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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 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 (thank you, readers, for continuing to update me with new versions of this thing as they come out)

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

Question 29 - 2020, Paper 2

You are the appointed welfare advocate for your unit. 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

Not available.

Discussion

This is a question basically identical to Question 28 from the second paper of 2014 and the Question 18 from the second paper of 2010, except this time you're the "the appointed welfare advocate".

  • The debrief should happen before the affected person has had time to sleep.
  • "Psychological first aid" is the framework that describes the approach to these situations, as what the trainee has experienced is a form of trauma, and 
    • Promote safety and calm:
      • Take the trainee out of the ICU and into a quiet nonclinical area to have this discussion; delegate their clinical responsibilities as well as your own
      • Introduce the process
      • Describe the event, using whatever factual information is available
    • Listen non-judgmentally
      • give the trainee time to discuss their experience and their narrative of what happened (non-judgmental, no interruptions)
      • 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.
    • Answer questions and offer advice:
      • ​​​​​​​Give advice regarding open disclosure process and medicolegal risk
      • Discuss the need to refer to the coroner (if relevant)
      • 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.
    • Promote connectedness:
      • Organise time off work for the trainee, if appropriate
      • Ensure that there are support people available from the extraclinical environment (friends, family)
      • Make an offer of professional counselling
      • Offer to involve an impartial mentor
    • Promote self-efficacy:
      • Discuss with the trainee the need for them to inform their own medicolegal indemnity and defence organisation 
      • Discuss whether the trainee would like to take part in any discussion with the patient or their family
      • Describe good practice for documentation and offer to help the trainee construct a  factual account for their own records

References

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 24 - 2022, Paper 2

Regarding the provision of palliative care to ICU patients, outline the advantages and disadvantages of using:
a) A traditional Intensive care consultant - based approach (integrative palliative care).
(50% marks)
b) Palliative care specialty involvement in the ICU by specific consultation (consultative palliative care). (50% marks)

College answer

Generally answered well by outlining the limitations of an ICM physician, especially time pressure, care of other critically ill patients and transition of care to the ward. There were multiple references to ICM physicians considering palliation as failure of ICU therapy or having "guilt" which impacts provision of palliative care. Virtually all candidates discussed specific clinical aspects, whereas other aspects such as resources, staffing, and model comparisons, were not addressed.

Discussion

This answer would work better as a table. The use of the terms "integrative" and "consultative" is not unique but suggests that specific (largely North American) resources were used by the examiners to create this question.

Advantages Disadvantages
"Integrative" intensivist-led palliative care
  • Family will already have rapport with the intensivist
  • Uniquely ICU-related aspects of ICU patient end-of-life symptoms would be better managed by ICU staff (eg. post-extubation stridor)
  • ICU staff may derive satisfaction from being able to provide "a good death"
  • Some may consider end-of-life care as an integral part of good ICU care
  • Skill mix of ICU staff and palliative medicine staff is sufficiently overlapping (especially in terms of communication skills)
  • Impact on ICU clinician may be significant (psychological and emotional burden)
  • ICU environment is a poor environment for restful endo of life care and patient/family privacy
  • Rapport may be interrupted by constantly rotating ICU staff
  • Busy intensivists may not have the necessary time or attention to dedicate to monitoring for symptoms and attending to family questions
"Consultative" palliative medicine referral
  • Specialist care with focused attention to symptoms (and perhaps better able to recognise subtle signs of distress)
  • Skill mix of nursing and medical staff is optimised for end of life care
  • Transition to ward-based palliative care is smoother, with less information loss during handover
  • Resources are optimally distributed (cost of a palliative medicine bed is much lower than that of an ICU bed)
  • The palliative medicine team should not have many other priorities other than symptom control, i.e. not distracted by other demands
  • Intensive care staff may experience dissatisfaction with the loss of agency over the management decisions
  • Interruption of rapport which has been developed between ICU staff and the family
  • The perception of "failure" can develop in the intensive care team, as the result of the perceived inability to meet the palliative care needs of the dying patient
  • The perception of abandonment by the family can develop as the result of the intensivist disenaging and handing over care
  • No evidence for benefit in a closed model. All the evidence for benefit comes from studies based on "open model" ICUs

References

Hill, Stephanie A., et al. "Palliative medicine in the intensive care unit: needs, delivery, quality." BMJ Supportive & Palliative Care 12.1 (2022): 38-41.

