Case study! please Help me!

Doing well until this response.

She doesn't need an explanation of hospice, especially does not need to hear what she needs or "doesn't need".

This is the time for open-ended questions.

Case study:

Mrs. Jones is admitted to your unit following a simple mastectomy for breast cancer. The tumor was staged as a T2, N0, M0. Estrogen and progesterone receptors were negative. A bone scan was negative for metastasis. She is scheduled for four chemotherapy treatments, 3 weeks apart. The medications prescribed are high doses of doxorubicin and cyclophosphamide. A central line has been inserted for chemotherapy.

1. You enter the room to provide the discharge instructions and find Mrs. Jones crying. She says to you, "Do you think I should get a second opinion about treatment?" Your response is:

2. Ordered: Reglan 1.5 mg/kg po 30 minutes prior to beginning chemo.

Can you determine the amount to be given? If yes, how much will be given? Show your work.

If no, why not?

3. Time lapse: Mrs. Jones returns for her final dose of chemo therapy. Her CBC reveals: RBC 3.7 million/mm3; WBC 3,700/mm3; Plt 25,000/mm3. She is unable to receive her chemotherapy today. Explain the reason for this.

4. Given Mrs. Jones labs above, describe her risk for complications and methods/interventions to prevent these complications.

5. At this visit, Mrs. Jones is upset that she is unable to receive her chemo and states, "Maybe I need hospice." What is your reply?

Please help me!

Ok, for #1, I wouldn't necessarily say "yes, get a second opinion" but discuss with the patient why she thinks she needs one and allow her to make the decision herself.

2. You are correct, the scenario doesn't give you her weight so you can't do the calculation.

3. The one glaring result here is her platelet count. I have never seen chemo held for a WBC count of 3.7 and we typically use Hgb/Hct rather than RBC count to gauge anemia. I've given chemo to patients with WBCs in the 1-2k range, we only hold for ANC

4. See above- what kind of complications can someone with thrombocytopenia develop?

5. It's not appropriate to just tell her "you don't need hospice". You need to explore why she thinks this. Does she think her cancer is going to grow uncontrollably if her chemo is delayed? Does she understand why she can't get chemo?

Expanding on my last brief answer. It appears you applied an intervention without doing any assessment. So what should you do?

One of the Laws from Shem's classic follow-up to House of God, Mount Misery, is, "Don't just do something, stand there." This is a roundabout way of explaining that although we spend a lot of our education learning about things to do, sometimes the best thing to do is nothing, and to get a little more information. "Tell me about what you think about that" is often a good way to get people talking about what their concerns really are.

Another thing to consider when a patient asks you what he should do, or what you would do in his shoes, is that you cannot and must not answer that question factually. That is, you can't say what you'd do, because you are not him. You can help him explore his thoughts, you can identify need for more information for him from his physician, you can discover that's not really the question and perhaps the chaplain would be his best bet, you can assess for a lot of things.

But you can't, in essence, tell him what to do. If it doesn't turn out well, he can say, "Well, my nurse told me that was best," and it is NOT your job to do that.

"Don't just do something, stand there" was one of the Fat Man's aphorisms in House of God, but not an actual law. My error.

The actual Laws from Mount Misery:

VIII. Your colleagues will hurt you more than your patients.**