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FAST FACTS
Click to edit Master text styles
second level
third level
fourth level
fifth level
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Click to edit Master title style=
Click to edit Master subtitle st= yle
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 © EPEC Project, 2003
Permission to reproduce for educational purposes granted
Page ‹#›
Module 4:= Pain Management
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Goals of Care
<= b>FAST FACTS
<= b>Module 7
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ACGME Competencies: Medical Knowledge, Patient Care, System-based Practice
Keyword(s): decision making, capacity, surrogates= 3;
Decision Making Capacity
Inf= ormed consent is based on the principle that patients should <= span style=3D'position:absolute;top:34.75%;left:10.11%;width:85.58%;height:4.5%= '>be allowed to make decisions for themselves.
Decision making capacity thus serves as a gatekeeper concept - patients who have it can make decisions for themselves; conversely, = a surrogate is needed for patients who lack decision- making capacity.
Note: Competency is a legal term referring to a decision made by judge, although a physician's opinion carries a l= arge amount of weight in a competen= cy hearing.
 
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Decision Making Capacity
 In contrast, Decision-Making Capacit= y (a.k.a. decisional) refers to a physicians' determination, based on clin= ical examination, that a pat= ient is able to make medical dec= isions for themselves.
Most state Power of Attorney for Health Care documen= ts require a physician to document that a patient has l= ost = Decision-Making Capacity for the surrogate to become the <= span style=3D'position:absolute;top:70.5%;left:11.04%;width:79.02%;height:4.5%'= >legal agent for medical decisions.
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To be deemed Decisional:
 a physician must be satisfied that= a patient is able to:
1) receive information (e.g. must be awake,     but not necessar= ily oriented x 4),
 2) evaluate, deliberate, and menta= lly =     manipulate infor= mation and
 3) communicate a treatment prefere= nce (e.g.         = ;          the comatose patient by definition is not             = ;          decisio= nal).
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Decision-Making Capacity is:
Understanding:
Does the patient truly understand the information about the risks, benefits, and alternatives of what is being proposed?
The patient does not have to agree with your interpretation, but should be able to repeat what you have said.
 Ask,
"Can you repeat to me the options for treating X
 I have just discussed with you?“
 Can you explain to me why you feel= that way?
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Task specific:
Deciding if the patient is decisional means weighing the degree to which the patient has decision-making capacity against the objective risks and benefits to the patient.
= Some decisions are more complex than others, requiring a higher level of decision-making capacity. Thus a moderately demented patient may be able to make some decisions (e.g. antibiotics for pneumonia) but not others (e.g. chemotherapy for metastatic lung cancer).
This sliding scale view of decisionality holds that it is proper to require a higher level of certainty when the decision poses great harm.
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Logical:
  Is the logic the patient uses= to arrive at the decision "not-irrational"?=
 One wants, as much as possible to = make sure the patient's values are speakin= g, rather than an underlying mental or physical illness.=
Note:
Severe depression or hopelessness will make it difficult to interpret decisionality;
= Consult psychiatry for assistance with this or other = complex cases.
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Time specific:
= When encephalopathic, a patient may not be decisional, = while after treatment decisionality may be regained.
Consistent:
Is the patient able to make a decision with some = consistency?
This means not changing one's mind every time one is asked. Is the decis= ion consistent with the patient's values; if there is a change in the patient values, can the patient explain the change.
Ref= erences
Drane, J. F. (1985). "= ;The Many Faces of Competency." Hasting Center Report: 17-19.
Practical ethics for stude= nts, interns and residents. A Short Reference Manual. Junkerman C and Schiederm= ayer D. Second Edition. University Publishing Group, 1998.
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ACGME Competencies: Medical Knowledge, Patient Care, System-based Practice
Keyword(s): treatment withholding/withdrawal, dying adult, refractory suffering
Controlled Sedation for Refractory Suffering
Controlled Sedation for Refractory Suffering
 (a.k.a. total, palliative, terminal) can be defined as:
 "sedation for intractable distress in the dying". &#= 13;
The use of sedation has been reported to= be anywhere from 2%-50% of hospice patients.
