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Question 1e - 2000, Paper 1

A 50 year old man is brought into the Emergency Department after acute flexion injury to the neck while surfing.  He is unable to move both arms or kgs and has a sensory level at C4·5.   He ls a heavy smoker with a history of chronic bronchitis.

(e) At 21 days he is ventilator dependent. He appears frustrated and angry. His wife be ves that he wished to die and she requests withdrawal of therapy. What will you do?

College Answer

(e) This ethical and communication question requires resort to basic principles. This is an open scenario because clinical details helping with prognostication  are  not  revealed. The candidate should not conclude that the prognosis is either hopeless or optimistic for functional recovery at this stage or that the wife has his interests at heart or that she knows his wishes.

Suggested steps in handling this problem include: 
(i)       Information gathering. As  much clinical and radiological information  as possible about prognosis and further function should be accumulated. Infonnation should also be gathered about his social setting, his lifestyle and previously expressed wishes, his family's resources to provide therapy at home.

(ii)      Communication. Over a period of time in family conferences this infonnation should be clearly explained. Time should be set aside to sit down with all the close relatives in  a  quiet  environment. Efforts should be made to  involve the  patient via communication aids (eg. Passy Muir valve, Pitt tube, Lip reading}.

(iii)     Specific issues. Causes for the patients agitation should be sought. Depression treated. Fi.nancial issues should be addressed with the social worker.

(iv)    Actions then should be based on : 
- respect for human life. 
- respect for human dignity. 
- respect for individual autonomy. 
- respect for social justice. 
- assessment of the benefit and harm of continued therapy.

A competent patient is entitled to withdraw consent to treatment but it is early in his course. The responsibility of the doctor is to ensure that the patient is competent. is fully informed and the treating team has a consensus. This will take time.

WHEN LIFE SUPPORT IS QUESTIONED EARLY IN THE CARE OF PATIENTS WITH CERVICAL·LEVEL QUADRIPLEGIA  NEJM 1993;328;7;PSQ6..9

Discussion

Normally, decisions can be made to limit or withdraw the therapy if any of the following conditions are satisfied:

  • The therapy is considered unlikely to succeed on grounds of basic physiology (i.e. it would be scientifically impossible for it to achieve the intended goals)
  • The therapy is known to fail in the vast majority of attempts under these conditions, and the attempt has known and serious adverse consequences
  • The therapy would (if successful) lead to a quality of life which is unacceptable to the patient, or (if the patient or family cannot comment) which would lead to a quality of life which "falls well below the threshold considered minimal by general professional judgment"
  • The therapy leads to the preservation of a state which is unacceptable for the patient, eg. the therapy merely preserves unconsciousness and dependence on intensive medical care.
  • There are parties (including other medical professionals and important figures from the patient's family) who agree that the cost or outcome of the therapy would be unacceptable to the patient.

As the patient themselves can participate, this is the most important opinion to consider.  That Patterson paper the college quotes (NEJM, 1993) is actually quite a good overview of what it takes to withdraw consent for therapy. The following conditions must be satisfied:

  • The patient is conscious and there are no medical reasons to suspect that their cognition or judgment are impaired (this is where a psychologist or psychiatrist comes in to consider depression or psychosis)
  • The patient is competent. 
  • The patient has the capacity to absorb all the required information, offered to them in a way they find acceptable. That information must include material on:
    • Long-term rehabilitation
    • Appropriate technological devices
    • Impact on mobility, continence, respiratory processes, etc
    • Depression and quality of life
  • The patient is able to process the information
  • The patient is able to form a reasoned internally consistent decision
  • The patient is able to articulate this decision in a manner which witnessess find unequivocal
  • The decision is consistent with their known values

The "medical consensus" issue does not matter as much if the patient himself decides that ongoing treatment is completely against his wishes.

References

Patterson, David R., et al. "When life support is questioned early in the care of patients with cervical-level quadriplegia." (1993): 506-509.

Myburgh, John, et al. "End-of-life care in the intensive care unit: Report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine.Journal of critical care 34 (2016): 125-130.

Palda, Valerie A., et al. "“Futile” care: Do we provide it? Why? A semistructured, Canada-wide survey of intensive care unit doctors and nurses." Journal of critical care 20.3 (2005): 207-213.

Sibbald, Robert, James Downar, and Laura Hawryluck. "Perceptions of “futile care” among caregivers in intensive care units." Canadian Medical Association Journal 177.10 (2007): 1201-1208.

Danbury, C. M., and C. S. Waldmann. "Ethics and law in the intensive care unit." Best Practice & Research Clinical Anaesthesiology 20.4 (2006): 589-603.

Myburgh, John, et al. "End-of-life care in the intensive care unit: Report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine." Journal of critical care 34 (2016): 125-130.

Schneiderman, Lawrence J. "Defining medical futility and improving medical care." Journal of bioethical inquiry 8.2 (2011): 123.

Ardagh, Michael. "Futility has no utility in resuscitation medicine." Journal of medical ethics 26.5 (2000): 396-399.

Schneiderman, Lawrence J., Kathy Faber-Langendoen, and Nancy S. Jecker. "Beyond futility to an ethic of care." The American journal of medicine 96.2 (1994): 110-114.

Waisel, David B., and Robert D. Truog. "The cardiopulmonary resuscitation-not-indicated order: futility revisited." Annals of internal medicine 122.4 (1995): 304-308.

Question 1e - 2001, Paper 1

A 72 year old woman (55kg), Mrs X, with a history of severe emphysema and chronic bronchitis is intubated in the Emergency Department (ED) because of drowsiness associated with hypercarbia after her initial arterial blood gas analysis revealed:

  • pH 7.219        
  • PC02 98mmHg     
  • PO2 48mmHg    
  • HC03 39mmol/l        
  • lactate 2.5 mmol/l

You are called to the ED to assess and admit this woman to ICU. The history from her daughter reveals that Mrs X lives independently but is limited by severe breathlessness with exercise.  After 3 weeks of difficult ICU management Mrs X is discharged to the ward.

(e)   What are the principles of managing her should she deteriorate and require readmission to ICU?

That  night  she  develops  sputum  retention  and  becomes  drowsy. Her daughter demands  ICU admission.

(f)   What will you do?

College Answer

After 3 weeks in ICU this 72 year old lady with severe CAL is entitled to the opportunity of a frank discussion about advance care planning. The aim of this question was to explore discharge planning to prepare Mrs X and family for eventualities. Much will depend on what has been learnt about her disease and whether the admission was the result of inexorable deterioration of her lung disease or precipitated by a reversible event. A group conference should be organised before discharge.

The general plan being:
-     prepare for the discussion by providing a suitable environment, gaining the medical facts, getting a medical consensus on a contingency plan
-     establish what the family and patient know
-     determine how much information they want. How open and frank a discussion.
-     explain the medical information and a proposed medical plan
-     assess the response of the patient/family and respond to their emotion, questions and disagreements
-     establish general, accepted goals for long term care
-     finalise a  plan
Details will include Mrs X’s desire for intubation if necessary in the future, the use of non-invasive ventilation etc

That  night  she  develops  sputum  retention  and  becomes  drowsy. Her daughter demands  ICU admission

(f)   What will you do?

The response will depend on the results of the conference, and the plan reached.  If her daughter demands ICU admission for Mrs X it is best to
-     assess the medical appropriateness of admission at this time
-     assess alternative or more appropriate avenues of management
-     discuss with admitting consultant to agree on a plan
-     communicate with Mrs X’s daughter and arrive at a mutually agreeable plan bearing in mind that the stated wishes of Mrs X are paramount

A  review  of  events  of  the  day  should  be  undertaken  to  ascertain  if  there  is  a  cause  for  this deterioration eg sedation, narcotic administration, sepsis, pneumothorax.
If readmission appears to be appropriate then there is no problem.
If it is not, because of terminal irreversible condition or it is against the clear wishes of Mrs X, the feelings and motivation of the daughter will need to be addressed and answered.

