Hospital as a teaching exercise or reference material is now eligible to receive a complete set of PowerPoint slides, including digital images, with identifying legends, shown at the live Clinicopathological Conference (CPC) that is the basis of the Case Record.This slide set contains all of the images from the CPC, not only those published in the Journal.Radiographic, neurologic, and cardiac studies, gross specimens, and photomicrographs, as well as unpublished text slides, tables, and diagrams, are included.Every year 40 sets are produced, averaging 50-60 slides per set.Each set is supplied on a compact disc and is mailed to coincide with the publication of the Case Record.

1.Identify the counter-transference factors that underly “difficult” interactions with patients and families.2.Apply management approaches for the “unmanageable” patient, including how to set limits and how to engender empathy for such patients.3.Discuss approaches for advising medical teams on caring for challenging patients. End-of-life care presents many challenges for clinicians, for patients and their families. This care is made all the more challenging when working with a patient or family that caregivers experience as “difficult.” These are individuals who evoke a series of negative feelings in their caregivers. As clinicians dedicated to providing caring and empathic care at the end of life, working with such patients or families can be particularly frustrating. This session will identify the underlying mechanisms that lead patients to be labeled as “difficult” by their caregivers. We will discuss the stressors inherent to the end-of-life care on both patients and clinicians that lead seemingly-agreeable patients to be labeled as difficult. We will also discuss the impact that they dying process has on individuals whom others find difficult to manage at baseline. Using clinical examples and an observed role-play, we will discuss how identifying one's negative feelings towards patients is valuable data that allows caregivers to be present with them and effective in their care. Using this information, we will identify approaches for the “unmanageable” patient, including how to set limits, how to not “take things personally” and how to engender empathy for such individuals. Participants will also gain approaches for advising medical teams on caring for challenging patients. Ultimately, it is not how one feels about patients, but how one behaves towards them that is most relevant to care. At the end of the day, we all want to be proud of the care that we give, particularly to those patients that challenge us the most.

Work is one of the central organizing structures of adult life. The significance of a cancer diagnosis to work life has been radically altered during the past half-century. Driven by innovations in diagnosis and treatment, individuals diagnosed with cancer are living longer, better-quality lives. For example, in 1960, 25% of adults diagnosed with cancer survived five years, while in 2007, 65% of cancer patients lived for five years [1]. In the majority of cases, the notion of a cancer diagnosis has evolved from an almost certain death sentence to either a persistent/chronic condition or even a curable disease with some long-term sequellae. Furthermore, not only are more adults surviving cancer, but the generation of children treated for cancer in the 1970s and 1980s are now entering the workforce [1].

1.Discuss the concept of boundaries, boundary crossings, and boundary violations within the patient-clinician relationship in palliative care.2.Discuss the importance of identifying boundary crossings and how they can be helpful or harmful to the patient-clinician relationship.3.Develop a framework for recognizing, interpreting, and managing boundary crossings and violations when they occur. The subject of patient-clinician boundaries has been most extensively explored in the psychiatric literature, but the recognition of boundary issues may be particularly relevant to the practice of palliative care. The relationship between a palliative care clinician and a patient at the end of life, can reach a level of intensity and intimacy that is commonly found in psychotherapy. Palliative care clinicians are trained to address various types of suffering— including physical, spiritual, and psychological distress. In facing suffering and death, patients often express their emotions more easily and authentically than is typical for the usual patient-clinician interactions. In the presence of such emotionality and intimacy, palliative care clinicians may experience a particular sense of closeness to their patients, which can increase the chances that boundary crossings may occur. Palliative care clinicians, especially those early in training or lacking specific psychological education, may be particularly susceptible to boundary crossings and violations. Utilizing both psychiatric and palliative care perspectives, this session will address the concept of patient-clinician boundaries. Clinicians will have the opportunity to reflect on potential boundary issues in clinical practice in general and palliative care specifically. We will explore the nature of the patient-clinician relationship within the context of the sociological model of role theory. Using the psychological concept of dual relationships, we will distinguish between neutral or therapeutic boundary crossings and harmful boundary violations. We will discuss why some palliative care practitioners and trainees are particularly vulnerable to boundary crossings and violations. Attendees will be provided with a framework for identifying and managing boundary crossings and violations when they occur. Structure and Processes of Care

