but also a desire for clarity and reassurance from the healthcare provider.

Introduction:
Greet the doctor politely.
"Hello, Doctor. Thank you for seeing me today."

Describing Symptoms and Impact on Daily Life:
I've been feeling very breathless lately, and it's been really hard to get around."
"I used to be active and involved in my community, but now I'm mostly housebound."

Expressing Understanding of DNACPR:
I understand that a DNACPR means that if my heart stops, I won't be resuscitated."
"My family and I discussed this decision, and they are supportive."

Discussing Concerns:
"I sometimes worry about what will happen if my condition gets worse."
"I'm concerned about my quality of life. I don't want to suffer or be a burden."

Responding to Doctor's Questions:
If asked about feelings towards the DNACPR: "I feel it’s the right decision given my health, but it's still a bit unsettling."
If asked about family: "My children live abroad, but they support the decision and keep in touch regularly."
If asked about daily activities: "I struggle with basic tasks and rely a lot on my carers. It’s frustrating not being able to do things on my own."

Expressing Wishes and Seeking Reassurance:
"I just want to make sure that my wishes are respected and that I don’t suffer unnecessarily."
"Can you help me understand what to expect as my condition progresses?"

Non-Verbal Cues:
Show signs of breathlessness or fatigue when speaking.
Exhibit slight anxiety or concern, especially when discussing future health.

Closing the Conversation:
"Thank you for listening, Doctor. It’s important to me to understand and feel supported in my decisions."
"I appreciate your help and guidance through this."

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

Name: Eunice Ferbin

Age: 85 years old

Past Medical History

End Stage Chronic Obstructive Pulmonary Disease (COPD) - Patient aware
Hypertension
Type 2 Diabetes Mellitus
Osteoarthritis
History of Stroke (2 years ago)

Medication History

LTOT 16 hours per day.
Salbutamol Inhaler PRN
Tiotropium Inhaler 18mcg daily
Metformin 500mg tds
Lisinopril 10mg daily
Amlodipine 5mg daily
Paracetamol 1g qds
Simvastatin 20mg nightly
No known drug allergies (NKDA)

Medical Notes

3 Hospital Admission in last 12months for COPD exacerbation, no ITU intervention.
DNACPR put in place 9 months ago following recurrent hospital admissions due to COPD exacerbations.

Investigation Results

Recent Chest X-ray: Hyperinflated lungs consistent with COPD, no features of cor pulmonale or any acute changes.
Blood Tests: HbA1c 7.5%, eGFR 40 mL/min/1.73m², stable electrolytes.

These key issues should help guide doctors in providing comprehensive, compassionate care for Eunice Ferbin, addressing both her medical needs and her overall well-being.

Assessment and Support for Quality of Life:
Evaluate the impact of Eunice's symptoms on her daily activities and overall well-being.
Address any mobility issues and provide referrals for physiotherapy or occupational therapy if necessary.
Discuss strategies to maintain as much independence as possible within her home environment.

Review and Communication of DNACPR Decision:
Regularly review the DNACPR decision with Eunice and her family to ensure it remains appropriate and understood.
Provide clear, compassionate communication about what DNACPR entails and its implications for her care.
Ensure documentation is up-to-date and accessible to all healthcare providers involved in her care.

Coordination of Care:
Coordinate with carers, community nurses, and other healthcare professionals to ensure comprehensive care.
Arrange for regular check-ins and assessments to monitor Eunice’s condition and adjust care plans as needed.
Facilitate communication among all members of the care team to address any emerging issues promptly.

Emotional and Psychological Support:
Offer ongoing emotional support to Eunice, addressing any anxiety or concerns about her condition and future.
Consider referrals to counseling or support groups for patients with chronic illness.
Engage family members in discussions to provide reassurance and support, ensuring they are informed and involved in the care process.

These are the key issues in this clinical scenario.

This marking scheme provides a comprehensive assessment framework for evaluating a GP’s management of Eunice Ferbin’s case. It emphasizes the importance of thorough data gathering, effective interpersonal skills, and a holistic approach to clinical management.

Data Gathering

Comprehensive Medical History
Elicits detailed history of COPD symptoms and frequency of exacerbations.
Reviews medication adherence and effectiveness.
Inquires about any recent changes in health status or new symptoms.

Social and Functional History
Explores the impact of symptoms on daily activities and quality of life.
Assesses living conditions, support systems, and carer involvement.
Discusses patient's ability to perform activities of daily living and any assistance required.

Review of DNACPR Decision
Confirms patient's understanding of DNACPR and reviews the decision.
Explores patient's and family’s thoughts and feelings about the DNACPR.
Checks for any changes in the patient’s wishes or condition that might affect the DNACPR status.

2. Relating to Others (Interpersonal Skills)
Building Rapport and Showing Empathy
Demonstrates active listening and maintains eye contact.
Uses open-ended questions to encourage patient to express concerns.
Shows empathy and understanding of patient's anxieties and frustrations.

Effective Communication
Provides clear explanations of medical terms and procedures.
Ensures patient and family understand the implications of DNACPR.
Uses language that is respectful, supportive, and non-judgmental.

Handling Sensitive Topics
Discusses DNACPR and end-of-life issues with sensitivity and respect.
Addresses patient’s and family’s emotional reactions appropriately.
Balances honesty with reassurance, avoiding false hope.

3. Holistic Clinical Management
Symptom Management
Optimizes COPD management, including medication review and possible adjustments.
Suggests non-pharmacological interventions (e.g., pulmonary rehabilitation).
Considers additional supports for managing breathlessness and mobility issues.

Quality of Life and Functional Support
Identifies and addresses factors affecting patient's quality of life.
Refers to physiotherapy, occupational therapy, or other support services as needed.
Provides advice on adaptive aids or modifications to the home environment.

Care Coordination
Ensures all members of the healthcare team are informed and involved in care planning.
Arranges regular follow-ups and reviews of patient’s condition.
Coordinates with carers and community services to provide comprehensive support.

Emotional and Psychological Support
Offers emotional support and reassurance to patient and family.
Refers to counseling or support groups for additional emotional support.
Encourages open communication between patient, family, and healthcare providers.

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 for Effective Consultation and Communication
Data Gathering

Thorough History: Collect detailed information on COPD symptoms, medication adherence, and any recent health changes.
Social Context: Understand the impact on daily activities, living conditions, and support systems.
Review DNACPR: Confirm the patient’s understanding and revisit the decision, ensuring it aligns with current wishes and conditions.

Interpersonal Skills

Build Rapport: Use open-ended questions and active listening to establish trust and empathy.
Clear Communication: Explain medical terms and procedures in an understandable way, ensuring patient and family comprehension.
Sensitivity: Discuss DNACPR and end-of-life issues with compassion, balancing honesty with reassurance.

Holistic Clinical Management

Symptom Control: Optimize COPD treatment and consider non-pharmacological interventions.
Quality of Life: Address factors affecting daily living and refer to supportive services as needed.
Care Coordination: Involve all healthcare team members and arrange regular follow-ups.
Emotional Support: Provide reassurance, refer to counseling, and encourage open communication.