Discussion

In the discussion with the family, 

  • Consider beneficence: is aggressive therapy in the patient's best interest? 
  • Consider non-maleficience: is aggressive therapy going to burden the patient? In this case, mechanical ventilation will certainly relieve the work of breathing, but will likely commit the patient to a prolonged course of ICU stay.
  • Consider fidelity: the patient or their surrogate decisionmaker need to be given a honest breakdown of exactly what the therapy will require, and what the goals of it will be. This should involve a discussion of prolonged ventilation and its complications, and the very real possibility of tracheostomy.
    • Consider utility (rather than futility): is the therapy going to be helpful? As far as what "helpful" means, one needs to defer to the values of the patient and their family as well as to the objective physiological effectiveness of the therapy. Would they be comfortable with a therapy which merely prolongs life in a state of dependence on intensive care services?
    • Invoke the principle of autonomy. The outcome achieved by this therapy: is this outcome one which the patient would find satisfactory? This is worth talking about in the first scenario.
  • Decisions can then be made to limit or withdraw the therapy if any of the following conditions are satisfied
    • The therapy is considered unlikely to succeed on grounds of basic physiology (i.e. it would be scientifically impossible for it to achieve the intended goals). 
    • The therapy is known to fail in the vast majority of attempts under these conditions, and the attempt has known and serious adverse consequences
    • The therapy would (if successful) lead to a quality of life which is unacceptable to the patient, or (if the patient or family cannot comment) which would lead to a quality of life which "falls well below the threshold considered minimal by general professional judgment"
    • The therapy leads to the preservation of a state which is unacceptable for the patient, eg. the therapy merely preserves unconsciousness and dependence on intensive medical care.
    • There are parties (including other medical professionals and important figures from the patient's family) who agree that the cost or outcome of the therapy would be unacceptable to the patient.

References

Myburgh, John, et al. "End-of-life care in the intensive care unit: Report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine.Journal of critical care 34 (2016): 125-130.

Palda, Valerie A., et al. "“Futile” care: Do we provide it? Why? A semistructured, Canada-wide survey of intensive care unit doctors and nurses." Journal of critical care 20.3 (2005): 207-213.

Sibbald, Robert, James Downar, and Laura Hawryluck. "Perceptions of “futile care” among caregivers in intensive care units." Canadian Medical Association Journal 177.10 (2007): 1201-1208.

Danbury, C. M., and C. S. Waldmann. "Ethics and law in the intensive care unit." Best Practice & Research Clinical Anaesthesiology 20.4 (2006): 589-603.

Myburgh, John, et al. "End-of-life care in the intensive care unit: Report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine." Journal of critical care 34 (2016): 125-130.

Schneiderman, Lawrence J. "Defining medical futility and improving medical care." Journal of bioethical inquiry 8.2 (2011): 123.

Ardagh, Michael. "Futility has no utility in resuscitation medicine." Journal of medical ethics 26.5 (2000): 396-399.

Schneiderman, Lawrence J., Kathy Faber-Langendoen, and Nancy S. Jecker. "Beyond futility to an ethic of care." The American journal of medicine 96.2 (1994): 110-114.

Waisel, David B., and Robert D. Truog. "The cardiopulmonary resuscitation-not-indicated order: futility revisited." Annals of internal medicine 122.4 (1995): 304-308.

Question 2d - 2001, Paper 1

After a year you become aware of a very high mortality in the post-operative patients of one of the surgeons.

(d) How will you approach this problem? 

College Answer

This is a topical and difficult problem. It is best approached by assessing the surgeon’s results in the light of available benchmarks. It is possible that there is a high referral rate of high-risk patients. Before precipitating alarm it would be best to start by gathering information from all available sources and then confiding in trusted colleagues for advice and personal experiences. Referral to the medical defence group would provide expert legal and medical advice. If there is concrete evidence of negligent, incompetent or poor practice it should be presented to hospital division and administration and the surgeon involved. Further avenues may then be regional medical board. 

References

Question 1c - 2002, Paper 2

You are called to see a 49-year old female in the general surgical ward who has become profoundly hypotensive (75/40 on auscultation). She is now 5 days after palliative surgery for a perforated malignant gastric ulcer.  She is barely rousable and the pulse oximeter saturation is 85% on face mask oxygen (10L/min).

(c)        Please discuss your plan for her definitive care.

College Answer

At this stage definitive information is required regarding her prognosis and expressed wishes. The palliative operation may have been performed to provide months of more comfortable existence, or to prevent severe discomfort during the last weeks of life.

Priorities for “comfort only” measures or limitations in therapies should be introduced when considered appropriate (with input from family, parent unit etc.).

If appropriate after all information is available, specific treatment to treat the potential underlying causes should be implemented. Specific therapies depend on the diagnosis (drainage/surgery/antibiotics for intra-abdominal sepsis; antibiotics/ventilation for pneumonia; anticoagulation ± surgery for pulmonary emboli; etc.).

Nonspecific supportive care should also be discussed (including DVT prophylaxis, GI bleeding prophylaxis, feeding, pressure area care, support for family etc.

References

Question 1a - 2003, Paper 1

A 50-year-old man with motor neurone disease presents to hospital  with respiratory distress following two (2) days of fever and malaise.  He is alert and anxious, and an arterial blood gas performed on oxygen (8L/min semi-rigid mask) revealed PaO2 45 mmHg, PaCO2  65 mmHg, pH 7.36 and HCO3 36 mmol/L.   He has used a motorised wheelchair for three (3) years but continues  to  work as  an  accountant.    His  attentive   wife states  that  they  have  discussed mechanical   ventilation   and   are  keen   for  him   to  receive   full  Intensive   Care  support.

•  How will you approach the issue of mechanical  ventilation  in this man?

College Answer

A decision about mechanical ventilation is necessary but is not urgently required.  Time should be taken to talk through the potential problems, and ensuring that the patient and wife are aware of the actual implications of ventilation (likely need for and potential complications of intubation & tracheostomy, difficult or impossible wean, prolonged ICU, long term hospital and home ventilation [if available!]).  Discussion should include what factors are likely to be reversible (including time frame).   Other input may be appropriate and should be sought (parent unit, treating doctors, neurologists, pastoral care).   The issues of consent (who and for what must be clarified).  After detailed discussion, patient and wife (if appropriate surrogate) should be able to decide.

Discussion

In discussing mechanical ventilation with a person who is "keen" on it but who will likely end up dependent on it for a long term, the main concepts which govern medical ethics need to be considered:

  • Consider beneficence: is the therapy in the patient's best interest? In this case, mechanical ventilation is acutely life saving, and the patient has not indicated otherwise, so - yes.
  • Consider non-maleficience: is the therapy going to burden the patient? In this case, mechanical ventilation will never be a "short trial" and a tracheostomy is a real possibility, but in the short term mechanical ventilation will likely be well tolerated.
  • Consider fidelity: the patient needs to be given a honest breakdown of exactly what the therapy will require, and what the goals of it will be. One might involve people who organise home ventilation to discuss this issue with the patient. A discussion of tracheostomy is also important.
    • Consider utility (rather than futility): is the therapy going to be helpful? As far as what "helpful" means, one needs to defer to the values of the patient and their family as well as to the objective physiological effectiveness of the therapy. 
    • Invoke the principle of autonomy. The outcome achieved by this therapy: is this outcome one which the patient would find satisfactory? A honest discussion of what long-term ventilation via tracheostomy looks like needs to take place after the acute physiological disaster has been managed.
  • Consider social justice as the last and least important consideration; are the needs of the community served best if this treatment is to go ahead? 
  • Decisions can then be made to limit or withdraw the therapy if any of the following conditions are satisfied
    • The therapy is considered unlikely to succeed on grounds of basic physiology (i.e. it would be scientifically impossible for it to achieve the intended goals)
    • The therapy is known to fail in the vast majority of attempts under these conditions, and the attempt has known and serious adverse consequences
    • The therapy would (if successful) lead to a quality of life which is unacceptable to the patient, or (if the patient or family cannot comment) which would lead to a quality of life which "falls well below the threshold considered minimal by general professional judgment"
    • The therapy leads to the preservation of a state which is unacceptable for the patient, eg. the therapy merely preserves unconsciousness and dependence on intensive medical care.
    • There are parties (including other medical professionals and important figures from the patient's family) who agree that the cost or outcome of the therapy would be unacceptable to the patient. 

