Summary written by Avnee Kumar, MD
Lecture starts at 57:20
Clinical Pearls
What is the Rapid Response System?
- Organized process for identifying critical and dangerous events by clinical observations, triggering notifications, and response by predetermined organized team to resolve the crisis
- Crisis determined by time frame and needs out of proportion to resources at hand
- Purpose is to prevent progression of
sudden deterioration and death among those NOT destined to die
- Those destined to die and those NOT destined to die both can trigger rapid response systems
Combining the Rapid Response System and End of Life Discussions
- Physicians communication with families and patients is not optimal and doctors delay goals of care discussions [1-3]
- This may be because predicting the
past is easier than predicting the future
- Most people will have numerous ‘good intervals’
- RRS is a natural opportunity to discuss death because it is
a near death experience that the families want to understand
- Creates a time pressure for family to confront the decision
Rapid Response System Call: An Indication for a Palliative Care Assessment
- What to do at the event?
- Read the situation – stabilize the patient
- Talk to family and patient – Reorient them to new data as the situation is evolving
- Do not forget to address emotions
- Provide therapeutic options – Discuss the outcome/goal instead of
intervention
- Intervention: ET tube, machines, chemotherapy
- Outcome/Goat: pain free days, spend time at home, die with family present
- Promote and urge a choice
A Guide to Discussions at the Bedside
- Language is important
- Simple words and sentences
- Go SLOW
- Watch body language
- Check understanding frequently
- Use silence to promote comments by others
- Good words to use to introduce death
- I am concerned that your ___ is going to die
- I feel that death is a likely outcome
- Your ___ is dying
- I am concerned about how you will manage if your ___ dies
- I am guessing that you are concerned about whether __ is going to die
- Language to describe goals of care [4]
- I want to give you the best care possible
- I want to ensure that you receive the care you want
- I’m worried about how you’ll manage
- I want you to know I will not allow you to be in pain
- Let me make sure I’ve got it right
- Spend effort
to learn why
- Sometimes the patient/family priorities/goals are different from the healthcare professional
- The Four Conversations of Information Exchange
- News is just news
- It’s the situation that makes it “good” or “bad”
- Gain appreciation by inquiring and listening to the family
- Emotion Management
- NURSE Emotions
- Name, Understand, Respect, Support, Explore
- NURSE Emotions
- Conflict
Resolution
- 95% of conflict is due to mistaken understanding of facts
- Correct/unify facts
- Listen for conflict, clarify disagreements of facts
- Find areas of consensus
- Decision Making
- Only after the first three conversations!
- Offer recommendation
- Try to stay within consensus opinion
- News is just news
References
- SUPPORT Principal Investigators. A controlled trial to improve care for seriously ill hospitalized patients. JAMA.1995;274:1591-1598.
- Curtis JR, Engelberg RA, Nielsen EL, et al. Patient-physician communication about end-of-life care for patients with severe COPD. European Respiratory Journal. 2004;24:200-205.
- Keating NL, Landrum MB, Rogers SO Jr, et al. Physician factors associated with discussions about end-of-life care. Cancer. 2010;116(4):998-1006.
- Roter DL, Larson S, Fischer GS, Arnold RM, Tulsky JA. Experts Practice What They Preach: A Descriptive Study of Best and Normative Practices in End-of-Life Discussions. Arch Intern Med. 2000;160(22):3477–3485.
