MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care April 12, 2010

Objectives Discuss how to approach the family Discuss how to approach the family Discuss how it affects staff Discuss how it affects staff Discuss how it affects the physician Discuss how it affects the physician

UNOS Over 115,000 on the wait list Over 115,000 on the wait list ,631 donors recovered ,631 donors recovered 28,464 transplanted 28,464 transplanted 21,854 from deceased donors 21,854 from deceased donors

Trauma Number one cause of death in those 3-44 years old Number one cause of death in those 3-44 years old Blunt trauma remains the majority Blunt trauma remains the majority

Surgical Intensivist/Trauma Encounter those who are young Encounter those who are young Patients you cannot resuscitate Patients you cannot resuscitate Caring for traumatic brain injury Caring for traumatic brain injury Understand the shortage of organs Understand the shortage of organs Understand your patients Understand your patients

Trauma Unplanned admissions Unplanned admissions Young Young No advanced directive or living will No advanced directive or living will Important to try to identify early patient’s wishes Important to try to identify early patient’s wishes

Family Perspective Important Attitude of news deliverer Attitude of news deliverer Well informed, knowledgable Well informed, knowledgable Privacy Privacy Clarity of message Clarity of message Clergy Clergy Autopsy information Autopsy information Jurkovich GJ. J Trauma 1999

Family Perspective Less important Rank or seniority of care giver Rank or seniority of care giver Attire of news deliverer Attire of news deliverer Physical contact Physical contact Jurkovich GJ. J Trauma 1999

Advanced Directives Written statement of your wishes, preferences and choices regarding end of life health care decisions Written statement of your wishes, preferences and choices regarding end of life health care decisions Tool to help you think through and communicate your choices Tool to help you think through and communicate your choices Only used: Only used: If you are seriously ill or injured AND If you are seriously ill or injured AND Unable to speak for yourself Unable to speak for yourself

Advanced Directives State specific State specific Living will Living will Medical power of attorney (MPOA) Medical power of attorney (MPOA) Do not resuscitate (DNR) orders Do not resuscitate (DNR) orders Out of hospital DNR Out of hospital DNR Not transferrable state to state Not transferrable state to state Need to execute by state Need to execute by state

Living will Legal document with your wishes about medical treatment Legal document with your wishes about medical treatment You choose: You choose: What you want What you want What you don’t want What you don’t want

MPOA Legal form that states who you want to make decision about medical care Legal form that states who you want to make decision about medical care Person is authorized to speak for you ONLY if you are unable to make your own medical decision Person is authorized to speak for you ONLY if you are unable to make your own medical decision May also be: May also be: ‘health care proxy or agent’ ‘health care proxy or agent’ ‘health care surrogate’ ‘health care surrogate’ ‘durable power of attorney for health care’ (DPOA) ‘durable power of attorney for health care’ (DPOA)

MPOA Power to make decisions Power to make decisions Receive/review medical information Receive/review medical information Discuss with medical team Discuss with medical team Consent to or refuse procedures Consent to or refuse procedures Authorize transfers Authorize transfers If you are MPOA, make sure you understand what patient wants If you are MPOA, make sure you understand what patient wants

Advanced Directives Advantages Advantages In charge of making your own decisions In charge of making your own decisions Documents can change anytime Documents can change anytime You do not need an attorney You do not need an attorney Document can help you express your wishes Document can help you express your wishes

Advanced Directives Executing Executing Do not need lawyer to complete Do not need lawyer to complete Decide what type of life sustaining treatments you do not want Decide what type of life sustaining treatments you do not want Discuss/inform with family and primary doctor Discuss/inform with family and primary doctor If you change your wishes, complete a new advance directive If you change your wishes, complete a new advance directive

Advanced Directives Disadvantages Disadvantages Not available to transfer between states Not available to transfer between states Living wills Living wills May not be specific enough May not be specific enough May be overridden by a treating doctor May be overridden by a treating doctor Does not immediately translate into doctor’s order Does not immediately translate into doctor’s order

TALKING IMPORTANT Honest discussion, reflection and planning Honest discussion, reflection and planning Opportunity to discover important information on family and patient Opportunity to discover important information on family and patient Most important gift you can give to prepare for the end of life Most important gift you can give to prepare for the end of life

