The process of breaking bad news to a patient may feel like a complicated one, and the idea of it daunting. But there are a few basic structure points to take into consideration to help one through it. In essence, it can sometimes turn into the unexpected but by the same token, you can expect the same thing to happen.
1.Preparation ( for you, for the disease or outcome of the patient concerned, what you know about it, what you want to say to them, what they need to know at the time, the room, the seating, the place and the day or time, the people around also listening.)
2. What does patient know? Could I ask you what you know so far about your condition, what have you been informed of /told so far?
3. Is more information wanted? ie, if they don't know, they need more information about what they need...this is to gauge their knowledge.
4. Give a warning shot... Mr.X I'm afraid to say its bad news, or I'm sorry to inform you that I have some bad news...or I'm sorry Mrs X, we tried everything we could, but he passed away, or I'm afraid I do not have good news to tell you...
5. Allow denial - if they deny, or cry - give them time for their grief - don't patronize them by saying anything during this time, silence is golden, especially where either rage or sorrow is concerned...eg in case of tears, saying anything more may encourage that emotion further, which may not be good if there is more to discuss with them. but don't rush them either.
6. Explain if requested - in layman's terms....explain results.condition.disease. whatever questions they have...ask if they have any qs.
7. Listen to their concerns - ask them how they are feeling if necesssary...
8. Encourage breathing -
9. Summary and plan
10. Offer availability (ie of ur service your bleep, nurse bleep, senior's contact bleep or whatever)
PART II:
Will I die doctor/do you mean I'm going to die doctor?
'It is true, that as your body gets weaker, it will not be able to sustain your life, and death will be the final outcome, as treatment is no longer sufficient to help you recover from this illness.'
~How long do I have doctor?
'I cannot really give you a specific known time frame, but based on what we know, that you are suffering with certain symptoms eg tiredness and sickness, in addition to what the results of the CT scan show, our best case scenario is between a couple of weeks and a couple of months, I very sorry to say - please note this is our best estimate'
'I'm sorry to have to tell you that the results are not good. ....'
Saturday 19 April 2008
Warfarin
Just some important points about warfarin:
(image taken from http://www.pharmacy-and-drugs.com/reviews/Warfarin.html and some of the notes supplemented with quotes from http://www.pharmacy-and-drugs.com/reviews/Warfarin.html in addition to my own personal notes)
1. 1mg (brown), 3mg (blue), 5mg (pink) tablets
(image taken from http://www.pharmacy-and-drugs.com/reviews/Warfarin.html and some of the notes supplemented with quotes from http://www.pharmacy-and-drugs.com/reviews/Warfarin.html in addition to my own personal notes)
1. 1mg (brown), 3mg (blue), 5mg (pink) tablets
2.That they inhibit F 10, 9, 7, 2
3.That PE/DVT aim INR 2-3 ; recurrent 3.5
4.That AF : 2-3; or cautious and no risk factors (no stroke/dm/ht/tia/under 65) then 2.5-3.5
5.That prosthetic valves : 3-4.9; higher risk valves (cage and ball;tilting disc/mitral and aortic valves) aim for 4-4.9; lower risk ~3
Monitoring
everyday for first week
every week for next 3 weeks
every month for next 6months
then every 8 weeks?
Vit K regenerating reductase enzyme inhibitor - therefore - state is like vit K deficiency :
patients should avoid VIT K containing foods : LIVER AND GREEN VEGETABLES -- stops anticoagulant effect of Warfarin.
Patient to be aware of menstruation - heavier/longer than normal
Patient to be aware of DENTAL WORK/SURGERIES - to always inform both the doctor, surgeon, dentist.
Pregnant women and breastfeeding women to avoid warfarin -- query first and last tri avoid?
(note also, NSAIDS, aspirin DO NOT GIVE TO PREG LADIES -- paracet only ok)
Always to inform docs about the fact that you are on warfarin --!! very very important, never shy away from that, never forget to inform them. - alters treatment /drug interactions
Remind them of dangers of alchol, binge drinking and they are allowed moderate etoh, but good idea to tell them to stop etoh.
