Elderly Flashcards
(180 cards)
1
Q
Who are the elderly?
A
- 60 years old
- senior citizens
2
Q
What Happens When We Age?
A
Aging -> normal process
As doctors, why is it important to know what happens?
- disease vs normal aging
- elderly patients are less likely to complain with the onset of illness
- we can communicate with them better
3
Q
What Happens When We Age? Cardiovascular System
A
- heart and blood vessels becomes stiffer
- heart enlarges
diseases: Hypertension; Myocardial Infarction
4
Q
What Happens When We Age? Respiratory System
A
- lungs become stiffer
- respiratory muscle strength and endurance diminishes
- chest wall becomes more rigid
5
Q
What Happens When We Age? Gastrointestinal System
A
- Stomach
Atrophic gastritis
Achlorhydria
Ulcers - Liver
- Intestines
6
Q
What Happens When We Age? Musculoskeletal System
A
- bone loss -> universal
- muscles
- decrease in strength, endurance, size and weight
- can be lessened by regular physical activity - increased body fat percentage
7
Q
What Happens When We Age? Female Reproductive System
A
menopause
- 45-52 years old
- ovaries become fibrotic and atrophy
- lower estrogen levels (atrophic changes in the uterus and vagina; menopausal symptoms)
8
Q
What Happens When We Age? Male Reproductive System
A
- more gradual decline
- andropause
- decrease in testosterone levels
- decreased libido
- loss in muscle strength - rate of sperm production is decreased but fertility is mostly maintained
9
Q
What Happens When We Age? Nervous System
A
- weight of brain peaks at 20 years old
- changes in nerve cells:
1. decrease in the number of dendrites
2. some may have demyelination - Attention (usually maintained up to old age)
- Language (semantic knowledge is affected)
10
Q
What Happens When We Age? Nervous System (Memory)
A
- most studied complaint
- 2nd most common complaint
- (+) decline in information processing:
encoding: getting information to the system
storage: retaining information
retrieval: recalling information
11
Q
What Happens When We Age? Nervous System
A
- Visual-Spatial Ability
- General Information
- problem solving ability declines with age
- stable:
comprehension
arithmetic
vocabulary
12
Q
What Happens When We Age? Sensory System (Vision)
A
- most common sensory problem
- dry eyes
- changes:
1. corneal flattening
2. lens transparency
3. less efficient retina
4. reduced lens elasticity
13
Q
What Happens When We Age? Sensory System (Hearing)
A
- after age 60, (+) decrease in hearing sensitivity by 10 dB each decade
- changes:
1. tympanic membrane stiffens
2. ossicles stiffen
14
Q
What Happens When We Age? Sensory System
A
- Smell
- decrease in functioning smell receptors
- by age 80, sense of smell is reduced by half - Taste - diminishes with age
- Touch - decreases with age
15
Q
COMPREHENSIVE GERIATRIC ASSESSMENT: SPECIAL CONSIDERATIONS
A
- Cognitive impairments are common
- Illnesses have atypical and non-specific presentations
- The severity of illnesses may be underestimated
16
Q
COMPREHENSIVE GERIATRIC ASSESSMENT
A
HISTORY TAKING
- Medication history
- Personal and social history
- Review of systems
- Functional assessment - Pt’s capacity for independent living
- Assessment of depression - Geriatric Depression Scale is used
- Environmental History
- Sexual history
17
Q
COMPREHENSIVE GERIATRIC ASSESSMENT: Personal and social history
A
Personal habits – immunization, alcohol use, tobacco use, caffeine intake, sleep patterns
Dietary assessment – Mini-Nutrition Assessment (MNA)
Emotional History – emotional difficulties and adjustments, patterns of coping with stress
Occupational /Retirement status
Social supports – living relatives, significant others
18
Q
ACTIVITIES OF DAILY LIVING (ADL)
A
D – ressing E – ating A – mbulating T – oileting H – ygiene
19
Q
INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL)
A
S – hopping H – ousekeeping A – ccounting F – ood preparation T – ransportation
20
Q
COMPREHENSIVE GERIATRIC ASSESSMENT: Environmental History
A
- living arrangements
- physical layout of homes
- recommendations for adaptive devices, etc
21
Q
COMPREHENSIVE GERIATRIC ASSESSMENT: PHYSICAL EXAMINATION
A
- Vital signs
- General Appearance
- HEENT examination
- Systems Exam
- Neurological and Psychiatric Examination
- Mini-Mental State Examination (MMSE) is good instrument for cognitive testing - Assessment of gait, mobility and balance
22
Q
Tips When Seeing Elderly Patients 1
A
- Establish rapport.
- Allow extra time for older patients.