Muller-Busch reported the indications for sedation included: anxiety/psychological distr= ess (40%),
 dyspnea (35%) and =
delirium/agitation (14%).
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While there exists objective criteria for
 quantifying and treating physical distress,
 evaluating psychological distress (a.k.a. existential suffering) is more difficul= t;
There are no simple and clinically oriented tools to evaluate spiritual= and psychosocial components of mental suffering.
Many clinicians find the idea of sedation for existential suffering to = be ethically more challenging than similar treatment for physical suffering.
In either case, the decision to begin a trial of sedation is always difficult= for clinicians, requiring thorough patient assessment and discussions with the patient, family and other t= eam members.
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Ethical/Legal Basis
In the United States, Supreme Court rulings =
 (Vacco v Quill (1997),
Washington v Glucksberg (1997))
supported the concept of sedation when used to relie= ve intractable suffering= .
However, controversy still surrounds the use of seda= tion due to confusion with euthanas= ia.
From an ethical and legal standpoint, the key differ= ence is intent.
In euthanasia the intent is to produce a hastened death.
In sedation, the intent is to relieve intractable suffering, not hasten death. &#= 13;
Of note, recent studies have found no difference in survival between hospice patients who required sedation for intractable symptom control = during their last days and those who did not.
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What is a refractory/intractable symptom?
 Cherney and Portenoy clarified the distinction betwe= en a difficult vs. a refract= ory symptom.
A refractory symptom, that is, one in which total sedation may be appropriate, should have the following three attributes:=
Aggressive efforts short of sedation fail to             = ;     provide relief
Additional invasive/non-invasive treatments         = ;     are incapable of providing relief
        = ;    Additional therapies are associated with   = =         = ;    excessive/unacceptable morbidity, unlikely to         = ;    provide relief with a reasonable time frame.
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Guidelines
 Several similar sedation guidelines have been publis= hed; listed below are Rousseau‘s guidelines for sedation in patients with existential suffering; these guidelines would a= lso be appropriate for decisio= ns concerning physical symptoms.
The patient must have a terminal illness
All palliative treatments must be exhausted, including = treatment for depression, delirium, anxiety, etc
Psychological assessment by a skilled clinician
Spiritual assessment by a skilled clinician or clergy
A DNR order must be in effect and informed consent = obtained and documented
Nutrition/hydration issues need to be addressed prior to sedation
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One additional consideration proposed by Rousseau and others is the concept of Respite Sedation -- a time limited trial (usually = 24 - 48 hours) in an attempt to break a cycle of psychological suffering.
Reference= s
Cherny NI. The use of seda= tion in the management of refractory pain. Principles and practice of supportive oncology Updates. 2000 3:1-11
Cherny NI and Portenoy RK. Sedation in the management of refractory symptoms: guidelines for evaluati= on and treatment, J. Pall. Care 10:2/1994 ;31-38.
Cherny, N., Commentary: Sedation in respons= e to Refractory Existential Distress: Walking the Fine Line, J Pain Symptom Manage, 1998 Dec; 16(6): 404-5.
Charter S et al. Sedation = for intractable distress in the dying-a survey of experts. Pall Med 1998; 12:255-269.
Braun TC et al. Development of a clinical practice guideline for palliative sedation. J Pall Med 2003; 6:345-350.
Hallenbeck, J., Terminal sedation for intractable distress, West J Med. 1999 Oct; 171(4):222-3.
Muller-Busch, H., etal, Sedation in palliative care ? a critical analysis of 7 years experience, B= MC Palliative Care. 2003 May 13; 2(1):2.
Rousseau, P., Existential suffering and palliative sedation: a brief commentary with a proposal for clinical guidelines, Am J Hosp Palliat Care, 2001 May-Jun; 18(3): 151-3.
 = ;
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Grief in Children and Developmental Concepts of Death
ACGME Competencies: Medical Knowledge, Patient Care, System-based Practice
Keyword(s): terminal care, developmental issues rela= ted to death
An understanding of age appropriate grief reactions and conceptions of death are important when assessing a child’s response to terminal illness a= nd a loved one’s death.
