Faculty: Dr. Farr Curlin Section of General Internal Medicine 02 Aug 2010

1. Faculty: Dr. Farr Curlin Section of General Internal Medicine 02 Aug 2010 Morning Report

2. MKSAP Question A 72-year-old man is evaluated at the hospital for colorectal cancer that has metastasized to the liver. A decision needs to be made regarding whether to initiate chemotherapy, which is not expected to be curative but could prolong the patient’s life by 12 to 18 months. The patient has experienced memory loss over the past 2 years, and his wife has taken over management of family finances and driving. A Mini–Mental State Examination reveals a score of 22 (normal ≥24/30). The remainder of the neurologic examination is normal. In consultation with the oncologist, the benefits and risks of chemotherapy as well as alternative treatments are explained to the patient and his wife.

3. MKSAP Question Which of the following is the best way to arrive at a decision regarding chemotherapy for this patient? A. Ask the patient if he wants chemotherapy B. Ask the patient if he wants chemotherapy now and ask him again later today C. Ask the patient to repeat the key benefits and risks of chemotherapy D. Ask the patient why he does or does not want chemotherapy E. Defer decision to the patient’s wife

4. MKSAP Question Which of the following is the best way to arrive at a decision regarding chemotherapy for this patient? A. Ask the patient if he wants chemotherapy B. Ask the patient if he wants chemotherapy now and ask him again later today C. Ask the patient to repeat the key benefits and risks of chemotherapy D. Ask the patient why he does or does not want chemotherapy E. Defer decision to the patient’s wife

5. MKSAP Question Soliciting a patient’s decision after explaining the benefits and risks of a particular treatment as well as alternative treatments is appropriate, but a mere yes or no answer does not guarantee that the patient has fully understood the consequences. A more stringent criterion, appropriate for a complex or potentially burdensome treatment, is to not only ask what a patient wants, but the reasons why he or she makes a particular treatment choice. In this patient in whom mental status testing has revealed mild dementia, it is appropriate to inquire about the reasons behind his decision regarding chemotherapy.

6. The Patient • 58 year-old with SLE and ESRD 2/2 lupus nephritis presenting with lethargy and confusion.

7. Presentation • One week of increasing lethargy and confusion • Patient noted possible right arm spasms 4 days prior to admission • Significantly decreased PO intake • Some difficult to characterized back and abdominal pain • No fevers, chills, cough, SOB, diarrhea, CVA tenderness or suprapubic pain • Presented on Saturday. Missed dialysis Friday • Patient present by herself in ER and no family was available to corroborate history. Eventually, a personal assistant provided some data • Overall, a difficult history to obtain 2/2 patient’s clinical state and her willingness to cooperate

8. PMH and Background • PMH • SLE – 1999 • ESRD 2/2 SLE • ? Sz disorder • HTN • COPD • Degenerative joint disease of L-spine • DVT of UE in distant past • Depression • Abdominal Aneursym • PSH • Tubal Ligation • Partial hysterectomy and salpingo-oopherctomy • Allergies • PCN  Anaphylaxis • Meds • ASA 81 mg qd • Clonidine 0.2 mg bid • Diltiazem SR 180 mg qd • Diovan 320 mg qd • Enalapril 10 mg qd • Metoprolol 50 mg qd • Plaquenil 200 mg qd • Prednisone 15 mg qd • Ranitidine 150 mg qd • Trileptal 450 mg bid – not taking • Social • Lives alone. Personal assistant helps with some ADLs and most iADLs. No significant family involvment.

9. Physical Exam • T: 36 P: 85 BP: 140/80 RR: 16 O2sat: 93% on RA • Gen: Cachetic and withdrawn • HEENT: PERRLA, EOMI. Mucus membranes dry. • Lymph: No palpable nodes • CV: RRR normal S1,S2 III/VI holosystolic murmur at apex, no LE edema • Pulm: Clear anteriorly • Abd: Soft, NT, BS+, palpable abdominal aorta • Neuro: Moving all extremities with no signs of focal weakness. Confused and somnolent but was A&O x 3 at other times • Skin: Skin tenting. No other significant lesions

10. Initial Laboratories 87.2 7.0 10.9 83 135 93 2.6 96 11.5 56 5.4 19 8.9 34.1 4.5 N 84 L 6 M 6 Bands 1 7.6 3.3 Ketones 2.7 Lactic Acid 3.0 CK 992 CK-MB 17.7 CK-MB RI 1.8% TnT 0.76 4.1 2.9 U 1.2 C 1625 544 178

11. Differential Diagnosis? • Multiple problems are present, let’s focus on altered mental status

12. Altered Mental Status • Metabolic • Hyponatremia • Hypoglycemia • Uremia • Acid-Base • Anemia • Pulmonary • Hypoxemia • Hypercarbia • Systemic • Infection: sepsis, menigitis, encephalitis • Neoplasm: CNS, paraneoplastic • Sensory deprivation: extreme fatigue • CNS • Seizure • Trauma • Infection • Stroke • CV • Shock • MI • Decompensated CHF • HTN encephalopathy • Arrhythmia • Toxins • Sedatives / Hypnotics • Opiates • Anticholinergics

