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second level
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Module 8:
Sudden Illness
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E
P
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=
Sudden
Illness
=
Module=
8
![](3D"master06_background.gif")
![](3D"master06_image003.gif")
Objectives
•De=
scribe
the features of sudden illness that require special skills&=
#13;
•K=
now
how to
communicate effectively
guide decision making
•E=
xplain
the benefits and risks of a time-limited trial approach
Sudden illness . . .
<=
span
style=3D'mso-special-format:bullet;color:#FF3300;position:absolute;left:-4=
.55%'>•Patient,
family, caregivers under stress
• Prognostic
uncertainty
•Chaotic environment,
multiple care providers
. . .
Sudden illness
•C=
ontinuous,
sequential decision making
assess / reassess the goals of care
•A=
cute
symptom management
•P=
atient,
family, caregivers need support
Overview . . .
<=
span
style=3D'font-weight:normal'>•Communicate possible
outcomes
<=
span
style=3D'font-weight:normal'>•Identify decision poin=
ts
in advance
•Use goals of care to g=
uide
decision making. . . Overview
•T=
ake
sociocultural issues into account
address differences
use clear language
•M=
anage
symptoms effectively
•I=
mpact
of stress on caregivers
Provide structured interaction
<=
span
style=3D'font-weight:normal'>•Prepare early for futu=
re
decisions
•Set expectations for
future communication
Communicate range of =
possible
outcomes . . .
<=
span
style=3D'font-weight:normal'>•Avoid waiting until mo=
re
is known
<=
span
style=3D'font-weight:normal'>•Identify most & lea=
st
likely outcomes
•Acknowledge limits of
individual experience
<=
span
style=3D'mso-special-format:lastCR;display:none'>
.
. . Communicate range of possible outcomes
<=
span
style=3D'font-weight:normal'>•Discuss what is likely=
to
happen next
<=
span
style=3D'font-weight:normal'>•Use evidence-based
information
Identify decision points in <=
/span>advance
•S=
igns
that a decision may be near
•T=
ime
course expected before next decision
•P=
repare
for
changing goals
discussion of informed consent
Use goals of care to =
guide
decision making
•G=
oals
of care determine the treatment plan
values, preferences help determine goals
•I=
dentify
the degree of
recovery that would be acceptable
certainty recovery could be achieved
Informed consent
<=
span
style=3D'font-weight:normal'>•Burdens, benefits of ea=
ch
alternative
Benefits, burdens of time-limited
trials
•Use while more information is gathered
• May result in a poor outcome
<=
span
style=3D'font-size:97%;font-weight:normal'>•Can stop life-sustaining treatment
<=
span
style=3D'font-size:97%;font-weight:normal'>•Provides structure, helps families
<=
span
style=3D'font-size:97%;font-weight:normal'>•Decision to stop may be more difficult
Sociocultural
differences . . .
differences . . .
•Distrust
of the medical system or physicians
•Unrealistic expectatio=
ns
of the medical system or physicians
•Any life, no matter ho=
w compromised,
is worth living
. .
. Sociocultural
differences
differences
Manage symptoms
Impact of stress on <=
span
style=3D'position:absolute;top:51.8%;left:1.09%;width:97.36%;height:49.39%=
'>professionals
<=
span
style=3D'font-weight:normal'>•Communication, common g=
oals
help
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End of Module 8:
Sudden Illness
Review Fast Facts
Complete Module 8 Post Assessment
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Sudden illness, particularly when=
it is
severe and unexpected and has an uncertain prognosis, challenges everyone.=
As
in other aspects of medicine, there are features and skills that can be
learned. Structured communication is especially important when the prognos=
is
is uncertain. Goals for care may need to change rapidly as the prognosis c=
hanges.
Discussions should include the possibility of time-limited trials. Sociocu=
ltural
differences may need rapid and sensitive appreciation to keep urgent care
consistent with the patient’s
values.
Situations of sudden illness are =
often
caused by an unexpected event, such as an accident or a sudden change in t=
he
patient’s health status. Frequently, the patient and family members =
find
themselves in a turbulent environment—such as the emergency room or
intensive care unit—where there are many people involved in the care=
of
the patient, the situation is constantly changing, and critical decisions =
need
to be made rapidly.
During these times, physicians and other members of
the health care team are simultaneously working to save the patient’s
life, manage symptoms, and prepare the patient and/or family for the possi=
ble
outcomes and the hard decisions they will need to make. The uncertainty and
chaotic nature of these situations can make it difficult for patient,
families, and the health care team alike.
The goal of this module is to ena=
ble
physicians to effectively facilitate decision making in situations of sudd=
en
illness where a patient’s condition is changing quickly and there is
prognostic uncertainty. The module discusses guiding principles and steps =
the
physician should take to optimize communication, provide structure in an a=
tmosphere
of uncertainty, and ensure that decisions are based on informed consent and
identified goals of
care.
An understanding of the character=
istics
common to stressful situations involving sudden illness will help the
physician to guide care more effectively. Although each situation will dif=
fer,
there are 7 guiding principles that are likely to aid decision making duri=
ng
intense situations. They are outlined here and discussed in detail in the =
sections
that follow.
1. Provide structured interaction. Establish regul=
arly
scheduled communications between
1 person from the family and one from the health care team. This
reduces
confusion and avoids misunderstandings. It helps to keep things on track. =
It
breaks activities
down into steps that can be taken one at a time:
· Use good communication skills. Get the setting right, ask the fam=
ily
what they understand
before giving them information, respond to their emotions, and establ=
ish
a
follow-up plan, even if it’s just for the next few hours (see
Module 2: Communicating
Bad News).