Children grieve differently than adults. They often grieve in spurts and can re-gr= ieve at new developmental stages as their understanding of death and perceptions of the world change. <= /span>
Childhood grief may be expressed as behavioral chang= es and/or emotional expression. &= #13;
The two most important predictive factors of a child’s successful out= come after suffering a loss are the availability of one significant adult <= /span>and the provision of a safe physical and emotional environment.
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<= b>0-2 years (Infant )
=
=
Children at this age have no cognitive understanding= of death.
However, grief reactions are possible and separation anxiety is a concern. <= /span>
Behavioral and developmental regression = can occur as children have difficulty identifying and dealing with their loss;
 they may react in concert with the distress experienced by their caregiver. <= /span>
There is a need to maintain routines and to avoid separation from significant others.=
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<= b>2-6 years (Preschool)
Preschool age children see death as temporary and reversible.
They interpret their world in a concrete and literal manner and may ask questions reflecting this perspective.
They may believe that death can be caused by thoughts and provide magical explanations, often blaming themselves for the = death.
Providing simple and straightforward explanations, avoiding euphemism= s, correcting misperceptions, and reminding them that the loved one will not return are important strategies.
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<= b>6-8 years (School Age)
Children understand that death is final = and irreversible but do not believe t= hat it is universal or could happen to them.
Death is often personalized and/or personified. =
Expression of anger towards the deceased or towards those perceived to have been unable to save the deceased can occur.
Anxiety, depressive symptoms, and somatic complaints= may be present.
The child often has fears about death and concerns a= bout their other loved ones’ safety. In addition to giving clear, realistic = information, offer to include the child in funeral ceremonies. Notifying= the school will help teachers understand the child’s <= span style=3D'position:absolute;top:90.5%;left:8.42%;width:87.26%;height:4.5%'>= reaction and provide additional adult support. <= /span>
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<= b>8-12 years (Pre-adolescent)
Children at this age have an adult understanding of death – that it is fin= al, irreversible, and universal.
They are able to understand the biological aspects of death as well as cause = and effect relationships.
They tend to intellectualize death as ma= ny have not yet learned to ide= ntify and deal with feelings.
They may develop a morbid curiosity and = are often interested in the phy= sical details of the dying process and they are interested in = religious and cultural traditions surrounding death.
The ability to identify causal relations= hips can lead to feelings of gui= lt, such feelings should be explored and addressed. To facilitate <= /span>identification with emotions, it may prove useful to talk about your own emoti= ons surrounding death and to offer opportunities for the child to discuss death. The child should also be all= owed to participate, as much as they feel comfortable, in seeing the dying patient and participating in activities surrounding = the death.
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<= b>12-18 years (Adolescent)
Adolescents also have an adult understanding of death.
They are developing the ability to think abstractly = and are often curious of the existenti= al implications of death.
They often reject adult rituals and support and feel that no one understands them. = ;
They may engage in high-risk activities in order to = more fully challenge their own mortality.
They often have strong emotional reactions and may h= ave difficulty identifying and expressing feelings.
It is important that adults support independence and access to peers, but to also provide emotional support when needed.
References
Gudas LS, Koocher GP. Grief and Bereavement. In: Behrman RE, Kliegman R= M, Jenson HB, eds. Nelson Textbook of Pediatrics, 17 th ed. Philadelphia: Saunders, 2004:117-120.
Hi= melstein BP, Hilden JM, Boldt AM, Weissman D. Pediatric Palliative Care. N Engl J M= ed. 2004;350:1752-1762.
Trozzi M, Dixon S. Stressful Events: Separation, Loss, Violence, and De= ath. In: Dixon SD, Stein MT, eds. Encounters with Children: Pediatric Behavior & Development, 3 rd ed. Philadelphia: Mosby, 2000: 547-567.
Fi= ne, P. (Ed). Processes to Optimize Care During the Last Phase of Life. Vista Care Hospice, Inc. Scottsdale AZ. 1998.