Trauma Surgeon ABCDE of trauma ABCDE of trauma

A Advanced preparation Advanced preparation Time Time Privacy Privacy No interruption No interruption Review information Review information Mental rehearse Mental rehearse Prepare yourself emotionally Prepare yourself emotionally

B Build a therapeutic environment/relationship Build a therapeutic environment/relationship How much do they need to know How much do they need to know All family present All family present Introduce yourself to everyone Introduce yourself to everyone Warn of bad news Warn of bad news

C Communicate well Communicate well What do they already know What do they already know No medical jargon No medical jargon Translator Translator Frank but compassionate Frank but compassionate Allow for silence/tears Allow for silence/tears If appropriate, repeat their understanding If appropriate, repeat their understanding Follow up plan Follow up plan

D Deal with family reactions Deal with family reactions Be empathetic Be empathetic Do not argue or criticize colleagues Do not argue or criticize colleagues

E Encourage and validate emotions Encourage and validate emotions Use interdisciplinary resources Use interdisciplinary resources What does this mean to family What does this mean to family RN, clergy or SW follow up after you leave RN, clergy or SW follow up after you leave

Family Anger Anger Shock or numbness Shock or numbness Searching for any hope Searching for any hope Disorganization and despair Disorganization and despair Reorganization Reorganization

Stages of Grief Kubler-Ross Stages of Dying (1969) Kubler-Ross Stages of Dying (1969) Denial Denial Anger Anger Bargaining Bargaining Depression Depression Acceptance Acceptance

Stages of Grief Engle’s Theory (1964) Engle’s Theory (1964) Shock and disbelief Shock and disbelief Developing awareness Developing awareness Reorganization and restitution Reorganization and restitution

Trauma Surgeon Feeling of failure Feeling of failure Fear of approaching topic Fear of approaching topic Constraint for time Constraint for time

Trauma Surgeon Important to take control Important to take control Leader of the team Leader of the team Know your resources Know your resources Recruit your resources Recruit your resources Take a moment for yourself Take a moment for yourself Review events in your head Review events in your head Remove signs of resuscitation Remove signs of resuscitation Emotionally not drained Emotionally not drained

Trauma Surgeon Develop a rapport with family early Develop a rapport with family early Trust Trust Sincerity Sincerity Empathy Empathy

Trauma Surgeon Stand firm Stand firm Ultimatum sometimes necessary Ultimatum sometimes necessary Offer evidence of finality Offer evidence of finality

Approaching the family When death is imminent When death is imminent Maximizing comfort Maximizing comfort Acceptance Acceptance Time Time Saying good-bye Saying good-bye

Approaching the Family Prepare info, location, setting Prepare info, location, setting Find out what they already know Find out what they already know Ask how much they want to know Ask how much they want to know Share information Share information Respond to family’s emotion Respond to family’s emotion Negotiate concrete follow-up step Negotiate concrete follow-up step

Approaching the Family Avoid rote responses Avoid rote responses Each family is different Each family is different Be genuine Be genuine Express your true feelings Express your true feelings Admit you don’t have words if you don’t know what to say Admit you don’t have words if you don’t know what to say Avoid common greetings Avoid common greetings Hi! How are things going? Hi! How are things going? Don’t be afraid to discuss death Don’t be afraid to discuss death

Approaching the Family Don’t preach or lecture Don’t preach or lecture Listen Listen Let them talk and express their concerns Let them talk and express their concerns Ask what you can do. Keep the promise Ask what you can do. Keep the promise Be aware of the tone in your voice Be aware of the tone in your voice Avoid being condescending or pitying Avoid being condescending or pitying Check in on the family frequently Check in on the family frequently

Approaching the Family Offer Clergy Offer Clergy Time of stress, needed more than people might realize Time of stress, needed more than people might realize Explain the need for autopsy Explain the need for autopsy

Conclusion Delivering bad news is difficult Delivering bad news is difficult Not well trained in medical school or residency Not well trained in medical school or residency Form relationship Form relationship Clear Clear Privacy Privacy Empathetic Empathetic

THANK YOU…….