Einav, Sharon, Nathan I. Cherny, and J. Randall Curtis. "Palliative medicine in the intensive care unit." Oxford Textbook of Palliative Medicine (2021): 121.

Kościuczuk, Urszula, et al. "Aspects of palliative medicine in intensive care units: A narrative review." Palliative Medicine in Practice (2022).

Stamper, Tara Orgon, Renee Kerr, and Daniela Sporter. "The Evolution of Palliative Medicine in Intensive Care." Critical Care Nursing Quarterly 45.4 (2022): 332-338.

Tomko, Caitlin, et al. "The Practical Implementation of an Embedded Palliative Care Team in a Medical Intensive Care Unit (QI435)." Journal of Pain and Symptom Management 63.5 (2022): 904.

Bhan, Swati, et al. "Palliative Care in Intensive Care Unit." Onco-critical Care: An Evidence-based Approach. Singapore: Springer Nature Singapore, 2022. 515-524.

Ito, Kaori, et al. "Primary palliative care recommendations for critical care clinicians." Journal of Intensive Care 10.1 (2022): 20.

Effendy, Christantie, et al. "Barriers and facilitators in the provision of palliative care in adult intensive care units: a scoping review." Acute and Critical Care 37.4 (2022): 516-526.

Martins, Belmira DCPCC, Reinaldo A. Oliveira, and Antonio JM Cataneo. "Palliative care for terminally ill patients in the intensive care unit: Systematic review and metaanalysis." Palliative & Supportive Care 15.3 (2017): 376-383.

Carson, Shannon S., et al. "Effect of palliative care–led meetings for families of patients with chronic critical illness: a randomized clinical trial." Jama 316.1 (2016): 51-62.

Strand, Jacob J., and J. Andrew Billings. "Integrating palliative care in the intensive care unit." The journal of supportive oncology 10.5 (2012): 180-187.

Trankle, Steven A. "Is a good death possible in Australian critical and acute settings?: physician experiences with end-of-life care." BMC palliative care 13.1 (2014): 1-14.

Question 3 - 2024, Paper 2

You are the Intensivist working at a regional hospital. A 45-year-old patient has presented with a head injury following an assault. The GCS is 7/15 (E2 V2 M3) and a CT scan shows an acute subdural haematoma. The retrieval team will arrive in 4 hours to transport the patient to a neurosurgical centre.


a) Outline your management of the patient until the retrieval team arrives. (6 marks)

b) Outline the principles of a safe and effective clinical handover of this patient to the retrieval team. (4 marks)

College answer

Syllabus topic/section:

2.2.1 Communication and collaboration in ICU: Handover and referrals


Discussion: 

Most candidates did reasonably on part a), but many were let down by part b). Some candidates did better in part b), but very few candidates performed well in both sections of this question. Candidates that scored less well in part a) simply listed targets without any detail or rationale for those chosen, or they over focused on a single aspect eg how to intubate. Good answers had structure (usually by system) and included specific management aspects and targets that related back to ICP control. Good answers also included an awareness of the regional location and the limitations this posed on ICP monitoring. Several candidates did not mention broader trauma issues like C spine management as part of their answer. Candidates that scored less well in part b) tended to limit the answer to repetition of the management outlined in part a) for the handover, but didn’t include the location, personnel or non-technical features required for a safe handover. Answers that scored higher marks in part b) included communication for safety (the accurate and careful exchange of information between clinicians) and used a formalised or non-formalised structure to aid this (for example ISBAR, MIST or AMPLE).

