Medical Ethics & Communication at End of Life

1. Medical Ethics & Communication at End of Life

2. Biomedical Ethics • Ethics is a set of methods that facilitate understanding and examining our moral lives. • Moralityrefers to the norms of right and wrong human conduct as generally accepted by society • When faced with a medical problem where right or wrong are not instinctively or immediately obvious we use ethics to assist us to make a morally good decision. • Biomedical ethics refers to the use of ethics within the practice of medicine.

3. Moral Principles • Beneficence (Health care workers should work for the patient’s good) • Non-maleficence (Health care workers should do the patient no harm) • Autonomy (Health care workers should respect a patient’s right to self-rule) • Distributive justice (Health care workers should ensure fair allocation of medical resources)

4. Goals of Healthcare • Restore health (saving life) • Relieve suffering (accompanying death) These goals are not incompatible. The treatment being offered must be defined within the context of the goals.

5. Surrogate • It is important for the physician to identify a suitable family member as a surrogate decision maker for the patient • Family means spouse, children, parents, next of kin, or even a trusted friend

6. Communication • Development of drugs & technology receive more attention while non-technical skills like communication are neglected • Poor communication between healthcare workers contributes significantly as a latent source of medical error. Sutcliffe et al. Acad Med 2004 • Patients have better outcomes when doctors & nurses communicate effectively about patient care. Dodek et al. Intensive Care Med 2003

7. Ineffective Information Transfer • Team factors responsible for 1/3rd critical events • 57% errors due to problems of verbal & written communication • 37% due to communication during handover Pronovost et al. J Crit Care 2006 • Handover – verbal, bedside, office • Interruptions

8. Inter-professional Communication • Open communication • Unit leadership • Interaction between Doctors & Nurses – nurses spend more time with ICU patients; their inputs are valuable • Providing nurses with more information, support, resources, & opportunity at work could improve communication with physicians • Case & Patient knowledge

9. Clinical Situation Requiring Effective Communication • Consent for intervention • Explaining medical risks • Uncertain prognosis • Breaking bad news • Unexpected death • Procedure related complication • Disclosure of error • Advance directive/CPR/withholding/withdrawal life support • Brain death & organ donation

10. Barriers to Good Communication • Hostile media, increasing litigation, lack of trust adversely affect communication. • Given the same facts, three different clinicians give different advise because of what they perceive as patient need • It is natural for someone with serious illness to seek second/third opinion. This often adds to increasing confusion. • Medical advice about outcome of treatment is nearly always indefinite

11. Barriers to Good Communication • Information flood – 34,000 articles/month • Vested interest – most doctors want to increase their income; patients want to minimize expenditure • Social Distance • Linguistic Differences

12. Teaching Communication Skills • Content skills – avoiding technical language, using a level of explanation appropriate to the relative’s understanding of events • Process skills – how a meeting with the family is structured • Perceptual skills – recognizing & dealing with feelings & emotions during course of conversation. Depends on attitude & relationship which can be improved with training

13. Managing Difficult Communication Tasks • Conveying Prognosis – when poor avoid instilling false hope. Do not focus on irrelevant positives. It distracts the family from the work of acceptance. • Dealing with difficult questions • Handling Denial – patience & repeating the same message over & over again • Overcoming Unrealistic Expectations – early, honest & consistent communication

14. Managing Difficult Communication Tasks • Breaking Bad News – no staged disclosure, no telephonic disclosure • Managing Distress • Avoiding Collusion – hiding from reality ends up hurting rather than enhancing acceptance • Working Within a Team – good inter-professional communication • Negotiating with Colleagues

15. Communication • Appropriate information & communication are nowadays essential needs of ICU patients’ family members & is a key component of their satisfaction, especially in case of death. • Shared decision-making model, balancing family members’ right to decide & their needs to be cared & comforted is gaining ground nowadays. Cook 2001

16. Communication • Communication is highly required in a shared decision-making process • It allows family members to receive information about the patient’s medical condition, prognosis & treatment • It allows care givers to receive information about the patient’s history, preferences & value

17. Communication • This two-way information model allows caregivers to provide care adjusted to the level of care wished by the relatives which is one of the main parameters of family satisfaction near EOL. Heyland et al 2003 • It helps ICU caregivers to perceive the proxies’ wishes regarding decision to forego life sustaining therapy & then tailor it based on a cautious case-by-case approach.