- Avoid distractions.
- Sit face to face.
- Maintain eye contact.
- Listen.
- Speak slowly, clearly and loudly.
- Use short, simple words and sentences.
23
Q
Tips When Seeing Elderly Patients 2
A
- Stick to one topic at a time.
- Simplify and write down your instructions.
- Use charts, models and pictures.
- Frequently summarize the most important points.
- Give an opportunity to ask questions and to express themselves.
- Keep the patient relaxed and focused.
- Say goodbye.
24
Q
primary goal: maximize the quality of life
- patient should be: pain-free; comfortable
- provide physical, social, psychological support
A
Hospice Care
25
Philosophy of Hospice Care
1. Hospice affirms life.
2. It recognizes dying as a normal process.
3. Palliative care is not withholding treatment but rather a proactive treatment plan appropriate to the end stages of life.
4. Neither hastens nor postpones death
5. Provides relief from pain and other distressing symptoms.
6. It exist in the hope that through appropriate care, patients and families maybe free to attain a degree of mental and spiritual preparation for death that is satisfactory to them.
26
Interdisciplinary Team (Hospice Care)
- Physicians
- Psychologists
- Therapists
27
Role of the Physician (Hospice Care)
1. leader of the hospice team
| 2. symptom-control
28
Symptom Control Principles (Hospice Care)
1. Listen to the patient.
2. Make a diagnosis before treating.
3. Terminally ill patients are likely to have multiple symptoms.
4. Explanation is part of treatment.
5. Know the drugs you use and know them well.
29
Symptom Control (Hospice Care)
1. PAIN
2. ANOREXIA
3. NAUSEA AND VOMITING
4. BED SORES
5. DEPRESSION
6. GRIEF
30
Symptom Control (Hospice Care) : PAIN
- Experienced by 70% of cancer patients
| - Could be: physical; psychosocial; spiritual
31
Principles: PAIN
1. Define the type and site of pain.
2. Treat each pain specifically.
3. Anticipate pain breakthrough.
4. Review the regimen frequently and regularly.
5. Treat “total” pain.
32
ANOREXIA: Causes
- Mouth infections
- Nausea
- Constipation
- Depression
- Drugs
- Radiotherapy
- The disease itself
33
ANOREXIA: Help the patient eat by
1. Knowing the patient’s preference
2. Serving the food that the patient wants
3. Offering small portions on a small plate
4. Serving hot soup, ice cream and fruits
5. Allowing someone to eat with the patient
6. Giving supplemental vitamins and minerals
34
True or False
IV fluid, total parenteral nutrition and tube feedings have not been shown to prolong lives of dying pts.
True
35
To alleviate nausea and vomiting
1. Offer very small meals, liquid & soft food, ice chips
2. Let the patientt sit up after eating
3. Let patient keep distance from smelly food/odor
4. Avoid fatty, sweet, spicy food
5. Schedule eating before radiotherapy or chemotherapy
6. Offer relaxation and breathing exercises
36
Nausea And Vomiting: Medications
Metoclopromide
Phenothiazines
- promethazine 25mg orally 4x a day
- prochlorperazine 10mg orally before meals
37
BED SORES: General principles of treatment
1. Pressure reduction
2. Control of infection
3. Debridement
4. Dressings and nutritional support
38
(Grief)
- normal process
- usually begins before an anticipated death
Grieving
39
- is a way of allowing us to prepare emotionally for the inevitable
Intense grieving: 3 months – 1 year
Profound grieving: > 2years
Anticipatory Grief
40
Stages of Grief
- Shock
- Emotional release
- Depression, loneliness, and a sense of isolation
- Physical symptoms of distress
- Feeling of panic
- A sense of guilt
- Anger or rage
- Inability to return to usual activities
- The gradual regaining of hope
- Acceptance as we adjust our lives to reality
41
- preventive intervention for high risk families
- optimize family functioning
- facilitate the sharing of grief
Family focused grief therapy (FFGT)
