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Older Patient with Multiple Co-Morbidities, Advanced Session


 


 
Goals:

A PGY-3 resident will be able to develop strategies for managing complex elderly patients, using the principles of the Patient-Centered Clinical Method.

Objectives:


Patient Care

  • Develop a differential diagnosis for a patient’s problem(s)
  • Develop a plan for management that incorporates an understanding of the patient’s feelings and ideas about their illness, functional state and expectation as well as an understanding of the whole person
  • Identify gaps in knowledge of these areas (patient’s feelings and ideas, etc. and their proximal and distal context)

Medical Knowledge

  • Describe which functional assessment tools would be appropriate in management of the patient
  • Demonstrate a knowledge of the patient’s disease process
  • Describe the patient-centered clinical method

Interpersonal Communication

  • Demonstrate an ability to contribute positively to group discussion

Systems-Based Practice

  • Describe the potential roles of other health professionals in the care of the patient
  • Identify community resources that would be appropriate for care of the patient

Professionalism

  • Demonstrate a sensitivity to the needs of the older patient
  • Recognize ethical issues encountered in these scenarios
  • Demonstrate respect of the older patient in discussion of these scenarios

Practice-based learning and improvement

  • Provide a scenario based on a patient you have seen, as well as several questions that have arisen for you in the care of this patient

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Session Guide

 

Time needed: 2 to 3 hours, depending on the how many scenarios are discussed

Equipment needed:

  • Tables and chairs for small group discussion
  • Flip charts and markers
  • LCD projector and computer is optional
  • White board with markers is optional.

Suggested Readings:

This reading discusses principles that may be helpful in caring for older patient with multiple co-morbities:

Patient-centered care for older patients with multiple chronic conditions: A stepwise approach from the American Geriatrics Society. J Am Geriatr Soc. 2012;60:1957-1968.

More resources available at:

3 or more: Managing multiple health problems in older adults. Availabe at: http://www.americangeriatrics.org/health_care_professionals/clinical_practice/multimorbidity

Recommend readings that address the conditions in the case scenarios. Sample readings below (taken from the JAMA series Care of the Aging Patient: From Evidence to Action)

Reuben, DB. Medical Care for the Final Years of Life: “When You’re 83, It’s Not Going to Be 20 Years.” JAMA. 2009;302(24):2686-2694

Carr, DB, Ott, BR. The Older Adult Driver with Cognitive Impairment: “It’s a Very Frustrating Life.” JAMA. 2010;303(16):1632-1641

Tinetti, ME, Kumar, C. The Patient Who Falls: “It’s Always a Trade-off.” JAMA. 2010;303(3):258-266

Breitbart W., Alicia, Y. Agitation and Delirium at the End of Life: “We Couldn’t Manage Him.” JAMA. 2008;300(24):2898-2910

Kleerekoper. Clnical Crossroads: A 73-Year Old Woman with Osteoporosis. JAMA. 1999;282(18):1723

Goode, PS, Burgio KL et al. Incontinence in Older Women

JAMA. 2010;303(21):2172-2181

Arroyo, JG. A 76-Year-Old Man with Macular Degneration. JAMA, May 24/31, 2006; Vol 295, No. 20:2394-2406


Instructor script and notes:


NB:
1 to 2 weeks prior to session, ask residents to identify an older patient they have cared for that has posed a difficult management issue for them. Ask them to draft a brief scenario describing the case, and two identify at least 2 questions they have regarding management of the patient. As instructor, you will need to collect these responses, edit them and collate them for the session.

  1. Briefly review the goal for the session. You will review the objectives in more detail before beginning the discussion. For example, “Today we are going to apply the principles of the patient-centered clinical method to some difficulty patient situations that you have encountered.”
  2. Review the patient-centered clinical method – 20 minutes
    1. Recommend drawing the outline of the method on a white board, and “filling it in” – ask the residents to describe the various components. Or, you can project a slide with an outline of the method on a smart-board, ask the residents to describe the various components and “fill it in.” Or you can project a slide with the method fully diagrammed and discuss the various components. Or you can handout a sheet with a diagram and discuss.
  3. Case discussion
    1. Provide an overview of the structure: we will break into X groups (of 3 to 4 residents, depending on the number present). Each group will discuss X number of cases (depending on time and number of residents), and will then present the results of your discussion to the entire group.
    2. Describe the format for group discussion, using the guidance below:
    3. As a group, identify:
      1. Medical conditions involved
      2. Include differential diagnoses
      3. Functional domains you need to assess and how you would assess them (which instrument)
      4. Which medical conditions pose greatest threat to functional status
      5. Other health professionals that might help you gather information, assess function, and help you implement a management plan
      6. Community agencies that might be helpful in management of the patient
      7. Review the patient-centered clinical method below, identify potentially useful (needed) information from:
        1. Understanding patient’s feelings and ideas about illness, functional impacts and expectations.
        2. Understanding the whole person (the person, their proximal context and distal context).
      8. Envision what common ground would look like for this patient
        1. What are the problems that could be agreed upon?
        2. What would your roles/patient’s roles/family or caregiver roles be?
        3. What are goals that might reasonable be held in common?
      9. Identify potential resources to help with medical decision making and medical management.
      10. Identify and prioritize unanswered questions/issues.
    4. Break the larger group into smaller groups of 3 to 4 residents.
      1. Give each group a flip chart and markers
      2. Give each group at least once copy of the Discussion Guide and the diagram of the Patient-Centered Clinical Method
      3. Give each group at least one copy of the cases
      4. Instruct the group to identify the cases provided by that group’s members. That group will discuss those cases. Have group select a case to discuss.
      5. Ask the group to discuss a case, using the Discussion Guide, and to write their key findings on a flip chart.
      6. Clarify that everyone understands the instructions.
      7. Give the groups about 10 to 15 minutes to discuss each case.
    5. Monitor groups’ progress, answer questions, and keep them on track.
    6. Group presentation: Once done with small group discussion, each group should present their case and their discussion to all of the groups. Give each group 5 to 7 minutes to do this. Keep track of important concepts, and highlight them at the end of each discussion.
    7. Repeat steps d through f until all cases are discussed or until group runs out of time. Give feedback to groups, especially after the first set of case discussions, to help them stay on task with use of the Discussion Guide.
  4. Summary and wrap –up
    1. Review some of the important points and questions that arose during the case discussions, with particular emphasis on understanding and assessment of the patient’s function, and on key elements that would facilitate the finding of Common Ground between patients and physicians.

Extra tips: If there are certain conditions that you want to highlight (e.g. driving assessment), include some illustrative cases in the list of cases, in the event that the condition is not included in the cases generated by the residents. Be sure to let residents know that these cases will be included ahead of time. Also be sure to let residents know that there may not be time to discuss all of the cases. Don’t spend too much time at the beginning on discussion of the patient-centered clinical method – this is a “refresher, and the case discussions will help to give residents a better understanding of the method.


Handouts and Teaching Materials:

  • Outline of the Patient-Centered Clinical Method (handout and PowerPoint slide)
  • Diagram of the Patient-Centered Clinical Method (handout and PowerPoint slide)
  • Discussion Guide (handout)
  • Cases (sample list of cases provided)

Instructor Reference Materials:

  • Review chapters 2, 3, 4, 5, 6, 7, 8, 9 and 10 in Patient Centered Clinical Method, 2nd Edition, Stewart, M, Brown, JB, Weston, et al., Radcliffe Medical Press, 2003.
  • Be familiar with the diagrammatic representation of the Patient Centered Clinical Method.