Withdrawal of Ventilatory Support Educational Issues

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Withdrawal of Ventilatory SupportEducational
Issues

• James Hallenbeck, MD
• Assistant Professor of Medicine
• Director, Palliative Care Services
• VA Palliative Care services

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What are the educational issues?
83 yo man 4 months post valve replacement for
critical aortic stenosis on chronic ventilatory
support. Patient suffered multi-system failure
and now thought to be unweanable. Wife angry at
you for doing surgery and then lying about his
prognosis. Asks that you remove the tube and
allow him to die with dignity.
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In teaching about possible ventilatory
withdrawal, what topic is most important to
stress?
AIRS Slide

• Relevant ethical principles
• Proper drug usage for palliation post extubation
• Communication skills
• None of the above
• All of the above

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Outline

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

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Knowledge
What new knowledge is important for the learner?

• Understanding of relevant ethical principles
• Knowledge of relevant therapies
• Role of opioids
• Role of sedatives
• Knowledge of relevant support systems

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Attitudes
What changes in attitude does the teacher believe
are necessary?
Potential attitudes to address

• That withdrawal of support is purely a medical
  decision
• That previous experience and training was
  adequate in addressing the issue
• That treatment withdrawal is solely an ethical
  problem
• Not my job

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Skills
What new skills are necessary?

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

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Like a battery
Learning requires TENSION
to work
So wheres the tension in the learner?
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Tension Overt and Covert

• Overt tension what people verbally identify as
  the problem
• If we dont get this straightened out, well have
  to trach this guy
• Covert tension unspoken, sometimes unconscious
  tension
• Im not sure Im competent
• I dont want to be the one pulling the plug

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Subtext

• Emotional subtext often present, but not
  addressed in patients and families AND in
  ourselves
• You doctors just used him as a guinea pig. Now
  you want to get rid of him!

What is the emotional subtext for the speaker?
What is your emotional subtext?
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Ethical Principles Knowledge
AIRS Slide
Rank your knowledge

• 1 Minimal, Inadequate
• 2 Barely adequate, Struggling
• 3 Adequate
• 4 Superior
• 5 Master

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Drug Usage for Dyspnea, Agitation
AIRS Slide
Rank your skill

• 1 Minimal, Inadequate
• 2 Barely adequate, Struggling
• 3 Adequate
• 4 Superior
• 5 Master

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Necessary Communication Skills
AIRS Slide
Rank your skill in USING communication skills

• 1 Minimal, Inadequate
• 2 Barely adequate, Struggling
• 3 Adequate
• 4 Superior
• 5 Master

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Necessary Communication Skills
AIRS Slide
Rank your skill in TEACHING communication skills

• 1 Minimal, Inadequate
• 2 Barely adequate, Struggling
• 3 Adequate
• 4 Superior
• 5 Master

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Challenges in palliative care education - general

• Arrogance-Ignorance phenomenon
• Hidden curriculum

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Ignorance
Weissman et al.
Survey of Internal Medicine residents and faculty
Mean Correct
Domain PGY 1 (n 1284) PGY 2 (n 980) PGY 3,4 (n 1076) Faculty (n 1711)
Total Test 48.3 52.9 56.0 59.1
Pain 52.2 55.5 57.2 60.5
Non-pain 60.4 65.7 70.6 72.8
Communication 42.2 45.0 46.3 57.0
Terminal Care 45.7 49.3 53.9 56.0
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Arrogance
Despite minimal differences in knowledge

• Interns admitted knowledge and skill deficits and
  were concerned about their competency TENSION
• Residents and faculty less concerned about
  ability to practice and teach palliative care
• Many faculty What ME worry?

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Curriculum or Hidden Curriculum?

• End-of-life issues often relegated to the hidden
  curriculum not worthy of instruction/modeling
  by attendings, but informally modeled among
  residents and students.

Reference Rappaport W, Witzke D. Education about
death and dying during the clinical years of
medical school. Surgery. 1993113(2)163-165.
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Rappaport Study
(n 53 surgical residents)
Key findings

• 84 of junior and 50 of senior residents
  reported never hearing an attending discuss how
  to do deal with a terminally ill patient
• How often are you with the attending when he/she
  talks with a dying patient?
• Junior residents 64 lt once/month
• Senior residents 43 lt once/month

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Special challenges for surgeons

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

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Example 83 yo with critical AS

• Suffered stroke, became vent dependent following
  elective valve replacement
• Angry wife He was mowing the lawn and now you
  made him a vegetable
• Frustrated surgeon She just doesnt get it
  it was a risk, but I thought it was a greater
  risk not to operate. You know what critical AS
  is like

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Challenges specific to difficult decisions

• Actions (stopping ventilator (or dialysis) are
  discrete and clear
• Discrete actions must occur in an environment of
  uncertainty and ambiguity

HOWEVER..
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Uncertainty/ambiguity regarding

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

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What is required is...
Exquisite Competence
Not just basic understanding
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Summary Check-list

• Knowledge
• Ethics
• Proper drug use
• Accessing support systems
• Skills
• Drug utilization
• Communication
• Offering support to patient, family, staff

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Final words

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