Discussion

It is telling that the examiners had chosen to label this SAQ with the "handover and referrals" syllabus item. Consider: six marks are in brain injury, but this generic question on neuroprotective strategies cannot possibly be a good discriminator, as everyone should be able to answer it with enough content to achieve near-100% pass marks at this stage in their training. 

a) Management of the patient is basically a reiteration of the BTF guidelines (mostly the prehospital sections), and consists of:

A - intubate the patient

- if impossible (i.e. nobody there knows how), introduce an airway device and await a skilled operator

B - maintain SpO2 > 90% and PaCO2

C - maintain normotension, but if there are features of raised ICP, aim for a higher MAP (80 or 90)

- Avoid cerebral venous hypertension; care not to tighten ETT tapes and ties

- loosen C-spine collar and sandbag the neck and head while awaiting a formal CT report for the neck

- Elevate head of bed 30-45o

D - sedation and analgesia to prevent ICP rises

- serial reexamination of pupils to detect herniation

- if ICP increase is suspected, give mannitol or hypertonic saline as rescue therapy

- detect and treat seizures

E - avoid causing hyponatremia or hyperglycaemia; rewarm the patient to normothermia

F - avoid albumin infusion

demand

b) Principles of a safe and effective clinical handover:

The best way to answer this would probably be to borrow from something like "Communicating for Safety". Note that the SAQ has specifically asked for the "principles", not "the specific information you think might be relevant to ask for". The principles of handover are:

  • Leadership: there needs to be a nominated handover facilitator to lead the process
  • Handover participants: members of the multidisciplinary team
  • Handover time: all agree on the timing
    • Must remain interruption free
    • If an emergency is taking place, prioritise stability;
    • once the emergency is resolved, a "hands off" handover is recommended so nobody is distracted
  • Handover place -  bedside, vs. "paper round" huddle, or even remote tele-handover
  • Handover process where the details are exchanged in some structured format. eg. ISBAR:
    • Identification of the teams
    • Situation
    • Background
    • Assessment details
    • Recommended course of action
  • Documentation of the receiving team / delivering team and that the receivers have taken over care

References

Australian Medical Association. "Safe handover-safe patients: guidance on clinical handover for clinicians and managers: AMA 2006." 2016,

Bywaters, E., et al. "Safe handover: safe patients." (2004).

Bomba, David T., and Robert Prakash. "A description of handover processes in an Australian public hospital." Australian health review 29.1 (2005): 68-79.

Garling, Peter Richard. "Final report of the special commission of inquiry into acute care services in NSW public hospitals." (2009).

Gordon, Morris, et al. "Educational interventions to improve handover in health care: an updated systematic review." Academic Medicine 93.8 (2018): 1234-1244.

Sonntag, Oswald, et al. Effective communication in clinical handover: From research to practice. Vol. 15. Walter de Gruyter GmbH & Co KG, 2016.

Slade, Diana, et al. "Effective communication in clinical handover: challenges and risks." Effective communication in clinical handover: From research to practice (2016): 1-17.

Miller, C. "Ensuring continuing care: styles and efficiency of the handover process." The Australian journal of advanced nursing: a quarterly publication of the Royal Australian Nursing Federation 16.1 (1998): 23-27.

Question 28 - 2025, Paper 1

With regard to long term, conscious intensive care patients who have a tracheostomy:

a)    Discuss the consequences of inadequate communication between staff and these patients (4 marks)

b)    Outline techniques to improve communication in these patients (6 marks)


 
 


 

College comments

Syllabus topic/section: 2.2.1 Communication and collaboration in Intensive Care: Topic - Communication with patients as part of care in the ICU.

Discussion: 

This is an essential topic. Good candidates could demonstrate the ability to have an in-depth discussion of consequences of long-term ICU care including relevant aspects of patient centred care, issues with decision making, dealing with negative emotions, sentinel events/adverse events and quality of life, as related to communication.

Specific strategies to improve marks could include a comprehensive outline of both nonverbal (e.g., writing, mouthing, gestures, switches and many more) and verbal methods of communication, with an emphasis on verbal techniques specific to patients with a tracheostomy (cuff inflated, ventilated; cuff deflated, not ventilated).