42
3 phases of FFGT
1. Assessment - identify issues or concerns; therapeutic plan
2. Intervention - Focusing on agreed concerns
3. Termination - Incorporating consideration and termination of therapy
43
Death and Bereavement
Bereavement: the event of loss
Grief: emotional response to the event of loss
44
Bereavement guidelines
1. Understanding anticipatory grief
2. Anticipating the dimensions of bereavement
3. Moving through grief
4. Working through pain
45
Stages of Dying
```
Denial
Anger
Bargaining
Depression
Acceptance
```
46
THE CAREGIVER: SUPPORT SYSTEM
- parent
- spouse
- children
- siblings
- friends and neighbors
47
Responsibilities of a GOOD Caregiver
1. Respect patient’s privacy and individuality.
2. Cultivate the patient’s trust.
3. Be objective in dealing with the patient. Never show pity.
4. Communicate thoughts clearly.
5. Approach the patient with an open mind. Never antagonize.
6. Be organized in the process of caregiving.
7. Have good hygiene.
8. Perform the different caregiver skills adequately
48
Managing the Stress of Caregiving 1-5
1. Take care of your health.
2. Involve others.
3. Maintain social contacts. – isolation increases stress
4. Get help from community services and organizations.
5. Talk about it
49
Managing the Stress of Caregiving 6-10
6. Deal constructively with negative feelings
7. Talking to older parents about independence
8. Make a list
9. Dealing with resistance
10. Focus on key points.
50
- process of social influence
- enlist the aid and support of others
GOAL: accomplishment of a common task
Leadership
51
leadership is about capacity:
1. to listen and observe
2. to use their expertise as a starting point to encourage dialogue between all levels of decision-making
3. to establish processes and transparency in decision-making
4. to articulate their own values and visions clearly but not impose them
52
leadership is about:
1. setting and not just reacting to agendas
2. identifying problems
3. initiate change that makes for substantial improvement rather than managing change
53
Leadership is about: 2
- creating a way for people to contribute to making something extraordinary happen
- influencing the actions of the people: -> toward the attainment of defined goals
54
Actions of a Good Leader
1. Issue orders that are: CLEAR; COMPLETE; WITHIN THE CAPABILITIES OF SUBORDINATES TO ACCOMPLISH
2. provide continual training activity to subordinates
3. motivate workers to meet expectations
4. maintain proper discipline
5. reward those who perform properly
55
Styles of Leadership
1. Authoritarian or autocratic
2. Participative or democratic
3. Laissez faire or delegative or Free Reign
56
- leaders:
make decisions alone
demand strict compliance to orders
dictate each step taken
- The leader is not necessarily hostile but is aloof from participation in work and commonly offers personal praise and criticism for the work done.
Authoritarian (autocratic)
57
When to become authoritarian:
1. when you have all the information to solve the problem
2. you are short on time
3. your employees are well motivated
58
Characteristics:
- collective decision process by the members
- members are given choices
- collectively decide the division of labor
leaders:
- provide technical advice
- obtain information from group discussion
- act as a facilitator
- maintain the final decision making authority
Participative (democratic)
59
When to become participative:
1. leader only has parts of the information - members have the other parts
2. leader is not expected to know everything
60
Characteristics:
- members have freedom to decide
- limited, or no participation from the leader
leaders:
- limited participation
- uninvolved in work decisions, unless asked
- does not participate in division of labor
- infrequently gives praise
- leader is still responsible for the decisions that are made
Delegative (free reign)
61
When to become delegative:
1. followers are able to analyze the situation
2. followers are able to determine what needs to be done
3. followers are able to do what needs to be done
4. leaders must set priorities and delegate certain tasks
62
What type of person makes a good leader?
- leaders share a number of common personality traits and characteristics
- leadership emerges from these traits
- leadership is an innate, instinctive quality that you either have or don't have
- empathy, assertiveness, good decision-making, and likability.
Trait theories
63
What does a good leader do?
- focus on how leaders behave
- Do they dictate what needs to be done and expect cooperation? Or do they involve the team in decisions to encourage acceptance and support?
Behavioral theories
64
Kurt Lewin developed a leadership framework based on a leader's decision-making behavior.
Lewin’s Model
65
Lewin argued that there are three types of leaders:
1. Autocratic leaders
2. Democratic leaders
3. Laissez-faire leaders
66
- the "best" leadership style is determined by balancing task, team, and individual responsibilities
- Leaders who spend time managing each of these elements will likely be more successful than those who focus mostly on only one element.
John Adair's Action-Centered Leadership model
67
How does the situation influence good leadership?
the best leadership style is contingent on, or depends on, the situation
- When a decision is needed fast, which style is preferred?
- When the leader needs the full support of the team, is there a better way to lead? Should a leader be more people oriented or task oriented?
Contingency theories
68
- A popular contingency-based framework
| - links leadership style with the maturity of individual members of the leader's team.
Hersey-Blanchard Situational Leadership Theory
69
- What is the source of the leader's power?
- based on the different ways in which leaders use power and influence to get things done, and the leadership styles that emerge as a result
Power and influence theories
70
- the most well known of these theories
| - using position to exert power VS using personal attributes to be powerful
French and Raven’s Five Forms of Power
71
French and Raven’s Five Forms of Power
- positional power
1. legitimate
2. reward
3. coercive
- personal power
1. expert
2. referent
72
- The model suggests that using personal power is the better alternative and, because expert power (the power that comes with being a real expert in the job) is the most legitimate of these
- Similarly, leading by example is another highly effective way to establish and sustain a positive influence with your team.
