Danielle Clarkson Tobacco Cessation Ready to Quit

Transcription

1 STANDARDIZED PATIENT CASE MATERIALS and LEARNER INSTRUCTIONS Danielle Clarkson Tobacco Cessation Ready to Quit Timing: minutes for the encounter 7 minutes for paperwork 8 minutes for feedback Revised:

2 LEARNER INSTRUCTIONS Danielle Clarkson is a 37 year old female who presents to your clinic to discuss quitting smoking. Vital Signs Temperature 98.6 Blood pressure 134/76 Pulse 88 Respirations 14 LEARNER TASKS Obtain a history or intake interview pertinent to the patient s problem, as appropriate for your discipline. As part of your interview with the patient, discuss and counsel on tobacco use. Do not conduct a physical exam. te to faculty: As appropriate, insert instructions for any additional activities (e.g., self reflection, inter station exercises, etc.) 2

3 CASE DETAILS GENERAL INFORMATION Danielle Clarkson is a 37 year old female who presents to your clinic to discuss smoking cessation. OPENING STATEMENT I want to quit smoking but I m I don t think I can do it on my own. HISTORY OF THE PRESENT ILLNESS Who am I? Name: Danielle Clarkson DOB/Age: 02/01/19XX [37 years old] Address: [insert regionally appropriate address] Phone: [insert regionally appropriate telephone] Appearance Casually dressed Behavior You are motivated to quit smoking but concerned that you will not be able to succeed. Case Props ne CURRENT MEDICAL HISTORY Details of Current Problem You are 37 year old Danielle Clarkson. You made an appointment to get some help with quitting smoking. You had your first child Samantha 18 months ago. You quit smoking when you decided to try to get pregnant and did not smoke during the year when you were trying, during your pregnancy, or postpartum while you were breastfeeding. You started back up again by just having a couple of cigarettes a day. Slowly, over the past year, you have increased your smoking and are now back up to about half a pack a day. After you quit, you had not planned to go back to smoking, and you do not want to continue. Standardized Patient Response to Counseling Questions Ask about tobacco use. Identify and document tobacco use status of every patient at every visit: If the learner asks about your current tobacco use or Do you smoke? or Do you ever smoke or use any type of tobacco? you will respond: I do. 3

4 Advise to quit in a clear, strong, and personalized manner: If the learner asks, May I tell you why this concerns me? or offers support of your choice to quit, you will respond: I feel guilty every time I have a cigarette, and I want to quit but I m not sure I can do it. I m here to get advice. Assess readiness to quit: If the learner asks, What are your thoughts on quitting? or Do you want to quit? you will respond: I really want to quit, but I can t seem to get the last few pounds of the baby weight off, and if I stop I m afraid I m going to gain it back. Assist with quitting: If the learner asks about your current tobacco use (types used, amount, etc.) or about any recent changes in levels of tobacco use, you will respond: About a year ago, I started having a cigarette or two when Samantha was sleeping, and somehow I m now back up to smoking about a half a pack a day. If the learner asks about past quit attempts, you will respond: I quit when we decided we wanted to have a baby. I just stopped but I was highly motivated at the time. I tried to quit again a few weeks ago, but it didn t work. I only lasted 3 days. If the learner asks, What are your reasons for wanting to quit? The main reason I want to quit is because of my daughter. And I m about to start a new job in a month. I don t want the people there to know I smoke. If the learner asks, What are your triggers/in what situations or routines do you want to smoke? you will respond: I smoke when Samantha is napping or sleeping, and I'm still trying to lose some weight. Smoking distracts me from eating. If the learner asks what coping methods you have tried/or could try in an attempt not to smoke prior to a situation in which you tend to smoke, you will respond: I have tried just going outside and walking around instead of smoking, but I almost always give in to the craving for a cigarette. If the learner asks what coping methods you have tried/or could try in an attempt not to smoke when you are in a situation in which you tend to smoke, you will respond: I usually just end up eating. If the learner asks, What are your concerns about quitting (for example, weight gain, withdrawal symptoms)? you will respond: I just got almost all of the weight off from the pregnancy, and I m worried I m going to gain it back. 4

