Common misconceptions and mistakes

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  Parsing out critical care into its individual interventions, asking surrogates what they think their loved one would want (eg, triple-lumen catheter [TLC] placement, nasogastric [NG] tube, continuous veno-venous hemofiltration [CVVHD])

  
  
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  Mixing advanced care planning with code status discussions (ie, discussions of intubation with discussions of long-term acute care [LTAC])

  
  
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  Using your authority (clutching an advanced directive in your hand) in attempting to get the patient’s family and loved ones to limit or withdraw support

Advanced care planning

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  Patients with significant preexisting comorbidities who suffer from a superimposed critical illness should plan for the advanced care they would or would not want to receive

  
  
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  The physician must first establish a surrogate decision maker in case the patient loses the ability to communicate (ie, intubation)

  
  
  
  
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    The surrogate is most often a family member but may be any individual acting in the patient’s best interest who knows the patient well enough to know how he or she thinks (this vague definition gives the physician enormous discretion in choosing a surrogate)

  
  

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  Initial advanced care planning discussions with the patient or surrogate should focus on:

  
  
  
  
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    The patient’s preexisting state of health and functional status

    
    
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    The postillness limitations that they would not be willing to accept (eg, permanent skilled nursing facility residence, hemodialysis, ventilator dependence, severe neurologic or cognitive impairment)

    
    
    
    
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      It is crucial that the discussion of potential permanent impairment (ie, ventilator dependence) is not misconstrued by the patient to mean that a short-term intervention, like intubation, should not be pursued

      
      
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      The physician should provide reassurance that aggressive measures can be stopped at any time should medical certainty predict an unacceptable outcome

      
      
      
      
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        Specifically, the physician should reassure the patient that the goals of care can be changed to focus on comfort, including compassionate extubation (providing a controlled, dignified, and comfortable death)

      
      

    
    

  
  

Establishing a surrogate decision maker

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  When a patient has a catastrophe, the responsible physician should reach out to the patient’s loved ones as soon as possible to establish a surrogate decision maker

  
  
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  If the patient has not designated a surrogate or DPOA, and several family members are available and clearly acting in the best interests of the patient, the priority goes:

  
  
  
  
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    Spouse → adult child → parent → sibling → adult grandchild → friend

  
  

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  Relatives may choose to share the responsibility, but an easy-to-reach spokesperson should be insisted on

  
  
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  The surrogate should be updated daily (in the same way one would update one’s patient)

  
  
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  The surrogate should be continually reminded that his or her responsibility is not to make decisions for the patient but rather to “divine” what the patient would choose, say or think based on the surrogates familiarity and knowledge of the patient

The family meeting (helping loved ones accept futility)

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  A family meeting should be held whenever it is requested

  
  
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  A family meeting must be held when there has been a significant clinical deterioration, or significant new “game changing” findings (eg, metastatic cancer), that makes the current care plans futile and thus inappropriate

  
  
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  Even though the patient may have a single, clearly defined surrogate, decisions regarding the limitation of life-sustaining measures or withdrawal of support are so profound that the physician should attempt to attain a consensus among all involved loved ones because :

  
  
  
  
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    It builds trust

    
    
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    It helps ensure a “good death” for the patient and loved ones

    
    
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    A first-time conversation with a loved one or a family member after you have withdrawn support has a palpable tension (“you killed my love one”)

  
  

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  Consensus can usually be achieved by answering questions and by spontaneously offering explanations and dispelling common misconceptions

  
  
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  Before the meeting, always :

  
  
  
  
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    Have the most up-to-date patient information (ie, examine the patient right before the meeting)

    
    
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    Have a sense of the most appropriate outcome (eg, change to comfort as the primary goal), but do not have an agenda

  
  

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  At the meeting, always :

  
  
  
  
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    Ask about the relationships of those in the meeting to the patient (make no assumptions)

    
    
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    Identify yourself as the responsible physician (eg, “there are a lot of doctors involved in your loved one’s care, but I am ultimately responsible”)

    
    
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    Ask the family to verbalize their understanding of the current illness, trajectory, and the possible diagnostic and therapeutic interventions they have contemplated or heard discussed

    
    
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    Listen , picture yourself in their shoes, and make sure that what you are going to tell them will make sense based on their understanding

    
    
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    Define the reason for the meeting

    
    
    
    
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      Significant patient trajectory change as opposed to routine update

    
    
    
    
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    Do your best to explain the situation in understandable terms

    
    
    
    
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      Adjust the detail level to the individual family member’s needs, but start broad

      
      
      
      
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        Example: “The cancer has made it impossible to beat the infection, and no more options exist for treating the cancer”

      
      

    
    
    
    
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    Attempt to empathize, and do not be afraid to show emotion (within reason); it builds trust, and it usually comes easily after reviewing a patient’s recent medical history leading up to the futile point in care

    
    
    
    
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      Example: “It has obviously been a very difficult few months for your loved one—learning that the cancer has returned after all that painful chemotherapy and then being admitted again after only being home for 2 weeks…”

    
    
    
    
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    Remind the family of the job of the surrogate decision maker

    
    
    
    
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      To report all previously expressed wishes of the patient

      
      
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      And failing any, they are to imagine what their loved one would want

      
      
      
      
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        Not what they would want for themselves or what they would want for their loved one

      
      

    
    

  
  

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  The empty chair technique

  
  
  
  
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    To refocus the discussion, or to bring the meeting to a conclusion, consider “the empty chair” technique

    
    
    
    
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      Turn and gesture to an empty chair at the table, or in the room, and say, “If your loved one was here right now, sitting in that chair, listening to all we have discussed, what would they say?”

    
    

  
  

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  Discuss your understanding of the patient’s wishes and your sense of the most appropriate code status

  
  
  
  
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    Explain that changing the goals of care to comfort as the primary goal means the discontinuation of all medications and therapies not directly aimed at comfort (eg, pressors and antibiotics), including compassionate extubation

  
  

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  Then verify that the outcome you have just discussed is what the loved one would have wanted

  
  
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  Documentation should list all in attendance by name