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>=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=3D20, 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("slide0056.htm",1,-1,1),new hrefList(= "slide0169.htm",1,-1,1),new hrefList("slide0189.htm",1,-1,1),new hrefList("= slide0170.htm",1,-1,1),new hrefList("slide0178.htm",1,-1,1),new hrefList("s= lide0177.htm",1,-1,1),new hrefList("slide0176.htm",1,-1,1),new hrefList("sl= ide0175.htm",1,-1,1),new hrefList("slide0173.htm",1,-1,1),new hrefList("sli= de0174.htm",1,-1,1),new hrefList("slide0172.htm",1,-1,1),new hrefList("slid= e0171.htm",1,-1,1),new hrefList("slide0179.htm",1,-1,1),new hrefList("slide= 0180.htm",1,-1,1),new hrefList("slide0181.htm",1,-1,1),new hrefList("slide0= 183.htm",1,-1,1),new hrefList("slide0182.htm",1,-1,1),new hrefList("slide01= 88.htm",1,-1,1),new hrefList("slide0187.htm",1,-1,1),new hrefList("slide018= 6.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('


' + ENDSHOW_MESG + '

') doc.close() } function SetSldVisited(){ GetSldList().mList[gCurSld-1].mVisited=3Dtrue } function IsSldVisited(){ return GetSldList().mList[gCurSld-1].mVisited } function hrefList( sldHref, visible, advDelay, advClk ) { this.mSldHref=3D this.mNtsHref =3D sldHref this.mOrigVis=3D this.mVis =3D visible this.mVisited=3D false this.mAdvDelay=3D advDelay this.mAdvOnClk=3D advClk } function SldList(arr,curSld,fEnd) { this.mCurSld =3D curSld; this.mList =3D new Array(); var idx =3D 1; for(ii=3D0;ii 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 ) mObj.style.visibility=3D"visible" } function Cancel() { window.event.cancelBubble=3Dtrue; window.event.returnVa= lue=3Dfalse } function Highlight() { ChangeClr("activecaption","threedhighlight") } function Deselect() { ChangeClr("threedface","menutext") } function Perform() { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) e.Action() else PPTSld.event.cancelBubble=3Dtrue } function ChangeClr( bg,clr ) { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) { e.style.backgroundColor=3Dbg e.style.color=3Dclr } } function M_HasPrevSld() { return( parent.HasPrevSld() ) } function M_GoNextSld() { if( gIsEndShow ) M_End(); else GoToNextSld() } function M_GoPrevSld() { if( gIsEndShow ) { gIsEndShow=3D0; history.back();= PPTSld.event.cancelBubble=3Dtrue; } else GoToPrevSld() } function M_True() { return true } function M_End() { window.close( self ) } function CreateMenuItem( node,text,action,eval ) { var e=3DCreateItem( node ) e.type=3D"menuitem" e.Action=3Daction e.IsActive=3Deval e.innerHTML=3Dtext if( !e.IsActive() ) e.style.color=3D"threedshadow" e.onclick=3DPerform e.onmouseover=3DHighlight e.onmouseout=3DDeselect s=3De.style; s.fontFamily=3DsFont s.fontSize=3D"9pt" s.paddingLeft=3D2 } function CreateSeparator( node ) { var sObj=3DCreateItem( node ) SetCMBorder(sObj,"menu","menu") var