Tell your doctor immediately if you are, or become pregnant, or are
breastfeeding, as Warfarin may cause birth defects.
Also tell your doctor of any other medications you are taking, including vitamins and herbal /supplements, and any medical conditions you may have.
So vitamins - which vits?
Herbal supplements : st.John's wort - interaction -? lessen or worsen anticoag effect?
Medical conditions : note our contraindications - also screening questions
1. have you ever had a stroke or tia
2. are you pregnant or breastfeeding
3. do you have an ulcer?
4. do you have high blood pressure?
5. do you have endocarditis -bacterial endocarditis
6. do you have any bleeding disorders
7. have you ever had any major head trauma or cerebral aneurysms?
8. ???? recent surgery?
NOTE that use with caution in the elderly and in those with past GI bleeds!
Don't ever give warfarin and NSAIDS together!
It is very important that you take this medicine exactly as your
doctor tells you to.
At the same time every evening -- once only in the
evening!!
Do not take more or less medicine than directed, and
never stop taking Warfarin without discussing it with your doctor first.
If you miss a
dose of this medicine, take it as soon as you remember, unless
it is almost time for your next
dose. Do NOT double doses.
Recall warfarin drug interactions (to be added later):
LIVER ENZYME INHIBITORS FECKIN COB(inging on alcohol) SCAM
So in this case they would potentiate/increase the effect of warfarin - ie more prone to bleeding, increase the INR, because the available warfarin is increased and not being broken down due to inhibited liver enzymes.
liver enzyme inducers CRAP GPS (chronic alcohol)
The opposite is the case here, where the individual is more likely to form clots, the anticoagulant effect of warfarin is decreased, less warfarin is available in the body because is has been eliminated or is being eliminated faster by the liver enzymes of the body induced by the respective drug.
check with doctor if :
LIVER ENZYME INHIBITORS FECKIN COB(inging on alcohol) SCAM
So in this case they would potentiate/increase the effect of warfarin - ie more prone to bleeding, increase the INR, because the available warfarin is increased and not being broken down due to inhibited liver enzymes.
liver enzyme inducers CRAP GPS (chronic alcohol)
The opposite is the case here, where the individual is more likely to form clots, the anticoagulant effect of warfarin is decreased, less warfarin is available in the body because is has been eliminated or is being eliminated faster by the liver enzymes of the body induced by the respective drug.
check with doctor if :
Check with your doctor immediately if any of the following symptoms occur:
bleeding from gums when brushing teeth; blood in urine; nosebleeds; pinpoint red
spots on skin; unusual bleeding or bruising; unusually heavy bleeding or oozing
from cuts or wounds; unusually heavy or unexpected menstrual bleeding; abdominal
or stomach pain or swelling; back pain or backaches; black, tarry stools;
bleeding in eye; blood in stools; blood in vomit or vomit that looks like coffee
grounds; blood in urine; blurred vision; chest pain; confusion; constipation;
coughing up blood; severe diarrhea; dizziness or fainting; joint pain,
stiffness, or swelling; loss of appetite; continuing nausea and vomiting;
nervousness; numbness or tingling of hands, feet, or face; paralysis; shortness
of breath; or sudden weakness.
Sunday 13 April 2008
The Diabetic Foot
The other day, whilst perusing whatever book it was that I was reading, I came across something called - neuropathic ulcers. This was linked with peripheral neuropathy. It just so happened that in my week off I was faced once again with diabetes. Such is the topic of diabetes that people either get bogged down by this big topic...or they embrace it whole-heartedly.
The diabetic foot, I reckon is a term either for the diabetic person with a foot or a condition that can develop in diabetics resulting in a specific foot problem or problems of the feet that are particular to those that suffer with diabetes. Any complications that develop are probably in the late stage of diabetes, but as many will say, many complications can be prevented overall or at least greatly delayed.
The problem with diabetes is the effect it has on the nervous system within the body. Sugar or sweet blood, which the diabetic individual aims to control with either insulin or diet, has overtime, in cases where there is poor control especially, has the effect of damaging the delicate structure of the nerve.
We know that nerves, have in essence many main functions.