References

Myburgh, John, et al. "End-of-life care in the intensive care unit: Report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine.Journal of critical care 34 (2016): 125-130.

Palda, Valerie A., et al. "“Futile” care: Do we provide it? Why? A semistructured, Canada-wide survey of intensive care unit doctors and nurses." Journal of critical care 20.3 (2005): 207-213.

Sibbald, Robert, James Downar, and Laura Hawryluck. "Perceptions of “futile care” among caregivers in intensive care units." Canadian Medical Association Journal 177.10 (2007): 1201-1208.

Danbury, C. M., and C. S. Waldmann. "Ethics and law in the intensive care unit." Best Practice & Research Clinical Anaesthesiology 20.4 (2006): 589-603.

Myburgh, John, et al. "End-of-life care in the intensive care unit: Report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine." Journal of critical care 34 (2016): 125-130.

Schneiderman, Lawrence J. "Defining medical futility and improving medical care." Journal of bioethical inquiry 8.2 (2011): 123.

Ardagh, Michael. "Futility has no utility in resuscitation medicine." Journal of medical ethics 26.5 (2000): 396-399.

Schneiderman, Lawrence J., Kathy Faber-Langendoen, and Nancy S. Jecker. "Beyond futility to an ethic of care." The American journal of medicine 96.2 (1994): 110-114.

Waisel, David B., and Robert D. Truog. "The cardiopulmonary resuscitation-not-indicated order: futility revisited." Annals of internal medicine 122.4 (1995): 304-308.

Question 1d - 2004, Paper 1

A 60-year-old woman has a right hemi-hepatectomy for invasive cholangio-carcinoma. She has been admitted to your unit for postoperative care.

On day 6 she has a massive melaena requiring urgent endoscopy in the Intensive Care Unit. She requires endotracheal intubation. 

d)        Subsequent laparotomy reveals an infective erosion of the hepatic artery, which is grafted.  She is now developing multiple organ failure. Describe your management.

College Answer

The ‘usual’ management of MSOF may be discussed here, but this is a woman with a limited outlook before these complications occurred (5% 5 year survival). Discussion of outlook with the patient (if possible), immediate family as well as the referring surgeon should be entered into, and of ‘how far’ therapy should go or whether it should be limited or even withdrawn should also be discussed by the candidates.

References

Question 1 - 2004, Paper 1

Outline your principles for conveying bad news to family members.

College Answer

There are many published studies (including multiple reviews) addressing this area. Most information relates to non-critical care areas, and the majority are written from a medical perspective,  and  relate  to  conveying new  to  a  conscious  patient.  Few  studies  address  actual outcomes of the process. The welfare of the deliverer of the news should also be considered (eg. preparedness, training). The general principles espoused include: the importance of knowledge (content) of the medical details; delivery in a comfortable location offering privacy and relative quiet; setting aside sufficient time; identifying support network for the family members and having them present; delivery by or with a staff member who knows the family; sitting close to family members without physical barriers in between; non-verbal messages consistent with the verbal message; consider warning of bad news before news actually broken; awareness of what family know/have been told; present information in a way that conveys respect and empathy, use of touch may be appropriate in some circumstances; deliver at a pace appropriate to the family, allowing time for discussion; use clear & simple language to avoid confusion, though specific medical terminology may be referred to; convey some hope, even if in terms of minimising discomfort; provide  for  follow  up  meetings;  document  information regarding meeting in  medical  record. (Ptacek JT. Breaking bad news. JAMA 1996 26(6):496-502; Fallowfield L. Communicating sad, bad, and difficult news in medicine. Lancet 2004 363:312-9)

Discussion

As far as resources go, one cannot go past the excellent Education Module for Critical Care Communication from the UCLA. The college answer also quotes two articles : Ptacec et al (1996) and Fallowfield et al (2004). These resources have been recompiled to form the answer offered below:

Basic premise

  • Breaking bad news is an individalised and complex process which takes many different shapes and is dramatically different between different cultures, including both the culture of the clinican and the family. Given the amount of interpersonal difference, it would be difficult to standardise some sort of guidelines which would suit all situations.
  • In spite of this, common sense dictates that there must be good ways and bad ways of delivering bad news.
  • In the absence of a firm definition (what exactly is "bad news", anyway?) or empirical standarads, we rely on psychological literature on stress and coping to inform our approach to breaking bad news. 

Location and setting

  • Comfortable - at the minimum, the family should be able to sit down (i.e. this should not be a conversation in the hospital corridor).
  • Private, away from the clinical area. 
  • Quiet- allowing for important words to sink in without interruptions by monitor alarms and yelling staff members.
  • Insulated from interruptions: one needs to ensure that this time is "protected" by giving away one's telephone and pager.

Personnel present

  • The person doing the talking should ideally be somebody who has already met the family, and who has some rapport with them.
  • The medical staff - wherever possible - should not outnumber the family members.
  • The ICU should be represented by at least the medical team members, and also ideally the nursing staff (bedside nurse or nursing team leader).
  • The social worker should be available for this discussion
  • Ideally, non-ICU medical team members should eb available (for example, the surgical or medical team who were looking after the patient outside of the ICU).

Essentials of the verbal communication

  • The senior clinican who will do the talking should identify themselves and introduce the other staff members who are present.
  • One may wish to warn the family that bad news are coming before actually delivering the bad news.
  • The news need to be conveyed "in a way that conveys respect and empathy". In fact, to cynically manipulate the college examiners, the savvy candiate will use words like "warmth", "caring" "empathy" and "respect" in their answer.
  • The pace of delivery needs to be appropriate, and that can be assessed from the responses of the family (i.e. assess whether hey are ready to recieve the next piece of information)
  • The deliverer needs to be comfortable with silence, allowing periods to pass for the family to process the last piece of information
  • The deliverer needs to be prepared to repeat themselves, as much of what is said may go unheard by the grieving family members.
  • Wherever possible, the patient and their family members need to be referred to by their actual names. 

Non-verbal communication

  • Sitting close to family members
  • Eye contact is important
  • Eliminate physical barriers; do not conduct the conversation from behind a desk or from across the room. 
  • Facing the person whom you are talking to.
  • Non-verbal message must be consistent with the verbal message. Do not keep your arms crossed or folded; do not put your hands in your pockets. Ensure an open posture, leaning towards the person you are speaking to.
  • Use of touch may be appropriate in some circumstances.

Importance of content: the medical details

  • Needless to say, the details must be correct.
  • The language should be clear, simple and unabiguous. One should not use complex metaphors and euphemisms. Avoid jargon and only use specific medical terminology if it is appropriate to the family's level of medical knowledge or if clarification of simpler terminology is specifically asked for.
  • One needs to be careful not to take away all hope; at the very least the family need to be reassured that comfort and dignity remain medical priorities in the management of their loved ones.

