The strategy for tackling the
communication and ethics station is described in detail in ACES for PACES
chapter 18
Information
A
67-year-old patient has been admitted to your ward with a history of cough,
breathlessness and weight loss. The chest x-ray looks suspicious of lung cancer.
Please explain your plan of investigation to the patient. The patient is
concerned that he has lung cancer and is apprehensive about invasive
investigations, as he has heard from friends that these may be uncomfortable.
Plan
(See ACES
for PACES Page 571)
Objectives
The objectives of investigation in this case are:
♥
Anatomical Diagnosis
Define the exact site of the
lesion
ª
Pathological Diagnosis
Type of cancer and staging
¨
Physiological Diagnosis
Pulmonary function
Methods
§
Fluids
Sputum cytology
♥
Imaging
CT scan; chest and abdomen
ª
Physiological Assessment
Pulmonary function tests
¨
Endoscopy
Bronchoscopy, endoscopic
ultrasound
§
Surgery
Mediastinoscopy
Risks and Benefits
Bronchoscopy and mediastinoscopy are associated with risk
but the benefits of accurate diagnosis and staging, leading on to tailored
treatment, outweigh these risks.
Introduce /Identify
Listen
(See ACES for PACES Page 581)
Thoughts (Views)
♥
Thinks he has lung cancer
Knowledge
ª
He has heard that lung cancer is a very serious condition and that
despite treatment, which can have a lot of side effects, it may still be fatal.
Expectations
¨
The patient expects to undergo several tests and he feels that
some of them may be unpleasant and dangerous
Causes
¨
He is worried that the illness has been caused by his smoking and
that his wife may have been affected by passive smoking
Effects
§
He is worried that the investigations that he is likely to undergo
are invasive and associated with a lot of complications
Survival
♥
He is worried that the invasive investigations themselves may
cause death and he may not live long enough to receive treatment.
Modify
(See ACES for
PACES Page 582)
ª
There is no necessity to modify the plan in this instance as the
patient’s line of thinking is in keeping with the suggested plan of
investigation.
Convey (Deliver)
(See ACES for PACES Page 580)
♥
Agree that the likely diagnosis is lung cancer but until
investigations have confirmed the diagnosis and staged the disease one would be
unable to proceed further.
ª
Agree that lung cancer is a very serious condition and treatment
is difficult but experienced clinicians who would tailor treatment to maximise
benefits and reduce risk would carry out treatment.
¨
Agree about the risk of passive smoking but say that the patient’s
GP could see his wife and if necessary arrange consultation with a chest
physician to look into the possibility of her having developed the condition
although the risk is low.
§
Discuss the investigations; list them say why they are necessary
and what the risks are
♥
Assure the patient that competent individuals who would ensure
that risk is kept to a minimum would carry out the invasive investigations.