Interpretation

  • Consequences of ineffective communicaton with invasively ventilated patients:
    • Patient effects: Depression, anxiety, frustration, poor understanding of their care, poor cooperation, loneliness, and disengagement
    • Staff psychological effects: Frustration with the process of communication, leading to avoidance and the reliance on sedation, decreased satisfaction with their work, and burnout
    • Effect on care: unmet patient needs, unrecognised distress, missed symptoms, increased sedation
  • Methods of two-way communication with invasively ventilated patients:
    • Gesture
      • clickers, buzzers, lights, bells (to get attention)
      • eye tracking apps, joystick or console controllers, foot pedals
    • Written
      • ​​​​​​​Communication boards with words, letters or symbols
      • Writing implements, ranging from pen and paper to whiteboards
      • Electronic methods (iPad, mouse/keyboard, eye tracking apps)
  • Additional methods afforded by the presence of a tracheostomy:
    • Nonvocal​​​: ​​​​​​​Mouthing words, tongue clicks
    • Vocal: speech permitted by various methods:
      • ​​​​​​​"Leak speech" using PEEP
      • Above the cuff gas flow
      • Cuff down, with or without speaking valve

References

Morris, Linda L., et al. "Restoring speech to tracheostomy patients." Critical care nurse 35.6 (2015): 13-28.

Hess, Dean R. "Facilitating speech in the patient with a tracheostomy." Respiratory Care 50.4 (2005): 519-525.

Zaga, Charissa J., et al. "A multidisciplinary approach to verbal communication interventions for mechanically ventilated adults with a tracheostomy." Respiratory care 68.5 (2023): 680-691.

IJssennagger, C. E., et al. "Caregivers' perceptions towards communication with mechanically ventilated patients: the results of a multicenter survey." Journal of Critical Care 48 (2018): 263-268.

Fowler, Susan B. "Impaired verbal communication during short‐term oral intubation." International Journal of Nursing Terminologies and Classifications 8.3 (1997): 93-98.

Khalaila, Rabia, et al. "Communication difficulties and psychoemotional distress in patients receiving mechanical ventilation." American journal of critical care 20.6 (2011): 470-479.

Question 6 - 2025, Paper 2

a. Discuss the considerations involved in the decision to discharge patients directly home from the ICU (6 marks)

b. Outline the reasons why two different ICUs might have different rates of direct home discharge from ICU (4 marks)

Discussion

Syllabus topic/section: 2.1.1 Structure and Process; 2.1.2 Decision Making; 2.2.1 Communication and collaboration in Intensive Care; 2.1.16 Populations requiring special considerations in Intensive Care

Candidates who scored better in this question exhibited a broad and high-level grasp of the more global issues and not simply the mechanics of moving the patient out of the ICU. For instance, answers that addressed issues such as identifying those groups of patients who may be suitable for discharge home tended to gain more marks.

Candidates are again reminded to take note of the Glossary terms, especially the subheadings of what a ‘discuss’ answer should include. Those candidates who incorporated this structure into their answer were rewarded for their attention to the glossary of terms instructions with higher scores.

Interpretation

A "discuss" answer should ideally include some pros, cons, controversies, etc. A definition or introductory statement is always helpful in such SAQs, as it tends to gently ease the examiners into a docile state of receptive grade generosity, where even vague and poorly handwritten answer statements are scored more highly because the candidate has given the appearance of understanding the problem. For example, for a), "Considerations involved in the decision to discharge patients directly home from the ICU":

"Discharge directly home from the ICU represents a convenient answer to bed pressure, potentially at the cost of less effective discharge communication and planning.
The role of planned discharge home, and the consequences of resorting to it because of bed pressure, remain to be fully established."

A block of advantages and disadvantages should then follow, and of these, a massive number could potentially be brought up. Here's a list of just the ones the author could come up with:

Advantages Disadvantages
Shorter hospital stay: avoids a pointless ward admission for a patient who is already fit to leave hospital, which was one of the main findings in Stelfox et al (2018). Premature discharge risk: bypassing the safety buffer of ward admission does not allow enough time for the team to identify patients who are unready for home discharge for reasons that are harder to observe in ICU (eg. mobility/falls risk)
Better patient flow: allows the ICU to free a bed and avoids using ICU capacity for patients waiting for low-acuity ward care Institution-centred bias: a decision based on bed availability is contaminated by the nonclinical pressure, i.e. it has nothing to do with the patient's interests.
Fewer care transitions: avoids another handover to a ward team which may add little value for a patient needing only prescriptions, follow-up, and discharge information. Less mature infrastructure: ICU teams may have zero idea of what a discharge is supposed to look like, and could omit vital prescriptions or appointments.
Avoids hospital complications: less ward time may reduce exposure to delirium-provoking environments, hospital-acquired infection, falls, VTE, sleep disruption, deconditioning, MROs, etc. Misses hospital complications: a period of hospital stay could be needed to detect complications of critical illness (DVTs, psedoaneurysms etc) which may go unrecognised in the community.
Patient and family satisfaction: the patients and their families want to go home, so naturally they are satisfied by this outcome (eg. in Lam et al, 2020)  Physician disssatisfaction with the risk: in the same study, a large percentage of physicians were uncomfortable with the idea of direct home discharge. Hilariously, most were uncomfortable because they thought the families would complain.
Potentially faster functional recovery: home may be a better environment for sleep, mobility, nutrition, family help, and return to normal roles in a genuinely recovered low-acuity patient. Potentially slower functional recovery: Sure, you will recover faster at home if you have housing, transport, health literacy, social supports, carers, phone access, money to see a physiotherapist. Or you have none of those things, and continue to deteriorate.
Resource stewardship: may reduce unnecessary hospital days, which have a nontrivial social and personal cost; to say nothing of the opportunity cost for patients who need the ICU bed. Resource burden export: all of the ongoing care and surveillance work is transferred to the community health providers, who have a lot less resources than hospitals,  but a lot more patients and certainly a lot less critical care experience to troubleshoot post-ICU problems.

Controversies:

  • The effect on patient safety is not well defined by the literature
  • In some health services the rate is significant (~20% in Martin et al, 2020 - a Canadian study), without significant increases in readmission rate or morbidity, i.e. it appears to be safe in well-developed health systems and for carefully selected patients
  • Methodology of case selection is not well established through prospective data (but in retrospective data where success was observed, the patients were young, low acuity, and with single organ problems). 
  • Whether this should be v

b) 

An ICU may differ in their rate of direct-to-home discharge if it has:

  • Younger/more elective case mix (eg. mostly elective surgical hospital, a trauma bypass ED, etc)
  • Local discharge criteria and ward capabilities vs. community capabilities
  • Local community health support network
  • Low, or high, socioeconomic status of the serviced population, which has has different implications. For example rich people are more healthy in general and require shorter ICU stay for mostly non-emergency problems and can be discharged earlier into better-resourced communities, but also it may be more lucrative to keep them in for longer to maximise the extraction of cash from their health insurance. Conversely, poor people may need to stay for longer because their access to post-ICU care will be limited and they need to be very "tidy" before they can be safely sent home, but at the same time they tend to turn up to understaffed public hospitals which are under greater bed pressure and more tempted to turf them out faster.
  • Cultural factors, eg. whether the family structures locally are more, or less, likely to have extended families with more in-home care and support
  • Definitions and denominators may differ, eg. jurisdictions may differ in whether they regard a transfer to a rehab facility nursing home or palliative care suite as "discharge home".
  • System-level problems, eg. the availability of beds and the pressure on the ICU bed capacity can inform these decisions (though some might argue that it should never)

References

Kennedy, Tessa K., and Andrew Numa. Factors associated with discharge delay and direct discharge home from paediatric intensive careJournal of Paediatrics and Child Health 56.7 (2020): 1101-1107.

Chawla, Sujata, et al. Homeward bound: An analysis of patients discharged home from an oncologic intensive care unitJournal of Critical Care 27.6 (2012): 681-687.

Lau, Vincent I., et al. Factors Associated With the Increasing Rates of Discharges Directly Home From Intensive Care Units-A Direct From ICU Sent Home StudyJournal of Intensive Care Medicine 33.2 (2018): 121-127.

Lam, Joyce N. H., et al. Patient, Family, and Physician Satisfaction With Planning for Direct Discharge to Home From Intensive Care Units: Direct From ICU Sent Home StudyJournal of Intensive Care Medicine 35.1 (2020): 82-90.