· Expect emotions to be prominent and fragile.
2. Communicate the range of possible outcomes. In situations of
prognostic uncertainty, do not wait to communicate, even if there is little
known information. Tell what you do know as soon as possible. Provide the
relevant information to help the patient and family make informed choices.
Discuss all possible outcomes. Be as clear and direct as
possible.
3. Identify decision points in advance. Identify the points in the
future when additional information will be available that will help with
decision making. Be clear about when you think decisions will be needed. I=
t is
important to begin to prepare the family early in the process.
4. U=
se
the general goals of care to guide decision making. Discussion of goal=
s of
care should be ongoing. Decisions about treatment priorities should be bas=
ed
on the patient’s goals and beliefs. It cannot be stressed enough how
important this step is. Have a plan but keep it flexible.
5. Take
sociocultural differences into account. If necessary, try to involve a=
colleague
to help transcend sociocultural differences that may impede supportive dec=
isions.
Explain concepts in clear language that is easy to understand. Use words l=
ike
“worse” rather than “progressing.” Check understan=
ding
regularly. When language is a barrier, use a skilled medical translator.&#=
13;6.
Manage symptoms effectively. Sudden illness, particularly trauma, is a=
ccompanied
by multiple symptoms and suffering. Always ensure that all symptoms are
managed effectively, throughout the course of the illness.
7. Consi=
der
the impact of stress on caregivers. The chaos and occupational stress =
of situations
involving sudden illness can have considerable impact on caregivers. They =
experience
a range of emotions during any given case of sudden illness. As cases accu=
mulate,
so may the stressors. These may be manifested in a caregiver’s perso=
nal and
professional life and may affect clinical decision making.
Each guiding principle will be discussed in the sections that
follow.
Provide structured interactions i=
n the
otherwise chaotic environment by establishing regularly scheduled
communications between specific identified parties from both the family and
the health care team.
Much of the information covered in this module d=
eals
with ways to bring structure to a situation of stress and uncertainty. Oft=
en
this is a confusing time. The family is trying to cope with the shock of t=
he
situation, things may be happening very quickly, and there may be a need to
involve multiple members of the family at a moment’s notice. Most
importantly, there will probably be multiple physicians and other members =
of
the health care team providing different aspects of care to the patient. C=
oordinating
information about the patient's condition and potential decisions can beco=
me a
challenge.
A structured communication process can help reduce confusion
and facilitate effective decision making. Encourage 1 person on each
side (physician/team and patient/family) to act as the primary spokesperson
and communicator. The goal is not to cut off communication between the fam=
ily
and other physicians, but rather to minimize confusion.
Depending on t=
he
situation, the primary doctor who serves as spokesperson could be the prim=
ary
care physician, the intensive care unit physician, or another physician. T=
he
spokesperson for the family does not necessarily have to be the
decision-maker. If there needs to be a health care proxy or family decision
maker, identify who that person is early.
Try to coordinate all
information and decisions through the spokesperson. Try to meet with the
patient/family spokesperson and decision maker at the same time, if both e=
xist.
Restricting the number of meetings may be challenging when there are many =
family
members visiting at various times throughout the day who all want informat=
ion.
It
is helpful if everyone on the health care team understands the communicati=
on process
that has been established. Tell all the family members and the members of =
the health
care team about the communication plan. Identify regular times when you wi=
ll communicate
with everyone who wishes to be present.
Use good communication skill .=
Get
the setting right for the information, find out what family members know
before sharing new information, respond to their feelings, and finish with=
a
concrete plan.
In situations of prognostic uncer=
tainty,
communicate the full range of possible outcomes. Physicians sometimes wait
until they have more information before they meet with the patient and fam=
ily.
Waiting actually heightens patient and family anxiety. It is better to
identify what is known early, even if such information is incomplete and t=
here
is uncertainty.
Even if the situation is very uncertain, you, as a
physician, know more than the patient or family. The sooner family
members have information, the sooner they will begin to understand what is
happening.
At times physicians choose to provide information in terms =
of
extreme outcomes, rather than discussing the full range of possibilities. =
As
excessive optimism is common among physicians and health care workers,
sometimes the discussion is limited to only one extreme outcome: the
possibility of full recovery.
In general, it is best to be spec=
ific
about all possible outcomes. Use concrete examples to help the family
understand. Discuss the current situation, the immediate future, and what =
is
likely to happen next. Convey a range of possibilities, since the actual o=
utcome
is often somewhere in the middle. Where possible, use evidence-based infor=
mation
to support discussions. When the situation is particularly difficult, cons=
ult with
colleagues who have a broad experience (eg, intensivists) and/or knowledge=
of the
relevant, evidence-based literature.
Acknowledge the limits of individ=
ual
case experiences, both yours and the family’s. Don’t say vague
things like, “It doesn’t look good” or “I don̵=
7;t
think the outcome will be good.” Be more specific by talking about t=
he
current information: what you are looking for as positive signs or signs o=
f a
worsening condition, what is more likely or less likely.
Ask frequently
what the patient and family understand in order to check what information =
they
have heard. Remember, patients and families may need gentle repetition in
order to take it all in.
Use other health care team members such as
nurses, social workers, and chaplains to help support the patient and fami=
ly
as well as to reinforce the information that has been given. Spend the tim=
e to
tell appropriate caregivers the substance of what you have told the patient
and family so that mixed messages and confusion are minimized.
