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You are an FY1 working on a respiratory ward. Ellie Factory, a 65 year old lady, was admitted 5 days ago with a severe infective exacerbation of COPD and Type 2 Respiratory Failure requiring BiPAP. She has had 2 failed weaning attempts and now desaturates and drops her GCS within a minute or so of removing the BiPAP mask, for example to allow her to eat and drink.

The medical and nursing staff feel that Ellie is likely nearing the end of her life and that active treatment is no longer her best interests. Your consultant has asked you to go and speak to Ellie’s husband Ollie.

This is a communication skills station. Please explain the situation to Ollie and discuss his and Ellie’s wishes regarding end of life care.  

You are Ollie Factory, a 67 year old man whose wife has been in hospital for nearly a week with a “chest infection”. This one seems to be much worse than previous ones and she doesn’t seem to be getting better as quickly this time.

PMH: Ellie has had a “bad chest” for a number of years now and often gets out of breath doing things that she could manage fine in the past. She has had a few chest infections over the years, sometimes they’ve settled with the rescue pack from the GP but over the last year she has needed to be admitted and have antibiotics through a drip. The last two admissions she has needed “the mask ventilator”, which seemed to improve things and make her better within a day or so and she usually got home within a week. As well as her bad chest, she’s got a bad heart and sometimes gets angina and needs the spray under the tongue to settle the pain. She was also told recently by her GP that she is borderline diabetic, but she’s not on any tablets and has been trying to control things with diet.

FH: Both of Ellie’s parents died of heart attacks in their 80s, no other significant FH.

DH: Ellie has 2 inhalers, a blue one and a purple one, and the spray for under the tongue if she gets chest pain.

SH: You live independently in a bungalow with Ellie and you celebrated your 45th wedding anniversary this year. You met Ellie when you were 20 and she was 18, married two years later and have been together ever since. You have two sons and a daughter who are grown up and married. Two still live locally but your younger son has recently moved to Australia with his wife and 4 year old son. Your daughter is married with two sons, and your younger son and his wife are expecting a baby due in a few months, your first granddaughter.

You are a retired office manager and your wife has just recently retired from her job as a dinner lady in a primary school. You are currently planning a big holiday, maybe a cruise, to celebrate your anniversary and Ellie’s retirement.

Ellie has been smoking for as long as you’ve known her. You’ve been nagging her to quit for a long time and she did cut down once the grandchildren were born but she never managed to quit completely.

ICE: You know that Ellie’s lungs are bad, but the mask ventilator worked last time so you think the doctors need to just give it a bit of a longer chance to work this time. You want to know if changing the antibiotics to something stronger would help as she’s had so many that “the usual ones” might not work on her.

You are completely shocked and devastated that the doctors think that Ellie is not going to survive this admission. You don’t understand how this could be happening since the treatment worked last time and you don’t see what’s different this time. You think that Ellie needs to be given every chance to survive as she still has so much to live for – your big cruise and her first granddaughter.

Your daughter is on her way in today anyway and should be here shortly, and you want to call the rest of your family but you’re worried about ringing your son in Australia as it will be the early hours of the morning there.

End of Life Care: If there really is nothing else that can be done, you want Ellie to be settled and comfortable. Ideally you would like her home if that is possible. Ellie was involved a lot in the church and you think she would probably like to have a priest with her at the end of her life.  

This is a communication skills station, the focus of which is breaking bad news and discussing end of life care. The student should use effective communication skills, both verbal and non-verbal, do communicate effectively and empathetically with the patient throughout.

This may include/be based on the SPIKES model for breaking bad news • S – Setting up: e.g. appropriate environment – is the person happy to talk where they are, would they like anyone with them etc., introduction and appropriate opening • P – Patient perception: How much is the person already aware of/what is their understanding of what’s happening? • I – Invitation from patient: Finding out how much the patient wants to know. • K – Knowledge: Passing on the required information to the patient – “warning shot”, deliver information in small chunks, avoid jargon, check understanding throughout, listen to the patients agenda and respond to it • E – Emotions: Address the patients emotions with empathetic responses – emotional reaction will vary – silence/distress/denial/anger. • S – Strategy and Summary: Make a plan/strategy with the patient, explain it, invite questions, and explain what happens next.

Other communication microskills which should be demonstrated are: • Signposting • Summarising • Open and closed questions • Exploration of patients ideas, concerns, expectations • Appropriate body language

Points for Discussion: • What symptoms do patients experience at end of life? • What medications can be used for these symptoms? • Who might be involved in a patients care at end of life?