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?

Like a battery…

So where’s the tension in the learner?

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)

Not just basic understanding

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