Informed participation of the pat=
ient and
family in health care and medical decisions is important for many
reasons:
· it demonstrates respect for the individual, perhaps =
the
most important of the ethical principles governing medical care
· it maximizes the likelihood that health care decisions will =
be
made with the patient’s
best interests in mind
· it improves the likelihood that the therapeutic goals of care
will actually be achieved
It is particularly helpful to identify decision points in advance. Clarify
which decisions need to be made immediately and those that will need to be
made in the near future. For instance, a patient may have need for immedia=
te
respiratory support and vasopressors for stabilization, but the possibilit=
y of
hemodialysis may or may not become an issue. Let the family know how you w=
ill
determine whether or not dialysis will need to be considered. For instance,
you may need time to determine the metabolic gap after respiratory
stabilization.
Let the family know what kind of information you will be
giving them about dialysis if it becomes relevant.
Even when things are
uncertain, the physician should be very clear that there will be decisions=
to
be made. All options for care are open for discussion, from aggressive att=
empts
to reverse the disease to purely comfort measures.
Begin preparing the
family early for decisions to be made in the future. For example, “W=
e’ve
talked about what we know at this point. Now let’s talk about the fu=
ture
and what we can expect to happen.” The earlier the family knows what
discussions will be needed, the better they can organize themselves
psychologically and logistically for the decisions they will need to make.=
At
each meeting, set expectations about when you will meet
again, and what
information you will need to discuss, eg, “I’ll talk to you ag=
ain
in the morning. At that point we should have more information from the tes=
ts
and can talk better about whether dialysis is a good choice.”
Use
other members of the health care team to support the patient and family an=
d reinforce
the plan that has been determined. Be sure to let them know the details an=
d rationale
for the plan you have established.
As prognosis changes and decision=
s come
up, use the general goals of care to guide decision making about treatment
priorities and the use of technology.
Assessing or reassessing the gen=
eral
goals of care is an important step in all medical decision making, since t=
he
overall goals of care provide the basis for further decisions about specif=
ic
treatment priorities. In
situations of sudden critical illness, radical readjustment of goals of ca=
re
is often appropriate. The physician, patient, and family need to wo=
rk
together to assess and reprioritize the goals of care in light of the rece=
nt developments,
the patient’s values, advance directives, and the range of possible =
outcomes.
The goal of informed consent is t=
o enable
patients, or parents if the patient is a young child, to make choices
consistent with their own personal goals, beliefs, and values. Achieving
informed consent can be a special challenge at times of sudden life-threat=
ening
illness because of the uncertainty and changing nature of the situation.&#=
13;
Four conditions need to be met for informed consent to occur:
· the patient (parents) must have the capacity to make an info=
rmed
decision
· pertinent information must be provided to the patient
(parents)
· the patient (parents) must comprehend the information well enough=
to
make a rational choice
· the decision itself must be voluntary, not coerced
When the patient lacks capacity
If the patient does not have the capacity to make an informed decision, th=
en
the physician’s next step is to work closely with the proxy decision
maker. Focus on what the patient would want if the patient were able to sp=
eak
for himself or herself. Avoid asking the proxy, “What do you want us=
to
do?” Instead, use words like, “Can you help me identify what he
would want in this situation?” or “What would she say?”&=
#13;
Steps in decision making
Patients, parents, and proxies need to know the nature of the illness,
recommended treatment, reasonable alternatives, the chance of each choice
achieving its intended goal, and the burdens and benefits of each option.
Clarifying the nature of the illness serves to verify that the patient,
parent, or proxy has an accurate understanding of the situation.
Discu=
ssing
the recommended treatment includes a description of what is recommended and
how it will be done. This information could also include the rationale for=
the
treatment based on the patient’s current medical condition. When cla=
rifying
the chance of each alternative achieving its intended goal, give informati=
on on
what the most likely outcomes of each alternative are, and the evidence on
which the statements are based.
List the most common and the most significant burdens and benefits.&#=
13;
Focus on the degree of recovery
Focusing on the degree of recovery that would be acceptable to the patient=
can
help families cope with confusion and guilt in situations of prognostic
uncertainty. By identifying the desired and acceptable degree of recovery,=
and
comparing this with the markers of recovery, it is possible to outline
decision points. For example, “If it becomes clear that the goal of
complete recovery of mental function is not possible, then we will withdraw
mechanical ventilation” or ”If we don’t see an improveme=
nt
in x, y, and z in 1 week, then I would recommend that we discontinue the
medications maintaining blood pressure.”
Often in situations of prognostic
uncertainty, there is the perception that the choice is limited to either
initiating a treatment or not. Characterizing treatment in terms of a time=
limited
trial offers another option that allows treatment to continue while time a=
llows
the prognosis to become clearer. In situations of prognostic uncertainty, =
all treatment
can be thought of as a time-limited trial. Use terms like, “We’=
;re
doing everything we can, but in
48 hours we may find that it’s not working.”
The use of time-limited trials in situations of prognostic uncertainty sho=
uld
be given careful consideration to assure that the trial is consistent with=
the
general goals of care and goals of recovery. Informed consent is necessary=
, as
there are both benefits and burdens associated with time-limited trials.&#=
13;A
time-limited trial can provide structure to situations of uncertainty.
However, once treatments have begun, a variety of powerful forces tend to
perpetuate them. It is important to establish clear guideposts or criteria=
for
decision-making in advance to prevent a difficult future decision-making
process. Otherwise, a time-limited trial may result in an undesired outcome
and a decision to stop treatment may seem more difficult.
