OSCE: Breaking Bad News – AAA

OSCE 7: Breaking bad news – AAA.

Scenario Stem:

You are the consultant in charge on an evening shift. George is an 85 yr old man brought to your tertiary ED by ambulance following a collapse at home. George complained of severe abdominal pain into his lower back prior to the collapse. He had no LOC and sustained no injuries during the fall.

The ambulance crew found him to be awake with an unrecordable BP and in a moderate amount of pain. They gave 500 mls of 0.9% saline and 2x 25mcg of IV fentanyl. They didn’t have time to gather any more information except to say that they think he has dementia.

On your assessment in the ED he has the following vital signs: HR 110, BP 70/45, GCS 12 and on examination a large pulsatile mass in his abdomen which is tender to light palpation and a FAST demonstrates a 7cm AAA. The vascular surgeon is not in the hospital but has asked for a decision to be made as to whether he is suitable for theatre.

The evening care nurse raised the alarm at George’s house and has informed his son. His son is in the relative’s room awaiting an update.

You have seven minutes

Domains assessed:

• Health Advocacy
• Professionalism and Communication

Advice / framework for a breaking bad news scenario:

1. Thank them for meeting with you. Some people may ask at this point if they have anyone else with them.
2. Fire a ‘warning shot’ – “I have some bad news” and give them a brief synopsis of their relative’s condition.
3. Check their understanding of what they know so far and fill in the gaps. Often if there is an image of an ICH then this makes the scenario more understandable.
4. Give a prognosis to the situation.
5. This is where breaking bad news can split in terms of a ‘dying conversation and a ‘treatment option discussion. In someone who is dying: offer and explain all the palliative supports you will provide. Sometimes, as is the case above, you are not sure which direction you will go in. This is where you need to establish the patient’s wishes, PMH and baseline activity to ascertain if you have a treatment option. If you have options both you and the relative need to decide what the patient would want – “If George were in the room, what do you think he would say in this situation”.
6. Decide your management plan and use examples that the relative has given to justify your reasoning. If there are treatment options you might want to open with “This is clearly a difficult decision, would you like me to offer an opinion?” Most people will agree and this also gives them the opportunity to disagree with you. If you believe the conversation is being sidetracked to the relative’s own wishes, keep bringing the conversation back to “What would George want?”
7. Explain to the relative all the supportive care you will provide for their loved one.
8. Offer to call other relatives, especially prior to anyone getting on a plane if there is a possibility that the patient will die before they get to the bedside.
9. Offer pastoral care, social workers, a private room and to be available at any time while they are with you in the ED. End of life is the most critical time in a patient’s life and everyone will remember what you do.

Additional comments on this video:

• Be definite, he will die from this. This is not a survivable condition (after a warning shot, don’t open with this). The vascular surgeon will want a definitive answer from you.
• He will not survive ICU and it would be better to be in comfort with his family, than on the end of lines and tubes.
• An operation is the only hope of a very slim chance of survival but in order to survive that and ICU you need everything going for you, you can’t have any significant past history including dementia.
• ICU supports the body while it repairs, unfortunately dementia is a terminal illness and we can’t make the brain better.