Risk factors for complicated grief include a history of mental illness, substance abuse, previous loss, and sudden unexpected death. Medicare pays for bereavement counseling for up to 1 year after the patient’s death. Additional grief counseling would then be through a local support group. Studies have shown that men are less likely than women to openly express emotions or openly cry. This is felt to be a reflection of social norms for males having to show strength, and crying being perceived as a sign of weakness. Men often prefer to grieve alone or in private.
Portal hypertension often occurs in the presence of cirrhosis. Increased intrahepatic vascular resistance, and increased blood flow through the portal venous system, leads to the development of portosystemic collateral veins. With medium to large veins in the esophagus, the patient has up to a 30% chance of bleeding out within 2 years.
A 3rd heart sound is indicative of increased ventricular filling and is found in congestive heart failure and with severe mitral or tricuspid regurgitation. S3 is usually faint and lower in pitch than S1 and S2. A pericardial effusion is associated with a pericardial friction rub which sounds high-pitched, scratching, or grating on auscultation. Cardiac tamponade is evidenced by tachycardia, diminished heart sounds, and a pericardial friction rub. Hearing a 3rd heart sound is not considered an arrhythmia and can be considered a normal finding in certain patient populations.
In a coma, the patient is unconscious and unresponsive. A patient in a persistent vegetative state is conscious but has lost cognitive function. A good example is the Terri Schiavo case in which she had sleep and wake cycles and was conscious. Her caregivers felt that she had purposeful awareness of them and her surroundings. In actuality, she had no purposeful connection with her environment due to the severity of her brain damage as was evidenced by the MRI of her brain. The prognosis for a patient in a coma depends on the underlying cause and severity of the brain damage. Patients in a persistent vegetative state have a very low chance of recovery after the first 6 months.
Hepatorenal syndrome is a common disorder that occurs in approximately 40% of patients with end-stage liver disease. Symptoms can be vague, and the patient’s renal failure can be overshadowed by the patient’s end-stage liver disease.
In the Korean culture, the husband, father, or eldest son ultimately makes the decisions, although the family is typically very involved in the patient’s care. This culture is family-focused, although the husband, father, or eldest son will most likely have the final way.
The purpose of advance directives is to have a way to voice your healthcare wishes when you can no longer do so. A healthcare proxy is an individual that is assigned by the patient to make healthcare decisions on their behalf. The healthcare proxy should be aware of what the patient’s wishes are, and this individual is being trusted to carry out those wishes. A power of attorney over an individual’s will and delegation of assets is not part of the components of an advance directive. Religious beliefs such as post-mortem rituals can be carried out by the healthcare proxy, but this is not one of the primary components such as life-sustaining measures.
Upholding a good relationship with your referral source and discussing referred cases is not only expected but is an important aspect for transparence in managing the care of the patients being referred. Either call oncology or set up a meeting for further discussion. While it is known that families and those close to the individual with a terminal illness frequently overestimate the possibility for a cure, it is good practice to review or correlate what the family is telling you with the chart or the referring provider. Terminal illnesses reach a point where life-sustaining methods are no longer an option and quality of life is the primary focus.
The Ask-Tell-Ask technique starts the dialogue by first asking the patient what they already know about their illness. This gives the provider insight as to what the patient already knows. This is important information because the patient may have the idea that further treatment or a cure is still available for their condition. The patient must first come to a realization that their illness has progressed far beyond a viable cure or treatment option before end-of-life discussions can effectively be held.