BACKGROUND:Family members of patients with cancer may reveal to the medical team that they are considering suicide after their loved one dies. No literature is available indicating how to assess risk and to intervene with these individuals.OBJECTIVE:The authors describe various alerting signs and seek to improve awareness and approaches to suicide prevention.METHOD:The authors present five cases of potential contingent suicide.RESULTS:Family members struggling with anticipatory grief challenge the clinical team at several points of decision-making.CONCLUSION:Close coordination among members of the patient's treatment team and psychiatric consultants is crucial for helping vulnerable family members move safely into adequately supported bereavement.

Objectives: To examine the relationship of sleep disturbance with complicated grief (CG) in patients with bipolar disorder (BD).Methods: Adults with DSM‐IV BD were asked if they ever experienced significant loss and, if so, completed the Inventory of Complicated Grief. Subjective sleep disturbance was assessed with the Pittsburgh Sleep Quality Index (PSQI). The association of CG with sleep disturbance was assessed in univariate t‐tests, and in multivariate analyses controlling for the presence of anxiety disorder comorbidity and current bipolar recovery status.Results: Individuals with CG had significantly higher mean PSQI scores (10.9 versus 7.9, p = 0.003) than those without CG. Further, within the group of BD participants who had experienced a significant loss, those with CG had significantly poorer sleep (p = 0.01). CG remained significantly associated with greater sleep impairment after adjustment for comorbid anxiety disorder and bipolar mood state. This additive impairment in sleep with CG comorbidity was evident for four of the PSQI component scales: sleep quality, sleep duration, sleep efficiency and sleep disturbance.Conclusions: Our data indicate a significant association of CG with poor sleep in individuals with BD. Disturbed sleep may be a mechanism by which CG increases the burden of illness in BD.

The Psychiatric Consultation Service at Massachusetts General Hospital (MGH) sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions.Such consultations require the integration of medical and psychiatric knowledge.During their thrice-weekly rounds, Dr.

The Psychiatric Consultation Service at Massachusetts General Hospital (MGH) sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. Such consultations require the integration of medical and psychiatric knowledge. During their twice-weekly rounds, Drs. Stern and Maytal, as well as other medical staff and members of the Consultation Service, discuss the diagnosis and management of conditions confronted. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.

The Psychiatric Consultation Service at Massachusetts General Hospital (MGH) sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. Such consultations require the integration of medical and psychiatric knowledge. During their thrice-weekly rounds, Dr. Stern and other members of the Consultation Service discuss the diagnosis and management of conditions confronted. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.

The low prevalence of extrapyramidal symptoms associated with atypical antipsychotics has led to their widespread use during the past decade. Aripiprazole, the newest medication in this class, has been associated with extrapyramidal symptoms (eg, akathisia) and with improvement of tardive dyskinesia (TD), but to date it has not been associated with the development of TD. We report a case of TD associated with the use of aripiprazole 15 mg/day for 18 months for refractory depression. Symptoms of TD resolved within several weeks of discontinuation of aripiprazole.

The Psychiatric Consultation Service at Massachusetts General Hospital (MGH) sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. Such consultations require the integration of medical and psychiatric knowledge. During their thrice-weekly rounds, Drs. Stern and Maytal and other members of the Consultation Service discuss the diagnosis and management of conditions confronted. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.

Physicians and patients are frequently concerned, and, at times, distressed, by nakedness during clinical encounters. When nakedness appears, clinicians should attempt to establish the reason for it and determine whether it is appropriate for the situation. Establishing the etiology of nudity can facilitate care by hospital staff and help to modulate their countertransference reactions and behavior. The authors present and discuss three cases involving nudity at times other than during the physical examination, within the context of differential diagnosis and treatment alternatives.