MDs Perspective on Working with Families after Trauma in Grief

MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care April 12, 2010

Objectives Discuss how to approach the family Discuss how it affects staff Discuss how it affects the physician

UNOS • Over 115,000 on the wait list • 2009--- 14,631 donors recovered • 28,464 transplanted • 21,854 from deceased donors

Trauma Number one cause of death in those 3-44 years old Blunt trauma remains the majority

Surgical Intensivist/Trauma Encounter those who are young Patients you cannot resuscitate Caring for traumatic brain injury Understand the shortage of organs Understand your patients

Trauma Unplanned admissions Young No advanced directive or living will Important to try to identify early patient’s wishes

Family Perspective Important Attitude of news deliverer Well informed, knowledgable Privacy Clarity of message Clergy Autopsy information Jurkovich GJ. J Trauma 1999

Family PerspectiveLess important Rank or seniority of care giver Attire of news deliverer Physical contact Jurkovich GJ. J Trauma 1999

Advanced Directives • Written statement of your wishes, preferences and choices regarding end of life health care decisions • Tool to help you think through and communicate your choices • Only used: • If you are seriously ill or injured AND • Unable to speak for yourself

Advanced Directives • State specific • Living will • Medical power of attorney (MPOA) • Do not resuscitate (DNR) orders • Out of hospital DNR • Not transferrable state to state • Need to execute by state

Living will • Legal document with your wishes about medical treatment • You choose: • What you want • What you don’t want

MPOA • Legal form that states who you want to make decision about medical care • Person is authorized to speak for you ONLY if you are unable to make your own medical decision • May also be: • ‘health care proxy or agent’ • ‘health care surrogate’ • ‘durable power of attorney for health care’ (DPOA)

MPOA • Power to make decisions • Receive/review medical information • Discuss with medical team • Consent to or refuse procedures • Authorize transfers • If you are MPOA, make sure you understand what patient wants

Advanced Directives • Advantages • In charge of making your own decisions • Documents can change anytime • You do not need an attorney • Document can help you express your wishes

Advanced Directives • Executing • Do not need lawyer to complete • Decide what type of life sustaining treatments you do not want • Discuss/inform with family and primary doctor • If you change your wishes, complete a new advance directive

Advanced Directives • Disadvantages • Not available to transfer between states • Living wills • May not be specific enough • May be overridden by a treating doctor • Does not immediately translate into doctor’s order

TALKING IMPORTANT • Honest discussion, reflection and planning • Opportunity to discover important information on family and patient • Most important gift you can give to prepare for the end of life

Trauma Surgeon ABCDE of trauma

A • Advanced preparation • Time • Privacy • No interruption • Review information • Mental rehearse • Prepare yourself emotionally

B • Build a therapeutic environment/relationship • How much do they need to know • All family present • Introduce yourself to everyone • Warn of bad news

C • Communicate well • What do they already know • No medical jargon • Translator • Frank but compassionate • Allow for silence/tears • If appropriate, repeat their understanding • Follow up plan

D • Deal with family reactions • Be empathetic • Do not argue or criticize colleagues

E • Encourage and validate emotions • Use interdisciplinary resources • What does this mean to family • RN, clergy or SW follow up after you leave

Family • Anger • Shock or numbness • Searching for any hope • Disorganization and despair • Reorganization

Stages of Grief • Kubler-Ross Stages of Dying (1969) • Denial • Anger • Bargaining • Depression • Acceptance

Stages of Grief • Engle’s Theory (1964) • Shock and disbelief • Developing awareness • Reorganization and restitution

Trauma Surgeon Feeling of failure Fear of approaching topic Constraint for time

Trauma Surgeon • Important to take control • Leader of the team • Know your resources • Recruit your resources • Take a moment for yourself • Review events in your head • Remove signs of resuscitation • Emotionally not drained

Trauma Surgeon • Develop a rapport with family early • Trust • Sincerity • Empathy

Trauma Surgeon • Stand firm • Ultimatum sometimes necessary • Offer evidence of finality

Approaching the family • When death is imminent • Maximizing comfort • Acceptance • Time • Saying good-bye

Approaching the Family Prepare info, location, setting Find out what they already know Ask how much they want to know Share information Respond to family’s emotion Negotiate concrete follow-up step

Approaching the Family • Avoid rote responses • Each family is different • Be genuine • Express your true feelings • Admit you don’t have words if you don’t know what to say • Avoid common greetings • Hi! How are things going? • Don’t be afraid to discuss death

Approaching the Family • Don’t preach or lecture • Listen • Let them talk and express their concerns • Ask what you can do. Keep the promise • Be aware of the tone in your voice • Avoid being condescending or pitying • Check in on the family frequently

Approaching the Family • Offer Clergy • Time of stress, needed more than people might realize • Explain the need for autopsy

Conclusion Delivering bad news is difficult Not well trained in medical school or residency Form relationship Clear Privacy Empathetic

THANK YOU…….

MDs Perspective on Working with Families after Trauma in Grief