Follow-up

  • Follow-up discussions need to be organised
  • The social worter will frequently remain in the room following the discussion, in order to "mop up" any questions which the family may have thought of after the medical staff had left, and to offer counselling or psychological support.
  • Spiritual support should be offered, if the family have specific religious needs or if there the expectation that the patient would have wanted such involvement. 
  • If a quiet private space has been designated for the discussion, that space should be made available to the family for some time forllowing the discussion, with the expectation that they will wish to spend some time in there, discussing the issues among themselves and coming to terms with the information they have just received.

Documentation

  • Documentation of the end of life discussion needs to be completed shortly after the discussion had taken oplace so that it is clear in the mind of the person doing the writing.
  • The people who were present need to be idenfied in the medical record
  • The content of the discussion needs to be documented carefully
  • The decisions which were reached need to be documented carefully, as well as the opinions voiced regarding these decisions (i.e. that the family agreed with the end of life plan, or that they had objections, and specifically what those objections were).

Welfare of the deliverer

  • Training in delivering bad news is important. 
  • Delivery of bad news is a stressful situation for medical staff, and this stress needs to be acknowledged. Post-conversation debriefing is valuable to maintain the energy of the deliverer and to allow them space for self-reflection. 
  • Feedback is important. Social workers, nursing staff and senior medical mentors should be used as sources of feedback for the trainees.

References

Arnold et al; "Educational Modules for the Critical Care Communication (C3) Course - A Communication Skills Training Program for Intensive Care Fellows"

Ptacek, J. T., and Tara L. Eberhardt. "Breaking bad news: a review of the literature." Jama 276.6 (1996): 496-502.

Fallowfield, Lesley, and Valerie Jenkins. "Communicating sad, bad, and difficult news in medicine." The Lancet 363.9405 (2004): 312-319.

Question 26 - 2005, Paper 1

Outline your approach to palliative care in the dying intensive care patient.

College Answer

This is a common scenario in the care of the critically ill.  The usual ethical principles need to be considered:

•    Autonomy (patient’s right to choose or refuse therapies),

•    Beneficence (obligation to further the patient’s interests),

•    Nonmaleficence (not inflict evil or harm, including refraining from interventions which are more likely to be of harm than benefit), and

•    Justice (social justice, including fair allocation of societal resources).

The key premise is one of full disclosure regarding medical condition, understanding of patient’s  wishes  (direct  or  via  appropriate  surrogate),  and  a  collaborative  plan  of management which clearly outlines priorities (eg. relief of pain and suffering versus prolongation  of  life  at  all  costs)  and  plans  regarding  interventions  (eg.  analgesic medications, removal of ETT, not for futile procedures or therapies [eg. CPR]).

One proposed tool is the PEACE tool, which considers:

•    Physical symptoms (including pain, nausea, other side effects)

•    Emotive and cognitive symptoms (including anxiety)

•    Autonomy (sense of control and participation in decision making)

•    Closure of life affairs (spend time with family, others to visit etc.)

•    Economic  (assistance,  arrangements,  insurance  etc)  and  existential  issues  (eg. religious and spiritual)

Conflict resolution is essential, and is usually prevented by adequate communication with patient and families involving complete and open discussion, but on occasions may require external input (eg. external specialist, courts etc)

References

Question 30 - 2006, Paper 1

A 40 year old man with end stage motor neurone disease takes a deliberate, lethal, benzodiazepine  overdose.  As he becomes sleepy, he tells his wife what he has done, and asks that  she stay with him as he dies.  They had discussed his wish to commit suicide before, rather than  suffer the indignity  and distress of respiratory failure in hospital. He has an advanced  directive not to be ventilated  in the event of respiratory failure. His power of attorney is a barrister who is also a close friend of both the patient  and his wife.

She panics, however, as he becomes unconscious and calls an ambulance.  Finding him unconscious and in drug induced  respiratory failure, the ambulance intubates and ventilates  him and  delivers him to the hospital  Emergency Department.  You are the intensive  care specialist  on call and  are asked  to take  him to your ICU for ongoing care.

Outline the principles of management

College Answer

This is a complex scenario. Answers should include some discussion of patient autonomy, the relevance of the medical diagnosis of end stage motor neurone disease (MND) versus overdose, determination whether anyone carries medical power of attorney, and support for the wife.


One reasonable approach, and factors to consider include:
•    Take him to ICU as ventilation has been instituted as a lifesaving measure in a clinical circumstance which has not been described in his advance directive.
•    Continue ventilation until the wishes of the patient can be determined either from him or from the advance directive.
•    Withdrawal of ventilation can only be made when you consider him dying from end stage respiratory failure from MND, even if this has been triggered by a deliberate overdose. This is provided the advance directive confirms his wish not to receive ventilatory support for this indication.
•    Ventilation cannot be withdrawn if he is still in the benzodiazepine overdose stage as this would be assisting suicide which is illegal and also outside the limits of the advance directive.
•    Wife must be reassured that she did the right thing and has not betrayed his trust.
•    Confirm nature of power of attorney – financial or health and discuss these issues with that person.
Any  reasonable approaches to  management were  given  credit  if  adequately supported  in  the candidate’s answer.

Discussion

Broadly, a generic approach to these problems should resemble the following:

  • Establish the utility of therapy. As CICM themselves put it, "there is no obligation to initiate therapy known to be ineffective, nor to continue therapy that has become ineffective".
  • Where possible, manage acute issues. If the patient is acutely unwell and no decision regarding their treatment limitations has been made, then it may be appropriate to rescue them in the acute setting. This might mean going ahead with such burdensome therapies as intubation.
    The argument for this course of action is:
    • To disregard uncertainty regarding prognosis and patient wishes may result in "false positive" situations where potentially beneficial treatments are withheld inappropriately
    • Resuscitation may offer some relief of symptoms (eg. decreased effort of breathing following intubation, and the relief of pain by the associated anaesthesia)
  • Establish medical consensus. Agreement should be sought between the medical teams and the ICU team regarding what is appropriate in the management of the patient. The ethical concepts of beneficience, non-maleficence and autonomy need to be considered.
  • Establish competence. The patient's right to self-determination is not degraded by mental illness or anaesthesia, but their ability to make reasoned judgements about their future certainly is. If the patient is not competent, family members may act as surrogate decisionmakers. 
  • Establish responsibility. Typically the patient themself is responsible for making decisions regarding their health. If the patient is incompetent, one needs to establishing who is the "person responsible". This may be the nominated enduring guardian or "medical power of attorney".
  • Establish broad consensus. There should ideally be an agreement between the medical consensus and the views of the patient and persons responsible. Important features of this process are:
    • Adequate time should be allowed
    • Adequate information (eg. factors taken into account in reaching the medical consensus) should be fully offered
    • Responsibility for decisonmaking does not rest solely with the next-of-kin - this should be abundantly clear
    • Issues should be discussed in the forum of a family conference, with input from a multidisciplinary care team involving nurses and social workers.
  • Document the consensus decision. Important components need to include:
    • Basis for the decision needs to be clearly documented
    • The document should identify those amongst whom the consensus has been reached
    • A completed Advanced Care Directive in writing
    • A plan for escalation of therapy with clearly defined limits
    • A clear plan of symptom control
  • Provide high-quality end of life care. This is characterised by:
    • Adequate pain and symptom management
    • Avoiding the inappropriate prolongation of dying
    • A sense of control over the process
    • Strengthening relationships with loved ones
    • Relieving the burden on loved ones
      (Singer et al, 1999)

References

Myburgh, John, et al. "End-of-life care in the intensive care unit: Report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine.Journal of critical care 34 (2016): 125-130.

Palda, Valerie A., et al. "“Futile” care: Do we provide it? Why? A semistructured, Canada-wide survey of intensive care unit doctors and nurses." Journal of critical care 20.3 (2005): 207-213.

Sibbald, Robert, James Downar, and Laura Hawryluck. "Perceptions of “futile care” among caregivers in intensive care units." Canadian Medical Association Journal 177.10 (2007): 1201-1208.

