Station Name: Mrs. Smith Issue: Transitioning to comfort measures only (CMO) Presenting Situation: The physician will meet with Mrs. Smith s children to update them on her condition and determine the future goals of care. Mrs. Smith is a 91-year-old woman who is found unresponsive on postoperative day 4 after exploration and reduction of small-bowel volvulus. She is found to have massive intracerebral hemorrhage, leaving her unlikely to survive longer than hours to days. Activity: The 2 adult children of Mrs. Smith are here to discuss the situation with the resident. Time Required: 15 minutes
Instructions to Candidate You are the resident on the general surgery team. Mrs. Smith is a 91-year-old woman admitted to your service with bowel obstruction. On postoperative day 4 after exploration and adhesiolysis and reduction of small-bowel volvulus, Mrs. Smith is found unresponsive. Computed tomography of the head shows massive intracerebral hemorrhage. She is intubated for airway protection and is breathing over the ventilator. The critical care team believes that if she is extubated, she will continue to breathe spontaneously. Neurosurgical intervention will not be helpful given the extent of her bleed. Neurology has seen the patient and predicts she will not survive this event due to the high risk of swelling and brain stem herniation within the next hours to days. Two of Mrs. Smith s children have arrived at the ICU. Your intern has broken the bad news to the family but needs your help in talking with them about a future plan of care for the patient. Resident Tasks: Talk with the patient s family to determine the next steps in caring for the patient No physical exam is required Time required: 15 minutes You have 12 minutes with this patient 2 minutes to complete a brief self-assessment 1 minute to receive verbal feedback from the standardized patient
Instructions to Standardized Patients Your names are Rhonda and Marcus. Rhonda is married and has 2 adult children. Marcus is not married. There are 2 other siblings. Three of you live locally, but your youngest sister lives in Philadelphia. Rhonda is the contact person for the hospital, and the 4 of you make medical decisions for your mother together as a group. Your 91-year-old mother has been found unresponsive this morning. The floor nurse called Rhonda to tell her that she wasn t waking up and that the medical team was going to get a CT scan to see if something happening in her head was causing her not to wake up. When Rhonda heard this, she called her siblings. She and Marcus came together to the hospital. The surgery intern met with Rhonda and Marcus about an hour ago and told you that your mom had suffered a large bleed inside her head. Additionally, the intern told you that because of the size of the bleed, there is no surgery and no medications that will help improve your mother s condition. You are now at your mother s bedside in the ICU. You are upset but able to think clearly. You have discussed the bad news with your other siblings. Your mother was living alone with some assistance from the family for shopping and cooking prior to this event. She valued her independence highly. She grew up in Alabama and loved to cook Southern food. She was a mother to many of the neighborhood children growing up, and many of them have been visiting her in the hospital. She had abdominal surgery last year and recovered well. You understand that her bowel obstruction, diagnosed during this admission, is directly related to her previous surgery. Understanding the risk of surgery last year, your siblings talked with your mom about unacceptable postsurgical outcomes that your mom thought would leave her with a poor quality of life. Your mother felt that if she was unable to be independent walking, talking, and living outside of a nursing home then she would not want continued aggressive medical care. You are expecting the surgery resident to come and meet with you to discuss what the next steps are. Be prepared to answer questions such as: o Could you tell me what the other doctors have told you about your mother s medical problems? o Had your mother ever talked about her wishes if she were to be this sick? o Does your mother have an advance directive, power of attorney, or living will? o What would your mother tell us if she could see what was happening with her medically right now? o How do we proceed from here?
