1) The document discusses various topics related to caring for specific patient populations including palliative care, giving bad news, difficult patients, and vulnerable groups. 2) Palliative care aims to relieve suffering and improve quality of life for patients with advanced illnesses through pain management, psychosocial support, and care coordination. 3) When giving bad news, it is important to prepare patients, give the news clearly, provide emotional support, ensure understanding, and make a follow up plan.

1. Lecture 7
Behavioral sciences
Patients - dealing with a
Specific Populations
( part 1)

2. Specific Populations
1. Palliative Care
2. Giving Bad News
3. Difficult Patients/Difficult Situations
4. Patient Adherence
5. Vulnerable Patients
6. Families
7. Domestic violence
8. Abused and neglected child
9. Abused and neglected elderly persons
10.- Empathy
11.Mistakes in Medical Practice

3. Palliative Care
• after the age of 65 most adults will have one
or more chronic illnesses with which they will
live for years before they die. These years are
often characterized by physical and
psychological distress, progressive functional
dependence and frailty, and increased needs
for family and external support .

4. The role of palliative
•Traditionally, medical care has
been articulated as having two
mutually exclusive goals: either
to cure disease and prolong life
or to provide comfort care

5. The role of palliative1
•Palliative care aims to relieve
suffering and improve the quality of
life for patients with advanced
illnesses and their families through
specific knowledge and skills,
including communication with
patients and family member

6. The role of palliative1
• management of pain and other
symptoms; psychosocial, spiritual, and
bereavement support; and
coordination of an array of medical
and social services Palliative care
should be offered simultaneously with
all other medical treatment.

7. physician–patient communication in
Palliative care
• Empirical evidence supports the effectiveness
of clinicians’ use of specific communication
skills in enhancing disclosure of the issues of
concern to a patient, decreasing anxiety,
assessing depression, and improving a
patient’s well-being and the level of the
patient’s and the family’s satisfaction with the
treatment

8. 2
•Those communication skills include making
eye contact with patients, asking open-ended
questions, responding to a patient’s affect,
and demonstrating empathy

9. 3
• Studies suggest that what most seriously ill
patients want is to have their pain and other
symptoms relieved, improve their quality of
life, avoid being a burden to their family, have
a closer relationship with loved ones, and
maintain a sense of control ,

10. 4
•Avoiding aggressive medical manipulations
when they are unneeded always should be a
goal to keep patient dignity and suffering

11. 5
•Clinicians can assist patients and their families
in establishing their own goals by means of
open-ended and probing questions. Some
examples of the types of questions include
“What makes life worth living for you?” “Given
the severity of your illness, what are the most
important things for you to achieve?” “What
are your most important hopes?” “What are
your biggest fears?”

12. 6
• Improved treatment of symptoms has been
associated with the enhancement of patient
and family satisfaction .
•

14. psychosocial, spiritual, and
bereavement support
•: Providing psychosocial,
spiritual, and bereavement
support to patients and
caregivers is a key component
of palliative care

15. 2
•Studies shows that patients welcome
inquiries about their spiritual well-being and
psychological from their physicians more than
anyone else .

16. Goals of care
1.Early Stage Discuss diagnosis, prognosis, likely
course of the illness, and disease-modifying
therapies; talk about patient- centered goals,
hopes, and expectations for medical
treatments

17. 2
1.Middle Stage Review patient’s understanding
of prognosis; review efficacy and benefit-to-
burden ratio for disease-modifying
treatments; reassess goals of care and
expectations; prepare patient and patient’s
family for a shift in goals; encourage paying
attention to important tasks, relation- ships,
and financial affairs

18. 3
1.Late Stage Assess patient’s understanding of
diagnosis, disease course, and prognosis;
review appropriateness of disease-modifying
treatments; review goals of care and
recommend appropriate shifts; help patient
explicitly plan for a peaceful death; encourage
completion of important tasks and increased
attention to relationships and financial affairs

19. Family support
1.Early Stage Inform patient and family about
eventual support; ask about practical support
needs (e.g., transportation, prescription-drug
coverage, respite care, and personal care);
listen to concerns

20. 2
-Middle Stage Encourage support or counseling
for family caregivers; ensure that caregivers
have information about practical resources,
stress, depression, and adequacy of medical
care; identify respite and practical support
resources; recommend help from family and
friends

21. 3
1. -Late Stage Encourage out-of-town family to visit; refer
caregivers to disease-specific support groups or
counseling; inquire routinely about health, well- being,
and practical needs of care- givers; offer resources for
respite care; after death, send bereavement card and
call after one to two weeks; screen for complicated
bereavement; maintain occasional contact after
patient’s death; listen to concerns.
•

22. Some final recommendations
•When a patient is informed of a life-
threatening illness, a wide spectrum of
feelings may emerge: denial, intense anxiety,
fear, sadness, and anger ( see lecture 4 ) , . If
the practitioner is inexperienced in palliative
care or is extremely discomfited by death,
there may be a tendency to withdraw from
the patient’s care or to minimize the meaning
and impact of the diagnosis

23. 2
 The goals of partnership and shared decision
making are sometimes limited by strong
emotional reactions ( the doctor should
decide )

24. 3
•In many countries there is a special unite for
terminal and dying patients( Hospice
programs provide comprehensive care to
dying patients, with a multidisciplinary team
of nurses, physicians, social workers,
volunteers ) this is because , physicians may
be unable to commit the time and energy
needed to develop close personal contact with
the seriously ill, potentially dying patient.

