Post on 03-Jan-2016
description
Withdrawal of Ventilatory Support
Educational Issues
James Hallenbeck, MDJames Hallenbeck, MD
Assistant Professor of MedicineAssistant Professor of Medicine
Director, Palliative Care ServicesDirector, Palliative Care Services
VA Palliative Care servicesVA Palliative Care services
What are the educational issues?83 yo man 4 months post valve replacement for critical aortic stenosis on chronic ventilatory support. Patient suffered multi-system failure and now thought to be unweanable. Wife angry at you for doing surgery and then “lying” about his prognosis. Asks that you remove the tube and allow him to die with dignity.
In teaching about possible ventilatory withdrawal, what topic is most important to stress?
Relevant ethical principlesRelevant ethical principles Proper drug usage for palliation post Proper drug usage for palliation post
extubationextubation Communication skillsCommunication skills None of the aboveNone of the above All of the above All of the above
AIRS Slide
Outline
Educational PrinciplesEducational Principles Knowledge, Attitudes and SkillsKnowledge, Attitudes and Skills Overt and covert tensionOvert and covert tension
Educational ChallengesEducational Challenges GeneralGeneral For surgeonsFor surgeons Relative to difficult decisions such as ventilator Relative to difficult decisions such as ventilator
withdrawalwithdrawal
Knowledge
Understanding of relevant ethical principlesUnderstanding of relevant ethical principles Knowledge of relevant therapiesKnowledge of relevant therapies
Role of opioidsRole of opioids Role of sedativesRole of sedatives
Knowledge of relevant support systemsKnowledge of relevant support systems
What new knowledge is important for the learner?
Attitudes
That withdrawal of support is purely a That withdrawal of support is purely a medical decisionmedical decision
That previous experience and training was That previous experience and training was adequate in addressing the issueadequate in addressing the issue
That treatment withdrawal is solely an That treatment withdrawal is solely an ethical problemethical problem
Not my job Not my job
What changes in attitude does the teacher believe are necessary?
Potential attitudes to address:
Skills
Communication SkillsCommunication Skills Demonstrate the ability to address cognitive and Demonstrate the ability to address cognitive and
affective components of communicationaffective components of communication Order writing skillsOrder writing skills
Write initial orders for treatment discontinuation, Write initial orders for treatment discontinuation, including drug doses and indicationsincluding drug doses and indications
Access skillsAccess skills Demonstrate the ability to access support for a Demonstrate the ability to access support for a
grieving familygrieving family
What new skills are necessary?
Tension – Overt and Covert Overt tension – what people verbally Overt tension – what people verbally
identify as the problemidentify as the problem If we don’t get this straightened out, we’ll If we don’t get this straightened out, we’ll
have to trach this guy…have to trach this guy… Covert tension – unspoken, sometimes Covert tension – unspoken, sometimes
unconscious tensionunconscious tension I’m not sure I’m competentI’m not sure I’m competent I don’t want to be the one pulling the I don’t want to be the one pulling the
plug…plug…
Subtext
Emotional subtext often present, but not Emotional subtext often present, but not addressed – in patients and families AND in addressed – in patients and families AND in ourselvesourselves ‘‘You doctors just used him as a guinea You doctors just used him as a guinea
pig. Now you want to get rid of him!’pig. Now you want to get rid of him!’
What is the emotional subtext for the speaker?
What is your emotional subtext?
Ethical Principles Knowledge
11 Minimal, InadequateMinimal, Inadequate 22 Barely adequate, StrugglingBarely adequate, Struggling 33 AdequateAdequate 44 SuperiorSuperior 55 MasterMaster
AIRS Slide
Rank your knowledge
Drug Usage for Dyspnea, Agitation
11 Minimal, InadequateMinimal, Inadequate 22 Barely adequate, StrugglingBarely adequate, Struggling 33 AdequateAdequate 44 SuperiorSuperior 55 MasterMaster
AIRS Slide
Rank your skill
Necessary Communication Skills
11 Minimal, InadequateMinimal, Inadequate 22 Barely adequate, StrugglingBarely adequate, Struggling 33 AdequateAdequate 44 SuperiorSuperior 55 MasterMaster
AIRS Slide
Rank your skill in USING communication skills
Necessary Communication Skills
11 Minimal, InadequateMinimal, Inadequate 22 Barely adequate, StrugglingBarely adequate, Struggling 33 AdequateAdequate 44 SuperiorSuperior 55 MasterMaster
AIRS Slide
Rank your skill in TEACHING communication skills
Challenges in palliative care education - general Arrogance-Ignorance phenomenonArrogance-Ignorance phenomenon
Hidden curriculumHidden curriculum
Ignorance…DomainDomain PGY 1 PGY 1
(n =1284)(n =1284)
PGY 2 PGY 2
(n =980)(n =980)
PGY 3,4PGY 3,4
(n =1076)(n =1076)
FacultyFaculty
(n =1711)(n =1711)
Total TestTotal Test 48.348.3 52.952.9 56.056.0 59.159.1
PainPain 52.252.2 55.555.5 57.257.2 60.560.5
Non-painNon-pain 60.460.4 65.765.7 70.670.6 72.872.8
CommunicatiCommunicationon
42.242.2 45.045.0 46.346.3 57.057.0
Terminal Terminal CareCare
45.745.7 49.349.3 53.953.9 56.056.0
Mean % Correct
Survey of Internal Medicine residents and facultyWeissman et al.