If the resident asks, What do you want us to do?, increase emotional expressiveness. Reply, I want you to make her better. You re the doctor. Can t you make her wake up? Are there any other specialists that might help? If the resident does not attend to emotion (does not make any NURSE statements), you should become more emotional. You need to feel heard by the resident about how much you love and value your mother and how you do not want her to die any sooner than God intends. Although you know transitioning to comfort care is consistent with your mother s values, you are experiencing significant grief at the anticipated loss of your mother and worry that you are causing her death. You will not be able to make decisions about transitioning to comfort care if you are not feeling heard emotionally. If the resident attempts to attend to emotion, decrease emotional expressiveness. If the resident attends to the family s emotion, this case should end with resident and family agreeing that the patient would not want continued ICU-level care, given that she will not return to being independent, walking or talking. Resident and family should discuss: o Patient s prognosis: hours to days o Interventions to be discontinued as care transitions to comfort IV fluids, tube feeds, ventilator, labs o Interventions to be continued/started: medications for pain, shortness of breath, other symptoms; mouth care to prevent dry mouth o Patient disposition staying in hospital versus going to outside facility (hospice) Prompts are used to standardize the scenario and give all candidates an opportunity to discuss relevant issues if they are attending to emotion. You do not need to use all or even any prompts if the candidate is reaching the issues independently. Prompt 1: What do we do next? Prompt 2: I don t think she would want to live like this not able to eat or talk or walk. Prompt 3: Do you mean you are not going to feed her? Prompt 4: What will happen to her if we let nature take its course? Prompt 5: How long will it take?
Checklist Items Skill Yes No 1. Demonstrated nonverbal empathy a. Sat down b. Made eye contact 2. Demonstrated verbal empathy* a. Named emotion b. Stated understanding of an emotion c. Stated respect for patient s decision-makers d. Offered support 3. Asked what the family already knew/assessed understanding 4. Used open-ended questions 5. Fired a warning shot, such as I m afraid I have some bad news 6. Stated prognosis 7. Attempted to elicit patient/family s treatment goals and expectations 8. Discussed treatment options 9. Used appropriate level of directiveness/made a recommendation 10. Was easily understood 11. Avoided medical jargon 12. Listened attentively/followed family s needs 13. Invited questions 14. Suggested a plan 15. Concluded with a review of what had been decided and a plan for follow-up Negative Behaviors 1. Interrupted 2. Asked surrogates what they would want or want to do 3. Made recommendation/suggestion before eliciting patient s preferences *See the following pages for examples of NURSE statements.
NURSE Statements These examples are not exhaustive Name an emotion Refers to an attempt by the physician to name an emotion that the patient seems to be experiencing but has not explicitly articulated. The attempt is still valid even if the patient claims the named emotion is not how they re feeling. NOTE: When a physician simply repeats an emotion a patient suggests, this does not count as naming an emotion. (PT: I m scared. MD: You sound scared. ) Acceptable examples: o Sounds like you re feeling scared. o You seem overwhelmed. o "You ve been worried about that, huh?" o MD: You seem shocked. PT: No, I m actually just worried about my kids. Unacceptable example: I know this is a shock, and it s tragic when complications come up after surgery. Understand an emotion Refers to an attempt by the physician to verbally show the patient that the physician comprehends and/or appreciates the patient s emotion. Acceptable examples: o I understand I gave you some bad news. o I see this is upsetting. o I cannot imagine what it is like to (X). Respect/praise the patient/family Refers to a statement made by the physician communicating to the patient that he/she admires, commends, or has a high regard for how the patient/family has and/or is handling the situation.
Acceptable examples: o "I m really impressed with the strength you ve shown throughout this illness." o "You ve done an amazing job coping despite everything this cancer s thrown at you." o "You ve done a great job taking care of yourself during this illness I know how much you ve worked on your diet and other things to stay healthy." o You have done a tremendous job handling everything that has been put before you. I think you should be very proud of what you have accomplished. Support/non-abandonment statement Refers to a statement made by the physician communicating to the patient that he/she will be available to the patient, or support them, throughout the entire disease process. Acceptable examples: o You are not in this alone. I am there for you. o I will be here for you throughout this process. o I m always going to be your doctor. o We ll do all we can to help you. o I will be here along the way. Unacceptable example: If you have any questions before your next visit, please feel free to call me.