Consider the role of palliative care
When considering reasonable alternatives, aggressive palliative care should
always be discussed. Physicians often inadvertently leave the impression t=
hat
they will either “do everything” or “do nothing.”
Aggressive relief of suffering is not an alternative to medical care, or t=
he
opposite of medical care, or what we do when we decide we “don’=
;t
want to do anything.” It can be included in curative approaches to
sudden illness as well as in
chronic and incurable conditions. When
aggressive attempts to maintain comfort are included in the care plan from=
the
beginning, it permits these aspects to be continued when other treatments =
are
discontinued.
Identify, acknowledge, and address
differences in values and beliefs with care and sensitivity.
Each pati=
ent,
family member, and member of the health care team will have a unique set of
values, beliefs, and experiences related to the health care system and uni=
que choices
about the type of health care that is appropriate for him or her. In addit=
ion,
each individual will experience a given situation from his or her social,
cultural, and spiritual perspective. When discussing important medical
decisions with patients and/or families,
it is important for everyone =
to
be sensitive to these differences, and acknowledge and address them openly=
. In
the end, the final decision about treatment remains with the patient and
family.
Examples of values and beliefs that could potentially impact discussions a=
bout
prognostic uncertainty and life-threatening illness include:
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s.fontSize=3DnewSize+"px"
s.posWidth=3Dg_origW*factor
s.posHeight=3Dg_origH*factor
s.posLeft=3D(cltWidth-s.posWidth+padding)/2
s.posTop=3D(cltHeight-s.posHeight+padding)/2
if( g_scaleHyperlinks )
ScaleHyperlinks( factor )
}
function _InitAnimations()
{
animRuntimeInstalled =3D ''+document.body.localTime !=3D 'undefined';
isFullScreen =3D (window.name =3D=3D "PPTSld") && !parent.IsFramesMode();
g_animUseRuntime =3D g_showAnimation && animRuntimeInstalled && !(isFullSc=
reen && parent.IsSldVisited());
if( g_animUseRuntime ) {
collSeq =3D document.all.tags("seq");
if( collSeq !=3D null ) {
for(ii=3D0;ii numSlds )
gSldJumpIdx =3D numSlds;
if ( gSldJumpIdx >=3D 0 ) {
if ( gSldJumpIdx =3D=3D 0 )
gSldJumpIdx =3D 1;
var jumpTo =3D parseInt(gSldJumpIdx);
gSldJump =3D 0; gSldJumpIdx =3D "";
win.GoToSld( parent.GetSldList().mList[jumpTo-1].mSldHref )
}
}
}
function _KDH()
{
if( event.keyCode =3D=3D 8 ) {
event.returnValue =3D 0;
parent.GoToPrevSld();
}
}function DocumentOnClick()
{
if( IsNts() || parent.HideMenu() ) return;
if( ( g_allowAdvOnClick && (window.name=3D=3D"PPTSld") && !parent.IsFrames=
Mode() ) ||
(event && event.keyCode=3D=3D32) ) {
=09
if( g_animUseRuntime && g_animMainSequence && g_animMainSequence.cangonex=
t )
return;
parent.GoToNextSld();
}
}
var g_supportsPPTHTML =3D SupportsPPTHTML(), g_scaleInFrame =3D 1, gId=3D""=
, g_bgSound=3D"",
g_scaleHyperlinks =3D false, g_allowAdvOnClick =3D 1, g_showInBrowser =
=3D 0, gLoopCont =3D 0, gUseSldTimings =3D 1;
var g_showAnimation =3D g_supportsPPTHTML && SupportsPPTAnimation() && ( (w=
indow.name=3D=3D"PPTSld" && !parent.IsFramesMode()) || g_showInBrowser );va=
r g_animManager =3D null;
var g_animUseRuntime =3D false;
var g_animItemsToHide, g_animInteractiveItems, g_animSlideTime;
var g_animMainSequence =3D null;
var ENDSHOW_MESG=3D"End of slide show, click to exit.", SCREEN_MODE=3D"Fram=
es", gIsEndShow=3D0, NUM_VIS_SLDS=3D18, SCRIPT_HREF=3D"script.js", FULLSCR_=
HREF=3D"fullscreen.htm";
var gCurSld =3D gPrevSld =3D 1, g_offset =3D 0, gNtsOpen =3D gHasNts =3D gO=
tlTxtExp =3D 0, gHasNarration =3D 0, gOtlOpen =3D true
window.gPPTHTML=3DSupportsPPTHTML()
var gMainDoc=3Dnew Array(new hrefList("slide0014.htm",1,-1,1),new hrefList(=
"slide0002.htm",1,-1,1),new hrefList("slide0003.htm",1,-1,1),new hrefList("=
slide0018.htm",1,-1,1),new hrefList("slide0004.htm",1,-1,1),new hrefList("s=
lide0021.htm",1,-1,1),new hrefList("slide0005.htm",1,-1,1),new hrefList("sl=
ide0022.htm",1,-1,1),new hrefList("slide0006.htm",1,-1,1),new hrefList("sli=
de0008.htm",1,-1,1),new hrefList("slide0009.htm",1,-1,1),new hrefList("slid=
e0010.htm",1,-1,1),new hrefList("slide0011.htm",1,-1,1),new hrefList("slide=
0020.htm",1,-1,1),new hrefList("slide0019.htm",1,-1,1),new hrefList("slide0=
023.htm",1,-1,1),new hrefList("slide0013.htm",1,-1,1),new hrefList("slide00=
15.htm",1,-1,1));
/*********************************************
Frameset functions
These functions control slide navigation
and state of the frameset.