That of light touch, pressure, pain, temperature and joint position and vibration sense, in addition to power, tone and movement.
In a diabetic individual, any one of these functions may fail if the nerve that is affected that carries out that particular function.
Often, what tends to happen is that there is what is called a peripheral neuropathy. Ie the nerves that have left the spine, travelling out to the respective organ or skin or muscle - is damaged. The process of this damage is rather complicated and has much to do with glycated proteins and maybe even free radical formation...but i'd rather not say...and this is where my revision is nonsense and needs me to look over it again....suffice to say that damage occurs.
So the diabetic foot - neuropathic ulcers...develop as a result of the individual not feeling their feet or pain in their foot or the pressure applied to their foot.
The management of an unaffected foot of a diabetic individual is beyond crucial. Managing it well can be the difference between preventing the formation of an ulcer or damage to bone or ligaments or blistering of the skin, to all of these things and the long term complications and difficulties in its healing.
Edited:
I was talking the other day to someone about this....and I've come across terms - 'neuroischaemic ulcers'
I learnt the following. That not only are the nerves affected : proprioception (hence joint injury or over usage of joints beyond what they are normally capable of..particularly the over-flexion or over extension of a joint - contributes to Charcots joints, which themselves im not sure .. get painful, poor healing due to poor microvasculature - infection>?)
But on the microvasculature : this is perhaps where the term neuroischaemic comes along -- poor healing of the skin - be that from a small injury, or to the tissue, or poor healing in infection due to poor blood supply.
And then high glucose levels too - encourage infections and generally affects or reduces the effectiveness of the immune system or inhibits the immune system...
Little nitty gritty things like this annoy me...when I don't know specifics...REALLY annoys me. But so far, this i believe is the general gist of things.
I need this to be clarified though.
The diabetic foot, I reckon is a term either for the diabetic person with a foot or a condition that can develop in diabetics resulting in a specific foot problem or problems of the feet that are particular to those that suffer with diabetes. Any complications that develop are probably in the late stage of diabetes, but as many will say, many complications can be prevented overall or at least greatly delayed.
The problem with diabetes is the effect it has on the nervous system within the body. Sugar or sweet blood, which the diabetic individual aims to control with either insulin or diet, has overtime, in cases where there is poor control especially, has the effect of damaging the delicate structure of the nerve.
We know that nerves, have in essence many main functions.
That of light touch, pressure, pain, temperature and joint position and vibration sense, in addition to power, tone and movement.
In a diabetic individual, any one of these functions may fail if the nerve that is affected that carries out that particular function.
Often, what tends to happen is that there is what is called a peripheral neuropathy. Ie the nerves that have left the spine, travelling out to the respective organ or skin or muscle - is damaged. The process of this damage is rather complicated and has much to do with glycated proteins and maybe even free radical formation...but i'd rather not say...and this is where my revision is nonsense and needs me to look over it again....suffice to say that damage occurs.
So the diabetic foot - neuropathic ulcers...develop as a result of the individual not feeling their feet or pain in their foot or the pressure applied to their foot.
The management of an unaffected foot of a diabetic individual is beyond crucial. Managing it well can be the difference between preventing the formation of an ulcer or damage to bone or ligaments or blistering of the skin, to all of these things and the long term complications and difficulties in its healing.
Edited:
I was talking the other day to someone about this....and I've come across terms - 'neuroischaemic ulcers'
I learnt the following. That not only are the nerves affected : proprioception (hence joint injury or over usage of joints beyond what they are normally capable of..particularly the over-flexion or over extension of a joint - contributes to Charcots joints, which themselves im not sure .. get painful, poor healing due to poor microvasculature - infection>?)
But on the microvasculature : this is perhaps where the term neuroischaemic comes along -- poor healing of the skin - be that from a small injury, or to the tissue, or poor healing in infection due to poor blood supply.
And then high glucose levels too - encourage infections and generally affects or reduces the effectiveness of the immune system or inhibits the immune system...
Little nitty gritty things like this annoy me...when I don't know specifics...REALLY annoys me. But so far, this i believe is the general gist of things.
I need this to be clarified though.
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