Arrogance
Interns admitted knowledge and skill Interns admitted knowledge and skill deficits and were concerned about their deficits and were concerned about their competency = competency = TENSIONTENSION
Residents and faculty less concerned about Residents and faculty less concerned about ability to practice and teach palliative careability to practice and teach palliative care
Many faculty – Many faculty – What ME worry?What ME worry?
Despite minimal differences in knowledge…
Curriculum or Hidden Curriculum? End-of-life issues often relegated to the End-of-life issues often relegated to the
“hidden curriculum” – not worthy of “hidden curriculum” – not worthy of instruction/modeling by attendings, but instruction/modeling by attendings, but informally modeled among residents and informally modeled among residents and students.students.
Reference: Rappaport W, Witzke D. Education about death and dying during the clinical years of medical school. Surgery. 1993;113(2):163-165.
Rappaport Study
84% of junior and 50% of senior residents 84% of junior and 50% of senior residents reported reported nevernever hearing an attending discuss hearing an attending discuss how to do deal with a terminally ill patienthow to do deal with a terminally ill patient
How often are you with the attending when How often are you with the attending when he/she talks with a dying patient?he/she talks with a dying patient? Junior residents 64% < once/monthJunior residents 64% < once/month Senior residents 43% < once/monthSenior residents 43% < once/month
(n = 53 surgical residents)Key findings
Special challenges for surgeons
Hierarchical organizational structure may Hierarchical organizational structure may inhibit discussion of controversial issuesinhibit discussion of controversial issues
Task-oriented people – focused on doing Task-oriented people – focused on doing rather than feelingrather than feeling
Withdrawal of support issues may be Withdrawal of support issues may be linked, at least emotionally, to prior actions linked, at least emotionally, to prior actions of the surgeonof the surgeon
Example – 83 yo with critical AS
Suffered stroke, became vent dependent Suffered stroke, became vent dependent following “elective” valve replacementfollowing “elective” valve replacement
Angry wife – “Angry wife – “He was mowing the lawn He was mowing the lawn and now you made him a vegetable…”and now you made him a vegetable…”
Frustrated surgeon – “Frustrated surgeon – “She just doesn’t get it She just doesn’t get it – it was a risk, but I thought it was a – it was a risk, but I thought it was a greater risk not to operate. You know what greater risk not to operate. You know what critical AS is like…”critical AS is like…”
Challenges specific to “difficult decisions” Actions (stopping ventilator (or dialysis) are Actions (stopping ventilator (or dialysis) are
discrete and cleardiscrete and clear
Discrete actions must occur in an Discrete actions must occur in an environment of uncertainty and ambiguityenvironment of uncertainty and ambiguity
HOWEVER..
Uncertainty/ambiguity regarding:
What people What people wantwant or (usually for the or (usually for the patient) might have wantedpatient) might have wanted
OutcomesOutcomes: not just : not just that that people will die but people will die but Actual time to deathActual time to death What it What it meansmeans to die or be dead to die or be dead
FeelingsFeelings What the right thing to do is What the right thing to do is (Ethics)(Ethics)
Summary Check-list KnowledgeKnowledge
EthicsEthics Proper drug useProper drug use Accessing support systemsAccessing support systems
SkillsSkills Drug utilizationDrug utilization CommunicationCommunication Offering support to patient, family, staffOffering support to patient, family, staff
Final words
In historical terms ventilation and other forms of In historical terms ventilation and other forms of life-support are recent innovationslife-support are recent innovations
As a society we have not ‘caught up’ with such As a society we have not ‘caught up’ with such innovationsinnovations
Historically, for all specialties education in Historically, for all specialties education in palliative care in general has been sorely lackingpalliative care in general has been sorely lacking
We need to work hard to figure out how best to We need to work hard to figure out how best to incorporate needed training into existing curriculaincorporate needed training into existing curricula