French and Raven’s Five Forms of Power
73
- assumes that work is done only because it is rewarded, therefore a leader focuses on designing tasks and reward structures
- This style of leadership starts with the idea that team members agree to obey their leader totally when they accept a job.
Transactional Leadership
74
- The "transaction" is usually the organization paying the team members in return for their effort and compliance.
- The leader has a right to "punish" team members if their work doesn't meet the pre-determined standard.
Transactional Leadership
75
Effective leadership qualities
- Intelligence
- dominance
- adaptability
- persistence
- Integrity
- self-confidence
- adjustment
- extraversion
- conscientiousness
- openness to experience
76
This theory says that leaders are not made, they are born. It is their calling to be a leader.
The Great Man Theory
77
This theory relies on the traits and make-up a human. Physiological, demographic, intellectual, and social characteristics all play into whether someone is a good leader or not.
The Trait Theory
78
This theory revolves around the idea of technical and conceptual skills. The position of leadership determines the amount of each skill needed.
The Skills Theory
79
This theory is the framework to the different styles of leadership. There is autocratic, democratic, and laissez-faire.
The Style Theory
80
- There is no one-size-fits-all-model, the leader must adapt
- This theory says that leaders have different styles for different situations, but as circumstances change so does the style that the leader uses.
The Situational Theory
81
- There is no one-size-fits-all-model, choose an appropriate leader
- This theory says that the success of the leader is based on the effectiveness of their followers.
The Contingency Theory
82
- People follow leaders based on 'transactions' - a mix of rewards, incentives and punishments. A quid pro quo approach
- This is a theory where leadership is focused on the role of supervision, organization, and group performance.
The Transactional Theory
83
- Leaders are gaining the commitment of their employees by inspiring, encouraging and caring for their followers
- This theory says that leaders want positive change in their group and are focused on the success of their followers.
Transformational Theory
84
- This theory focuses on the relationships between the leader and their followers. They go through the phases of role taking, role-making, and routinization.
- similar to transactional theory, but stresses the presence of an ingroup and outgroup
Leader-member Exchange Theory
85
- The leader starts by idenfying the needs of the followers and views his own role as merely serving the followers
- The leader serves others first and then focuses on the task that is at hand.
Servant Leadership Theory
86
- Natural course of the psychosocial aspects of disease
- Knowledge of the trajectory allows the physician to predict, anticipate, and deal with a family’s response to illness
- Indicates normal and pathologic responses thus enabling physicians to formulate special therapeutic plans
The Family Illness Trajectory-Passage Thru Sufferings
87
Why study impact of illness?
1. Sickness of a patient causes suffering and severe disruption for the patient’s family, thus when a patient is sick the whole family suffers.
2. Illness sets in motion processes that are disruptive and hazardous to health of family members, there is a role reversal, income loss and disruption of activities and susceptibility of disease transmission.
3. Prolonged and complicated illnesses result in structural change within the family system to a point that leads to different roles and functions.
88
Stages in Family Illness Trajectory
Stage I - Onset of Illness to Diagnosis
Stage II - Impact Phase-Reaction to Diagnosis
Stage III - Major Therapeutic Efforts
Stage IV - Recovery Phase- Early Adjustment to Outcome
Stage V - Adjustment to the Permanency of the Outcome
89
- Warning sign of malaise which initiates preliminary stage of the illness trajectory
- Stage experienced prior to contact with medical care providers
- Nature of illness may play an important role on impact of illness
Stage I- Onset of Illness to Diagnosis
90
Types of Illness:
1. Acute, rapid
| 2. Chronic, debilitating
91
Types of Illness: Acute, rapid
Nature of illness: Acute, rapid
Nature of onset: Rapid, clear onset
Characteristics of experience
- Provide little time for physical/psychological adjustments- short period between onset, diagnosis, and management thereby leaving a little time to remain in a state of certainity.
Impact on family
- Caught up in suddenness
- Immediate decision
- Little support w/in and outside family
92
Types of Illness: Chronic, debilitating
Nature of illness: Chronic, debilitating
Nature of onset: Gradual onset
Characteristics of experience
- Suffer from state of uncertainty over meaning and symptom
Impact on family
- Vague apprehension and anxiety
- Fear, denial of seriousness of symptoms and possible implications
93
Physician Responsibilities in Stage I
- Explore fear that the patients/ family bring up in the clinic
- With inappropriate label of illness, acknowledge and explore conflicts the patient and family may be experiencing
- Explore aspects of pre-diagnostic phase of patients and families
94
(Stage II- Reaction to Diagnosis: Impact Phase)
2 PLANES OR AREAS BY WHICH A PATIENT/FAMILY REACT AND ADJUST
- EMOTIONAL PLANE
| - COGNITIVE PLANE
95
2 PLANES OR AREAS BY WHICH A PATIENT/FAMILY REACT AND ADJUST: EMOTIONAL PLANE
- Denial, disbelief, anxiety (min to hrs)
- Emotional upheaval such as anger, anxiety and depression (wks)
- Accommodation and acceptance- this is very important for the implementation of therapeutic plans.
