Month: March 2015

The save

the save cardio inventor

Sergei Brukhonenko (1890-1960), inventor of an early heart-lung machine

 

In a continuing (but I hope not tiresome) effort to understand why doctors are poor at engaging patients in end of life discussions, I want to explore what makes many doctors tick. This is the opportunity to help someone survive against the odds. For most doctors, especially those in training, the absolute zenith of job satisfaction occurs when a patient arrives in hospital close to death, and with careful attention, timely decision-making and a little luck they recover, take to their feet, and walk out alive. These are the stories one carries through a career, the vignettes one recounts to colleagues when faced with similar scenarios. The memory can help to motivate a team and maintain optimism when the situation appears to be slipping. The ability to grab the smallest chance of life and build on it with all that modern medicine has to offer is one of the most seductive aspects of the vocation. If asked to speak to a room of school children, these are the stories one might tell. The case described by Atul Gawande of the 3 year old girl who slipped into ice cold water and was only found 30 minutes later is a good example. She had drowned; she was dead.  But she was transferred to a specialist unit, established on a bypass machine (the ultimate, I think, in life preservation) and survived. This true story typifies the sense of wonder that medicine can inspire. Who wouldn’t want to part of that team? Or part of a team that works in less dramatic circumstances, yet periodically saves lives that would otherwise have been lost?

 

I can recall a handful of cases in my own career – the highlights. Most of the ‘miracles’ or ‘saves’ were seen during rotations in intensive care, where life support machines and minute attention to detail arrested the descent into death and gave patients time to heal from infection or benefit from definitive surgery, or transplantation. Outside the intensive care unit miracles are less visible. Patients may pass through your hands on the day of admission only to disappear into the operating theatre, thence to intensive care, for a month or more. You may have contributed to their early management, but other patients soon take their place at the forefront of your mind. You may never see them again. If they do leave hospital only a chance mention of their dramatic recovery in the doctors’ mess, or a fleeting glimpse in the corridor as they prepare to stagger into the daylight for the first time, will remind you.

 

The miracles. These are the what many of us who work in acute medicine live for. But they are rare. Yet, they command a disproportionate influence over our thought processes. They feed the optimism that allows us to meet every new clinical challenge in a positive way, such that we grab the small chance and work on it. The reward for such optimism, for a refusal to give in to nature’s perverse agenda, is the preservation of life. The reward appears to justify the means, however expensive and extensive. Resources, money – very few clinicians give this matter a passing thought as they rush through corridors in response to a trauma call. This is what we do, there is no price for such engrained positivity.

 

Or is there?

 

The alternative stories are harder to describe, and would not feature in a school hall lecture. Yet, numerically, the patients in these stories heavily outnumber the ‘saves’; they are the patients who have entered their final days, weeks or months, who will not survive even if they receive the most aggressive forms of treatment. Doctors in a position to offer life saving interventions (intensivists, for example) are good at identifying those who will not benefit, and the best are willing and able to explain to patients or relatives their reasons for denying admission. But there is an even more dramatic intervention that is often offered before the trained eye of an intensivist is brought to bear – cardiopulmonary resuscitation. The decision to offer or withhold this rests primarily with the admitting team. If the patient suffers an unexpected deterioration and cardiac arrest they will receive all that I have described above – the hastily convened team, the application of technology, the grasping of a precious chance that life can be sustained and an acceptable degree of function restored. This is what we want to do. Yet, the truth is we often get it wrong, and choose the wrong patients. We don’t seem to be very good at identifying those who can be brought back from the brink, the ones in whom the glimmer of hope can truly be transformed into a realistic chance of life. Perhaps we are over-influenced by the miracles that have captivated and motivated us before. The thought of reducing a small percentage to zero with the stroke of a pen (and, of course, the agreement of the patient or their relatives) contradicts the learning that has always prioritised salvage, and the instincts that have always made us alert to its possibility.

 

Does entraining an equal alertness to the possibility that CPR will cause harm, and will be futile, necessarily lead to a less positive, less optimistic approach to patients? I ask myself this question on ward rounds. So much time is spent considering how to protect patients from all that can be done, and how to maximise their comfort as their final illness takes hold, I become paranoid that when a true chance of recovery faces me I will not recognise it. I imagine this concern is more prevalent in those who treat many frail, elderly patients. But all of us involved in general medicine will see a mixture of patients who are near the end of life, and patients who may have entered a hinterland, in which aggressive treatment may bring about an improvement, but may well not. To allow ourselves to veer too far down the path of comfort and early palliation could result in borderline patients being deprived of a fighting chance. Uncertainty is a great challenge, there is very little science. Even the signs of dying are disputed, as shown during the debate about the Liverpool Care Pathway.