Danbury, C. M., and C. S. Waldmann. "Ethics and law in the intensive care unit." Best Practice & Research Clinical Anaesthesiology 20.4 (2006): 589-603.

Myburgh, John, et al. "End-of-life care in the intensive care unit: Report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine." Journal of critical care 34 (2016): 125-130.

Schneiderman, Lawrence J. "Defining medical futility and improving medical care." Journal of bioethical inquiry 8.2 (2011): 123.

Ardagh, Michael. "Futility has no utility in resuscitation medicine." Journal of medical ethics 26.5 (2000): 396-399.

Schneiderman, Lawrence J., Kathy Faber-Langendoen, and Nancy S. Jecker. "Beyond futility to an ethic of care." The American journal of medicine 96.2 (1994): 110-114.

Waisel, David B., and Robert D. Truog. "The cardiopulmonary resuscitation-not-indicated order: futility revisited." Annals of internal medicine 122.4 (1995): 304-308.

Corke, Charlie, William Silvester, and Rinaldo Bellomo. "Avoiding nosocomial dysthanasia and promoting eleothanasia." Critical Care and Resuscitation 12.4 (2010): 221.

Dickens, Bernard M., Joseph M. Boyle Jr, and Linda Ganzini. "Euthanasia and assisted suicide." The Cambridge textbook of bioethics (2008): 72.

Singer, Peter A., Douglas K. Martin, and Merrijoy Kelner. "Quality end-of-life care: patients' perspectives." Jama 281.2 (1999): 163-168.

CICM Document IC-14, "ANZICS Statement on withholding and withdrawing treatment"

Question 8 - 2009, Paper 2

A 40 year old male, with no significant past medical history, has a severe head injury following a motor vehicle accident one week previously. It is deemed that he has a non survivable injury, although  he is not brain dead. The wife has raised the possibility of organ donation  post cardiac death (DCD). In your conversation with his wife about donation  after cardiac death, outline the important discussion points about DCD.

College Answer

DCD issues
Details of the process of treatment withdrawal, including the available locations, and ability for the
family to be present until shortly after the time of death.

That organ retrieval needs to begin without delay after death in order to minimise the effect of warm ischaemia. This allows family members very little time with their loved one after death has been declared.

That anxiolytics and analgesics will be given, as necessary, until the moment of death.

That predicting the time from treatment withdrawal to death is difficult. If this interval is greater than the maximum that allows organ retrieval for transplantation, organ donation will not be possible. Tissue donation may still occur if suitable and the family consents.

The organs that may be suitable for transplantation and the effect on this of the time from treatment withdrawal to death.

That if organ donation is not possible, care for the patient will be continued in the ICU or another suitable location. That consenting to donation will usually result in a significant delay in the time that treatment may be withdrawn, due to the complex logistics associated with arranging donation and transplantation. The family must be prepared for and consent to this.

That blood is taken for serology and tissue typing before treatment is withdrawn.

That the family’s permission will be sought for the administration of drugs (e.g. IV heparin)
and procedures (e.g. bronchoscopy) to facilitate organ donation.

That pre-operative assessment or organ removal surgery may reveal medical reasons why donation may not proceed.

That the circumstances of the death may need to be reported to the coroner and a coronial post- mortem examination may occur. This is independent of the donation process.

That families may change their minds and withdraw consent at any time.

Discussion

Consent:

  • Under most Australian and NZ legislations, organ donation can only take place "if the deceased patient had expressed a wish or given consent to donation of issue, which had not been revoked, and had not expressed an objection to donation".
  • Donation should  not proceed if the family disagrees.
  • Consent for organ donation can be withdrawn at any time.
  • Though Australian  state legislation refers to the consent of a "senior available next-of-kin",  any member of the family may raise concerns about organ donation.
  • Though there may not be unanimous support for organ donation within the family, such consensus is required which would represent "agreement as defined by the family".

Inconveniences for the family, for their patience with which we are grateful:

  • Detailed questions about their loved one will be asked by the donation coordinator
  • Many forms will need to be signed by the family
  • The senior next of kin may be approached to give consent to various procedures such as bronchoscopy, angiography etc.
  • Consent for bloods and serologies will be required
  • Testing for hepatitis virus and HIV will take place
  • After the withdrawal, there may be little time for the family to spend with their loved one
  • The organ retrieval process takes time and is an imposition on the grieving time
  • Following organ retrieval, the family may spend time with their loved one, but this may not be in the ICU and may instead take place in the viewing room of the mortuary (or a similar location)

Reassurance of high standards:

  • Patient-centered care with a focus on dignity and respect will be continued throughout the process, irrespective of whether or not donation takes place

Pre-conditions for donation after circulatory death:

  • Treatment withdrawal is in the patient’s best interest, and is agreed upon by the family and all relavant medical staff involved
  • The family agree to organ donation after death is confirmed (or, more rarely, the competent patient may give consent)
  • The decision to withdraw treatment is made independently of the decision to go ahead with organ donation
  • Circulatory death is confirmed

Ongoing treatment which is unhelpful to the patient, but which maintains organ viability:

  • There are certain procedures and techniques which may be required to either maintain organ viability pre-retrieval, or to ascertain their suitability. 
  • These may include such benign procedures as the injection of subcutaneous heparin, or such invasive procedures as bronchoscopy or antemortem insertion of femoral cannulae and injection of 20,000 units of heparin prior to withdrawal.
  • These may go ahead if the patient or family have consented to organ donation and have no objections to these interventions, nor do they contribute to death or compromise the quality of otherwise comfort-directed care.

Conditions during and after treatment withdrawal

  • Location for withdrawal can be variable and is open for negotation
  • Possible locations include ICU, OT or a room close to the OT 
  • "Comfort care" including anxiolytics and analgesics can be administered at any time up until death
  • If the patient does not die wthin the specified timeframe, such "comfort care" will continue (in the ICU or at another suitable location, such as a palliative care unit).
  • It is unethical to make any changes to management which might be seen to hasten the dying process

Possible ineligibility

  • The timing of death is unpredictable
  • If death does not occur within a specific time frame, organ donation may not be possible (but tissue donation may still be possible)
  • Organ removal surgery may reveal medical reasons for organ donation not to proceed
  • The Coroner may decide that a post-mortem examination is necessary (depending on the circumstances of death), which may either limit the range of organs available for donation or preclude the possibility of donation altogether.
 

References

Question 18 - 2010, Paper 2

A  junior   trainee   in  distress   has  asked to speak to you regarding a medical error  she  has  committed   that  has  resulted  in  a  life-threatening   adverse outcome for the patient.

Outline the key points of the initial discussion with the trainee.

College Answer

The key points that the candidate needs to cover are:

1.  Facilitating the initial critical incident debrief of the Registrar and allowing him/her to vent and tell his/her version of events

2.  Ensuring there is ongoing psychological and emotional support for the Registrar
a.   Give him/her the option of standing down for the rest of the shift or providing support if he/she chooses to stay
b.   Arranging a mentor within the department (eg SOT)
c.   Ensuring there is back-up from friends/family at home d.   Offering professional counselling

3.  Providing advice on the medico-legal process that will ensue a.   Open disclosure with family
b.   Need for comprehensive and accurate documentation in records and factual account for registrar’s own records
c.   Early contact with medical defence organisation and hospital medico-legal advisors
d.   Reporting to coroner if/when the patient dies
e.   The event will be the subject of a Root Cause Analysis by the hospital