25. 4
• This sadness, which may be a way of preparing for death,
has been called preparatory or anticipatory grief. Grieving
over the loss of physical abilities, social position, and
contact with pleasurable routines—whether one’s own or
those of a loved one— is a natural reaction. The absence of
grief over these losses may indicate denial and emotional
numbing. Sharing and exploring the grief help both patient
and clinician enter a relationship that acknowledges one
another’s humanity. Having the courage to explore these
feelings assists the patient in coming to terms with death
and may prevent the isolation and subsequent clinical
depression to which some patients are prone

26. 5
 Depression Distinguishing clinical depression
from the natural grieving process that
accompanies a terminal illness may be
difficult, as they share many common
symptoms
•The vegetative symptoms of depression—as
loss of interest, withdrawal, sadnessfatigue,
changes in appetite, sleep disorders

27. 6
•Pseudo –hope the information about
diagnosis and prognosis is totally denied by
patient and his family , they may neglect
treatment or begin searching about some
absurd recovery reading about it in popular
newspapers , or seeking nonscientific
alternative treatment

28. 7
•Patients who experience altered states at the end of
life need supportive treatment. Once this stage has
been reached, decisions about artificial hydration and
feeding ideally should have already been made and
formalized through advance directives. If they have not
(as is frequently the case) the designated health care
agent or the family, taking into consideration the
patient’s condition and prognosis, must make a
substituted judgment as to what the patient would
want. If this cannot be determined, the physician’s
decision should be based on a consensus among family
and providers about what is in the best interest of the
patient .

29. 8
•When dying patients go to terminal pre-death
coma or delirium it will be better to isolate his
family away .

30. 9
•Some patients are not afraid of dying and
come to accept death as a natural step in
completing the life cycle. Many such persons
are able to die with grace and ease,
demonstrating that death does not always
have to be feared or denied.

31. Unexpected Death
•Sudden or traumatic death sends a shock through the
family and, when it occurs in a medical facility, may
elicit strong doubt about competence in clinicians
• Family members should be allowed to view and stay
with the deceased; when possible, the eyes and
mouth should be closed and the limbs arranged
peacefully, removing blood , hiding distorted organs .
Strong emotional reactions should be anticipated and
the tears of grief welcomed ( to avoided developing of
complicated grief) .

32. Giving Bad News
• Techniques for giving bad news.
•
• Category Technique
• Preparation Forecast possibility of bad news
• Clarify who should attend the bad news visit
• Clarify who should give the bad news
•
• Setting Give bad news in person
• Give bad news in private
• Sit down and make eye contact
•
• Delivery Identify what the patient already knows ( if you have decided to tell him )
Give the news clearly and unambiguously Identify important feelings and concerns
•
• Emotional support Remain with the patient and listen
• Use empathic statements
• Invite further dialogue
•
• Information Use simple,clear words and concepts
• Summarize and check patient’s understanding
• Use handouts and other resources
•
• Closure Make a plan for the immediate future
• Ask about immediate needs
• Schedule a follow-up appointment

33. 2
•Giving bad news is hard. Most physicians
struggle to find the proper balance between
honest disclosure and providing
encouragement, hope, and support.
Physicians giving bad news may experience
feelings of sadness, anger, guilt, or failure.

34. 3
•Receiving bad news is usually more an
emotional than a cognitive event. Common
immediate emotional reactions are fear,
anger, grief, and shock or emotional
numbness. An important challenge for many
physicians is to remain with patients having
strong emotional reactions and to tolerate
their distress.

35. 4
• Remember it is difficult in many cases to hide the
real information because most patients consult
an informal health advisor (a family member,
friend, book, or web site) at some point during
the illness and may have some ideas about what
is wrong, what it means, and what can be done.
Asking about these ideas shows respect for the
patient’s coping efforts and helps the physician
put new information into a familiar context

36. DEATH NOTIFICATION
•when notifying family members of the death
of a loved one. Unexpected or traumatic
deaths are most difficult because families are
unprepared and rarely have a prior
relationship with the notifying physician

37. 2
•Once given the news, families often want to
view the body. This is an important part of
the grieving process and should not be
discouraged

38. 3
•. Families are often concerned about whether
their loved one suffered or was alone at the
time of death and whether they could have
done anything to prevent it. Usually, they can
be truthfully told that the patient was
unconscious prior to death, there was no
evidence of suffering, and that maximal
efforts were made to help. Families may also
need to be reassured that none of their
actions hastened the patient’s death