5 If the learner asks you to set a quit date, you will respond: I m ready, but I don t think it s going to be easy. I m starting a new job in a month, so hopefully before then. If the learner asks, Would you be able to take a medicine at least 9 times a day? you will respond: Hmmm that would be a challenge. I don t think so. If the learner asks how you feel about nicotine replacement therapy options, or if the learner asks, What do you think you want to try this time to quit? you will respond: I had a friend who quit with the nicotine patch, and it worked for her, but I don t think I really want to try that. I have super sensitive skin. Are there other options? If the learner suggests nicotine gum, you will respond: I have jaw issues, and my dentist told me I shouldn t chew gum. If the learner suggests the nicotine nasal spray, nicotine lozenges, or nicotine inhaler, you will respond: How many times a day do I have to use that? [NOTE: All of these medications are dosed at least 8 9 times a day initially, and in response, you will indicate that you are not able to do this and would like a simpler option.] If the learner suggests bupropion (Zyban) or varenicline (Chantix), you will respond: Tell me more about [recommended medication name]. After the learner has provided information about the drug, you will respond: That sounds like a good choice for me. [NOTE: If both medications are discussed and the learner does not recommend a specific medication you will state, What do you recommend that I take? ]. Arrange: If the learner encourages a follow up appointment, you will respond: Okay as long as it s before I start my new job. Additional Information for the Standardized Patient You have smoked today. You had your last cigarette in the parking lot before you came into the clinic. Your smoking has been increasing over the past year, and you are having stronger and more frequent cravings for cigarettes. As soon as Samantha falls asleep, you go outside and light up. You have your first cigarette when she goes down for a nap about 1 pm. You have tried to quit cold turkey a few times (last time was 2 weeks ago) since you started back up, but you haven t succeeded. 5

6 You quit cold turkey when you decided to get pregnant; at that time, you had withdrawal symptoms including difficulty sleeping, feeling on edge, and strong cravings for cigarettes. It was tough for the first few weeks, but you powered through and didn t smoke (not even a puff) throughout your pregnancy. You did not anticipate that you d start smoking again after you had Samantha. You thought you had quit for good, but once you started, you slipped back into the habit. You initially started smoking again, instead of snacking, and now it has just become part of your daily routine. You do not feel very confident about quitting. The last time you quit, you had a strong motivation: wanting to have a baby. You re worried that without that motivation, you won t be able to just stop like you did last time. You will be highly motivated to quit if the learner discusses third hand smoke and the effect of smoking on Samantha. You do not want to enroll in a behavioral change program that you need to attend in person. With parenting and starting a new job, you don t feel you have time for that. You will agree to call the tobacco quitline, if suggested. PAST MEDICAL HISTORY Do you have any past medical history/illnesses? Medical Conditions Your blood pressure has been borderline high since you were in your early 30s. It was elevated throughout your pregnancy, although you did not develop preeclampsia. You hoped that it would go back down after your pregnancy, but it hasn t. You get frequent heartburn and use over the counter antacids frequently. You were last seen by your primary care physician about 4 months ago for your annual physical. You were last seen by your OB/GYN about 6 months ago. You started menstruating when you were 14 years old. Your periods have always been irregular. You and your husband tried for about a year before you were able to get pregnant. Your pregnancy was relatively uncomplicated, although they did closely monitor your blood pressure. You had a caesarean 6

7 section delivery. You breastfed for the first 6 months and then switched to formula. Last Visit to the Doctor Related Symptoms Positives You get a little short of breath when you go up and down stairs. Your jaw clicks when you chew gum (secondary to temporomandibular joint disease TMJ). Negatives You do not smoke in the house or around Samantha. Prescription medications? ne Over the counter medications? Over the counter antacids Herbal supplements? ne Dietary supplements? ne Allergies to medications or foods? known medication or food allergies FAMILY MEDICAL HISTORY Any question pertaining to medical issues/problems in your family. Your father is 61 years old. He had a heart attack when he was 52. He is a smoker. He has tried to quit but has never been able to stick to it. He has high blood pressure and high cholesterol, and is overweight. Your mother is 60 years old and is overweight. She has type II diabetes, high blood pressure, and high cholesterol. You have a 39 year old brother who is also overweight and smokes. He was diagnosed with high blood pressure about 5 years ago. SOCIAL HISTORY Education? BA in business administration Work? You are going back to work in a month. You left your job as an administrative assistant for Blue Cross Blue Shield when you had the baby. You have just been hired by State Farm Insurance as an office manager. 7

