Ethics OSCE Station Blueprint

Station Name: Do Not Intubate Me

Issue:

Decisions to Forgo Treatment

Presenting Situation:

Seventy year old Ms. Stone wants to make it known that she does not want to be intubated again. She was intubated a few days ago when she arrived at the hospital with acute pulmonary edema.

Activities:

Patient encounter.

Time Required:

10 minutes

This station was developed by Dr. Peter A. Singer (Centre for Bioethics and Department of Medicine, University of Toronto), and Anja Robb (Department of Family and Community Medicine, University of Toronto. It is part of the Ethics OSCE Project which is funded by Educating Future Physicians for Ontario (EFPO). There is an accompanying videotape. This material can be used for teaching or evaluation. It is not copyrighted and may be freely reproduced for educational purposes.



Instructions to Candidate:

You are about to see 70 year old Ms. Stone. A couple of days ago, Ms. Stone came to the Emergency Department in acute pulmonary edema. At that time Ms. Stone had been intubated and admitted to the ICU where she was kept intubated for 48 hours. Ms. Stone is presently extubated and has just been transferred to the ward under your care. You have been informed by the nurses that Ms. Stone is anxious to speak with you because she does not want to be intubated again.



CHECKLIST ITEMS:
^^^^^^^^^^^^^^^^

YES     NO     The Candidate:
        
               1.      asks about patient's mental or emotional
                       state. (e.g. Could you manage your own
                       affairs?  Are you feeling blue?)
----|-----------------------------------------------------------
               2.      ascertains that patient understands
                       disease. (pulmonary edema)
----|-----------------------------------------------------------
               3.      ascertains that patient understands the
                       treatment. (intubation)
----|-----------------------------------------------------------
               4.      ascertains that patient understands
                       consequences of decision.  (i.e. that
                       she may die without intubation.)
----|-----------------------------------------------------------
               5.      asks about the presence of other
                       potential decision makers/involved
                       persons.  (e.g. family, friends, spouse,
                       children, etc.)
----|-----------------------------------------------------------
               6.      asks whether patient wants other life-
                       sustaining treatments.  (e.g. CPR,
                       diuretics, oxygen, etc.)
----|-----------------------------------------------------------
               7.      agrees to respect patient's request or
                       states that people have the right to
                       make such decisions.  (e.g. We will
                       respect your wishes.  I think it's
                       certainly your right. etc.)
----|-----------------------------------------------------------
               8.      describes plan to act on patient's
                       request while patient is in hospital. 
                       (e.g. note in patient's chart, DNR
                       order, discussion with nurses or
                       housestaff, etc.)                    
----|-----------------------------------------------------------
               9.      describes plan to act on patient's
                       request after patient is discharged from
                       hospital.  (e.g. discusses advance
                       directive, living will, or durable power
                       of attorney, plans to communicate
                       patient's request to nursing home staff
                       or family doctor)
----|-----------------------------------------------------------
               10.     states that patient can change her mind.
----|------------------------------------------------------------ 
=================================================================

                              
RATE FROM 1-5:
 +------------------------------------------------------------+
 |        |          |          |    VERY    |                |
 | POOR   |   FAIR   |   GOOD   |    GOOD    |    EXCELLENT   |
 |  1     |    2     |    3     |     4      |       5        |
 +------------------------------------------------------------+

1.      How would you rate the candidate's communication skills?                                 
        1      2       3      4      5

2.      How would you rate the candidate's ability to address the
        ethical issue in this case?                 
        1      2       3      4      5


Instructions to Standardized Patients:

Your name is Dorothy Stone. You are 70 years old. You have never been married. Until 6 months ago, you lived in your own home (a condominium). For the past 6 months, you have been living in a convalescent home.

For the past 10 years you've had something wrong with your heart. It's not working as well as it should. The doctor told you it was because of coronary artery disease. You know that means your arteries are clogged up. There was no angina (i.e. like a knot or pressure in your chest).

