Intern Survival Series Lecture #5 Dying, Death and Breaking Bad - - PowerPoint PPT Presentation

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Intern Survival Series Lecture #5

Dying, Death and Breaking Bad News

Shaping the Future of Healthcare | www.thewrightcenter.org

Objectives

– Be able to identify the internists role in palliative care – Become familiar with the S-P-I-K-E-S protocol – Have an understanding of the process of pronouncing someone as deceased – Identify the most common causes of death in the USA

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A Brief Note

• This lecture series is not meant to be all inclusive
• r totally comprehensive to all of medicine
• It is not meant to supersede clinical judgment
• It is not meant to replace daily reading or bedside

teaching

• It is meant to act as a starting point for which to

grow from as new primary care physicians

• It is a tool to help you survive the your new job

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Questions?

• Who are you?
• Who do you want to be?
• What do you see in your future?
• What are your goals?

– Short term? – Long Term?

• What is the likely hood you accomplish what you set out to?
• What are your barriers to will you face?

– Personal? – Financial? – Educational? – National?

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What if….

• You became sick….
• Would you have more questions

– Diagnosis? – Prognosis? – Treatment?

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What if….

• Your diagnosis was terminal?
• Who would you want to tell you?
• How would you want to be told?
• What would you want to know?

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What if…

• It wasn’t you, but a member of your family

– Wife – Mother – Brother – Sister – Child Would that change your answers?

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The Challenge

• As physicians we are faced with difficult tasks and decisions everyday
• Telling someone that there is no cure/life prolonging treatment options

left is: – Difficult

• the nature of the conversation is tense
• most people aren’t ready to die and most def don’t want to hear

it from a resident – Variable

• each patient handles the news differently

– Denial, Angry, Bargaining, Depression, Acceptance – Complicated

• family dynamics you are no longer just dealing with Mr. Y, but
• Mrs. Y, John Y, Sally Y, etc

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How do you tell someone they have a terminal diagnosis?

• ????
• As a busy resident, seeing many patient’s in
• ne morning, constricted by time, pressure,

fatigue how do you tell someone they have terminal disease?

• Most times you don’t know they have one

initially.

• The diagnosis comes through in the course of

the investigation

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Case Presentation

• Mr. Y, 50 y.o. male, former 30y 2PPD smoker

comes to the office c/o SOB despite quitting smoking 2 yrs ago. He has had an OP stress test which was negative, he had PFTs which showed moderate COPD and started on appropriate inhalers. Despite this his SOB has worsened from moderate with exertion to mod to severe with minimal exertion and is present at rest. He reports a 10lbs weight loss

• ver the last 6 weeks and this am coughed up

a ¼ cup of dark red, bloody sputum.

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Case Presentation

• PMHx: HTN, COPD
• PSxHx: none
• Allergies: NKDA
• Medications:

– HCTZ 12.5mg PO Daily – Spiriva 18mcg, 2 puffs daily – Advair Disckus 50/100mcg 1 puff PO BID

• Family Hx:

– Mother, deceased 81, Alzheimer's Disease – Brother: 39, no PMHX – Father: Estranged

• Social Hx:

– Former 2PPD x 30y cigarette smoker, quit May of 2010 – 20 cans of beer/week, mostly on weekends – Works as a Computer programmer for a local hospital

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Case Presentation

• ROS

(+)SOB, +hemoptysis, +worsening productive cough, +10lbs weight loss, +3 pillow orthopnea, +anorexia, (-)Chest pain, -dysphagia -dizziness, -confusion,

• N/V/D, -hematemsis, -Abd pain, Remainder of

ROS is negative

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Case Presentation

PE: VS: 98.9, 96, 20, 122/74, O2sats 90% RA G: NAD, anxious CV: RRR, +s1/s2, no m/c/g/r R: Decreased BS at bases, faint wheezes throughout B/L lung fields, (+) Right sided rhonchi in mid lung field, palpable R subclavicular LN present A: +BS, s/nt/nd, no organomegally, no pain with deep palpation Ex: + peripheral pulses intact and equal in U&LE B/L, -edema, -cyanosis, +clubbing HEENT: EOMI, PERRLA, Normal Sclera, no thyromegally, No appreciable lesions lesions on upper or lower lip or buccal mucosa, TM visualized and clear B/L

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Case Presentation

A/P 1) Worsening SOB with, weight loss, hemoptysis palpable LN

• Sent for CXR, has OP appointment with pulm in 3

Days.

