Dr Peter Saul, Intensive Care Specialist, John Hunter Hospital, NSW
We have to learn something new. We shouldn't go around imagining that we understand how to manage end-of-life. We delude ourselves into thinking that we're good at this. We actually aren't and this is a relatively new undertaking for us.
Advance CPR decision-making in the hospital setting
About this video: This video is for use by Clinicians to stimulate discussion and sharing of experiences.
This exchange should be linked to changes in practice to improve patient care.
Supporting resources are available to optimise the learning experience.
Part A: The Clinical Issues
Part B: The decision-making framework
Park C: Communication tips and examples.
Video opens with Dorothy Roberts, aged 76 years old with severe COPD on home oxygen admitted to ED for the fourth time in six months. Dr Belinda Murphy, Emergency Medicine Consultant
Look, I think we find in ED it is really frustrating and it's distressing for patients and their families when we've got a patient who is clearly at the endpoint in a terminal illness and nobody's had a meaningful discussion about end-of-life care.
Part A
1. The current situation
Why has the situation arisen?
How can we improve our clinical care?
"CPR was designed to save 'hearts too good to die'. Pioneers never argued for it to be universal.” Dr Kieran Lennon, Intensive Care Consultant
What has happened is that we have got into this pattern of resuscitating anyone and everyone umm, whether it's in their best interest or not. Professor Leon Flicker, Director WA Centre for Health and Ageing, Royal Perth Hospital, WA
We know that CPR in older people in general, but certainly in old frail people, is of no benefit. Virtually everybody doesn't survive and if they do survive they don't leave hospital. Dr Peter Saul, Intensive Care Specialist, John Hunter Hospital, NSW
Most of us working acute care settings including intensive care think when managing end-of-life well, but we've run a series of audits that show that actually we do quite badly, not just in intensive care but in hospital as a whole. Dr Jacqueline Donnelly, Intensive Care Consultant, Armadale Health Service, WA
I've seen make calls frequently where no end-of-life decision's been made, despite the fact patient is on a deteriorating pathway and no counsel sought as to the patient's wishes; what the family think the patient's wishes are and what the patient would deem as a good outcome. It's just not discussed.
Dr Geoffrey Chong, Medical Registrar
I guess as junior staff we often feel like we're left by ourselves and we could do with a lot more consultant support and guidance in this area.
Requires assistance for personal care.
Dr Nicholas Waldron, Clinical Leader & Consultant Geriatrician, WA Health
Medicine’s had an amazing history but also peppered with some really stupid things that we've done along the way, umm and unfortunately resuscitation could be one of those stories if we don't change the way we approach it.
Part A
The current situation
2. Why has this situation arisen?
How can we improve our clinical care? Dr Peter Saul, Intensive Care Specialist, John Hunter Hospital, NSW
The main problem is us. I think the people are willing to talk about end-of-life, but that we are not willing to have that conversation with them. Professor Leon Flicker, Director WA Centre for Health and Ageing, Royal Perth Hospital, WA
The fundamental problem is that a lot of the interventions that we commonly use in medicine have been developed on a single issue or a single problem, or a single disease, and when we have multiple diseases, multiple problems, frailty, loss of physiological reserve, those interventions don't necessarily work. Dr Barbara Hayes, Palliative Care Physician & Clinical Leader, Advance Care Planning, Northern Health, Victoria
I think patients have a very falsely high expectation of success of resuscitation and are not really aware of the harms that it can also do.
Dr Geoffrey Chong, Medical Registrar
At the moment is probably a lack of consistency and a lack of umm... the lack of across the board consistency with how consultants approach these discussions and conversations.
Dr Jacqueline Donnelly, Intensive Care Consultant, Armadale Health Service, WA
I don't think the medical profession have been well-educated in the past on making decisions. It's a much more comfortable position to do everything than to do nothing. Dr Peter Saul, Intensive Care Specialist, John Hunter Hospital, NSW
We always do everything. People say we want you to do everything we always do everything, it just everything looks different for different people. So everything may include intensive care and ventilation or everything may include a palliative care consult and active palliative care but we never do nothing.
Professor Leon Flicker, Director WA Centre for Health and Ageing, Royal Perth Hospital, WA
Managing uncertainty towards the end of life is really difficult. Umm sometimes it can be clear-cut and everybody is on the same page - they understand where we going. But other times the medical staff are uncertain about what's happening and they're not quite sure what the patient's expectations are, nor the family.
Dr Derek Eng, Palliative Care Physician, St John of God, Subiaco Hospital, WA.
Doctors and clinicians struggle with conversations, particularly these difficult ones.
Discussion with Dot and Dr Nick
[Dr Nick] …Umm hi
[Dot] Hello
[Dr Nick] Mrs Roberts, yeah my name's Nick I'm one of the consultants
[Patient interrupts] Hello
[Dr Nick] I just wanted to have a quick chat
[Patient interrupts] oh thank you yeah...
[Dr Nick] Do you mind if I grab a seat and we have a quick chat? Look, you, you're really not well at the moment.
[Dot] No
[Dr Nick] … and um there's something I need to ask you, is it, er if your heart stops are you wanting us to start up again?
[Dot] Course I do! Course I do...yeah.
[Dr Nick] Well the trouble is it probably wouldn't make any difference, I don't think we'd be able to get it started.
[Dot] Well that's nice, well you'd have to try, surely?
[Dr Nick] Well we could do
Dot makes sounds of distress.
[Dr Nick] … but it'd ...you know it might put you through unnecessary suffering so I wouldn't want to do that to you .
