soft task hard to do: the challenge of do not resuscitate discussions
DESCRIPTION
A presentation given at the Royal Free Hospital, London, UK, in March 2014TRANSCRIPT
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A soft task hard to doThe challenge of resuscitation
discussions
Dr Philip BerryConsultant Hepatologist,
Gastroenterologist and General Physician
@philaberry www.illusionsofautonomy.wordpress.com
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Resuscitation
• Life saving• Highly symbolic: the final fight against death• Peter Safar, 1956 "save the hearts and brains of
those too young to die."• …but not very effective in some groups– 12.2% >90 yrs survive to discharge1
– For every survivor >80yrs, need to do CPR on 292
• Default
1. Ehlenbach et al NEJM 20092. Paniagua et al Cardiology 2002
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National Confidential Enquiry into Patient Outcome and Death
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National Confidential Enquiry into Patient Outcome and Death
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Bertie Leigh
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How to do a DNAR discussion
• 6 step model
Von Gunten, 2001
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Setti
ng
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Setti
ng
Understanding
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Setti
ng
Understanding
Expectation
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Setti
ng
Understanding
ExpectationD
iscussion
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Setti
ng
Understanding
ExpectationD
iscussionRespond
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Setti
ng
Understanding
ExpectationD
iscussionRespond
Implement
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Setti
ng
Understanding
ExpectationD
iscussion
Respond
Implement
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`
Barriers
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`
Situation
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`
Situation
Behaviour
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`
Situation
Behaviour
Patient response
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`
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Space and Time ‘Hard’ tasks
Nature of emergency: uncertainty
Nature of emergency: incapacity
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Space and Time
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Space and Time
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Space and Time
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‘Hard’ tasks
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‘Hard’ tasksHe’s shocked,
give a litre of
fluid
Do an LP
Order an
urgent CTCall the GP,
find out what
drugs she’s on
Chat to the family about DNAR
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‘Hard’ tasks
He’s shocked, give a litre of fluid
Do an LP
Order an urgent CT
Call the GP, find out what drugs she’s on
…and chat to the family about DNAR
6.30PM
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Nature of emergency: incapacity
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CapacityNo
Capacity
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He must consider, so far as is reasonably ascertainable—(a) the person's past and present wishes and feelings (and, in particular, any relevant written statement made by him when he had capacity),(b) the beliefs and values that would be likely to influence his decision if he had capacity, and(c) the other factors that he would be likely to consider if he were able to do so
MCA 2005 Section 4
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CapacityNo
Capacity
Next of kinFamilyFriendsCarers
GP
IMCA?
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Nature of emergency: uncertainty
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†
†
Admission
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Oblique phrases: clues to uncertainty
• ‘Cautious’• ‘Serious’• ‘Worrying’• ‘Guarded’• ‘Day at a time’
- Preparing the ground -
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Oblique phrases
• ‘Cautious’• ‘Serious’• ‘Worrying’• ‘Guarded’• ‘Day at a time’
…indicating death is possible
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Oblique phrases
• ‘Cautious’• ‘Serious’• ‘Worrying’• ‘Guarded’• ‘Day at a time’
…indicating death is possible
† ∴ a trigger to consider discussion
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Space and Time ‘Hard’ tasks
Nature of emergency: uncertainty
Nature of emergency: incapacity
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Dropping a gear
Normalisation
Defensiveness
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Defensiveness
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Dropping a gear
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Active Tx
PalliationURGENCY/PRIORITY
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DNAR
Active Tx
PalliationURGENCY/PRIORITYA tendency to equate DNAR
with palliation…
And a subsequent lessening of the sense of urgency
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DNARActive Tx
Palliation
But DNAR should probably be considered earlier in the natural history…
…when the patient is more able to engage
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DNAR
Active Tx
Palliation
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DNAR
Active Tx
Palliation
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DNAR
Active Tx
Palliation
!
Perhaps even on admission…
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DNAR
Active Tx
Palliation
!
DNAR = No active Tx
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Normalisation
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(Frequency of death)
(Superficial involvement) Normalisation
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Normalisation
(Frequency of death)
(Superficial involvement)
(Bureaucracy)
(Beds)
Brutalisation( ) Ref: media criticism around LCP
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Normalisation
(Frequency of death)
(Superficial involvement)
(Bureaucracy)
(Beds)
Brutalisation( )
Deprioritisation
?
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Only by talking, listening and reflecting on the patient’s predicament…
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EMPATHY
…will a 3 dimensional image form, and the need to make appropriate plans become clear.
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At last…
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…but there is another barrier…
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Physiciandiscomfort !
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Important, but part of professional life…
And we need to be able to overcome it.
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SensitivityGentlenessKindness
StatisticsLikelihood
Reassurance
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The words… (suggestion only!)
• “Mrs ____, I’d like to discuss something with you. It may sound rather pessimistic and serious, but it’s important that we talk about it. I need to ask you about what we should do if your heart were to suddenly stop.”
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• “As you probably know, for some patients we try to restart the heart with compressions on the chest and electric shocks, but we know that this doesn’t work very well as you become more frail, or if you already have problems with the heart or the lungs.”
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• “It’s important that we understand your feelings about this, and that you know what we think. Then we can write it in the notes so that other doctors know what to do if something like that were to happen.”
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Responses
• Bewilderment:“Oh…I’ve never really thought about that before doctor. I didn’t think I was that unwell.”
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Responses
• Defiance (of mortality):“Well I want to live as long as I can. I don’t want to give up that easily.”
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Responses
• Fatalism:“Whatever happens, it’s meant to be…”
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Responses
• The ‘old fashioned’ (paternalistic mode):“Do whatever you think is best…”
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Responses
• The sure:“No. No, I definitely wouldn’t want that, I’ve had quite enough time.”
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Responses
• And the hesitant:“OK doctor, but I would like to discuss it with my family. They would want to be involved.”
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The ‘Slow code’
“A leading textbook calls slow codes ‘dishonest, crass dissimulation, and unethical.’”
‘…deplorable, dishonest and inconsistent with established ethical principles.’
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The ‘Slow code’
“Nevertheless, we believe that slow codes may be appropriate and ethically defensible in situations in which cardiopulmonary resuscitation (CPR) is likely to be ineffective, the family decision makers understand and accept that death is inevitable, and those family members cannot bring themselves to consent or even assent to a do-not-resuscitate (DNR) order.”
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Scenario
• A 91 year old lady is admitted to hospital with symptoms of urinary tract infection and significant kidney dysfunction.
• Known aortic valve disease (not for surgery) • Confused, temporarily, by the sepsis. Lacking
capacity.
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Scenario
• The consultant decides that CPR would definitely be ineffective, and speaks with the family.
• They are shocked, uncertain, afraid…and resistant to a DNAR decision; ‘she’d wouldn’t want to give up…’
• What should the consultant do tonight?
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Decision
A
Re-engage with family tomorrow
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Decision
A B
Complete a DNAR form anyway
Re-engage with family tomorrow
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A
Crash call
Outcomes (in the event of unexpected arrest at 0200hrs)
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A
Crash call: rapid abandonment by arrest team
Outcomes (in the event of unexpected arrest at 0200hrs)
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Outcomes (in the event of arrest)
A B
Natural death
Crash call: rapid abandonment by arrest team
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Morality
A B
Duplicitous?Moral cowardice?
Brave?Risking censure?
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- Inevitable?-- Justifiable? -
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?
Thank you