Case Summary:

• You are Elaine Stuart, a 55-year-old high school math teacher.
• You returned to work about 6 weeks after surgery, on 3/17/98. It has not been easy.
• This visit occurs about 3 months after you had the bowel resection.
• You saw an oncologist, Dr. Johnson, while in the hospital (2/6/98).
• You were discharged from the hospital on 2/9/98.
• You started adjuvant chemotherapy 3 weeks after surgery on 2/23/98.
• Your initial treatment of rapid IV injection chemo was for 5 consecutive days. Since then, you have had one treatment per week each Monday for the last 11 weeks.
• Your oncologist, Dr. Johnson, recommends continuation of the chemotherapy, but you are becoming very tired of it. The side effects that you are experiencing include mouth sores and diarrhea. Because of the treatments and the side effects, you’ve missed 1-2 days of work per week for the last 2 months.
• You have been experiencing nausea and abdominal pain for 2 weeks now.
• You talked to Dr. Johnson about this during your last visit for chemo (11th visit on 5/4/98). He prescribed Compazine and sent you for a CT scan and blood tests performed 3 days ago (5/5/98).
• The scan revealed that further metastasis of the cancer has been found in your liver.

Why You Are Seeing The Doctor Today:
You are seeing the resident today to get the results of the CT scan and blood tests performed 3 days ago. You also want to discuss your options at this time: more chemo (as recommended by the oncologist) or Hospice/palliative care. The additional symptoms you have been experiencing for the last 2 weeks (nausea and abdominal pain) have not been relieved by the Compazine that Dr. Johnson prescribed. In addition, you have lost 8 pounds in the past month. You suspect that the cancer has spread further. You are very worried and need reassurance. You are also hoping for better control of your symptoms (the Compazine isn’t helping much).

Opening Statement:
In order to start all of the encounters in a similar manner, your opening statement should be about how you’ve been feeling. It’s hard to predict what the resident will say when he/she comes in the room; your response should be appropriate to the resident’s statement or question. For example:

The resident may ask you, "How are you doing, Ms. Stuart?"

• You would respond: "OK, could be better, I guess. I’ve had nausea and stomach pain. I’ve really been feeling lousy and I’m worried about the results of the scan."

Physical Description:

• Well-groomed, dressed neatly, but now looking "pale/haggard" (no makeup).

• You appear to be somewhat depressed/worried.
• You seldom look the resident in the eye.
• You are very worried and are really feeling "lousy" now. Besides the nausea and abdominal pain, you have no energy whatsoever and are feeling depressed. It is a real struggle to go to work every day.
• You may become a bit agitated as the interview proceeds, once you’ve been told that your cancer has recurred/spread. The CT scan of the abdomen revealed multiple hepatic (liver) lesions that indicate metastasis (spreading).
• As the resident explains the treatment that you will need, he/she should acknowledge or ask about your feelings or concerns.
• If he/she does not, you will become even quieter, as if you are thinking about something or are worried. Hopefully, this will prompt the resident to ask about your concerns, which are:
  • how to treat the pain/make you feel better.
  • you wonder if you will need further surgery.
  • you wonder if you will need additional chemotherapy/continue the present regimen.
  • you are worried about how much pain & suffering you will have to endure.
  • you wonder how long you have to live.

• You had been generally in good health until 4 months ago when you noticed rectal bleeding.
• No allergies.
• No hospitalizations prior to this illness except for tonsillectomy at age 9.
• Surgeries: Tonsillectomy at age 9 and bowel resection 3 months ago.
• No serious prior illnesses except for pneumonia in 1980.
• Immunizations up to date.

You have now been experiencing the nausea and other symptoms noted above.

• Your current symptoms began about 2 weeks ago when you began experiencing nausea and some abdominal pain. The pain has gotten progressively worse each day. It is a constant, diffuse upper abdominal ache, about a "3-4 out of 10."
• You have lost 8 pounds in the last month.
• You have been feeling even more fatigued in the last couple of weeks.
• You are very worried that the cancer has come back.
• You have very little social support, which may contribute to your feeling of depression.
• You have trouble falling asleep because of the pain and worry.
• Since you began the chemo treatments, you have had diarrhea on and off most of the time. One week it was so bad that the oncologist checked your blood and had you skip one week’s treatment.
• You have missed 1-2 days of work a week because of the treatments and/or side effects.

• Prescription Medication: Compazine for the nausea. This is what you will answer when asked, "Are you on any medication?"
• Over-the-Counter Medication: Tried Extra Strength Tylenol, but it doesn’t help. Over-the-counter vitamins. This is what you will answer when asked "Do you take any over-the-counter medicine?"

Personal Habits:
Alcohol Use: A glass or two of wine on weekends.
Tobacco Use: None.
Caffeine Use: 2 cups of coffee a day.
Drugs (Illicit): No history of illicit drug use.
Vitamins: Take "One a Day," one tablet per day; occasional aspirin for joint aches.
Exercise: You don’t have time.
Health Insurance: You are covered under your school’s Independent Health Association Plan.

• You will respond the same to all interviewing styles.

• "Do you really think I need Hospice? Am I that far gone? I don’t think so, I’m not ready yet."

• You are concerned about the need for further surgery and/or chemotherapy; if there are any odds for getting well; the fact that you very well may/will die from this.

Your response at this time will be to appear resistant, you say that you will "think it over," you’re not ready yet. (In reality you’ve almost made up your mind to stop treatment because you are very tired of it, but it’s a shock, a big step and you need to mull all of this over.)

• "Has it spread anywhere else?"
• "Will I need more surgery? Will I need more chemotherapy?"
• "How serious is this?"
• "Can you get rid of this nausea and pain/make me feel better?" (Ask this question at the end if you have not been reassured in this regard.)
• "How bad is this pain going to get?"
• "I’m not sure if I can continue working. What do you think?"
• "Will I be bed-ridden soon?"