96
2 PLANES OR AREAS BY WHICH A PATIENT/FAMILY REACT AND ADJUST: COGNITIVE PLANE
Phase 1: TENSION AND CONFUSION, LACK OF CAPACITY FOR PROBLEM SOLVING
Phase 2: REPEATED FAILURE IN DERIVING THE DIAGNOSIS LEADING TO INCREASED DISTRESS- some patient may resort to prayers and still they have the capacity to problem solve
Phase 3: RECEPTIVITY OF FAMILY TO NEW APPROACH FOR RELIEF OF DISTRESS - patient go doctor shopping, some patienst are capable and willing to actively participate and accept responsibility.
- The physician have the opportunity to assist the family in realigning roles and expectations
Phase 4: EVENTUAL ACCEPTANCE OF DIAGNOSIS
97
Responsibilities of the Physician in Stage II 1-5
1. Anticipate problems and help family cope and adapt through family meetings/ discussion.
2. Make clear about the nature of illness by helping the family maintain openness that allows sharing and support.
3. Know that the feeling of guilt is a natural response to stress of grief and loss, anticipate such feelings, and make realistic goals to correct the feeling.
4. Help the family assess the likely effect of the illness on the family
5. Assess the capability of the family to cope with stress
98
Responsibilities of the Physician in Stage II 6-10
6. Offer alternative interpretation of proposed therapeutics
7. Describe disease and treatment according to patient’s level of comprehension and understanding
8. Make a clinical judgment about the amount of information to give and be absorbed by the patient
9. Give small doses of information over time
10. If diagnosis is confusing or stressful
a. Provide support and continuity of care
b. Interpret findings
c. Offer advice and encouragement
99
- Represents one of the most challenging and rewarding part of medical practice
- Physician should deal with multiple variables
* work in harmony with the wishes of the patient and family
* Coordinate all aspect of the therapy
Stage III - Major Therapeutic Efforts
100
WORKING WITH FAMILIES: METHODS
1. Family-oriented approach with individual patient
2. Involving family members in routine office visits
3. Family conference/ meeting
101
- One or more family members are present
- Common medical Situation: Well-child and prenatal care, diagnosis of a chronic illness
- Length of visit: 15-20 min
- How scheduled: Request family member attendance
- Family Interviewing
Involving Family Members in Routine Office Visits
102
- A specially arranged meeting requested by the physician, patient or family to discuss the patient’s health problem in more depth than can be addressed during a routine office visit
- Medical Situation: Terminal Illness; Institutionalization
- Length of visit: 30-40min
Family Conferences
103
CRITICAL ISSUES IN CHOOSING THE THERAPEUTIC PLAN
1. Psychological state and preparedness of the patient and family- if patient’s belief system in certain treatment plan is different with that of the physician, he might resist the treatment. Thus the physician should investigate for signs and symptoms of non-compliance.