You have chronic congestive heart failure, which means your "pump" (heart) is not working as efficiently as it could. This can result in water on the lungs. This is called pulmonary edema. You have had frequent hospital admissions for pulmonary edema (3 times in last year).

With acute pulmonary edema you experience an inability to get your breath. It feels like you are going to suffocate. You were intubated each time you were admitted to hospital. Intubation involves a tube being forced down your throat. It is very uncomfortable. Without intubation, you know you would die. With each successive episode of congestive heart failure, your heart was further weakened. After the last time, you were sent to the convalescent home because you needed time to recuperate.

Two days ago, you collapsed at the convalescent home. You experienced an inability to catch your breath. The nurses called an ambulance and you were rushed to the Emergency Department (ER). They forced a tube down your throat even though you tried to gesture that you didn't want it. You were taken to the Intensive Care Unit (ICU) and left on a respirator (breathing machine) for 48 hours. You are now off the respirator, out of the ICU, and on a ward in the hospital. You still feel weak but you are able to breathe for yourself (and speak for yourself).

You are not happy about having been intubated in the ER against your wishes. You want to make it perfectly clear that if you ever come back to the hospital, or if anything happens in the hospital, you do *NOT* want a tube down your throat again. You are extremely displeased about the indignity of having the tube forced down your throat.

You are a religious person, but your religion does not require you to accept "heroic" life-sustaining treatments. You are also a very practical person. You believe that if it's your time to go, it's your time to go. You believe you've had a long, good life and you are ready to die. You want to "die with dignity".

If asked about other life-sustaining treatments, you are willing to accept things like oxygen or drugs, but you do not want invasive (violent) action such as CPR. You definitely would not like to be hooked up to a breathing machine in the noisy environment of the ICU.

You miss the independence of living in your own home and being able to take care of yourself. You are not suicidal or acutely depressed. You are not expressing a "death wish". You just want to make it clear that you don't want that tube again. You are able to eat and sleep.

Timeline of Health Problems:

10 years ago:          diagnosed with coronary artery disease.

7 years ago:           hospitalized with pulmonary edema

4 years ago:           hospitalized with pulmonary edema

2 years ago:           hospitalized with pulmonary edema

1 year ago:            hospitalized with pulmonary edema

6 months ago:          hospitalized with pulmonary edema

2 days ago:            hospitalized with pulmonary edema
Prompts are used to standardize the scenario and give all candidates an opportunity to address relevant issues.

PROMPT 1 (immediately):
"Two days ago I came to the Emergency and they treated me by putting a tube down my throat even though I didn't want it and I tried to show them. I don't want to go through what I went through again!"

PROMPT 2 (by 2 minutes):
"I'm worried about what will happen if I need that tube again. I don't want it. I want to make sure you understand that I don't want to be intubated again."

PROMPT 3 (by 5 minutes):
"If this happens again will *YOU* put down that tube?"
(If candidate uses the word "they"- referring to doctors who might intubate the patient again - SP should use the word "you", because the patient is now under the candidate's care.)

PROMPT 4 (by 7-8 minutes):
"How will *YOU* make sure that my wishes will be respected?" (...in hospital and after discharge)

Sample Script:

Doctor: Patient: What's your understanding of what's going on? I have heart disease and I'm getting water on the lungs.

Do you know how we treat that condition? Can you describe what doctors have done in the past? They've put in the tube and they've given me drugs.

Are the drugs and oxygen OK with you? Yes. I just don't want that tube.

Do you have any family or friends who know about your decision? I have no family and most of my friends have worries of their own.

Do you know what would happen if we didn't put the tube in? I know it means I could die but when my time comes I want to die with dignity.

Do you want to die? I don't want to die, but I don't want that tube again.

Have you talked about this with anyone? Not really. I know my own mind.

What would you like to do if this happens again? If this happens to me again I don't want you to put a tube down my throat. You don't know what it's like to go through this.

Why do you want to make that decision? I've been through this agony 3 times already this year and I don't want to go through this again! God's given me a good life and I'm ready to die when my time comes.

Would you be willing to sign a form for me? What kind of form?


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