18. Communication • Around 50% of family members have misunderstanding of Diagnosis, Prognosis, or Treatment after meeting the Physician. Azoulay et al. Crit Care Med 2000 • Conducting Family Conference is very Important • Pre-conference meeting of the clinicians to develop consensus so that there is no conflict before meeting the family. • The essence of family conference are consistent communication & a private place for communication (quiet, dedicated, everybody seated & feel welcome)

19. How to Communicate • Every caregiver in ICU should acknowledge that the need to improve their communication skills • Ability to listen (70:30) • Conflict management • Using open ended questions • Clear & honest information may allow them to vent emotions, to feel reassured, empowered & comforted

20. Communication Components for Family Satisfaction • Increase proportion of time spent listening to the family. MacDonagh et al. Crit Care Med 2004 • Listen &respond to family members • Acknowledge & address family emotions • Explore & focus on patient values & treatment preferences • Explain the principle of surrogate decision making to the family • Affirm non-abandonment of patient & family. (alleviate suffering while ensuring comfort, allow family members to be present at bedside, be accessible)Curtis et al. J RespirCrit Care Med 2005

21. Communication Components for Family Satisfaction • Assurances that the patient will not be abandoned prior to death • Assurances that the patient will be comfortable & will not suffer • Providing explicit support for family’s decisions about end-of-life-care, including support for family’s decision to withdraw or not to withdraw life-support. Stapleton et al. Crit Care Med 2006

22. V – value statements/questions made by family members A - acknowledge family emotions L - listen to family members U - understand & address who the patient is E – elicit family questions Lauterette et al. NEJM 2007 Communication Components for Family Satisfaction

23. Communication Components for Family Satisfaction • Time should be spent discussing, understanding & accommodating cultural & religious preferences. Kagawa-Singer et al. JAMA 2001 • Adequacy of physician & nurses • Help from family physician

24. Preparation for Family Conference • Data updating about patient & relatives • Resolution of intra-team conflict • Evaluation of family knowledge, identification of team-family conflict • Location, timing

25. Structure of Family Conference • Introduction • Two-way information exchange (reassurance & creation of climate of trust) • Patient’s condition (Diagnosis & Prognosis for the future) • Treatment - Discussion of goals of care & the decision to be taken (futile, witholding/withdrawing)

26. Structure of Family Conference • Therapeutic communication skills – reflections & pauses, allow families to speak, to ask questions & to express emotions. • Avoid technical terms & detailed explanation. • Ending – relatives needs met (questions answered, emotions acknowledged, silences respected) • Summarize major points & plan (expected event, next meeting) • Repeating availability of caregivers

27. The Apollo Protocol Category – 1 • > 3 days ICU/7 days ward stay – every 3/5 days • On ventilator for 3 days – every 3 days Category – 2 • Developed complication or on toward incident – same day & there after every alternate days. Category - 3 • Potential source of trouble – immediately & there after every alternate days.

28. The Apollo Protocol Members who need to attend • All consultants treating the patient • Social Worker(Clinical Psychologist) • MS/AMS • Executive of the area • ICU in-charge/Care manager(responsible for coordination & conducting the meeting)

29. The Apollo Protocol • Documented in the form. • Filed in the Case sheet.

30. Summary • Communication with families in ICU has gained scientific credibility & is nowadays considered as a priority target to achieve excellence in End-of-Life care in ICU. • Communication with family members should be seen as a key-component of family-centred care near End-of-Life • The awareness of ICU caregivers & training in communication provided to every medical student & ICU residents is essential.

31. Summary • Value end-of-life care & make it an important part of the rounds & documentation. • Nurses & other ICU clinicians of the interdisciplinary team should take responsibility for end-of-life decision making & care. • Hospitals should humanise ICUs by liberalising visiting hours, & providing educational material about the ICU & critical illness. Azoulay et al 2002

32. Summary • Withdrawal of life support should be considered a clinical procedure that warrants attention & quality improvement. • Protocols for withdrawing life sustaining treatment & forms for documenting this process should be considered. Treece et al 2004