2. Assume responsibility of care very early in the treatment plan. Define roles
3. Economic status- of what good is the treatment if the family can’t afford it.
4. Lifestyle and cultural characteristics of the family
5. Effects of hospitalization, surgery, and other therapeutic methods are emotionally stressful to the family.
104
Economic impact of illness
a. Emotional trauma
b. Social dislocation
c. Economic catastrophe- wipes out family savings
105
Hospitalization give rise to stressful logistic problem
Father- special economic burden
Mother- greatest impact on other family member and poses high risk of family dysfunctions
106
RESPONSIBILITIES OF THE PHYSICIAN in Stage III
1. Remain open and work in harmony with the patient and his family
2. Deal with multiple variables; consider all factors when planning
3. Coordinate all aspects of therapy
4. Anticipate pathologic responses and be able to deal with them
107
- Return from the hospital or major therapy
- Gradual movement from the role of being sick to some form of recovery or adaptation
- Adjustment of relation within the family
Stage IV- Early Adjustments to Outcomes- Recovery
108
Types of Outcomes
1. Return to full health- simplest outcome
• Gains from illness experience
• Patient allowed to take over abandoned obligation
2. Partial recovery
• Followed by a period of waiting to see if illness will return
• Fear of death
• Constant sense of vulnerability
3. Permanent disability
109
RESPONSIBILITIES OF THE PHYSICIAN in Stage IV
1. Deal with immediate effects of trauma
2. Alleviate anxiety and assure adequate rest
3. Psychological support
4. Explore level of understanding of patient and family
110
- Family’s adjustment to crisis
| - Second crisis occurs as family realizes that they must accept and adjust to a permanent disability
Stage V- Adjustment to the Permanency of the Outcome
111
ADJUSTMENT FOR ACUTE ILLNESS:
- Potential for crisis when routines are suspended
| - Physician can facilitate acceptance of diagnosis
112
ADJUSTMENT FOR CHRONIC ILLNESS:
Prolonged fear and anxiety leads to higher incidence of illness in other members of the family
- Feeling of guilt brings about anger and resentment
- Physician should encourage ventilation of feelings, give reassurance and reinforcement of care
113
ADJUSTMENT FOR TERMINAL ILLNESS:
Highly emotional and potentially devastating
- Single most difficult time of the entire illness experience
- If family is functional: members are drawn close together
- If family is dysfunctional: seed for future family discord and breakdown
- Physician should provide quality home care
114
- Dr. George Engel conceptualized a new paradigm to challenge the prevailing model
- this model emphasized the unit of body, mind and social context; it emphasizes that out concern as physicians should not be just the disease process but should also be how the patient feels about his condition, how he perceives his illness and how these feelings and perceptions together with the disease interact with the family, community, culture and biosphere
- based on the Systems Theory
Biopsychosocial Model
115
- set of techniques, skills, and attitudes to help people manage their own problems using their own resources
- addresses the psychosocial aspects of biopsychosocial illnesses
- should not only focus on whats wrong but also on opportunities for development and growth
Counseling
116
Purpose of Counseling
1. help people manage their own problems
2. helps patients use their own resources
3. seeks to provide self-insights, behavior change and symptom relief
117
People need counseling when
1. They are not mobilizing their energies
2. They are not solving problems which they have resources to solve
3. Their thinking is clouded
4. They are not making necessary decision
5. They are not responding to usual motivators
6. They are engaging in self-defeating behavior
7. They are unusually troubled, tense or anxious
8. There is noticeable change in behavior
9. They seem unaware of the consequences of their behavior
118
Functions of Counseling
1. Support
2. Challenge
3. Education
4. Prevention
119
Phases of Counseling
1. Catharsis
2. Insight
3. Action
120
- this stage is spent on clarifying or defining the problem
- task: make sense of the problem by telling it to someone else
- ventilation of emotion is the cathartic aspect of this stage
- for the doctor-counselor: role is to understand and to assist the patient's efforts to develop self-understanding; suspending judgement and practicing active listening
Catharsis
121
- main objective: patient to achieve a shift in thinking or perspective
- there is challenge or confrontation from the doctor-counselor to the redefinition of the problem
- by the end of this phase, the patient is moving in a definite direction and finally knows where he is going
Insight
122
- the patient makes his own plan for himself, with the doctor's assistance, in order to resolve his difficulties
- doctor acts a guide, a philosopher and a friend
- the solutions best come from the patient himself
Action
123
Attitudes of the Counselor (Rogerian Model/ Carl Rogers)
1. Genuineness
2. Unconditional Positive Regard
3. Empathy
124
- demands transparency - the absence of pretense. there is no hiding behind a professional mask or use medical jargon in order to hide inadequacies
- ingredients: self-awareness, self-acceptance, self-expression
Genuineness
125
- knowledge of one's biases and prejudices, perceptions, values and belief systems
Self-awareness
126
- one's ownership of the full range of feelings and thoughts one has and not being ashamed of any part of it - whether positive or negative
Self-acceptance
127
True or false
A genuine counselor myst be aware of his innermost thoughts and feelings, accepts them and when appropriate expresses them responsibly
True
128
- as doctor-counselors, we also carry within us the tendency to judge people based on standards and biases and prejudices that we have inherited from our upbringing
- should set aside these conditions, if only for the period that we are dealing with our patients
- the atmosphere of acceptance and positive regard without condition is the healing environment that allows a patient to himself
- it is the doctor-counselor who creates such environment by setting aside his own tendency to judge so that he can be a therapeutic presence to his patient
Unconditional Positive Regard
129
- ability to put oneself in the situation of another
- doctors warned against being "over involved" - not only feels the emotional state of the patient but actually comes to assume that state
- emphatic doctor: fell what the patient feels and see the world through the eyes of the patient without losing control of his own feelings and without getting sucked in to the issues of the patient
Empathy
130
- the client or counselee, sets the pace and the direction of the counseling process
- he believes in the ability of the client to come to terms with his own problem
- counselor: helps counselee see things more clearly by providing an atmosphere of emphatic listening, unconditional positive regard and genuineness
- in this model: PATIENT LEADS, COUNSELOR FOLLOWS
CARL ROGERS - CLIENT-CENTERED COUNSELING
131
- used by doctor-counselor to obtain psychosocial information that will allow him enter the inner emotional world of the patient, understand how the patient sees the world and how he perceives the problematic reality
- use of the skills will help bring out the Emotionally Critical Misperceptions (ECM)
Active Listening Skills
132
the misperception that is causing the greatest emotional upset; it is the misperception that created the emotional force which has brought the patient to the doctor
Emotionally Critical Misperceptions (ECM)
133
Active Listening Skills
1. Attending Skills
2. Bracketing
3. Leading
4. Reflecting content
5. Reflecting feeling
6. Reflecting experience
7. Focusing
8. Probing
134
- non-verbal; "paying attention"
- refer to the way in which we use our bodies to communicate the message nonverbally that: “I am listening to you and I understand where you are coming from.”
