Withdrawal of Ventilatory Support Educational Issues

1. Withdrawal of Ventilatory SupportEducational Issues James Hallenbeck, MD Assistant Professor of Medicine Director, Palliative Care Services VA Palliative Care services

2. What are the educational issues? 83 yo man 4 months post valve replacement for critical aortic stenosis on chronic ventilatory support. Patient suffered multi-system failure and now thought to be unweanable. Wife angry at you for doing surgery and then “lying” about his prognosis. Asks that you remove the tube and allow him to die with dignity.

3. AIRS Slide In teaching about possible ventilatory withdrawal, what topic is most important to stress? • Relevant ethical principles • Proper drug usage for palliation post extubation • Communication skills • None of the above • All of the above

4. Outline • Educational Principles • Knowledge, Attitudes and Skills • Overt and covert tension • Educational Challenges • General • For surgeons • Relative to difficult decisions such as ventilator withdrawal

5. Knowledge What new knowledge is important for the learner? • Understanding of relevant ethical principles • Knowledge of relevant therapies • Role of opioids • Role of sedatives • Knowledge of relevant support systems

6. Attitudes What changes in attitude does the teacher believe are necessary? Potential attitudes to address: • That withdrawal of support is purely a medical decision • That previous experience and training was adequate in addressing the issue • That treatment withdrawal is solely an ethical problem • Not my job

7. Skills What new skills are necessary? • Communication Skills • Demonstrate the ability to address cognitive and affective components of communication • Order writing skills • Write initial orders for treatment discontinuation, including drug doses and indications • Access skills • Demonstrate the ability to access support for a grieving family

8. Like a battery… Learning requires TENSION to work So where’s the tension in the learner?

9. Tension – Overt and Covert • Overt tension – what people verbally identify as the problem • If we don’t get this straightened out, we’ll have to trach this guy… • Covert tension – unspoken, sometimes unconscious tension • I’m not sure I’m competent • I don’t want to be the one pulling the plug…

10. Subtext • Emotional subtext often present, but not addressed – in patients and families AND in ourselves • ‘You doctors just used him as a guinea pig. Now you want to get rid of him!’ What is the emotional subtext for the speaker? What is your emotional subtext?

11. AIRS Slide Ethical Principles Knowledge Rank your knowledge • 1 Minimal, Inadequate • 2 Barely adequate, Struggling • 3 Adequate • 4 Superior • 5 Master

12. AIRS Slide Drug Usage for Dyspnea, Agitation • 1 Minimal, Inadequate • 2 Barely adequate, Struggling • 3 Adequate • 4 Superior • 5 Master Rank your skill

13. AIRS Slide Necessary Communication Skills Rank your skill in USING communication skills • 1 Minimal, Inadequate • 2 Barely adequate, Struggling • 3 Adequate • 4 Superior • 5 Master

14. AIRS Slide Necessary Communication Skills Rank your skill in TEACHING communication skills • 1 Minimal, Inadequate • 2 Barely adequate, Struggling • 3 Adequate • 4 Superior • 5 Master

15. Challenges in palliative care education - general • Arrogance-Ignorance phenomenon • Hidden curriculum

16. Weissman et al. Survey of Internal Medicine residents and faculty Ignorance… Mean % Correct

17. Despite minimal differences in knowledge… Arrogance • Interns admitted knowledge and skill deficits and were concerned about their competency = TENSION • Residents and faculty less concerned about ability to practice and teach palliative care • Many faculty – What ME worry?

18. Curriculum or Hidden Curriculum? • End-of-life issues often relegated to the “hidden curriculum” – not worthy of instruction/modeling by attendings, but informally modeled among residents and students. Reference: Rappaport W, Witzke D. Education about death and dying during the clinical years of medical school. Surgery. 1993;113(2):163-165.

19. Rappaport Study Key findings (n = 53 surgical residents) • 84% of junior and 50% of senior residents reported never hearing an attending discuss how to do deal with a terminally ill patient • How often are you with the attending when he/she talks with a dying patient? • Junior residents 64% < once/month • Senior residents 43% < once/month

20. Special challenges for surgeons • Hierarchical organizational structure may inhibit discussion of controversial issues • Task-oriented people – focused on doing rather than feeling • Withdrawal of support issues may be linked, at least emotionally, to prior actions of the surgeon

21. Example – 83 yo with critical AS • Suffered stroke, became vent dependent following “elective” valve replacement • Angry wife – “He was mowing the lawn and now you made him a vegetable…” • Frustrated surgeon – “She just doesn’t get it – it was a risk, but I thought it was a greater risk not to operate. You know what critical AS is like…”

22. Challenges specific to “difficult decisions” • Actions (stopping ventilator (or dialysis) are discrete and clear • Discrete actions must occur in an environment of uncertainty and ambiguity HOWEVER..

23. Uncertainty/ambiguity regarding: • What people want or (usually for the patient) might have wanted • Outcomes: not just that people will die but • Actual time to death • What it means to die or be dead • Feelings • What the right thing to do is (Ethics)

24. What is required is... Exquisite Competence Not just basic understanding

25. Summary Check-list • Knowledge • Ethics • Proper drug use • Accessing support systems • Skills • Drug utilization • Communication • Offering support to patient, family, staff

26. Final words • In historical terms ventilation and other forms of life-support are recent innovations • As a society we have not ‘caught up’ with such innovations • Historically, for all specialties education in palliative care in general has been sorely lacking • We need to work hard to figure out how best to incorporate needed training into existing curricula