**********************************************/
function FullScrInit()
{
g_allowAdvOnClick =3D GetCurSld().mAdvOnClk
document.body.style.backgroundColor=3D"black"
document.oncontextmenu=3Dparent._CM;
document.onkeydown =3D _KDH;
document.ondragstart=3DCancel
document.onselectstart=3DCancel
self.focus()
}
function Redirect( frmId )
{=09
var str=3Ddocument.location.hash,idx=3Dstr.indexOf('#'), sId=3DGetSldId()
if(idx>=3D0) str=3Dstr.substr(1);
if( window.name !=3D frmId && ( sId !=3D str) ) {
obj =3D GetObj("Main-File")
window.location.href=3Dobj.href+"#"+sId
return 1
}
return 0
}
var MHTMLPrefix =3D CalculateMHTMLPrefix();=20
function CalculateMHTMLPrefix()
{
if ( document.location.protocol =3D=3D 'mhtml:') {=20
href=3Dnew String(document.location.href)=20
Start=3Dhref.indexOf('!')+1=20
End=3Dhref.lastIndexOf('/')+1=20
if (End < Start)=20
return href.substring(0, Start)=20
else=20
return href.substring(0, End)=20
}
return '';
}
function GetTags(base,tag)
{
if(g_supportsPPTHTML) return base.all.tags(tag);
else return base.getElementsByTagName(tag);
}
function UpdNtsPane(){ if(frames["PPTNts"]) PPTNts.location.replace( MHTMLP=
refix+GetHrefObj( gCurSld ).mNtsHref ) }
function UpdNavPane( sldIndex ){ if(gNavLoaded) PPTNav.UpdNav() }
function UpdOtNavPane(){ if(gOtlNavLoaded) PPTOtlNav.UpdOtlNav() }
function UpdOtlPane(){ if(gOtlLoaded) PPTOtl.UpdOtl() }
function SetHasNts( fVal )
{
if( gHasNts !=3D fVal ) {
gHasNts=3DfVal
UpdNavPane()
}
}
function ToggleOtlText()
{
gOtlTxtExp=3D!gOtlTxtExp
UpdOtlPane()
}
function ClearMedia()
{
// Clear any sounds playing before launching another browser window. Other=
wise,
// in fullscreen mode, you'll continue to hear the sound in the frames mod=
e.
if (PPTSld.pptSound) PPTSld.pptSound.loop =3D 0;
}
function FullScreen()
{=20
if ( PPTSld.g_animUseRuntime )
PPTSld.document.body.pause();
ClearMedia();
var href =3D ( document.location.protocol =3D=3D 'mhtml:') ? FULLSCR_HREF =
: FULLSCR_HREF+"#"+GetHrefObj(gCurSld).mSldHref;
if(PPTNav.event.ctrlKey) {
var w =3D (window.screen.availWidth * 1.0) / 2.0
var h =3D w * (PPTSld.g_origH * 1.0) / PPTSld.g_origW
win =3D window.open( MHTMLPrefix+href,null,"toolbar=3D0,resizable=3D1,top=
=3D0,left=3D0," + "width=3D"+ w + ",height=3D" + h );
if( win.document.body && PPTSld.g_animUseRuntime )
win.document.body.PPTSldFrameset=3Dwindow;
}
else
{
win =3D window.open( MHTMLPrefix+href,null,"fullscreen=3Dyes" );
if( win.document.body && PPTSld.g_animUseRuntime )
win.document.body.PPTSldFrameset=3Dwindow;
}
}
function ToggleVNarration()
{
rObj=3DPPTSld.document.all("NSPlay")
if( rObj && !PPTSld.g_animUseRuntime ) {
if( (rObj.playState =3D=3D 1)||(rObj.playState =3D=3D 0) )
rObj.Play()
else if( rObj.playState =3D=3D 2 )
rObj.Pause()
else
return;
}
else if( PPTSld.g_animUseRuntime )
{
narObj =3D PPTSld.document.all("narrationID")
if( narObj )
narObj.togglePause()
}
}
function GetCurSldNum()
{ =20
obj=3DGetHrefObj(gCurSld)
if( obj.mOrigVis =3D=3D 1 )
return obj.mSldIdx
else =20
return gCurSld
}
function GetNumSlds()
{ =20
if( GetHrefObj(gCurSld).mOrigVis =3D=3D 1 )
return GetSldList().mNumVisSlds;
else
return GetSldList().mList.length
}
function GetSldNum( href )
{
for(ii=3D0; ii 1 )
PopSldList();
else if( !IsFramesMode() ) {
if( gLoopCont )
GoToFirst()
else
EndShow()
}
}
function GoToPrevSld()
{
ii=3DgCurSld-1
if( ii > 0 ) {
obj=3DGetHrefObj(ii)
while ( obj && ( obj.mVis =3D=3D 0 ) && ( ii>0 ) )
obj=3DGetHrefObj(--ii)
if( ii =3D=3D 0 ) ii=3D1
GoToSldNum(ii)
}
}
function GoToFirst(){ GoToSld( GetHrefObj(1).mSldHref ) }
function GoToLast()
{
ii=3DGetSldList().mList.length
if( ii !=3D gCurSld )
GoToSld( GetHrefObj(ii).mSldHref )
}
function GoToSldNum( num )
{
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
obj =3D GetHrefObj( num )
obj.mVis=3D1
gPrevSld=3DgCurSld
gCurSld =3D num;
PPTSld.location.replace(MHTMLPrefix+obj.mSldHref)
if( IsFramesMode() ) {
UpdNavPane(); UpdOtlPane(); UpdNtsPane()
}
}
function GoToSld( href )
{
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
GetHrefObj( GetSldNum(href) ).mVis=3D1
PPTSld.location.replace(MHTMLPrefix+href)
}
function SldUpdated( id )
{
if( id =3D=3D GetHrefObj(gCurSld).mSldHref ) return
gPrevSld=3DgCurSld
gCurSld=3DGetSldNum(id)
if( IsFramesMode() ) {
UpdNavPane(); UpdOtlPane(); UpdNtsPane()
}
}
