Responsibility for end of life decision making

Todd Fraser on 08-01-2012

Is it just me? It appears that ICU is relied upon more and more to provide end of life decision making support for ward patients. It seems that fewer ward clinicians are comfortable enough and knowledgeable enough about ICU and long term outcomes to have this level of conversation with their patients. I've had many conversations with frustrated colleagues who share sentiments such as "no one can die without a trial of ICU these days". What has led to this? A specialty in its own right now in some countries, perhaps there is a dilution of exposure to ICU among inpatient teams. Perhaps the fear of litigation prevents some from bringing up the subject of limitation of care. Perhaps the ethics of care for patients has changed in some way. Fundamentally though, it appears many doctors do not have the skills to deal with this type of question. How are they going to get them?

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gerard fennessy wrote 01-29-2012 07:27:28 pm
Hi,
This is a double edged sword. On one hand, a doctor has the role of patient advocate - "representing the patient" (incidentally a role that in most hospitals has now been farmed out to a non-doctor), and many do not actually know what the patient wants - therefore are unable to advocate for the patient! Is it lack of time (or lack of a "want") to sit down and engage the patient and their family in these "tough decisions" - which are really not decisions, but more objective statements about where the patient is at, and where they are likely to head? Are the doctors scared of engaging the patient or family because they themselves might feel sadness or sorrow (clearly the sign of a weak doctor)?

On the other hand, the lack of ICU exposure or knowledge or experience could lead to some doctors advising the patient that they SHOULD get treatment that is inappropriate, instead leaving ICU to decline (dialysis or intubation or inotropes) and painting us in a bad light.

In my experience, most patients and families are relieved to have that conversation, (and we should definitely not leave it to them to bring it up - after all for most, it is usually the first time they have talked about death, unlike doctors).

Almost every single patient over the age of 75 (or younger if the patient has comorbidities) should have that conversation with the doctor!

The answer? In the apprenticeship model, the only way to get these conversations going regularly

Todd Fraser wrote 01-30-2012 11:55:26 am
What a brilliant post Gerard!

I couldn't agree more.

Medicine has in the past been built on the concept of mentorship, something we are barely hanging onto now. This goes both ways of course - I suspect there is a perception among older clinicians that the younger generation expect education as a right. Its time to meet in the middle somewhere.

Neil does some great "bad" interviews in the communication section (and he stresses that it was incredibly difficult for him to be that bad!). I wonder if we should put some examples of good communication there too.

Li Huey Tan wrote 01-31-2012 04:15:50 pm
I honestly beleive that we should run EOL care workshops in conjunction with communication of bad new sessions. There are some clinicians who are just very good at leading those discussions, irrespective of their underlying specialties. It's a very complex area and it's not only a medical experience thing, but also predetermined by our preconceived biases and cultural values. Attending bioethics courses is something I find useful too.

Alex McKenzie wrote 01-15-2012 12:03:43 pm
I think you're right Todd, the physicians are particularly bad at this now - perhaps because they have almost no exposure to ICU anymore. I have found it rare for the medical teams to come to ICU to see the patients that they DO have there, let alone rotate to ICU during their training.

Todd Fraser wrote 10-07-2012 10:42:41 am
Early last year I spoke with Charlie Corke about this. He runs a great course called "Enough is enough" and looks at teaching junior staff how to have these conversations. Here's where you can find the podcast - http://crit-iq.com/index.php/Podcast