8 Home? Spouse/partner: You have been married to Mark for 10 years. He does not smoke. Children: You have an 18 month old daughter, Samantha. Tobacco use? You started smoking in high school (because it seemed like the cool thing to do) and smoked about a pack a day for about 18 years. You quit smoking when you decided to try to get pregnant and did not smoke while you were trying (for a year), during the pregnancy, or while you were breastfeeding. You started back up again by just having a couple of cigarettes a day when the baby was napping or had gone to bed for the night. Slowly, over the past year, you have increased your smoking and are now back up to about half a pack a day. It has now become a part of your daily routine. Alcohol? You can t even remember the last time you had a drink. It has never been your thing. Recreational/illicit/illegal drugs? You have never used any recreational drugs. Diet? Exercise? You have been trying to diet, but it is hard because you are home all day and tend to snack. After you had the baby, the initial weight came off pretty easily, but now you are not losing any more weight, although you are still trying to limit your caloric intake. You really haven t had a chance to exercise, although you do take a walk with the baby every day. Hobbies? You enjoy reading and watching old movies. While you have been at home with the baby, you joined a mom s group and take the baby to a couple of classes (music/swim). ne of the other mothers smoke. Stress? You really enjoy being home with Samantha. You are nervous about sending her to daycare and going back to work full time. 8

9 Content Checklist Danielle Clarkson (Ready to Quit) 1. Assessed the patient s readiness/willingness to quit 2. Asked about current tobacco usage (amount, duration, pattern, recent changes, etc.) 3. Asked about past quit attempts 4. Asked if the patient received behavioral counseling or coaching during past quit attempts 5. Asked if the patient used medications for cessation during past quit attempts 6. Asked the patient reasons for relapse on prior attempts to quit 7. Asked the patient reasons/motivations for wanting to quit 8. Asked what triggers/situations/routines cause the patient to want to smoke 9. Asked what concerns the patient has about quitting (for example, weight gain, withdrawal symptoms) 10. Suggested enrolling in a behavioral counseling or coaching program 11. Discussed the use of medications for cessation (nicotine patch, gum, lozenge, nasal spray, inhaler, bupropion, varenicline; at least two options must be discussed) 12. Suggested a medication regimen with varenicline or bupropion SR 13. Asked the patient to set a quit date 14. Encouraged a follow up appointment 9

10 Standardized Patient Guide to the Checklist Danielle Clarkson (Ready to Quit) 1. Assessed the patient s readiness/willingness to quit You mentioned you wanted some help quitting, so it sounds like you are ready to quit now. Are you ready to quit now? Will you consider quitting in the next month? 2. Asked about current tobacco usage (amount, duration, pattern, recent changes, etc.) How much do you currently smoke? How long have you been smoking? Is there a pattern to your smoking routine? Have you made any recent changes in the amount you smoke? How soon do you smoke your first cigarette when you wake up? 3. Asked about past quit attempts Have you ever tried to quit in the past? Tell me about your previous quit attempts. 4. Asked if the patient received behavioral counseling or coaching during past quit attempts Did you receive behavioral counseling or coaching from a trained professional? 5. Asked if the patient used medications for cessation during past quit attempts Did you use a medication to help you quit smoking? Have you ever tried any of the medications for smoking cessation? 6. Asked the patient reasons for relapse on prior attempts to quit Why do you think you went back to using tobacco the last time you quit? What part of your quit plan didn t work last time and led you to start smoking again? 7. Asked the patient reasons/motivations for wanting to quit What are your reasons for wanting to quit? What is motivating you to quit? What would be the benefit of quitting? 8. Asked what triggers/situations/routines cause the patient to want to smoke What triggers make you want to smoke? In what situations do you tend to smoke? Are there patterns or routines that you associate with smoking? 9. Asked what concerns the patient has about quitting (for example, weight gain, withdrawal symptoms) Many people worry about withdrawal symptoms, weight gain, etc. when trying to quit. Does this concern you? What concerns do you have about quitting? What roadblocks are you concerned about while trying to quit? 10. Suggested enrolling in a behavioral counseling or coaching program I suggest you contact the quitline, QUIT NOW, or another program for additional assistance. 10