function PrevSldViewed(){ GoToSld( GetHrefObj(gPrevSld).mSldHref ) }
function HasPrevSld() { return ( gIsEndShow || ( gCurSld !=3D 1 && GetHrefO=
bj( gCurSld-1 ).mVis =3D=3D 1 )||( GetCurSldNum() > 1 ) ) }
function HasNextSld() { return (GetCurSldNum() !=3D GetNumSlds()) }
function CloseWindow() {
if( HideMenu() ) return;
=09
var event =3D PPTSld.event;
if( !IsFramesMode() && event && (event.keyCode=3D=3D27 || event.keyCode=3D=
=3D32 || event.type=3D=3D"click" ) )
window.close( self );
CatchNumKeys( self, event );
}
function Unload() { gIsEndShow=3D0; }
function SetupEndShow() {
gIsEndShow=3D1;
PPTSld.document.body.scroll=3D"no";
PPTSld.document.onkeypress=3DCloseWindow;
PPTSld.document.onclick=3DCloseWindow;
PPTSld.document.oncontextmenu=3D_CM;
}
function EndShow()
{
if( IsFramesMode() ) return
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
doc=3DPPTSld.document
var dir =3D doc.body.dir
if( dir !=3D "rtl" ) dir =3D "ltr";
doc.open()
doc.writeln(' 0) {
PushSldList(sldList,fEnd);
gCurSld =3D 1;
}
else
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
}
function PushSldList(arr,fEnd) {
var ii =3D gSldStack.length;
gSldStack[ii] =3D new SldList(arr,gCurSld,fEnd);
GoToSld( gSldStack[ii].mList[0].mSldHref );
}
function PopSldList() {
if (gSldStack[gSldStack.length-1].fEndShow)
EndShow()
else {
gCurSld =3D gSldStack[gSldStack.length-1].mCurSld;
gSldStack[gSldStack.length-1] =3D null;
gSldStack.length--;
var sldList =3D gSldStack[gSldStack.length-1];
GoToSld( sldList.mList[gCurSld - 1].mSldHref );
}
}
var custShowList=3Dnew Array();
/*********************************************
Navigation button implementation
There are 2 types of buttons: ImgBtn, TxtBtn
implemented as function objects. They share
a similiar interface so the event handlers
can call SetActive, for example, on a button=20
object without needing to know exactly=20
what type of button it is.
**********************************************/
//----------------------------------
function ImgBtn( oId,bId,w,action )
//----------------------------------
{
var t=3Dthis
t.Perform =3D _IBP
t.SetActive =3D _IBSetA
t.SetInactive=3D _IBSetI
t.SetPressed =3D _IBSetP
t.SetDisabled=3D _IBSetD
t.Enabled =3D _IBSetE
t.ChangeIcon =3D null
t.UserAction =3D action
t.ChgState =3D _IBUI
t.mObjId =3D oId
t.mBorderId=3D bId
t.mWidth =3D w
t.mIsOn =3D t.mCurState =3D 0
}
function _IBSetA()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 )
obj.style.posTop=3D0
}
}
function _IBSetI()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 )
obj.style.posTop=3D0=20
}
}
function _IBSetP()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gShadowClr,gHiliteClr,2 )
obj.style.posLeft+=3D1; obj.style.posTop+=3D1
}
}
function _IBSetD()
{ =20
obj=3Dthis.ChgState( gFaceClr,gFaceClr,0 )
obj.style.posTop=3D0=20
}
function _IBSetE( state )
{
var t=3Dthis
GetObj( t.mBorderId ).style.visibility=3D"visible"
if( state !=3D t.mIsOn ) {
t.mIsOn=3Dstate
if( state )
t.SetInactive()
else
t.SetDisabled()
}
}
function _IBP()
{
var t=3Dthis
if( t.mIsOn ) {
if( t.UserAction !=3D null )
t.UserAction()
if( t.ChangeIcon ) {
obj=3DGetObj(t.mObjId)
if( t.ChangeIcon() )
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-4)*t.mWidth
else
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-0)*t.mWidth
}
t.SetActive()
} =20
}
function _IBUI( clr1,clr2,nextState )
{
var t=3Dthis
SetBorder( GetObj( t.mBorderId ),clr1,clr2 )
obj=3DGetObj( t.mObjId )
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-nextState)*t.mWidth-obj=
.style.posTop
t.mCurState=3DnextState
return obj
}
//-----------------------------------------
function TxtBtn( oId,oeId,action,chkState )
//-----------------------------------------
{
var t=3Dthis
t.Perform =3D _TBP
t.SetActive =3D _TBSetA
t.SetInactive=3D _TBSetI
t.SetPressed =3D _TBSetP
t.SetDisabled=3D _TBSetD
t.SetEnabled =3D _TBSetE
t.GetState =3D chkState
t.UserAction =3D action
t.ChgState =3D _TBUI
t.mObjId =3D oId
t.m_elementsId=3D oeId
t.mIsOn =3D 1
}
function _TBSetA()
{
var t=3Dthis
if( t.mIsOn && !t.GetState() )
t.ChgState( gHiliteClr,gShadowClr,0,0 )
}
function _TBSetI()
{
var t=3Dthis
if( t.mIsOn && !t.GetState() )
t.ChgState( gFaceClr,gFaceClr,0,0 )
}
function _TBSetP()
{
if( this.mIsOn )
this.ChgState( gShadowClr,gHiliteClr,1,1 )
}
function _TBSetD()
{ =20
this.ChgState( gFaceClr,gFaceClr,0,0 )
