MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center...
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Transcript of MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center...
MDs Perspective MDs Perspective on Working with on Working with
Families after Families after Trauma in GriefTrauma in Grief
Lydia Lam, MDLydia Lam, MDLAC-USC Medical CenterLAC-USC Medical Center
Division of Acute Care Division of Acute Care Surgery/Surgical Critical CareSurgery/Surgical Critical Care
April 12, 2010April 12, 2010
ObjectivesObjectives
Discuss how to approach the familyDiscuss how to approach the family Discuss how it affects staffDiscuss how it affects staff Discuss how it affects the physicianDiscuss how it affects the physician
UNOSUNOS
Over 115,000 on the wait listOver 115,000 on the wait list 2009--- 14,631 donors recovered2009--- 14,631 donors recovered
28,464 transplanted28,464 transplanted 21,854 from deceased donors21,854 from deceased donors
TraumaTrauma
Number one cause of death in those Number one cause of death in those 3-44 years old3-44 years old
Blunt trauma remains the majorityBlunt trauma remains the majority
Surgical Surgical Intensivist/TraumaIntensivist/Trauma
Encounter those who are youngEncounter those who are young Patients you cannot resuscitatePatients you cannot resuscitate Caring for traumatic brain injuryCaring for traumatic brain injury
Understand the shortage of organsUnderstand the shortage of organs Understand your patientsUnderstand your patients
TraumaTrauma
Unplanned admissionsUnplanned admissions YoungYoung No advanced directive or living willNo advanced directive or living will
Important to try to identify early Important to try to identify early patient’s wishespatient’s wishes
Family Perspective Family Perspective ImportantImportant
Attitude of news delivererAttitude of news deliverer Well informed, knowledgableWell informed, knowledgable PrivacyPrivacy Clarity of messageClarity of message Clergy Clergy Autopsy informationAutopsy information
Jurkovich GJ. J Trauma 1999
Family PerspectiveFamily PerspectiveLess importantLess important
Rank or seniority of care giverRank or seniority of care giver Attire of news delivererAttire of news deliverer Physical contactPhysical contact
Jurkovich GJ. J Trauma 1999
Advanced DirectivesAdvanced Directives
Written statement of your wishes, Written statement of your wishes, preferences and choices regarding preferences and choices regarding end of life health care decisionsend of life health care decisions
Tool to help you think through and Tool to help you think through and communicate your choicescommunicate your choices
Only used:Only used: If you are seriously ill or injured ANDIf you are seriously ill or injured AND Unable to speak for yourselfUnable to speak for yourself
Advanced DirectivesAdvanced Directives
State specificState specific Living willLiving will Medical power of attorney (MPOA)Medical power of attorney (MPOA) Do not resuscitate (DNR) ordersDo not resuscitate (DNR) orders Out of hospital DNROut of hospital DNR
Not transferrable state to stateNot transferrable state to state Need to execute by stateNeed to execute by state
Living willLiving will
Legal document with your wishes Legal document with your wishes about medical treatmentabout medical treatment
You choose:You choose: What you wantWhat you want What you don’t wantWhat you don’t want
MPOAMPOA Legal form that states who you want to Legal form that states who you want to
make decision about medical caremake decision about medical care Person is authorized to speak for you Person is authorized to speak for you
ONLY if you are unable to make your ONLY if you are unable to make your own medical decisionown medical decision
May also be:May also be: ‘‘health care proxy or agent’health care proxy or agent’ ‘‘health care surrogate’health care surrogate’ ‘‘durable power of attorney for health care’ durable power of attorney for health care’
(DPOA)(DPOA)
MPOAMPOA
Power to make decisionsPower to make decisions Receive/review medical informationReceive/review medical information Discuss with medical teamDiscuss with medical team Consent to or refuse proceduresConsent to or refuse procedures Authorize transfersAuthorize transfers
If you are MPOA, make sure you If you are MPOA, make sure you understand what patient wantsunderstand what patient wants
Advanced DirectivesAdvanced Directives
AdvantagesAdvantages In charge of making your own decisionsIn charge of making your own decisions Documents can change anytimeDocuments can change anytime You do not need an attorneyYou do not need an attorney Document can help you express your Document can help you express your
wisheswishes
Advanced DirectivesAdvanced Directives
ExecutingExecuting Do not need lawyer to completeDo not need lawyer to complete Decide what type of life sustaining Decide what type of life sustaining
treatments you do not wanttreatments you do not want Discuss/inform with family and primary Discuss/inform with family and primary
doctordoctor If you change your wishes, complete a If you change your wishes, complete a
new advance directivenew advance directive
Advanced DirectivesAdvanced Directives
DisadvantagesDisadvantages Not available to transfer between statesNot available to transfer between states
