Shunichi Nakagawa Profile picture
Jul 6 3 tweets 1 min read Twitter logo Read on Twitter
When I see a new pt, there is some info that is important to me.

- The date of admission: Admitted 2w ago vs 2m ago is very telling in itself.

- Where patient lives, with who? : Not only for GOC, but also for pain regimen, this is important.

1/
- The time of diagnosis: Cancer diagnosed 3yrs ago vs 3 wks ago is very telling in itself.

- How many admissions over the last 6 (or 12) months: especially for HF. Sometimes I need the exact date of admission and discharge, so that I know how long patient stayed at home.

2/
With the ICU case,
- the date the key life support (vent/CVVH/ECMO) started or finished.

- the date patient was transferred in/out of the ICU.

Some may not think these matter, but these help me imagine how patient has been doing.

3/

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More from @snakagawa_md

Apr 19
Thrilled to announce that our paper is just out in @BMJ_SPCare!!

Common pitfalls in exploring values.

"What would he say?" --> "I don't know" --> freeze
"What is important?" --> "Getting better" --> freeze

What should you do?

spcare.bmj.com/content/early/…

1/ ImageImage
Among opening Qs, start with general ones, then proceed with more specific ones.

Many start with "What would they say?"
But this Q is too negative. Many cannot answer.

Instead, start with more general/positive ones.
Very few cannot answer "What makes you happy?"

2/ Image
Once you get the answer to any opening Qs, many physicians either stop there or freeze.

Don't stop/freeze.

Now this is the time to use "follow-up Qs"
- Tell me more
- Why?
- What else?

See the examples below.

These can be used repeatedly and alternatively.

3/ Image
Read 7 tweets
Feb 24, 2022
I don't care too much about how we call it (ACP, SIC, GOC, etc).

We just need 3 steps, 1)prognosis--> 2)goals/values --> 3)treatment preferences.

2) depends on 1), 3) depends on 2).

If you are healthy, don't worry about 1) and 3), but still you need to talk about 2).

1/
When you get older, or you have some disease (like cancer or HF), 1) starts to become not forever, then 2) might change (that's ok).

Still, you don't need 3). Just keep talking about 2) regularly, make sure your family knows it.

2/
Trying to get 3) and make it official in a living will is ok, but only 3) without 2) will not help, as many studies have shown.

3/
Read 6 tweets
May 25, 2021
It is better to sit down when you talk to a patient/family, even for a few min.

By standing, you give the impression that you are busy and you can leave at any moment, which makes pt uncomfortable.

Let me share my anecdote.

1/
Several years ago, I got a consult in the ICU.

Pt was in his 70s, intubated for a week, was at end of life.

A sister was sitting at the bedside, looked anxious.

I went into the room, introduced myself, grabbed a chair,and sat down next to her.

2/
I told her I had only 5 min and I had to come back.

She told me she comes here to see him and spends several hours at the bedside every day.

After 5 min, when I was about to leave, she said

"THANK YOU, doctor, you are the first doctor who sat down to talk to me."

3/
Read 5 tweets
May 12, 2021
One of my favorite consults is goals of care BEFORE high-risk CT surgery.

Why palliative care/GOC before surgery?

It is because we need to have a high-quality conversation, in very challenging cases.

In my opinion, there must be 2 phases of conversations.

1/
First of all, we need to decide whether or not to do surgery.

The best tool for this is BC/WC model by @GretchenSchwa10

The beauty in this model is, by giving the WC of surgery and the BC of no surgery, you can create the story for both options.

2/

jamanetwork.com/journals/jamas…
The patient can picture both options more clearly and they can make a better decision.

Even if they say "OK, I will do surgery", we are not done yet.

Then you have to have the 2nd phase of the conversation.

Basically, you need to ask 4 questions.

3/
Read 11 tweets
Mar 2, 2021
The reason for palliative care consult is GOC.

Yes, you have to start GOC by asking "What did doctors tell you?"

But this question should NOT come right after you introduce yourself.

If I were a patient, I would think "Who are you?"

It won't make a good impression.

1/
First, you have to explain what is palliative care and why you are here.

Then, you have to ask about symptoms. Pain? SOB? nausea?

Then, ask about the patient and family.
- Where do you live?
- With who?
- Any family?
- Where do they live?
- Do they come see you?

2/
Then, ask about pre-admission functional status.
- How strong were you?
- Who cooks for you?
- Do you go to the grocery store for shopping?
- Do you take medications by yourself?

With these info, you should be able to picture who/how he/she was before admission.

3/
Read 6 tweets
Feb 10, 2021
In a family meeting, after you explained the situation is worse, I see many doctors ask,

"What would he WANT?"

I think this is a BAD question, although I'm aware it is well-intentioned.

I will tell you why...(thread)

1/
What you should do at this point is exploring goals/values of the patient.

But if you use "want", that q is (automatically) asking about treatment options, not goals/values.
(I want chemo, I want dialysis, etc).

2/
For example, your laptop got broken, and you came to a store to buy a new one.

An attendant comes and explains to you.
"model A is 1.4GHz processor/500GB storage/$1000, model B is 2.9GHz processor/1000GB storage/$1500. Which do you WANT?"

Can you answer the question?

3/
Read 10 tweets

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