Ethics OSCE Station Blueprint

Station Name: Alzheimer's Disease

Issue:

Truth Telling

Presenting Situation:

David Forrester has come to the office for results of neuropsychological and neurological testing. According to neurologist, Mr. Forrester has a clinical presentation typical of Alzheimers Disease.

Activities:

Patient encounter.

Time Required:

10 minutes

This station was developed by Dr. Peter A. Singer (Centre for Bioethics and Department of Medicine, University of Toronto), and Anja Robb (Department of Family and Community Medicine, University of Toronto. It is part of the Ethics OSCE Project which is funded by Educating Future Physicians for Ontario (EFPO). There is an accompanying videotape. This material can be used for teaching or evaluation. It is not copyrighted and may be freely reproduced for educational purposes.

Instructions to Candidate:

You are about to see David Forrester, a 62 year old man who works as a senior stockbroker at a large firm. He has been a widower for the past 6 years. He has a son living in Vancouver. About 8 months ago, Mr. Forrester began seeing YOU about a number of complaints including: headaches, fitful sleep, low energy, not much interest in life, finding job too stressful, and feeling depressed. Mr. Forrester did not want to see a psychiatrist. He believed his problems were physical (caused by stress) and not psychological. Mr. Forrester also complained of memory problems and trouble concentrating (there had been a major work-related error that cost a client a lot of money). The patient was tested for evidence of depression with the geriatric depression scale and results indicated a mild depression. His physical exam and blood work were normal.

Six months ago, you referred Mr. Forrester for Neuropsychological testing. Tests included: writing, verbal memory, visual memory, calculation ability. Results were consistent with diffuse cerebral dysfunction. Most suggestive of a dementing problem - a progressive neurological disorder. Results were highly consistent with diagnosis of Alzheimer's Disease. You advised Mr. Forrester that his problems were due to neurological deficits, not depression. Mr. Forrester continued to blame his problems on stress and denied your diagnosis. You agreed to reassess his condition in 6 months.

The test was repeated after 6 months. Results showed slight declineAccording to Neurologist, Mr. Forrester has a clinical presentation typical of Alzheimers.

Mr. Forrester is now back in your office asking "What's going on? What do all those tests mean? I need answers."

CHECKLIST ITEMS:
^^^^^^^^^^^^^^^^

YES     NO     The Candidate:
        
               1.      informs patient the tests indicate
                       strong possibility of Alzheimer's
                       Disease.
----|-----------------------------------------------------------
               2.      Asks about patient's knowledge regarding
                       Alzheimer's Disease.
----|-----------------------------------------------------------
               3.      informs patient that diagnosis is not
                       100% sure.  (There is a lack of
                       precision in both diagnosis and
                       prognosis and disease cannot be
                       confirmed until death.)
----|-----------------------------------------------------------
               4.      informs patient that pattern of the
                       disease is that it worsens over time but
                       the rate is unpredictable.
----|-----------------------------------------------------------
               5.      Asks about patient's social supports.
----|-----------------------------------------------------------
               6.      offers to help tell family or trusted
                       friends.
----|-----------------------------------------------------------
               7.      advises patient to think about getting
                       financial affairs in order (e.g. power
                       of attorney, testamentary will).                           
----|-----------------------------------------------------------
               8.      advises patient to think about drawing
                       up a living will/advance directive.
----|-----------------------------------------------------------
               9.      informs patient that receiving
                       experimental or unconventional treat-
                       ment may be an option (e.g. randomized
                       trials of cognition-enhancing drugs).
----|-----------------------------------------------------------
               10.     mentions that it will be necessary to
                       see how diagnosis will affect everyday
                       life (e.g. driving, work, living alone).
----|-----------------------------------------------------------
               11.     offers ongoing support.
----|------------------------------------------------------------ 
=================================================================

                              
RATE FROM 1-5:
 +------------------------------------------------------------+
 |        |          |          |    VERY    |                |
 | POOR   |   FAIR   |   GOOD   |    GOOD    |    EXCELLENT   |
 |  1     |    2     |    3     |     4      |       5        |
 +------------------------------------------------------------+

1.      How would you rate the candidate's communication skills?                                 
        1      2       3      4      5

2.      How would you rate the candidate's ability to address the
        ethical issue in this case?                 
        1      2       3      4      5

Instructions to Standardized Patients:

Your name is David Forrester. You are a 62 year old patient who has been in a high functioning job at a stock brokerage firm. About 8 months ago you began seeing the doctor about a number of complaints including: headaches, fitful sleep, low energy, not much interest in life, finding job too stressful, feeling depressed. It was suggested that you see a psychiatrist. You didn't want to. You think your problems are physical (caused by stress) and not psychological. You also complained of memory problems and trouble concentrating. There had been a major work related error that cost a client a lot of money. You had forgotten to buy some stock that client requested.

Six months ago, doctor referred you for (neuropsychological) testing. Tests included: writing, verbal memory, visual memory, calculation ability. You were also tested for psychological factors (on geriatric depression scale). The doctor told you that the results were not consistent with depression. The doctor also told you that the test indicated there may be a problem with the way your brain was working - he said it was most likely a neurological disorder that would probably get worse.

Tests were repeated a month ago. Results showed no improvement (in fact they showed a slight decline) in functioning. You were then referred to a neurologist (you can't remember the neurologist's name) who did tests and sent a report with the results to your family doctor. The neurologist spoke to you about the results for about 1/2 hour, but you do not have a clear memory of what was said. ("He talked for about half an hour but I really don't know what he said.") You do remember that the neurologist said you didn't have a brain tumour. He also said something about Alzheimer's but you're sure he doesn't know what he's talking about.

You are now back at your family doctor for a diagnosis. ("What's going on?")

You still don't believe the neurologist's diagnosis. You still want to think that the problem is stress related but now you're confused and anxious. You are having real difficulty coping with work. You think the problems couldn't be as serious as test results show.

You have a son who lives in Vancouver, and a sister who lives in a small town not too far away. You have one close and trustworthy friend.

Prompts are used to standardize the scenario and give all candidates an opportunity to address relevant issues.

PROMPT 1 (by 3 minutes):
So what about all these tests? Have you got the results?

IF ASKED WHAT THE NEUROLOGIST TOLD YOU, SAY:
"Well I gather it's not a brain tumour anyway. The neurologist said something about Alzheimer's but I can't believe he knows what he's talking about."

AS THE PATIENT YOU CAN ACT IMPATIENT TO GET DIAGNOSIS. IF CANDIDATE IS NOT LABELLING IT, YOU SHOULD ASK:
"Is this a disease? Does it have a name?

PROMPT 2 (by 3-4 minutes):
If you're right, what does it mean? What's going to happen to me? (i.e. Am I going to deteriorate quickly? What's the worst scenario?)

PROMPT 3 (by 5-6 minutes):
Isn't there anything anybody can do?

PROMPT 4 (by 6-7 minutes):
What happens now? What should I do?

YOU CAN PUSH FOR INFORMATION WIHOUT SPECIFICALLY MENTIONING POWER OF ATTORNEY, OR LIVING WILLS.

[You had a friend whose mother had this sort of thing. She became completely incompetent to do anything for herself. It scares you to think of losing control like that.]

PROMPT (conditional):
What can I tell the family?
[Ask this question if family supports are explored.]

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