4.  Counselling with regards to future career and training

5.  Arrange follow-up meeting with mentor and departmental head for next day

Discussion

  • Ensure the critical incident is being managed appropriately from a medical standpoint
    • Commit staff to ensure the patient is safe 
    • Ensure appropriate steps are being taken to ameliorate the risk from the critical incident (for example, if this is a line that has been accidentally inserted into a carotid artery causing a stoke - ensure that the vascular surgical team, neurology team and neurosurgerical team have been consulted and have offered their opinions).
    • Delegate clinical duties so as to focus yourself on the debriefing session
  • Critical incident debrief (management of the traumatised trainee)
    • The debrief should happen before the affected person has had time to sleep.
    • Introduce the process
    • Describe the event, using whatever factual information is available
    • Allow the trainee (or whatever participants) to describe their cognitive and emotional reactions to the event
    • Help the trainee identify the most traumatic aspect of the event for them
    • Help the trainee identify personal symptoms of distress and explore their emotional reaction to the event, assuring them that their reactions are normal.
    • Educate the trainee regarding normal reactions and adaptive coping mechanisms, helping them find a "cognitive anchor". Adaptive reaction suggestions may include advice on rest, talking to one's friends and family, working with supervisors to initiate procedural changes, dealing with stress through exercise and reflection, etc. This helps the trainee transition back to a cognitive level domain, away from the emotional content of the experience.
    • Clarify any ambiguities and arrange a follow-up discussion, to ensure that this debrief does not seem like a stand-alone measure but rather a part of a continuum. In a group session, this phase would end with final statemwents from the participants.
  • Other management of the staff involved:
    • Organise time off work for the trainee, if appropriate
    • Involve an impartial mentor
    • Ensure that there are support people available from the extraclinical environment (friends, family)
    • Make an offer of professional counselling
    • Give advice regarding open disclosure process and medicolegal risk
  • Management of the affected patient and family
  • Management of the organisation
    • Factual and detailed documentation
    • Inform the clinical governance administrators
    • Inform the hospital medicolegal team
    • Inform the director of the department
    • Inform own medicolegal indemnity and defence organisation - as you were supposed to be supervising that trainee, and may even be responsible for the training program locally (if you happen to be the SOT).

References

International Critical Incident Stress Foundation

CICM: GUIDELINES FOR ASSISTING TRAINEES WITH DIFFICULTIES (T-13), 2010

Mitchell, Jeffrey T. "Stress. The history, status and future of critical incident stress debriefings." JEMS: a journal of emergency medical services 13.11 (1988): 46-7.

Mitchell, Jeffrey T., and George S. Everly Jr. "Critical Incident Stress Debriefing (CISD) and the Prevention of Work-Related Traumatic Stress among High Risk occupational Groups.Psychotraumatology: Key papers and core concepts in post-traumatic stress (1994): 267.

Bledsoe, Bryan E. "C RITICAL I NCIDENT S TRESS M ANAGEMENT (CISM): B ENEFIT OR R ISK FOR E MERGENCY S ERVICES?."Prehospital Emergency Care 7.2 (2003): 272-279.

Harris, Morag B., Mustafa Baloğlu, and James R. Stacks. "Mental health of trauma-exposed firefighters and critical incident stress debriefing.Journal of Loss &Trauma 7.3 (2002): 223-238.

Laurent, Alexandra, et al. "Error in intensive care: psychological repercussions and defense mechanisms among health professionals." Critical care medicine 42.11 (2014): 2370-2378.

Question 28 - 2014, paper 2

You arrive at work one morning to learn that, overnight, the on-call junior trainee committed a medical error that has resulted in a life-threatening adverse outcome for the patient. The trainee has been waiting for your arrival to talk to you.

Outline the key points of this discussion with the trainee.

College Answer

Facilitation of an emotional debrief not an operational debrief
Allow the trainee to vent and tell his/her version of events
Remain neutral and avoid criticism/censorship of the trainee’s actions

Ensure there is on-going psychological and emotional support for the trainee
Give him/her the option of time off work or ensure support if he/she chooses to stay
Arrange an appropriate mentor within the department who is not otherwise involved in this incident (may be self or other senior colleague)

Ensure there is back-up from friends/family at home
Offer professional counselling

Advice on:
Open disclosure with patient’s next-of-kin
The medico-legal process that will ensue
Need for comprehensive and accurate documentation in records and factual account for
registrar’s own records
Early contact with medical defence organisation and hospital medico-legal advisors
Need for reporting to coroner if/when the patient dies
Root Cause Analysis of the event by the hospital

Counselling with regards to future career and training

Plan follow-up meeting with mentor and SOT/departmental head for next day

Discussion

This question is identical to Question 18 from the second paper of 2010.
That answer is reproduced below:

  • Ensure the critical incident is being managed appropriately from a medical standpoint
    • Commit staff to ensure the patient is safe 
    • Ensure appropriate steps are being taken to ameliorate the risk from the critical incident (for example, if this is a line that has been accidentally inserted into a carotid artery causing a stoke - ensure that the vascular surgical team, neurology team and neurosurgerical team have been consulted and have offered their opinions).
    • Delegate clinical duties so as to focus yourself on the debriefing session
  • Critical incident debrief (management of the traumatised trainee)
    • The debrief should happen before the affected person has had time to sleep.
    • Introduce the process
    • Describe the event, using whatever factual information is available
    • Allow the trainee (or whatever participants) to describe their cognitive and emotional reactions to the event
    • Help the trainee identify the most traumatic aspect of the event for them
    • Help the trainee identify personal symptoms of distress and explore their emotional reaction to the event, assuring them that their reactions are normal.
    • Educate the trainee regarding normal reactions and adaptive coping mechanisms, helping them find a "cognitive anchor". Adaptive reaction suggestions may include advice on rest, talking to one's friends and family, working with supervisors to initiate procedural changes, dealing with stress through exercise and reflection, etc. This helps the trainee transition back to a cognitive level domain, away from the emotional content of the experience.
    • Clarify any ambiguities and arrange a follow-up discussion, to ensure that this debrief does not seem like a stand-alone measure but rather a part of a continuum. In a group session, this phase would end with final statemwents from the participants.
  • Other management of the staff involved:
    • Organise time off work for the trainee, if appropriate
    • Involve an impartial mentor
    • Ensure that there are support people available from the extraclinical environment (friends, family)
    • Make an offer of professional counselling
    • Give advice regarding open disclosure process and medicolegal risk
  • Management of the affected patient and family
  • Management of the organisation
    • Factual and detailed documentation
    • Inform the clinical governance administrators
    • Inform the hospital medicolegal team
    • Inform the director of the department
    • Inform own medicolegal indemnity and defence organisation - as you were supposed to be supervising that trainee, and may even be responsible for the training program locally (if you happen to be the SOT).

References

International Critical Incident Stress Foundation

CICM: GUIDELINES FOR ASSISTING TRAINEES WITH DIFFICULTIES (T-13), 2010

Mitchell, Jeffrey T. "Stress. The history, status and future of critical incident stress debriefings." JEMS: a journal of emergency medical services 13.11 (1988): 46-7.

Mitchell, Jeffrey T., and George S. Everly Jr. "Critical Incident Stress Debriefing (CISD) and the Prevention of Work-Related Traumatic Stress among High Risk occupational Groups.Psychotraumatology: Key papers and core concepts in post-traumatic stress (1994): 267.

Bledsoe, Bryan E. "C RITICAL I NCIDENT S TRESS M ANAGEMENT (CISM): B ENEFIT OR R ISK FOR E MERGENCY S ERVICES?."Prehospital Emergency Care 7.2 (2003): 272-279.

Harris, Morag B., Mustafa Baloğlu, and James R. Stacks. "Mental health of trauma-exposed firefighters and critical incident stress debriefing.Journal of Loss &Trauma 7.3 (2002): 223-238.

Laurent, Alexandra, et al. "Error in intensive care: psychological repercussions and defense mechanisms among health professionals." Critical care medicine 42.11 (2014): 2370-2378.