11 11. Discussed the use of medications for cessation (nicotine patch, gum, lozenge, nasal spray, inhaler, bupropion, varenicline; at least two options must be discussed) There are several different medications that, when used alone or in combination, can help you quit. There are five forms of nicotine replacement therapy (gum, lozenge, patch, nasal spray, inhaler) and two oral medications (bupropion, varenicline) that help to make you more comfortable while quitting. 12. Suggested a medication regimen with varenicline or bupropion SR I suggest you start (or talk with your primary care provider about prescribing) [bupropion SR or varenicline]. Begin your treatment one week before your quit date. 13. Asked the patient to set a quit date I would like to suggest that you choose a date to quit. Are you ready to choose a quit date? 14. Encouraged a follow up appointment I would like to set up a follow up appointment. I would like to see you again in X days/weeks. I encourage you to set up a follow up appointment, so we can see how your quit plan is working. 11

12 TOBACCO CESSATION EXAMINEE POST ENCOUNTER SELF REFLECTION Each item is answered with a yes or a no. 1 Did you advise the patient to quit or congratulate him/her on the decision to quit? 2 Did you assess the patient s readiness/willingness to quit? 3 Did you quantify the amount of tobacco used? 4 Did you ask about patterns of tobacco use? 5 Did you ask about past quit attempts? 6 Did you discuss smoking triggers (friends, drinking, eating, stress, etc.)? 7 Did you ask the patient how quitting is personally relevant and/or explore motivations for quitting? 8 Did you discuss the risks of continued tobacco use? 9 Did you discuss the rewards/benefits of quitting? 10 Did you inquire about perceived/anticipated roadblocks to quitting? 11 Did you tell the patient you would discuss quitting at the next visit? For Ready to Quit and Relapse cases, OMIT item #11 above and add the following items: 11 Did you ask/discuss what methods the patient has used in the past? (behavioral counseling, medications) 12 Did you discuss use of smoking cessation medication(s) for this quit attempt? 13 PHARMACY ONLY: Did you provide medication counseling and discuss proper use of the selected agents? 14 Did you discuss resources for smoking cessation (tobacco quitline, websites, local group programs, etc.)? 15 Did you ask the patient to set a quit date? 16 Did you offer follow up assistance/counseling? Final question for all SP encounters: My interaction with this standardized patient increased my confidence for counseling a real patient. 1 = Strongly disagree 2 = Disagree 3 = Neutral 4 = Agree 5 = Strongly agree Additional thoughts or comments about this patient encounter? 12

13 COMMUNICATION CHECKLIST: Standardized Patient will complete one form for each encounter. Scoring: = 2 points, Needs Improvement or Maybe = 1 point, = 0 points. All bulleted items must be done to achieve full credit. TOTAL SCORE Learner s first name: Learner s last name: Item Description (must address all for YES response) Circle one response 1 The learner greeted me Introduced himself/herself. 2 appropriately. Explained his/her role. Addressed me by name. 0 2 The learner expressed interest Showed interest in me as a person, not just in my condition. 2 in me as a person. Explored my reasons for tobacco use. 0 3 The learner listened and paid attention to me. Used nonverbal expressions of interest (body language, nodding, eye contact). 2 te taking was balanced with conversation and eye contact. 0 Did not talk down to me. Summarized and/or repeated information I gave during the encounter. 4 The learner encouraged me to tell my story. Collected information in an organized fashion (using open ended and focused questions and no unnecessary interruptions). 2 Explored my willingness to quit. 0 Helped me reflect on my tobacco use (triggers for tobacco use, roadblocks to quitting). Used words I could understand and explained any technical terms in plain language. 5 The learner offered explanations as to why tobacco Asked questions to find out how much I understood the risks of continued tobacco use. 2 cessation could be beneficial to my health. Offered explanations as to why and how tobacco cessation could be beneficial to my health. 0 Offered reinforcement for current/past quit attempts. Continued on next page 13

14 Learner s first name: Learner s last name: 6 The learner provided me with information regarding next steps. 7 The learner included me in the decision making process. 8 The learner was emotionally supportive. 9 I would return to this learner for future care. Provided information related to methods for quitting. (More than one possible method must be discussed.) Provided information/guidance related to the next steps in a way I could understand. Elicited my perspective. Encouraged questions (asked me if I had any questions or concerns). Explored my concerns about willingness/ability to accomplish the quit/follow up plan. Expressed empathy and/or support through verbal statements. Validated my concerns/emotions. Used nonverbal expressions of concern/empathy (nodding, facial expression, eye contact). Please indicate your rating Maybe 0 14