 

I don’t know how to encourage a balanced degree of alertness to the small chance of life and the large chance of unacceptable therapeutic burden on a day-to-day basis. The first instinct should be therapeutic aggression – most would agree with this. But if this instinct is not tempered by a cool appraisal, when all the facts are known, of how realistic survival is after CPR (and intensive care, if offered), then we have allowed our attachment to the romance, to the drama, to the warm feeling of success, to taint the truth. Somehow we need to train our young doctors such that they regard a sensible, appropriate and honest approach to treatment as a success of magnitude to ‘the save’.

 

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Beyond the implicit

There has been another controversy regarding DNACPR decisions in the press this week. A doctor has been defending her actions at inquest. She wrote a DNACPR certificate after thinking ‘long and hard about it,’ for a patient with end-stage lung disease whom she knew well. After an abortive resuscitation attempt the certificate was found by family members who then complained that doctors had ‘played God’ and deprived him of a chance to extend his life. Even an extra week would have been precious to him, in their opinion. Today, the coroner found that the DNACPR order did not contribute to his death.

Once again the realities of resuscitation in end stage disease are being discussed, and the exceptional nature with which this frequently ineffective treatment is regarded has been emphasised. The fact is – from what we can gather – the decision to allow natural death rather than attempt resuscitation was not discussed explicitly with the patient or the family. These events pre-dated the Janet Tracey judgment and the hospital’s revised resuscitation guidelines, which incorporated the judgment. Under that judgment, such an omission represents an illegal violation of Article 8 of the European Convention on Human Rights.

Not all the details of this case are known to us, but it appears that the doctor had an open discussion with the patient regarding his prognosis, his mortality, and the lack of any other available treatment options. She then risked opprobrium by completing a DNACPR notice without engaging the patient on the subject. It is reported that she feared this conversation would cause additional distress. The judges in the Tracey case were very clear on this – fear of causing distress is not sufficient reason to avoid a DNACPR discussion. Therefore, cast in the light of the Tracey judgment, we have a paradox: a doctor who seems to have known and understood her patient, a patient who seems to have known and understood his the terminal nature of his condition… yet, within that therapeutic relationship, a possible deprivation of human rights.

I worry greatly about how we are to work through this.

Whenever I speak with a patient who has terminal disease I must consider their resuscitation status, especially if they have come into hospital with worsening symptoms. If I don’t consider it I have abdicated an important duty.  However, the focus of our discussion is what we can do to make them feel better and improve their quality of life, not what we can’t or don’t want to do. We discuss death openly, and perhaps, if pressed, I may even suggest a timeframe. We talk about how death will be managed, whether here in the hospital or at home. The palliative care team will do the same. Death is expected. Death is not far away. There may be tears – more often from the family than the already cognizant patient. We formulate a plan. And then…

‘There’s something else we need to discuss – the subject of resuscitation. If, when, the end comes and your heart stops we should have something in your notes to say that the crash team should not be called. As you probably know we often put out an emergency call and try to restart the heart with compressions and electric shocks. After everything we have been saying, about how to help you as you get weaker, I definitely don’t think we should do that…’

The reactions? They have varied from bewilderment (why am I talking about electric shocks after fifteen minutes on palliation?), to confusion (I have now suggested that death can be avoided in some cases… really? Is there a chance I won’t die?) to disengagement (the patient cannot focus; their emotional and intellectual energy has been sapped by the preceding discussion; they just nod and say ‘Yes’). Sometimes that final chapter, with its visualisation of a dying process (phones ringing, bleeps bleeping, doctors running, defribrillators charging) causes a crisis. The inevitability of death is confirmed. Again, relatives often react to this more than patients themselves.

I am suggesting that an honest discussion about dying does not need to mention CPR explicitly to be complete. The law disagrees. How did this happen? Why the disparity? I write this as a doctor, but doctors represent only one side of the process. It seems that the judges in the appeal court felt the need to protect patients from doctors like me assuming that discussing a natural death, with its implicit assumption that CPR will not be a part of that, was enough. In their view patients need to be made aware, however distasteful it seems, that a potentially ‘life-saving’ intervention is going to be withheld.

Several doctors have said to me something along the lines of,

‘But there are many treatments that we don’t discuss, because they are irrelevant to the patient’s condition, or so ineffective as to be irrelevant. We don’t talk about bone marrow transplants in 87 year old patients with end stage myeloma, even though it could, theoretically, be done. We don’t talk about lung transplants for patients with lung cancer, even though, theoretically, they could extend life. We don’t mention intensive care when patients with advanced Alzheimer’s disease begin to succumb to bronchopneumonia, even though it could be done. Why? Because those things would be largely ineffective. So why talk about CPR with a dying man even though it could theoretically be done?’