Question 5 - 2015, Paper 2

a)    Define “Open Disclosure” in the healthcare setting.    (10% marks)

b)    Outline the general steps involved in Open Disclosure?    (50% marks)

c)    Discuss the importance of Open Disclosure.    (40% marks)

College Answer

a)

Open Disclosure is the process of communicating with a patient and/or their support person(s) about a patient-related incident or harm caused during the process of healthcare.

b)

Acknowledge the incident and its impact Explain the known clinical facts

Apologise for what has occurred
Reassure and agree on a plan for ongoing care

Investigate the incident to learn what has happened. Feedback to patient and staff
Document by incident reporting tool and in the patient’s medical record

c)

Actively and openly managing such incidents, including through the exchange of timely and appropriate information, is important for:

The recovery process of patients and next-of-kin

Clinicians to manage their involvement in, and recovery from, adverse events Health service organisations to learn from errors.

Practising open disclosure can assist health service organisations develop a reporting culture as it supports clinicians managing unintended patient harm.

Effective and timely communication, transparency and establishing a rapport with the patient and/or family along with an apology when incidents occur might mitigate potential legal action.

Additional Examiners’ Comments:

Candidates who did not pass this question did not demonstrate an understanding of Open Disclosure with failure to offer an apology an important omission.

Discussion

a) Definition of open disclosure:

  • The CEC defines open disclosure as " a process for ensuring that open, honest, empathic and timely discussions occur between patients and/or their support person(s) and health care staff following a patient safety incident". This wording is slightly different from the college answer. As far as the great oracle of Google is concerned, the exact phrasing of the college answer appears to be unique and is not plagiarised from anywhere. 
  • Essential elements  of open disclosure are:
    • An apology (the college were particularly insistent we include this in our answers and CEC views it as an "essential element")
    • A factual explanation of what happened.
    • An opportunity for the patient to relate his or her experience.
    • A discussion of the potential consequences.
    • An explanation of the steps being taken to manage the event and prevent recurrence.

b) Steps of open disclosure:

  • Clinician disclosure: an  informal process which is conducted by a senior clinician and which takes place as soon as possible (ideally, within 24 hours) of the event. The NSW CES recommends we use the "STARS" tool, developed by the Patient Safety Unit at Queensland Health.  
    • Sorry: Acknowledge what happened, apologise for it, acknowledge the impact of the incident
    • Tell me about it: ask about the experience of those involved
    • Answer questions from those involved
    • Respond: discuss the plan for what will be done to ameliorate harm
    • Summarise: conclude the discussion with a summary of events, and plan future discussions.
  • Formal open disclosure: a structured process, involving a multidisciplinary team and a senior administrator trained in formal open disclosure. This thing has many stages:
    • Preparation:
      • Notification of all relevant staff, eg. Director of Clinical Governance, senior managers, etc
      • Initiation of the process is documented
      • Notification of the managers responsible for insurable risk
      • Appointment of a coordinator for the process
      • Appointment of an open disclosure advisor
      • Appointment of a person who will lead the discussion
      • Arrangement of a formal discussion
      • Meeting of the open disclosure team to prepare their approach
    • Formal discussion:
      • Introduce all attendees
      • Acknowledge the patient safety incident
      • Offer a sincere apology 
      • Explain the formal open disclosure process
      • Opportunity for the patient/family to recount their experience
      • Appropriate empathetic response and explanation of events
      • Provide the findings of any review or investigation 
      • Discuss and agree on a plan for care
      • Arrange follow up discussions
    • Follow-up with clinical team:
      • Meet the clinical team involved after the formal discussion
      • Outline the points discussed and the outcomes
      • Provide an opportunity for clinicians to debrief
    • Completion:
      • The patient or their representative may indicate that they are satisfied that open disclosure is complete
      • Otherwise, various complaints processes may be followed (eg. HCCC)
      • A final investigation report should be completed
      • Lessons learned from the safety incident need to be communicated widely
      • System improvesments should be implemented by the clinical governance administrators

c) Importance of open disclosure: This again comes straight from the CEC  Open Disclosure Handbook, specifically from page 18 ("Why does open disclosure matter?")

  • Importance for patients:
    • A meaningful apology
    • An explanation when things go wrong
    • An acknowledgement of their concerns and distress
      A reassurance that the organisation will learn lessons to prevent harm happening to someone else
    • A reduction of the trauma experienced (hopefully)
    • An opportunity to ask questions and to have those questions answered
    • An increased respect for and trust in the organisation
    • A reassurance that they will continue to be treated according to their clinical needs
  • Importance for clinicians:
    • Improved confidence in effective communication when things go wrong
    • Support in making ab apology 
    • Satisfaction in an appropriate and formalised communication process
    • An improved understanding of incidents from the perspective of the patient and/or their support person(s)
    • An improved relationship with the patient and/or their support person(s) through demonstrating integrity
    • Developing a good reputation for managing a difficult situation well
  • Importance for organisations:
    • Development of a reputation of respect and trust for the organisation and/or team
    • A culture of openness and safety is reinforced
    • The costs of litigation are potentially reduced
    • The patient experience and satisfaction with the organisation are improved
    • Development of a reputation for supporting staff when things go wrong
    • Improvement of internal processes which prevent future events

References

The CEC  Open Disclosure Handbook

Australian Commission on Safety and Quality in Health Care (ACSQHC) Australian Open Disclosure Framework, Sydney, 2013

Disclosure Working Group. Canadian disclosure guidelines: being open with patients and families. Canadian Patient Safety Institute, 2011.

Question 26 - 2017, Paper 1

A 65-year-old male with a severe hypoxic brain injury following an out of hospital cardiac arrest has been   in your ICU for eight days. The only evidence of neurological activity is that he takes an occasionalbreath whilst on the ventilator. The decision has been made to withdraw treatment on the grounds of futility. You consider him to be a candidate for donation after cardiac death (DCD).

The family has indicated that they support a previously expressed desire by the patient to donate his organs should such a situation arise.

Outline  the  points  that  should  be   discussed  with  the  family  concerning  the  process  of  DCD.

College answer

NB: Different states have different legislation and practices.

• Treatment withdrawal in patient’s best interest
• Discuss the process of treatment withdrawal including the location where treatment 
withdrawal will occur (ICU, OT or a room next to the OT etc.) as well as the family’s ability 
to be present until shortly after death
• Organ retrieval will need to occur very shortly after death thus limiting the time that the 
family can spend with their loved one after death has occurred
• Any medications including anxiolytics and analgesics can be administered at any time up 
until death to ensure patient comfort
• Predicting the time of death is very difficult, and, if it does not occur in a time frame, it may 
preclude organ donation but tissue donation is still a possibility
• The organs that can be donated will also be dependent on the time from withdrawal of 
treatment to death
• If organ donation is not possible because death has not occurred within the time frame, 
then the care of the patient will be continued either within the ICU or another suitable 
location
• Family consent will need to be gained for bloods to be taken for tissue typing and serology 
as well as for any procedures that need to be done to assess organ suitability, e.g.
bronchoscopy, femoral catheters
• Organ removal surgery may reveal medical reasons for organ donation not to proceed
• Depending on the circumstances surrounding the cardiac arrest, there may be a need to 
refer the case to the Coroner who may decide on a post-mortem examination
• The family has the right to withdraw consent at any time

Discussion

Consent:

  • Under most Australian and NZ legislations, organ donation can only take place "if the deceased patient had expressed a wish or given consent to donation of issue, which had not been revoked, and had not expressed an objection to donation".
  • Donation should  not proceed if the family disagrees.
  • Consent for organ donation can be withdrawn at any time.
  • Though Australian  state legislation refers to the consent of a "senior available next-of-kin",  any member of the family may raise concerns about organ donation.
  • Though there may not be unanimous support for organ donation within the family, such consensus is required which would represent "agreement as defined by the family".