• Pt offered admission, denied, called pulm and made

earliest appointment possible

• Advair dose increased

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Case Presentation

3 Days later pt presents to a local hospital in severe respiratory distress

• Day 1 (Monday): Requires BiPAP, high dose steroids
• Day 2 (T): Titrated off BiPAP, CXR ordered & reviewed

showed R sided pulm nodules, Chest CT ordered but delayed due to difficulty lying flat

• Day 3(W): CT shows Right sided hilar mass with

liver nodules Consult Pulm

• Day 5 (F): subsequent bronch performed, mass seen

and Bxs taken.

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Case Presentation

• Day 6 (S):Awaiting results, meet with pt’s wife and brother,

long discussion had about possible diagnosis, treatment

• ptions and pt wishes.
• Day 7 (Su): Awaiting results……
• Day 8(M): preliminary report from pathology indicated SCLC,

hem/onc consulted, patient made aware

• Day 9 (T) Final path confirms SCLC, Hem/onc recommends

palliative radiation, does not tell patient what palliative means, glance over cell type, do not spend much time with

• patient. Pt’s wife states she is relieved that treatment is

available and that he will be ok………..

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Case Presentation

How do you fill the patient-provider knowledge gap?

• Recap: At this point you know pt has a terminal disease, but

patient and family do not, despite meeting with sub-specialist.

• Who’s responsibility is it to ensure they have better

understanding of what is going on.

• Interesting fact: It takes the average adult learner hearing

something 8 (EIGHT) times before they are able to retain 75% of what they are told (and that is not including all the medical terminology)

• On first pass through, patients retain <25%

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S-P-I-K-E-S Protocol for Breaking Bad News

• SETTING and Listening Skills
• Perception by the patient of the medical problem
• Invitation from patient for medical information
• Knowledge - giving medical facts
• Explore emotions and empathize as the patient

responds

• Strategy & Summary

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SETTING and Listening Skills

Ensure Adequate Physical space

• Try to ensure privacy
• Sit down! with eyes on same level as patient's
• Arrange about 2 feet of space and no physical barriers between you
• Have a box of tissues nearby if likely to be needed
• Seat relative/friend next to patient (not between you and patient)
• Body language and eye contact
• Try to look relaxed and unhurried
• Maintain eye contact (except during patient's distress)

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SETTING and Listening Skills

• Touch may also be helpful during the interview:
• if a non-threatening area is touched (e.g., hand or forearm)
• if you are comfortable with touch
• if the patient appreciates touch and does not withdraw
• Switch on your listening skills to show that you are an

effective listener

• Use open questions that elicit information from the

patient

• "how are you”
• "what did that make you feel?

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SETTING and Listening Skills

• Facilitate, by pausing when the patient speaks
• by nodding, smiling,
• saying "tell me more about that”
• by repeating one key work from the patient's last sentence

in your first sentence

• Clarify, by making any ambiguous or awkward topic obvious
• Handle telephone/pager interruptions sensitively
• tell the patient about any time constraints
• clarify when discussion will resume

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Perception by the patient

• f the medical problem
• Ask the patient to tell you what he or she knows or suspects

about the current medical problem

• for example
• "What did you think when . . .“,
• "Did you think it might be serious . . . "
• As the patient replies:
• Listen to the level of comprehension and vocabulary.
• Notice any mismatch between the actual medical

information and the patient's perception of it (including denial)

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Invitation

From the patient for medical information

• Find out from the patient if he/she wants to

know the details of the medical condition and/or treatment

– “Are you the sort of person who “ – “Is it ok to tell you what I know”

• Accept the patient's right not to know
• But offer to answer questions later as the

patient wishes

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Knowledge

• Bring the patient toward a comprehension
• f the medical situation,

filling in any gaps

• Use language that is intelligible to the

patient and start at the level at which he/she finished with at the end of telling you about their PERCEPTION of the problem

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Knowledge

• Give information in small chunks
• Confirm that the patient understands what

you are saying after each significant chunk

• Explore the patient's reactions as they occur

(see E)

• Respond empathetically to denial (if present)
• "it must be very difficult for you to accept the

situation"

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Explore Emotions and Empathize

• Identify the emotion

– shock, anger, sadness etc. – If you are not certain what the patient is feeling, use open- ended and direct questions until you are

• Identify the cause or source of the emotion

– unexpected bad news, confirmation of the worst news

• Respond in a way that shows you have made the connection

between the emotion and its source – "this must have felt awful", – "this information has obviously come as quite a shock“

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Explore Emotions and Empathize

• The empathetic response is a technique or

skill, not a feeling

• It is not necessary for you:

– to experience the same feelings as the patient – to agree with the patient's view or assessment

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Strategy & Summary

• Offer a reasonable management plan that the patient

understands and will follow.