13. Altered Mental Status • Metabolic • Hyponatremia • Hypoglycemia • Uremia • Acid-Base • Anemia • Pulmonary • Hypoxemia • Hypercarbia • Systemic • Infection: sepsis, menigitis, encephalitis • Neoplasm: CNS, paraneoplastic • Other: TTP, SLE flare • Sensory deprivation: extreme fatigue • CNS • Seizure • Trauma • Infection • Stroke • CV • Shock • MI • Decompensated CHF • HTN encephalopathy • Arrhythmia • Toxins • Sedatives / Hypnotics • Opiates • Anticholinergics

14. Work-Up / Management ?

15. Fast Forward Diagnostics • CT Head: No acute intracranial process • CT A/P: abdominal aneurysm, possible fatty infiltration of liver and 2.7 cm cystic lesion in pancreas • Blood cultures negative • C3, C4 decreased • LP refused • Smear analyzed, heme consulted. Felt not TTP • MRI showed punctate acute infarcts in the R external capsule, junction of R frontal / parietal lobe, L parietal lobe as well as subacute infarct in L occipital lobe with hemorrhagic component • TTE demonstrated worsening EF from prior (to 30% from mid 40%s), regional wall motion, intra-atrial shunt and significant valvular disease

16. Fast Forward / Summary Therapeutics • Patient placed on D5 ½ NS at low dose x 1 day. Over several days, MS improved and patient took PO well with no further episodes of hypoglycemia • Placed on broad spectrum abx initially but these were stopped as patient not thought to be systemically infected • Treated for SLE flare with solu-medrol • Received dialysis with minimal volume removal as quite dehydrated on admit • LFTs, thrombocytopenia and MS all gradually improved

17. Continued Management • Overall, believed that patient had stroke and lupus flare acutely and additional findings that would need: • Cardiac procedures, vascular consult, interventional GI • The patient’s course was complicated by several refusals of tests and the tests that were completed required several attempts • Many hours spent negotiating with the patient what tests we could do, what therapies we could give, and the necessity of all of these interventions • It was unclear how much of this the patient completely comprehended

18. An Ethical Dilemma • By hospital Day #6, patient was refusing further testing and the team was beginning to experience significant burn-out related to the patient’s care. • Did the patient have the capacity to refuse? • Was the team’s burn-out affecting it’s care of the patient?

19. Decisional Capacity • What is it? • How to assess it? • Did this patient have it?

20. Decisional Capacity • Capacity versus Competency: • Competency is a legal term indicating whether a person has the authority to make personal choices for him/her self. Only a judge determines this • Legally competent persons can have their mental capacity diminished by illness, anxiety, pain or hospitalization • Capacity is determined by physicians • Assessing this is an essential component of informed consent. • Determining whether a patient has capacity is a clinical judgement • Psychiatry consult service and ethics consults are a resource that can be used to help make the determination

21. Decisional Capacity • Psychiatry was consulted • After initially indicating that they did not believe the patient had capacity, they ultimately felt that the patient did have the decisional capacity to refuse medical procedures / treatments

22. Does burn-out affect your care of patients?

23. Does burn-out affect your care of patients? • Burn-out is defined as a syndrome of depersonalization, emotional exhaustion and low personal accomplishment • Survey at a single residency program found that 76% of medical residents met criteria for burn-out • Same study showed that depersonalization was associated with suboptimal patient care. TD Shanafeit et al. Ann Intern Med. 2002; 136:358-367

24. Physician Burn out and Unrecognized Emotions • Physician feelings are usually seen as being extraneous. • Psychiatrist have long used emotions generated in clinical encounters as therapeutic information. • If not recognized and managed these emotions can affect both the medical care that the physician provides and the well being of the physician themselves Meier, DE JAMA 2001;286(23):3007-3014

25. Medical Model for Approaching Physician Emotions • Identify risk factors. • Monitor for signs (Behaviors) and Symptoms (Feelings) of Emotions. • Name and Accept the Emotion • Reflect back on the risk factors and identify possible sources (Differential Diagnosis). • Respond Constructively to the Presence of the Emotion.

27. Management • Respond Constructively to the Presence of the Emotion • Step Back From the Situation to Gain Perspective. • Identify Behaviors Resulting From the Feeling. • Consider Implications and Consequences of Behaviors. • Think Through Alternative Outcomes for Patients According to Different Behaviors • Consult a Trusted Professional Colleague.

28. Take Home Points • Altered mental status is a complicated and common presenting symptom that requires constant re-evaluation as you attempt to identfiy a source • Decisional capacity is a clinical judgement that can be made by you but you may consider obtaining opinions from psych and / or ethics. • Burn-out can be dangerous for both the patient and he physician. It is often secondary to unrecognized physician emotions . If you start to experience it, talk to someone – your senior, a colleague, a chief, etc.