[Dot] Well how would you know, I mean, what about my family?
[Dr Nick] … um yeah that's a good point. Well I guess we could get them in and see what they think but...
[Dot] Well, yes, you must.
[Dr Nick] so you're wanting us to do it, are you?
[Dot] Get them in and, of course, you would try everything, surely?
[Dr Nick] Okay, well, we’ll keep doing everything we can then and see you know and see, see how you go?
[Dot] I can fight this, I can fight this.
[Dr Nick] … yeah okay then we'll keep going to
[Dot] … good, yeah, of course. Discuss why CPR is not being offered
Patient sits up in bed breathing hard and clutching at chest in distress. Dr Kieran Lennon, Intensive Care Consultant
So I think we need to improve our recognition of people who are sick and who are deteriorating, umm, to actually step in earlier prevent their progression to cardiac arrest.
In the Emergency Department - patient is unconscious and staff gather around her bedside.
[Off screen] Have we confirmed cardiac arrest?
[Nurse Off screen] Yes, we have
[ED Male Staff Member] We carry on fifteen to two. Vicky can you just get the, man the defib?
[Vicky] Sure
[ED Male Staff Member] Can you just umm do a rhythm check for us please? Dr Geoffrey Chong, Medical Registrar
And I guess having a framework for how to approach it and what we should be looking for, and how we should making these decisions, would be really useful.
In the Emergency Department
[ED Male Staff Member] Okay, can we please do another rhythm check Vicky?
[Vicky] Compressions continue, everyone else stand clear, oxygen away. Charging, top clear, middle clear, bottom clear, I'm clear [flat line sound]. Hands off compressions.
[ED Male Staff Member] Okay we're still in asystole can we dump the charge?
[Vicky] Dumped
[ED Male Staff Member] … and can we continue with CPR?
Are you happy you're getting oxygen in at the top end?
[Interrupts] Yes I am.
[ED Male Staff Member] Sarah, can you please, get a little more adrenalin? Can someone get a hold of this lady's notes for me? And uh, can someone also try and find out ah if the consultant who is looking after her or one of the registrars is available and can get a bit more information on her? Thanks.
Mr Frank Prokop, Executive Director, Health Consumer’s Council of WA
If the doctors have no information the default will always be to save the life to the best extent possible, but in many and in an increasing number of cases, the families are wanting CPR not to be administered if the benefits to quality of life are not likely. It's important that those possible prognoses and the pathways are explained.
Part A
The current situation
Why has this situation arisen?
<strong>3. </strong><strong>How can we improve our clinical care? </strong> Dr Alison Maclean, Director Clinical Services, Armadale Health Service, WA
I truly believe that ah managing end-of-life decision-making is a critically important function of the clinician. I believe that wherever possible the question should be raised and ah good solid discussions held with the person and their support people or their family.
Dr Belinda Murphy, Emergency Medicine Consultant
I guess we can improve the situation by being open and honest with patients. So firstly about the care, about what the expectations are and about umm what they really want out of their admission and what they really want out of their illness as well.
Dr Geoffrey Chong, Medical Registrar
Yes, there's two questions that can be asked all the time. Firstly umm you could ask a patient if you were so unwell that you couldn’t talk about your treatment to your doctors is there someone else that you would want to speak for you? I guess the follow up question, the second question would be, have you actually discussed this with that person?
Professor Leon Flicker, Director WA Centre for Health and Ageing, Royal Perth Hospital, WA
So the first thing is to actually have that conversation, to actually understand what the patient's wishes are, understand what the family's wishes are, getting some feedback from the other members of the allied health team who may know the patient much better than you do and understand where they are in their lives.
Mr. Frank Prokop, Executive Director, Health Consumer’s Council of WA
In all medical procedures patients have responsibilities as well as the doctors. The best ways that you can have discussions about CPR is to have had them early with family members so the family is not trying to second guess what your wishes might be.
Dr Kieran Lennon, Intensive Care Consultant
The general practitioners need a role in this to actually speak to patients before they even come near a hospital. Specialists in medicine and surgery, cardiology, all the other specialties, need to actually address these issues in the outpatient clinics.
Advance Care Planning … is the process of planning for future and personal care whereby the person’s values and preferences are made known.
Dr Nicholas Waldron, Clinical Leader & Consultant Geriatrician, WA Health
It gets confusing, advance care planning and advance care health directives and all the terminology but the long and short of it is: if in different settings we're having this type of dialogue patients become educated, aware of the realities of resuscitation but also medical treatments, they don't always work and they're much more likely to make decisions that are in their own health interests and have a good outcome, a good experience of healthcare, but also a good death if that’s if their time is up.
Dr Peter Saul, Intensive Care Specialist, John Hunter Hospital, NSW
Managing end-of-life and dying is not something that can be subject to some kind of protocol. It isn't like having a heart attack where we know if we give people some aspirin or something like that this will have great benefit and is applicable to the vast majority of people. There's a very high variability in what people would regard as a good end-of-life management or a good death. And we should therefore resist the idea that this is protocolised. What we really want to do is to systematise it so we know that we have a system and that people will be spoken to and they will be some intervention and that there will be some interaction and conversation, but we want to preserve variability.
Mr Frank Prokop, Executive Director, Health Consumer’s Council of WA
CPR and end-of-life discussions can be quite straightforward and, in fact, extremely enlightening. If the family has had the discussion, if the level of understanding and knowledge is high, then you'll find that you have extremely strong support and strong advocacy for making your decision.
ENDS