Attending Skills
135
Attending Skills
```
L- eaning forward
O-pen stance
V-oice of compassion
E- ye contact
R- elaxed position
S- it at an angle
```
136
- Mental skill
- Seeing aside your own thoughts, feelings and judgement that detract from emphatizing with the patient
- Setting aside our biases, prejudices and pre-conceived notions about the patient or the situation he is describing
- We need to see the world from the patient's point of view
Bracketing
137
- Open invitations for the patient to talk about anything that he wishes
- "What would you like to talk about?" or "What can I do for you?"
- It may also be in a form or words or phrases: "yes", "go on", "and then"
- minimal prompts - "uh-hmmm"
Leading (Indirect lead)
138
- Doctor-counselor makes a judgment call as to where the patient should go and ask him to go in that direction
- Guidelines for the doctors to make judgement:
1. focus in filing that is greatest or most intense
2. most important issues saved for last
3. useful to pay attention to what the patient has
Leading (Direct lead)
139
Reflective Skills
1. Reflecting Content
2. Reflecting Feeling
3. Reflecting Experience
140
- the doctor-counselor takes the verbal content of what the patient says, repackages and rephrases it so that it becomes clearer
- 2 ways of doing it:
1. Paraphrasing - to summarize in ten words what it took the patient hundred words to say
2. Perception-checking - same as paraphrasing but it is in the interrogative
Reflecting Content
141
- the doctor-counselor will articulate the feelings for the patient
- giving a name to the patient's feeling - becomes more aware of his emotions
- it is important for the doctor-counselor to realize the feelings that are neither right or wrong
- example: "you seem to be quite anxious about your sore throat"
Reflecting Feeling
142
- Taking note of patient’s gestures/non-verbal clues
- patient becomes aware of his/her behavior by pointing out the non-verbals
- the patient may be able to gain insight if he/she becomes aware of the feeling or perception behind the gesture
Reflecting experience
143
- when a patient is anxious or emotionally in pain, they have the tendency to bring up a lot of things in their mind or they present with jumble of emotions
- Ask the patient to choose which among the issues raised is most important to him
- Enumerate problems/emotions brought up then ask which one is the most troublesome
Focusing
144
- Asked in order to elicit more information
- Must be open-ended ("could you tell me more about..")
- probes beginning with "how", "could you explain", "could you tell me more", "could you give an example of"
- Probe for content or feeling
Probing
145
Probe...
- where the emotional content is greatest
- what the patient decides to mention last
- when the patient repeats several times
146
Active listening in health education: the CEA method
C – atharsis
E – ducation
A - ction
147
- Becoming aware of hidden emotion
- Giving the emotion a name
- Experiencing it fully
- Coming to a realization of what is behind it
Catharsis
148
Catharsis: steps
1. What did you think?
2. What did you feel?
3. What makes you feel that way the most?
4. Summarize ECM and the emotions associated with it
149
- begin education with the emotionally critical misperception (ECM) of the patient
- after ECM has been addressed, discussed the pathophysiology and pharmacology
Education
150
- after educating the patient, the doctor-counselor should propose an Action plan to the patient
- make sure that ECM of the patient has been addressed
- Tip: sometimes Patient will have another ECM during the action planning
Action
151
- “Any news that drastically and negatively alters the patient’s view of his or her future”
- "results in a cognitive, behavioral, or emotional deficit in the person receiving the news that persist for sometime after the news is received" (AL Back)
Bad News
152
- a two way activity that requires sensitivity, empathy and active listening skills
- enables the patients to make informed choices and future plans for themselves
Communicating bad news
153
How to be a good communicator?