s=3DsObj.style s.borderTopColor=3D"threedshadow" s.borderBottomColor=3D"threedhighlight" s.height=3D1 s.fontSize=3D"0px" } function CreateItem( node ) { var elem=3DPPTSld.document.createElement("DIV") node.insertBefore( elem ) return elem } function SetCMBorder( o,ltClr,rbClr ) { var s=3Do.style s.backgroundColor=3D"menu" s.borderStyle=3D"solid" s.borderWidth=3D1 s.borderColor=3DltClr+" "+rbClr+" "+rbClr+" "+ltClr } ------=_NextPart_01C7D4E2.54D633D0 Content-Location: file:///C:/4E921AF3/Module7GoalsofCare_FastFacts_files/fullscreen.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" ------=_NextPart_01C7D4E2.54D633D0 Content-Location: file:///C:/4E921AF3/Module7GoalsofCare_FastFacts_files/buttons.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODlhWAESAPf4AAAAAIAAAACAAICAAAAAgIAAgACAgICAgAQEBISEBASEBISEhAQEhMTExAQE /KTM9Pz8/ERERPz8BAT8/KSkpGRkhMTcxCRkxAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAMDAwP8AAAD/AP//AAAA//8A/wD//////yH5BAEAAPgALAAAAABYARIA QAj/APEJHEiwoMGDCBMqXMiwocOHECNKnEixosWLGCEiQKCRo8YDIEHig2DxAD4LKD1avDDhgUuV GUOGbHBR5QGYFBG4fHAB58EKECJEwCfUYAWPFGAygLCRKQIIUKM6WAohKUGgCikcFWh1INWoYKVS 7SrQ41GbIhGYLAuVQVOoC+IyXUuUAkG1HE3KFDhAwkgJc5/qDZmxsOHDiBMrXsy4sePDGyP7lChT 5MULmDPnlDw5YmW6FTNrfgi0aNGEZPEtbfo2bNTUpYeeRph69dPWrqvCNFuBIGG1A59CYPAVQtwF cw0OxWdTIOiBCQAjaAB17fOFII8voGmRc+eOkilm/z9OvTtnjN4hYk1YoT3H2rnBOphPAB9skgq3 2lcaX/5YnJVt9BloAar12UEIRGCZdQghMABI1Tn32IQUVthYexhmqGGGMBHAgIfEhSiiiATAtOGJ GnYI4ogsEldicAYOGNJGZaml3Y0L3NTZUBz1xlB0PUoUI0jlVWRSVN89xBKSGB1YU1TMoRfVBEle hR9HQs1GEHxQ3RZZbveZthxt/LEmXHyp5XWABSCpaRJwbM13gAACPHVccgJFgF+NEhqUAEkQSCfc ddhVhh5dVTaEAEsTUNlkZUWKN9BNGDE6QU8OrSdbllzpxyVTTrU21Uj3scfhp7nNpyoDaTIEJ3P9 If8J2kbLNYegg9JRBwGhFvbq66+ZUiDssMQWK2yHxiZLrInKNotss8l+B5yBrr5p2UIJvortANoC 6+234IbLla/elRtZjeamh5CC3Sb0YLvixivvYkDFGlZqBNh7r4n6goVvv6/ZlCicN+kL71ALTnpQ dCIZp7CihkLA3UQmoWRBogyxtBPGCTnZncVR1rSTo5nuydC/Eo8kUH+lOoTyyvjoCuZu+PjYIKLD rZybtrM1d10C0QXKEVz48GrQkEeWdFJKlbb0UmEeV0SzyC6RvNB646LWIVjUNeC1zAFb+RDKXksM 9r531bwmpQW9+hQDDsx5pqwDRWBXcFES2hc+gEn/wJGdEEWdE6LoWcoxQweaTNmkhydkKaYMYY2Q p1unbLl/pPKbn3v7EZRvrKvqlja2ONvrtoIw9tn2g32/tQBlhtYkU+MNikZ7QYlPDPuMldpOmuJX nVo5VF3HjI+q89mteX5IDd/fVFClma5kiE4f2XUJhlz09gj2NbTDRifkmu7zXjR++RVJ/lPznuvr QH2iD6S+UewP9Dnon6d2NLwN8n90BB6hC68cFMCHoe+ACASP9c4DowUyEF0OPFcDI0ij/VXPaAKC UfhS95AKGoQ7IBRICI1HwhGaUIQoLGEKT6jCFrLwhSuMoQtlCMMZ2rCGOKShDm+4wxzy8Ic+DGIP B4cIRCKGMCAAOy== ------=_NextPart_01C7D4E2.54D633D0 Content-Location: file:///C:/4E921AF3/Module7GoalsofCare_FastFacts_files/frame.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Module 4 ------=_NextPart_01C7D4E2.54D633D0 Content-Location: file:///C:/4E921AF3/Module7GoalsofCare_FastFacts_files/outline.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii"
 No= tes
Slide Show
Outline
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