• Identify what is best medically, then . . .
• Assess the patient's expectations of :
• Condition
• Treatment
• Outcome
• Summarize in your mind, or clarify and summarize aloud if

needed

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Strategy & Summary

• Propose a strategy
• Assess the patient's response
• what stage of action are they in:
• Pre-contemplation
• Contemplation
• Implementation
• Reinforcement phase

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Strategy & Summary

• Agree on a plan (as far as possible)
• Ending the interview:

– Summary of the main topics you discussed

• "Any important issues or questions that we ought to be

discussing?“

• Even if you don't have time to discuss them in the

present interview, they can be on the agenda for the next

• A clear contract for the next discussion

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Getting Back to Mr. Y

• Day 10(W): Plan to DC from hospital in am

with home with home health, plan for OP radiation Tx. After discussion, pt made DNI/DNR

• Day 11~ 0100

– Pt goes into Respiratory Failure – Fails BiPaP – Dies at 0130

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Pronouncing Death

• 0135

– Intern called to floor to pronounce patient dead

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When you get the call:

In General

• Ask about the patient’s

– location – whether family is present – the patient’s age – circumstances of death

• expected or sudden, details of the event.

– Death pronouncement is the official time of death so do not delay unnecessarily

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At Nursing station:

• Speak with nurse to get details of

circumstances of death

• review chart for relevant medical history,

social history, directives regarding autopsy or

• rgan donation and other pertinent

information such as family issues.

• Call the attending physician if he or she hasn’t

already been called.

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In Patients Room:

• Consider asking the nurse to accompany you

for the first few pronouncements.

• If family is present, introduce yourself or have

the patient’s nurse introduce you, make a comforting empathic statement, “I’m Dr. Jones and I’m very sorry for your loss”

• Explain your role, “I’m here to examine your

father, mother…and pronounce his/her death.”

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In Patients Room:

• Sit down if the family is sitting
• Be comfortable with silence and do not be

rushed about your task.

• Ask if they have any questions and refer to the

attending for any you cannot answer.

• Be as flexible as possible with requests, and

affirm that the nurses and you are there if they need you.

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In Patients Room:

• If family is not present, call the legal next of kin
• Identify yourself

– “this is Dr Jones from the Hospital”

• Deliver the message

– “Mrs. Smith, your husband died at 8:30 this evening. I’m sorry for your loss”

• If possible (true), tell family the patient died comfortably

– “I wasn’t with him, but the nurses tell me he passed away peacefully”

• Ask if family wish to see the patient, and let nursing staff

know.

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Confirming death:

• Examine the patient as unobtrusively as

possible

• Confirm identity of the patient with

hospital tag

• Note general appearance of the body

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Confirming death:

• Lack of reaction to verbal or tactile

stimulation;

• Lack of pupillary light reflex
• Presence of fixed and dilated pupils
• Palpate carotid and note absence of pulse
• Listen with your stethoscope for absence of

breath sounds and absence of heart sounds.

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Documentation:

• Each hospital has a “death packet” of

paperwork which will be sent to the floor for you to fill out.

• It includes information about autopsy, medical

examiner cases, organ and tissue donation and completion of the death certificate, and has corresponding forms to be filled out.

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Documentation:

• Write a death note in the chart
• include date and time of death
• information about the circumstances of the

death

• exam findings
• information about notification of family and

attending physician.

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Documentation:

• Called to pronounce Mr. X at (Date and Time).
• Circumstances of the death were as follows:
• Physical exam shows….
• Describe appearance of body, e.g., cachectic in fetal

position, ashen, jaundiced, well developed, etc,

• with lack of reaction to verbal or tactile stimulation, lack
• f papillary light reflex, presence of fixed and dilated

pupils, absence of pulse and heart and breath sounds”.

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FAST STATS for CDC

• Leading Causes of Death in USA for 2010
• Heart disease: 597,689
• Cancer: 574,743
• Chronic lower respiratory diseases: 138,080
• Stroke (cerebrovascular diseases): 129,476
• Accidents (unintentional injuries): 120,859
• Alzheimer's disease: 83,494
• Diabetes: 69,071
• Nephritis, nephrotic syndrome, and nephrosis: 50,476
• Influenza and Pneumonia: 50,097
• Intentional self-harm (suicide): 38,364

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• Questions