Living willsLiving wills May not be specific enoughMay not be specific enough May be overridden by a treating doctorMay be overridden by a treating doctor Does not immediately translate into Does not immediately translate into
doctor’s orderdoctor’s order
TALKING IMPORTANTTALKING IMPORTANT
Honest discussion, reflection and Honest discussion, reflection and planningplanning
Opportunity to discover important Opportunity to discover important information on family and patientinformation on family and patient
Most important gift you can give to Most important gift you can give to prepare for the end of lifeprepare for the end of life
AA
Advanced preparationAdvanced preparation TimeTime PrivacyPrivacy No interruptionNo interruption Review informationReview information Mental rehearseMental rehearse Prepare yourself emotionallyPrepare yourself emotionally
BB
Build a therapeutic Build a therapeutic environment/relationshipenvironment/relationship How much do they need to knowHow much do they need to know All family presentAll family present Introduce yourself to everyoneIntroduce yourself to everyone Warn of bad newsWarn of bad news
CC
Communicate wellCommunicate well What do they already knowWhat do they already know No medical jargonNo medical jargon TranslatorTranslator Frank but compassionateFrank but compassionate Allow for silence/tearsAllow for silence/tears If appropriate, repeat their If appropriate, repeat their
understandingunderstanding Follow up planFollow up plan
DD
Deal with family reactionsDeal with family reactions Be empatheticBe empathetic Do not argue or criticize colleaguesDo not argue or criticize colleagues
EE
Encourage and validate emotionsEncourage and validate emotions Use interdisciplinary resourcesUse interdisciplinary resources What does this mean to familyWhat does this mean to family RN, clergy or SW follow up after you RN, clergy or SW follow up after you
leaveleave
FamilyFamily
AngerAnger Shock or numbnessShock or numbness Searching for any hopeSearching for any hope Disorganization and despairDisorganization and despair ReorganizationReorganization
Stages of GriefStages of Grief
Kubler-Ross Stages of Dying (1969)Kubler-Ross Stages of Dying (1969) DenialDenial AngerAnger BargainingBargaining DepressionDepression AcceptanceAcceptance
Stages of GriefStages of Grief
Engle’s Theory (1964)Engle’s Theory (1964) Shock and disbeliefShock and disbelief Developing awarenessDeveloping awareness Reorganization and restitutionReorganization and restitution
Trauma SurgeonTrauma Surgeon
Feeling of failureFeeling of failure Fear of approaching topicFear of approaching topic Constraint for timeConstraint for time
Trauma SurgeonTrauma Surgeon
Important to take controlImportant to take control Leader of the teamLeader of the team
Know your resourcesKnow your resources Recruit your resourcesRecruit your resources
Take a moment for yourselfTake a moment for yourself Review events in your headReview events in your head Remove signs of resuscitationRemove signs of resuscitation
Emotionally not drainedEmotionally not drained
Trauma SurgeonTrauma Surgeon
Develop a rapport with family early Develop a rapport with family early TrustTrust SinceritySincerity EmpathyEmpathy
Trauma SurgeonTrauma Surgeon
Stand firmStand firm Ultimatum sometimes necessaryUltimatum sometimes necessary Offer evidence of finalityOffer evidence of finality
Approaching the familyApproaching the family
When death is imminentWhen death is imminent Maximizing comfortMaximizing comfort AcceptanceAcceptance TimeTime Saying good-byeSaying good-bye
Approaching the FamilyApproaching the Family
Prepare info, location, settingPrepare info, location, setting Find out what they already knowFind out what they already know Ask how much they want to knowAsk how much they want to know Share informationShare information Respond to family’s emotionRespond to family’s emotion Negotiate concrete follow-up stepNegotiate concrete follow-up step
Approaching the FamilyApproaching the Family
Avoid rote responsesAvoid rote responses Each family is differentEach family is different
Be genuineBe genuine Express your true feelingsExpress your true feelings Admit you don’t have words if you don’t Admit you don’t have words if you don’t
know what to sayknow what to say Avoid common greetingsAvoid common greetings
Hi! How are things going?Hi! How are things going? Don’t be afraid to discuss deathDon’t be afraid to discuss death
Approaching the FamilyApproaching the Family
Don’t preach or lectureDon’t preach or lecture ListenListen
Let them talk and express their concernsLet them talk and express their concerns Ask what you can do. Keep the Ask what you can do. Keep the
promisepromise Be aware of the tone in your voiceBe aware of the tone in your voice
Avoid being condescending or pityingAvoid being condescending or pitying Check in on the family frequentlyCheck in on the family frequently
Approaching the FamilyApproaching the Family
Offer ClergyOffer Clergy Time of stress, needed more than Time of stress, needed more than
people might realizepeople might realize Explain the need for autopsyExplain the need for autopsy
ConclusionConclusion
Delivering bad news is difficultDelivering bad news is difficult Not well trained in medical school or Not well trained in medical school or
residencyresidency
Form relationshipForm relationship ClearClear PrivacyPrivacy EmpatheticEmpathetic