this.mIsOn =3D 0
}
function _TBSetE()
{
var t=3Dthis
if( !t.GetState() )
t.ChgState( gFaceClr,gFaceClr,0,0 )
else
t.ChgState( gShadowClr,gHiliteClr,1,1 )
t.mIsOn =3D 1
}
function _TBP()
{
var t=3Dthis
if( t.mIsOn ) {=20
if( t.UserAction !=3D null )
t.UserAction()
if( !t.GetState )
return
if( t.GetState() )
t.SetPressed()
else
t.SetActive()
} =20
}
function _TBUI( clr1,clr2,lOffset,tOffset )
{
SetBorder( GetObj( this.mObjId ),clr1,clr2 )
Offset( GetObj( this.m_elementsId ),lOffset,tOffset )
}
function Offset( obj, top, left ){ obj.style.top=3Dtop; obj.style.left=3Dle=
ft }
function SetBorder( obj, upperLeft, lowerRight )
{
s=3Dobj.style;
s.borderStyle =3D "solid"
s.borderWidth =3D 1=20
s.borderLeftColor =3D s.borderTopColor =3D upperLeft
s.borderBottomColor=3D s.borderRightColor =3D lowerRight
}
function GetBtnObj(){ return gBtnArr[window.event.srcElement.id] }
function BtnOnOver(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetActive() }
function BtnOnDown(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetPressed() }
function BtnOnOut(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetInactive() }
function BtnOnUp()
{
b=3DGetBtnObj()
if( b !=3D null )
b.Perform()
else
Upd()
}
function GetNtsState(){ return parent.gNtsOpen }
function GetOtlState(){ return parent.gOtlOpen }
function GetOtlTxtState(){ return parent.gOtlTxtExp }
function NtsBtnSetFlag( fVal )
{
s=3Ddocument.all.item( this.m_flagId ).style
s.display=3D"none"
if( fVal )
s.display=3D""
else
s.display=3D"none"
}
function _BSetA_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etActive() }
function _BSetI_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etInactive() }
function _BSetP_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etPressed() }
function _BSetA_BorderImg()
{=20
b =3D gBtnArr[this.mBorderId]=20
if( b !=3D null && this.mIsOn && !b.GetState() ) {
obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 )
obj.style.posTop=3D0
}
}
function _BSetI_BorderImg()
{=20
b =3D gBtnArr[this.mBorderId]
if( b !=3D null && this.mIsOn && !b.GetState() ) {
obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 )
obj.style.posTop=3D0
}
}
var gHiliteClr=3D"THREEDHIGHLIGHT",gShadowClr=3D"THREEDSHADOW",gFaceClr=3D"=
THREEDFACE"
var gBtnArr =3D new Array()
gBtnArr["nb_otl"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOtlPan=
e,GetOtlState )
gBtnArr["nb_otlElem"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOt=
lPane,GetOtlState )
gBtnArr["nb_nts"] =3D new ImgBtn( "nb_nts","nb_ntsBorder",10,parent.ToggleN=
tsPane )
gBtnArr["nb_nts"].SetActive =3D _BSetA_BorderImg;
gBtnArr["nb_nts"].SetInactive =3D _BSetI_BorderImg;
gBtnArr["nb_ntsBorder"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.=
ToggleNtsPane,GetNtsState )
gBtnArr["nb_ntsElem"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.To=
ggleNtsPane,GetNtsState )
gBtnArr["nb_prevBorder"] =3D gBtnArr["nb_prev"]=3D new ImgBtn( "nb_prev","n=
b_prevBorder",30,parent.GoToPrevSld )
gBtnArr["nb_nextBorder"] =3D gBtnArr["nb_next"]=3D new ImgBtn( "nb_next","n=
b_nextBorder",30,parent.GoToNextSld )
gBtnArr["nb_sldshw"]=3D new ImgBtn( "nb_sldshw","nb_sldshwBorder",18,parent=
.FullScreen )
gBtnArr["nb_sldshwBorder"] =3D new TxtBtn( "nb_sldshw","nb_sldshwBorder",pa=
rent.FullScreen,null )
gBtnArr["nb_sldshwBorder"].SetActive =3D _BSetA_Border;
gBtnArr["nb_sldshwBorder"].SetInactive =3D _BSetI_Border;
gBtnArr["nb_sldshwText"] =3D new TxtBtn( "nb_sldshw","nb_sldshwText",parent=
.FullScreen,null )
gBtnArr["nb_sldshwText"].SetActive =3D _BSetA_Border;
gBtnArr["nb_sldshwText"].SetInactive =3D _BSetI_Border;
gBtnArr["nb_voice"] =3D gBtnArr["nb_voiceBorder"] =3D new ImgBtn( "nb_voice=
","nb_voiceBorder",18,parent.ToggleVNarration )
gBtnArr["nb_otlTxtBorder"] =3D gBtnArr["nb_otlTxt"]=3D new ImgBtn( "nb_otlT=
xt","nb_otlTxtBorder",23,parent.ToggleOtlText )
gBtnArr["nb_ntsBorder"].m_flagId=3D "nb_nts"
gBtnArr["nb_ntsBorder"].SetFlag =3D NtsBtnSetFlag
gBtnArr["nb_otlTxt"].ChangeIcon=3D GetOtlTxtState
/*********************************************
Context menu implementation
_CM() is the function that's hooked up to
the oncontextmenu event. Once we're asked to
show the menu, we first build it by creating
DIVs on-the-fly. Then we position it=20
within the screen area so it doesn't get
clipped.