The answer is – CPR is different. It is an invention that has been imposed on the dying process because in certain circumstances it is life saving. It is a now part of the transition between life and death. In the minds of many, and I do not decry this, it is a symbol of resistance, of a commitment to living, however diminished or short the extension to life might prove. It is different, and as doctors we need to accept that our utilitarian and ‘realistic’ view of it will never be shared by the majority of the patients and relatives we see.

In the current climate I see no option but to find a way of completing every end of life conversation with an addendum about CPR, however brutal it feels. What was once implicit must now be explicit. Perhaps the judges were right – patients need it, and we, the doctors who thought we knew how to talk about death, are mistaken.

 

oOo

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The corrections

 

corrections1

I can number on the fingers of one hand the times I have been explicitly corrected during my medical career. There was the time I treated a patient all night for septic shock when in fact he had cardiogenic shock – the fluid nearly drowned him. There was the time I performed a lumbar puncture on an obese patient, and put the needle three inches away from the correct inter-spinous space. There was the time I failed to check a gentamicin level before the weekend, and came back on Monday to find the patient in renal failure. And during higher training, the course where my endoscopic technique was picked apart against a list of errors that the assessor held in his hand; he described three issues, but I glimpsed the piece of paper and the list was at least ten items long. There are others, some of which are littered across this blog.

Each time I felt embarrassed and defensive. I reacted by rationalizing. The reasons, or excuses, were various, and included the way I had been trained, the pressure of time, the load of patients, the need to balance speed and vigilance, and plain bad luck. But each time the fact that I had been criticised ate away at me. I was not used to it. Few of us are.

Medical students tend to come from the highest strata of achievement in secondary education, where their performance requires very little correction. Most float through training in the middle of the pack, periodically struggling to stay above the flood of knowledge, neither excelling nor failing. They require little in the way of feedback, just the odd nudge back on track. They become competent in the early years on the job and deliver medicine safely. Errors occur, many due to weaknesses in the system rather than personal fallibility. Corrections happen, but they are infrequent. And then, before you know it… they are practising more or less independently. They are part of a team, but they are essentially ‘complete’. They habituate to many forms of stress, but one that they are not accustomed to is ‘constructive’ feedback. When it comes, if it comes, it hurts.

How else do we improve once we have arrived at our natural ceiling of seniority? Continuing professional education is mandatory, we do it, and our knowledge is augmented, but weaknesses are not identified by passive absorption. Appraisal? Somewhat routine, and focused more on our perception of ourselves than feedback. Revalidation – mmmm… we’ll see. So how do our weaknesses get identified? The answer is, by our peers – those whom we work with day in and day out. The difficulty with this is that they are the last people who wish to engage us on our deficiencies. They are colleagues and friends.

Most error is self detected and self corrected. Although I listed only a handful of occasions where mistakes were fed back to me, there are hundreds (well, let’s say ‘tens’) of similarly significant mistakes which I identified myself, and reflected on. Nobody came to tell me that such and such happened because I missed a clinical clue or performed a procedure incorrectly – there is no ubiquitous or all-seeing observer to perform this function. The continuous feedback loop of self-improvement requires attention to consequence, and the ability to accept that something bad has happened because of what you did or omitted to do. Without a willingness to seek the consequences of our decisions we will blunder on regardless. However, a safe culture cannot be expected to rely solely on such of subjective system.

Receiving  feedback as a junior doctor in training is hard enough, but it is standard and expected. You rely on it. The discomfort that comes with receiving negative feedback from a colleague of equal seniority, at consultant or GP level, is even more acute. The same rationalisations occur, recourse to the same ‘excuses’ – the pressures, the pace, the reaction to diffuse responsibility that appears to have unjustly landed on your head just because your name was over the patient’s bed. So much for receiving; how about giving? It’s even worse. But becoming comfortable with discomfort seems an absolute requirement for a safe medical culture. It is easily described, but not so easily undertaken.

Soon after becoming a consultant I took on the task of reviewing the notes of patients who had suffered ‘hospital acquired’ venous thromboembolism (ie. DVT or PE). It sounded easy, and quite interesting. I flicked through the charts, identified possible lapses in prescriptions of anti-coagulant, and marked them as avoidable or unavoidable. The catch was… I had to interview the consultant in charge of patients deemed to have suffered avoidable events. I sent out emails, arranged convenient times to meet, and found myself addressing equally experienced or more established consultants. It was not easy. The key to converting it from a repeatedly painful and nerve-wracking exercise was this – I too had been called up to justify a similar lapse, months earlier. The discomfort, the access of humility, the acceptance that yes, it could have been done better, we (I) should have been more vigilant, served as a brief lesson in correction. That was the angle when it came to phrasing my own feedback:

‘It happens to all of us at some point, it’s bound to. Happened to me last year. And it worked. If I hadn’t been asked to attend the meeting I wouldn’t have known that so and so had a big PE three weeks after they went home from my ward. It worked. It made be think twice about checking it on ward rounds, brought it home. It’s not about criticism, it’s about focusing minds on the things that are easy to let slip through your fingers…’

You get the gist. Correction shouldn’t be exceptional; it’s inevitable.

