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OSCE: actor and procedure stations · Core12 / 22

Ventilation and ceiling of care before emergency laparotomy in severe COPDActor: 76-year-old man, severe COPD, home oxygen 2 L/min

Actor: postoperative ventilation and ceiling-of-care discussion with patient and family

From memory: the diagnosis and the notes are hidden. Answer each question aloud, then press Show.

Know this first

  • COPD: regional techniques linked with fewer pneumonias, less prolonged ventilation, fewer reintubations.
  • Neuraxial anaesthesia added to GA lowered postoperative pneumonia (RR 0.69).
  • Severe COPD: excellent analgesia helps avoid postoperative ventilation.
  • A capable adult may refuse treatment, even lifesaving treatment.

The patient

Actor: 76-year-old man, severe COPD, home oxygen 2 L/min; perforated bowel needing emergency laparotomy. His wife is with him. Vitals: BP 104/62, HR 108, RR 26, SpO2 88% on 2 L, temperature 38.2 °C. Task: discuss the risks, postoperative ventilation and his wishes.

The examiner asks

Answer aloud, then press Show.

  1. Open

    How do you start?

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    • I'm seeing a 76-year-old on home oxygen before emergency bowel surgery, with his wife present. Patient
    • Are you happy for your wife to hear this and take part? Communication
    • What do you understand about the operation, and how your lungs might cope?

  2. Explain

    Explain the risks and your anaesthetic plan.

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    • There's a hole in your bowel; without surgery, the infection will very likely kill you. (Communication)
    • I'll be honest: with your lungs and this infection, there's a high risk of dying even with surgery.
    • You'll need a general anaesthetic, with a breathing tube in your windpipe.
    • An epidural for pain if your blood pressure and clotting allow; otherwise strong pain relief through the drip.
    • Good pain relief helps you breathe and cough, lowering the chance of chest infection.
    • There's a real chance you'll need the breathing machine for a while afterwards.

  3. Respond

    He asks: 'Will I end up on a breathing machine?'

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    • It's possible. If so, it would be in intensive care, kept comfortable with sedation. (Communication)
    • We'd aim to take you off it as soon as your lungs allow.
    • Some people with lungs like yours can't come off it. I won't hide that.

  4. Respond

    He says: 'I don't want to be kept alive on machines.'

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    • Thank you for telling me. That matters, and we'll respect it. (Communication)
    • Let's talk through what you would and wouldn't want: surgery, the ventilator, and restarting your heart.
    • Would you accept a short spell on the ventilator after surgery, but not a long stay?
    • If your heart stopped during or after surgery, would you want us to try to restart it?

  5. Close

    How do you close?

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    • I'll write down which treatments you want and don't want, including restarting your heart. Communication
    • Take a few minutes with your wife. I'll come back before we go to theatre.
    • I'll share the plan with the surgeon and the intensive care team.
    • The plan, his capacity and who was present are documented before he leaves the ward. After surgery

Fatal mistakes

  • Hiding the risk of death.
  • Ignoring his stated wishes.
  • Not documenting the ceiling of care.

Checked against: Barash 9e · Miller 10e

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