- Willingness to talk about dying
| - Disclosing about bad news sensitively
154
Physician-related Factors
1. Honest
2. Compassionate
3. Caring
4. Hopeful
5. Informative
155
Patient-related Factors
1. To be done in person
2. With privacy
3. At their pace
4. Adequate time for discussion
5. In the presence of a supportive person
156
The SPIKES Strategy
```
S - etting, Listening Skills
P - atient's Perception
I - nvite patient to share Information
K - nowledge transmission
E - xplore emotions and Emphasize
S - ummarize and Strategize
```
157
Setting up the interview and getting the physical context right
- arrange for some privacy
- involve significant others
- sit down
- make connection with patients
- manage time constraints and interruptions
- use your active listening skills
158
Assessing the PATIENT'S PERCEPTION
- determine how much the patient knows
- "Before you tell, Ask"
- use open-ended questions
- ascertain their current understanding
159
Obtain the patient's INVITATION
- find out how much information the patient wants to know
160
Giving the KNOWLEDGE and information to the patient
- warn the patient that bad news is coming
- use ordinary language in giving medical facts
- avoid excessive bluntness
- give information in small pieces and always assess if understood well
- be emphatic and be not afraid to say sorry or I do not know
- use humor with care
- Use drawings
- Do not argue
- Avoid words, " There is nothing I can do for you."
161
EXPOSING the patient's EMOTIONS and giving EMPATHY
Offer support to the patient - reduce isolation, expresses solidarity, and validates patients feeling or thoughts
- observe emotion
- identify emotion
- identify the reason for the emotion
- allow the patient to experience the feeling and respond emphatically
162
Common emotional reactions
- Shock
- Isolation
- Grief
163
SUMMARIZE and STRATEGIZE
- ask the patient is he or she is ready to discuss the prognosis and treatment options
- shared responsibility for decision making
- planning and following though further meetings
- try to leave them with some hope
164
The ABCDE mnemonic
- Advance preparation
- Build a therapeutic environment/relationship
- Communicate well
- Deal with patient and family reactions
- Encourage and validate emotions
165
- Arrange for adequate time, privacy and no interruptions. - Review relevant clinical information
- Mentally rehearse, identify words or phrases to use and avoid.
- Prepare yourself mentally.
Advance preparation
166
- Determine what and how much the patient wants to know
- Have family or support persons present
- Introduce yourself to everyone
- Warn the patient that bad news is coming
- Use touch when appropriate
- Schedule follow up appointments
Build a therapeutic environment/relationship
167
- Ask what the patient or family already knows
- Be frank but compassionate; avoid euphemisms and medical jargon
- Allow for silence and tears; proceed at the patient’s pace
Communicate well
168
- Have the patient describe his or her own understanding of the news; repeat this information at subsequent visits.
- Allow time to answer questions
- Conclude each visit with a summary and follow up plan
Communicate well
169
- Assess and respond to the patient’s and family’s emotional reaction; repeat at each visit.
- Be emphatic
- Do not criticize colleagues
Deal with patient and family reactions
170
- Explore what the news means to the patient
- Offer realistic hope according to patient’s goals
- Use interdisciplinary resources
- Take care of your own needs; be attuned to the needs of involved house staff and office or hospital personnel
Encourage and validate emotions
171
Special Issues (Breaking Bad News)
1. Denial
2. Collusion
3. Prognosis
4. Anger
172
- When a patient maintains a positive outlook in the illness/prognosis
- can be a coping mechanism to protect oneself against distress
Denial
173
How to deal with patients who are in Denial?
- Explore the denial
- Is it an absolute barrier?
- Is there evidence of awareness that can ultimately lead to understanding of the illness?
- Leave it for some time and follow up to reassess
174
- when a physician is approached by a relative to withhold medical information from the patient
Collusion
175
relatives can only be told with explicit permission from the patient
Ethics of Medical Confidentiality
176
How to deal with Collusion?
- See the patient and the family initially apart form each other then do a FAMILY MEETING
- For the patient: Assess his/her understanding of the illness
177
How to deal with Collusion? (For the relatives)
- Focus on the feelings
- Know the reason for not wanting disclosures
- Know there perception of the patient's understanding
- Acknowledge their motives
- Assure that information will not be forced onto the patient
- Explain the opportunity to fix unfinished business
- Allow the patient to participate in the treatment
178
- inadequately informed cancer patients tent to choose aggressive anticancer treatments
- awareness of the prognosis is associated with greater satisfaction with care and lower depression levels
Prognosis
179
- a normal response to bad news
Anger
180
How to deal with Anger?
- Acknowledge it and do not be defensive
| - Listen to your patient and clarify