If hospitals and surgeries are to witness more of those ‘difficult conversations’ we keep hearing about, in order to promote a safe culture, each of us has to find a way to get comfortable with starting those conversations. The best way – in my limited experience – is to bracket them in the context of our own fallibility, for none of us are perfect, and we are all bouncing from error to error as we move forward in our careers. That’s medicine.

___

There do not seem to be many articles on how to deal with the discomfort of giving negative feedback, but I did find these two in the BMJ and the Hospitalist (US).

 

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Intrusion

 

intrusion

Two students arrive on the ward, as per the arrangement that has slipped my mind. I see them loitering by the nurses station. They are eager to see and hear signs – that’s all I wanted when I was at their stage. Unprepared, I scan the names on the white boards at the end of each bed bay. There! An elderly patient with florid aortic stenosis, a slow rising pulse, oedema in the lungs and in the skin… but she is frail, she is ‘end stage’. Some days she is bright and talkative, some days she is withdrawn. Today she is in between. Her clinical signs are classic, and it would be a shame if the students did not have the opportunity to examine her.

 

I remember similar encounters from my own training – the first murmur, the first example of bronchial breathing; they stuck in my mind, and advanced my knowledge. So, I am decided… I will ask the patient for permission to be examined by the students. Before doing so I flick through the notes to catch up on any developments. I see the coloured A4 sheet used by the palliative care team. They have been asked to see her for symptom control, and to help arrange her discharge. They came this morning, just two hours ago. And prior to that entry is a short note from the registrar saying that she has spoken to the patient and her middle aged son to explain that there is now nothing more that can be done to optimise her breathing or oedema. She has progressed from ‘end stage’ to ‘end of life’. It is not obvious to the passing observer. She is the same woman.

 

The students are looking at me in expectation. Should I ask her? It will not benefit her. It will probably tire her. It will not be in her best interests. But neither is it positively harmful. And the signs… so precious, educationally. No, I’ll leave it. It’s not fair. I approach the students and explain that in the absence of any other obvious patients we will tour the acute medical unit and find something there. Then I glance back to the patient and watch her. She is sitting out, and looking out across the ward. I reconsider. I approach.

“Mrs ______,” I say (gabble actually), “I wondered… if you wouldn’t mind… please say No if you are too tired… if two students came to ask you some questions and examine your heart?”

She looks around slowly. I think she heard and understood. But I have to ask again. She nods, which I interpret as consent. I beckon the students over, and watch as they perform the examination. I then demonstrate the signs, before getting them to examine again, until they are satisfied that they have heard and absorbed the features of the disease. We leave. It has taken twenty-five minutes, with feedback given along the way. The patient sits passively. It has tired her, as I thought it would. The look in the eyes of the students is priceless. Descriptive words on a page in a book have evolved into physical, memorable reality.

 

They thank the patient and they thank me. Their morning was well spent. My morning was well spent. Her morning was devoted to the education of two students who had nothing to do with her, and the convenience of a doctor, an educator, who offered nothing in the way of medical care. But that’s what happens in hospital. When there are students, or doctors studying for exams, the question will always be asked. Sometimes it feels uncomfortable, and the path of least resistance appears attractive (‘Sorry guys, I don’t want to trouble her today…’). However that path does not lead to the best educational experience – the palpable liver, full of metastases, nystagmus secondary to a disabling cerebellar stroke, the petechial rash due to acute leukaemia.

 

Patients can say No of course, but in my experience they rarely do. The thing that is asked of them sits outside the usual therapeutic transaction. Consent, when asked, relates not to an intervention, but to what amounts to a ‘favour’ – their time, their inconvenience, in exchange for knowing that they have contributed to a general good. Often the reply is not so much a ‘Yes, of course…’ but a ‘Well they’ve got to learn haven’t they!’ That phrase contains an imperative – an expectation. I have very rarely heard a patient say ‘No, no thanks, not today,’ although I have read as much in their look of pained exasperation, or the unfocussed gaze that betrays distraction, by unresolved concerns – questions, prognosis, a scan result, disability, mortality. It is easier when you know the patient, but sometimes a colleague will have tipped you off about a valuable examination before a teaching session. Then you must introduce yourself, explain the purpose of your visit and ask permission all in one go – the fast track. It feels intrusive. It is intrusive. But it is necessary.

 

See also ‘Signs’

 

oOo

 

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