When we started last month's celebration of PAs for October, we discussed breaking bad news. We were then going to expand on that discussion with reference to end of life discussions. However, through some very unfortunate audio issues, we lost the original content in a way that made it so we could not present the original conversation. However, Melodie Kolmetz was gracious enough to record it again on her own and we are presenting this for our newest post.
Most, if not all of us, have experienced some of the end of life discussions at a personal level outside of being a clinician. We have a dying family member, friend, or someone else of significance in our lives at some point. However, the conversations at the provider level can be even more tricky. Here to assist us in reviewing the approach to such a situation is Melodie Kolmetz.
In our first bit of evidence, advanced care planning is difficult but can be performed. This is usually not something that will happen in the emergency department or in the prehospital setting, but is beneficial when performed early especially for patients with a high likelihood or morbidity or mortality. Importantly, assessing patient values in a structured system has been found to be both feasible and scalable. Questions were phrased, "How valuable is it to me..." and only consisted of 10 of those questions. It is important to encourage honest answers to provide the best and most appropriate care that this particular patient requests and to understand its implications.
For our patients with advanced directives, we need to do our best to honor them in the emergency department and prehospital environment. Sometimes, we do not know this ahead of time, but once we are aware we should correct and address those issues as quickly as possible and respect patient wishes. Keep in mind that patients who are altered may not fully understand questions asked at the time versus when they had previous directives in place.
Another tool when discussing advanced directives are "Conversation Starters" presented by the John A. Hartford Foundation. Essentially, there are two types of conversations: those while people are healthy versus when they are receiving a diagnosis or in a disease state that is more severe and potentially terminal. Sometimes what defines a terminal illness can be difficult, but if we start planning early, this can be beneficial. Even heart failure can be a diagnosis that leads to confusion in this matter. Again, this is something rarely done in the emergency type settings, but something that we can help facilitate at least some of the time.
When it comes to discussing with patients what these measures mean, it is very difficult to explain not only what a type of procedure such as intubation and mechanical ventilation means but to further break it down as far as the risks, benefits, potential complications, and likelihood of success in a way that is patient-oriented. Recent anesthesia literature demonstrates this with cardiopulmonary resuscitation (CPR) and the patient's perspective. It is both insightful and important to understand patients have usually not thought end-of-life care thoroughly and very few understand the likelihood of success or its complications which leads to points we can discuss even in an emergency setting.
There are some projects out that that can help patients and their families during this time. Keep in mind, their primary care provider (PCP) or specialist may be talking with them but may not be always giving them information in a way that is helping them more fully understand the implications. This is another place where we in the emergency settings can be beneficial. For example, The Conversation Project is dedicated to helping with explaining wishes in end-of-life care in multiple languages. The American Medical Association (AMA) has Steps Forward with a section devoted to end-of-life planning. It includes some unique features such as creating a letter (not a legal document) and is available for CME. The letter can help with creating an advanced directive which a patient can use with their PCP and/or their family.
Keep in mind, discussing end-of-life care and advanced directives are billable. Mostly, this has started to happen with PCPs, but it is worth documenting the time spent with these discussions as this could potentially translate to emergency medicine, as well (given how the documentation is established to meet the criteria as seen in the link).
A lot of this may feel like primary care, and I am sure that we will discuss more emergency medicine specifics in the near future. However, we need to understand what PCPs and specialists are doing with their patients as well as how we can help. This information is still highly valuable. Let us know what you think by giving us feedback here in the comments section or contacting us on Twitter or Facebook. Remember to look us up on Libsyn and on iTunes. If you have any questions you can also comment below, email at firstname.lastname@example.org, or send a message from the page. We hope to talk to everyone again soon. Until then, continue to provide total care everywhere.
Libsyn and iTunes