Creating the DIVs using createElement() means
we don't have to write out any extra HTML
into the slide HTML files.
**********************************************/
var sNext=3D"Next",sPrev=3D"Previous",sEnd=3D"End Show",sFont=3D"Arial",sAr=
row=3D"Arrow",sFreeform=3D"Freeform",sRect=3D"Rectangle",sOval=3D"Oval"
function ShowMenu()
{
BuildMenu();
var doc=3DPPTSld.document.body,x=3DPPTSld.event.clientX+doc.scrollLeft,y=
=3DPPTSld.event.clientY+doc.scrollTop
m =3D PPTSld.document.all.item("ctxtmenu")
m.style.pixelLeft=3Dx
if( (x+m.scrollWidth > doc.clientWidth)&&(x-m.scrollWidth > 0) )
m.style.pixelLeft=3Dx-m.scrollWidth
m.style.pixelTop=3Dy
if( (y+m.scrollHeight > doc.clientHeight)&&(y-m.scrollHeight > 0) )
m.style.pixelTop=3Dy-m.scrollHeight
m.style.display=3D""
}
function _CM()
{
if( !parent.IsFullScrMode() ) return;
if(!PPTSld.event.ctrlKey) {
ShowMenu()
return false
} else
HideMenu()
}
function BuildMenu()
{
if( PPTSld.document.all.item("ctxtmenu") ) return
var mObj=3DCreateItem( PPTSld.document.body )
mObj.id=3D"ctxtmenu"
mObj.style.visibility=3D"hidden"
var s=3DmObj.style
s.position=3D"absolute"
s.cursor=3D"default"
s.width=3D"120px"
SetCMBorder(mObj,"menu","black")
var iObj=3DCreateItem( mObj )
SetCMBorder( iObj, "threedhighlight","threedshadow" )
iObj.style.padding=3D2
CreateMenuItem( iObj,sNext,M_GoNextSld,M_True )
CreateMenuItem( iObj,sPrev,M_GoPrevSld,M_HasPrevSld )
=09
CreateSeparator( iObj )
CreateMenuItem( iObj,sEnd,M_End,M_True )
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Content-Location: file:///C:/1EF8A2D3/Module8SuddenIllness_files/fullscreen.htm
Content-Transfer-Encoding: quoted-printable
Content-Type: text/html; charset="us-ascii"
Module 8
------=_NextPart_01C7D4E2.C5A104F0--
· distrust of the medical system or physicians
· unrealistic expectations of the medical system or
physicians
· any life, no matter how compromised, is worth living
When language is an issue, ensure that information is communicated through=
a medically
trained translator who is sensitive to the cultural nuances of the patient=
and
family members. Subtleties in language can lead to significant differences=
in understanding.
Try to avoid using a family member to translate who may be wrapped up in t=
he
drama of the situation and unable to convey information accurately, partic=
ularly
when emotions are
· belief in miracles
· death is “the enemy”
· death should not be discussed openly
heightened
Stress that the provision of comf=
ort and
relief of symptoms is part of the management plan.
Practice good sympt=
om
management in order to maximize quality of life even during periods of max=
imum
effort to restore full function and health. Many patients, parents, and fa=
mily
members unnecessarily remember their periods of acute health crisis as mis=
erable.
Approaching the relief of suffering in this way permits the physician=
to
convey accurately to the family what aspects of the plan are going to
continue, even if other treatments will be stopped.
The impact of stress on professio=
nals can
be significant and debilitating. Although this module has focused on the
skills of the physician in dealing with patients and families during sudden
illness, it is worth considering the stress that may be experienced by pro=
fessionals.
Physicians
and other health care professionals have their own responses to sudden ill=
ness
in the patients they are caring for. Unrecognized, these responses may lea=
d to
occupational stress and burnout. All members of the health care team may f=
eel
stress, loss, and grief in relation to their needs, values, and hopes for
patients. Particularly when the outcome is not what was initially hoped fo=
r,
physicians may experience unrealistic feelings
of guilt and fear of
rejection (by patients, families, or colleagues) and may project these
feelings in unhealthy ways.
Careful negotiation of goals of care with
patients and families in light of the situation, the prognosis, and the li=
kely
outcomes will make these distressing reactions less likely and will enhance
the possibility of meaningful human interactions that can sustain rather t=
han
stress the clinician.
Nonetheless, many clinicians find additional sup=
port
necessary in order to continue functioning effectively. Support may come in
the form of professional counseling or it may come informally from family
members, from religious advisors, or from supportive colleagues, some of w=
hom
may meet regularly in small groups to discuss their feelings.
' + ENDSHOW_MESG + '
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tes![](3D"buttons.gif")