Inconveniences for the family, for their patience with which we are grateful:

  • Detailed questions about their loved one will be asked by the donation coordinator
  • Many forms will need to be signed by the family
  • The senior next of kin may be approached to give consent to various procedures such as bronchoscopy, angiography etc.
  • Consent for bloods and serologies will be required
  • Testing for hepatitis virus and HIV will take place
  • After the withdrawal, there may be little time for the family to spend with their loved one
  • The organ retrieval process takes time and is an imposition on the grieving time
  • Following organ retrieval, the family may spend time with their loved one, but this may not be in the ICU and may instead take place in the viewing room of the mortuary (or a similar location)

Reassurance of high standards:

  • Patient-centered care with a focus on dignity and respect will be continued throughout the process, irrespective of whether or not donation takes place

Pre-conditions for donation after circulatory death:

  • Treatment withdrawal is in the patient’s best interest, and is agreed upon by the family and all relavant medical staff involved
  • The family agree to organ donation after death is confirmed (or, more rarely, the competent patient may give consent)
  • The decision to withdraw treatment is made independently of the decision to go ahead with organ donation
  • Circulatory death is confirmed

Ongoing treatment which is unhelpful to the patient, but which maintains organ viability:

  • There are certain procedures and techniques which may be required to either maintain organ viability pre-retrieval, or to ascertain their suitability. 
  • These may include such benign procedures as the injection of subcutaneous heparin, or such invasive procedures as bronchoscopy or antemortem insertion of femoral cannulae and injection of 20,000 units of heparin prior to withdrawal.
  • These may go ahead if the patient or family have consented to organ donation and have no objections to these interventions, nor do they contribute to death or compromise the quality of otherwise comfort-directed care.

Conditions during and after treatment withdrawal

  • Location for withdrawal can be variable and is open for negotation
  • Possible locations include ICU, OT or a room close to the OT 
  • "Comfort care" including anxiolytics and analgesics can be administered at any time up until death
  • If the patient does not die wthin the specified timeframe, such "comfort care" will continue (in the ICU or at another suitable location, such as a palliative care unit).
  • It is unethical to make any changes to management which might be seen to hasten the dying process

Possible ineligibility

  • The timing of death is unpredictable
  • If death does not occur within a specific time frame, organ donation may not be possible (but tissue donation may still be possible)
  • Organ removal surgery may reveal medical reasons for organ donation not to proceed
  • The Coroner may decide that a post-mortem examination is necessary (depending on the circumstances of death), which may either limit the range of organs available for donation or preclude the possibility of donation altogether.

References

Question 29 - 2018, Paper 2

a)    Define “Open Disclosure” in the healthcare setting.                       (10% marks) 
 
b)    Outline the general steps involved in “Open Disclosure”.                (50% marks) 
 
c)    Discuss the importance of “Open Disclosure”.                      (40% marks) 
 

College answer

a) 
Open Disclosure is the process of communicating with a patient and/or their support person(s) about a patient-related incident or harm caused during the process of healthcare. 
 
b) 
•    Acknowledge the incident and its impact  
•    Explain the known clinical facts  
•    Apologise for what has occurred  
•    Provide support to staff  patient and families including avenues of complaint/patients’ rights 
•    Reassure and agree on a plan for ongoing care  •     Investigate the incident to learn what has happened.  
•    Feedback to patient and staff and families 
•    Document by incident reporting tool and in the patient’s medical record  
 
c) 
Actively and openly managing such incidents, including through the exchange of timely and appropriate information, is important for: 
•    The recovery process of patients and next-of-kin 
• Clinicians to manage their involvement in, and recovery from, adverse events  
• Health service organisations to learn from errors. 
Practising open disclosure can assist health service organisations develop a reporting culture as it supports clinicians managing unintended patient harm.  
Effective and timely communication, transparency and establishing a rapport with the patient and/or family along with an apology when incidents occur might mitigate potential legal action. 
 

Discussion

This question is identical to Question 5 from the second paper of 2015, with the exception of the fact that some sub-editor removed the awkward question mark from the end of question b).

a) Definition of open disclosure:

  • The CEC defines open disclosure as " a process for ensuring that open, honest, empathic and timely discussions occur between patients and/or their support person(s) and health care staff following a patient safety incident". This wording is slightly different from the college answer. As far as the great oracle of Google is concerned, the exact phrasing of the college answer appears to be unique and is not plagiarised from anywhere. 
  • Essential elements  of open disclosure are:
    • An apology (the college were particularly insistent we include this in our answers and CEC views it as an "essential element")
    • A factual explanation of what happened.
    • An opportunity for the patient to relate his or her experience.
    • A discussion of the potential consequences.
    • An explanation of the steps being taken to manage the event and prevent recurrence.

b) Steps of open disclosure:

  • Clinician disclosure: an  informal process which is conducted by a senior clinician and which takes place as soon as possible (ideally, within 24 hours) of the event. The NSW CES recommends we use the "STARS" tool, developed by the Patient Safety Unit at Queensland Health.  
    • Sorry: Acknowledge what happened, apologise for it, acknowledge the impact of the incident
    • Tell me about it: ask about the experience of those involved
    • Answer questions from those involved
    • Respond: discuss the plan for what will be done to ameliorate harm
    • Summarise: conclude the discussion with a summary of events, and plan future discussions.
  • Formal open disclosure: a structured process, involving a multidisciplinary team and a senior administrator trained in formal open disclosure. This thing has many stages:
    • Preparation:
      • Notification of all relevant staff, eg. Director of Clinical Governance, senior managers, etc
      • Initiation of the process is documented
      • Notification of the managers responsible for insurable risk
      • Appointment of a coordinator for the process
      • Appointment of an open disclosure advisor
      • Appointment of a person who will lead the discussion
      • Arrangement of a formal discussion
      • Meeting of the open disclosure team to prepare their approach
    • Formal discussion:
      • Introduce all attendees
      • Acknowledge the patient safety incident
      • Offer a sincere apology 
      • Explain the formal open disclosure process
      • Opportunity for the patient/family to recount their experience
      • Appropriate empathetic response and explanation of events
      • Provide the findings of any review or investigation 
      • Discuss and agree on a plan for care
      • Arrange follow up discussions
    • Follow-up with clinical team:
      • Meet the clinical team involved after the formal discussion
      • Outline the points discussed and the outcomes
      • Provide an opportunity for clinicians to debrief
    • Completion:
      • The patient or their representative may indicate that they are satisfied that open disclosure is complete
      • Otherwise, various complaints processes may be followed (eg. HCCC)
      • A final investigation report should be completed
      • Lessons learned from the safety incident need to be communicated widely
      • System improvesments should be implemented by the clinical governance administrators

c) Importance of open disclosure: This again comes straight from the CEC  Open Disclosure Handbook, specifically from page 18 ("Why does open disclosure matter?")

  • Importance for patients:
    • A meaningful apology
    • An explanation when things go wrong
    • An acknowledgement of their concerns and distress
      A reassurance that the organisation will learn lessons to prevent harm happening to someone else
    • A reduction of the trauma experienced (hopefully)
    • An opportunity to ask questions and to have those questions answered
    • An increased respect for and trust in the organisation
    • A reassurance that they will continue to be treated according to their clinical needs
  • Importance for clinicians:
    • Improved confidence in effective communication when things go wrong
    • Support in making ab apology 
    • Satisfaction in an appropriate and formalised communication process
    • An improved understanding of incidents from the perspective of the patient and/or their support person(s)
    • An improved relationship with the patient and/or their support person(s) through demonstrating integrity
    • Developing a good reputation for managing a difficult situation well
  • Importance for organisations:
    • Development of a reputation of respect and trust for the organisation and/or team
    • A culture of openness and safety is reinforced
    • The costs of litigation are potentially reduced
    • The patient experience and satisfaction with the organisation are improved
    • Development of a reputation for supporting staff when things go wrong
    • Improvement of internal processes which prevent future events

References