What happens now? OSCE by Michael

 
You have 3 minutes reading time. This OSCE will run for a maximum of 7 minutes.

Scenario:

You have been assessing and treating Desmond, a 74yo man who was brought by ambulance with altered mental state, hypothermia and hypotension. Des is normally bed-bound and fully dependent in a high-level-of-care nursing home following an acquired brain injury 30 years ago. His normal GCS is 12 (E4 V2 M6), and was noted to be 9 tonight (E3 V1 M5).

You have determined Des has severe sepsis of unknown source. His ABG showed a pH of 7.1 with a lactate of 6. You have fluid resuscitated and given appropriate antibiotics. After 3L of fluid, he has produced 25mL of urine via an IDC.

In his paperwork from the nursing home is an Advanced Care Directive from 2 years prior indicating that "All measures are to be undertaken, including CPR". This was signed by Des' sister, his only family, who has just arrived.

Instructions for the candidate

You are to discuss Des' current situation with his sister, Jane. As part of this discussion, you are to clarify the Advanced Care Directive and end of life wishes.

Domains being examined

  • Medical Expertise
  • Communication
  • Health Advocacy
  • Professionalism
 
The candidate has 3 minutes reading time. This OSCE is expected to run for a maximum of 7 minutes.

For the actor

You are a 71yo lady, married with 2 grown children and 3 grandchildren.

Des is your only remaining direct family member, and you were always close. Since his injury, you visit him almost daily. You feel he remains interactive. His eyes brighten and follow you when you visit, and he makes some sounds. He is unable to use any of his limbs effectively due to spasticity.

You want all appropriate treatment to be provided. At the time of the Advanced Care Directive you were asked this question, and you answered yes. No further details were explored.

You would like to see Des returned to his nursing home in similar state to his normal self. You are unfamiliar with the terms "for resuscitation", "CPR", "intubation" and any medical jargon.

When the candidate raises the issue, you may be surprised, you may ask "are you going to withdraw care?".

You are worried that if you do not say "do everything" that he will receive inadequate care, and he may thereby suffer. You would like him to receive antibiotics and IV fluids. You would not like him to be intubated, receive CPR nor have any invasive procedures. You feel certain Des would not like to be on a mechanical ventilator, nor have his life prolonged using artificial methods.

You firmly believe that Des should receive maximal therapy to treat the current infection, but if this illness turns out to be insurmountable that Des should be kept as comfortable as possible.

Ask:
- "Is he going to die?"
- "When will he die?"
- "What happens now?"

For the examiner

None

Domains Assessment Objectives

Medical Expertise
Prognosis and management of severe sepsis in highly comorbid patient

Communication
Clear, specific and empathetic.
Appropriate body language.
No euphemisms.

Health Advocacy
Focus on good end of life care, maintaining dignity and comfort

Professionalism
Respectful, empathetic

Other Assessment Notes


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