Progressive neurologic disease is managed by anticipating the next loss — ventilation, swallowing, communication, safety — and having the equipment, the teaching and the goals-of-care conversation in place before the loss arrives. Sort four competing patients, decide what the assistive personnel may and may not do, then slide an ALS patient down the vital capacity curve and see which conversations are already overdue.
You hold four assignments. It is 0728.Tap them in the order you will get to them, first to last. The board only accepts the correct next patient — and it will tell you why the one you reached for comes later.
Who do you see next?
Delegation in this population is unforgivingAssessment, teaching, evaluation and unstable patients stay with the registered nurse. Decide each task for a patient with Guillain–Barré syndrome and a patient with moderate Alzheimer disease.
Task 1
Mr Vance, 61, limb-onset ALS — clinic visitMedian survival is around three to five years from symptom onset, with respiratory failure the usual cause of death. Move his numbers and watch which conversations should already have happened.
Measured at every visit. This one number drives both of the big conversations.
Weigh at every visit — a falling weight predicts poorer survival.