1. Withdrawal of Ventilatory Support Educational Issues James Hallenbeck, MD Assistant Professor of Medicine Director, Palliative Care Services VA Palliative Care services

2. 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.

3. In teaching about possible ventilatory withdrawal, what topic is most important to stress? Relevant ethical principles Relevant ethical principles Proper drug usage for palliation post extubation Proper drug usage for palliation post extubation Communication skills Communication skills None of the above None of the above All of the above All of the above AIRS Slide

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

5. Knowledge Understanding of relevant ethical principles Understanding of relevant ethical principles Knowledge of relevant therapies Knowledge of relevant therapies  Role of opioids  Role of sedatives Knowledge of relevant support systems Knowledge of relevant support systems What new knowledge is important for the learner?

6. Attitudes That withdrawal of support is purely a medical decision That withdrawal of support is purely a medical decision That previous experience and training was adequate in addressing the issue That previous experience and training was adequate in addressing the issue That treatment withdrawal is solely an ethical problem That treatment withdrawal is solely an ethical problem Not my job Not my job What changes in attitude does the teacher believe are necessary? Potential attitudes to address:

7. Skills Communication Skills Communication Skills  Demonstrate the ability to address cognitive and affective components of communication Order writing skills Order writing skills  Write initial orders for treatment discontinuation, including drug doses and indications Access skills Access skills  Demonstrate the ability to access support for a grieving family What new skills are necessary?

8. Like a battery… So where’s the tension in the learner?

9. Tension – Overt and Covert Overt tension – what people verbally identify as the problem Overt tension – what people verbally identify as the problem  If we don’t get this straightened out, we’ll have to trach this guy… Covert tension – unspoken, sometimes unconscious tension Covert tension – unspoken, sometimes unconscious tension  I’m not sure I’m competent  I don’t want to be the one pulling the plug…

10. Subtext Emotional subtext often present, but not addressed – in patients and families AND in ourselves 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?

11. Ethical Principles Knowledge 1Minimal, Inadequate 1Minimal, Inadequate 2Barely adequate, Struggling 2Barely adequate, Struggling 3Adequate 3Adequate 4Superior 4Superior 5Master 5Master AIRS Slide Rank your knowledge

12. Drug Usage for Dyspnea, Agitation 1Minimal, Inadequate 1Minimal, Inadequate 2Barely adequate, Struggling 2Barely adequate, Struggling 3Adequate 3Adequate 4Superior 4Superior 5Master 5Master AIRS Slide Rank your skill

13. Necessary Communication Skills 1Minimal, Inadequate 1Minimal, Inadequate 2Barely adequate, Struggling 2Barely adequate, Struggling 3Adequate 3Adequate 4Superior 4Superior 5Master 5Master AIRS Slide Rank your skill in USING communication skills

14. Necessary Communication Skills 1Minimal, Inadequate 1Minimal, Inadequate 2Barely adequate, Struggling 2Barely adequate, Struggling 3Adequate 3Adequate 4Superior 4Superior 5Master 5Master AIRS Slide Rank your skill in TEACHING communication skills

15. Challenges in palliative care education - general Arrogance-Ignorance phenomenon Arrogance-Ignorance phenomenon Hidden curriculum Hidden curriculum

16. Ignorance… Domain PGY 1 (n =1284) PGY 2 (n =980) PGY 3,4 (n =1076) Faculty (n =1711) Total Test 48.352.956.059.1 Pain52.255.557.260.5 Non-pain60.465.770.672.8 Communicati on 42.245.046.357.0 Terminal Care 45.749.353.956.0 Mean % Correct Survey of Internal Medicine residents and faculty Weissman et al.

17. Arrogance Interns admitted knowledge and skill deficits and were concerned about their competency = TENSION 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 Residents and faculty less concerned about ability to practice and teach palliative care Many faculty – What ME worry? Many faculty – What ME worry? Despite minimal differences in knowledge…

18. 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. 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. 1993;113(2):163-165.

19. Rappaport Study 84% of junior and 50% of senior residents reported never hearing an attending discuss how to do deal with a terminally ill patient 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? How often are you with the attending when he/she talks with a dying patient?  Junior residents 64% < once/month  Senior residents 43% < once/month (n = 53 surgical residents)Key findings

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

21. Example – 83 yo with critical AS Suffered stroke, became vent dependent following “elective” valve replacement Suffered stroke, became vent dependent following “elective” valve replacement Angry wife – “He was mowing the lawn and now you made him a vegetable…” Angry wife – “He was mowing the lawn and now you made him a vegetable…” Frustrated surgeon – “She just doesn’t get it – it was a risk, but I thought it was a greater risk not to operate. You know what critical AS is like…” Frustrated surgeon – “She just doesn’t get it – it was a risk, but I thought it was a greater risk not to operate. You know what critical AS is like…”

22. Challenges specific to “difficult decisions” Actions (stopping ventilator (or dialysis) are discrete and clear Actions (stopping ventilator (or dialysis) are discrete and clear Discrete actions must occur in an environment of uncertainty and ambiguity Discrete actions must occur in an environment of uncertainty and ambiguity HOWEVER..

23. Uncertainty/ambiguity regarding: What people want or (usually for the patient) might have wanted What people want or (usually for the patient) might have wanted Outcomes: not just that people will die but Outcomes: not just that people will die but  Actual time to death  What it means to die or be dead Feelings Feelings What the right thing to do is (Ethics) What the right thing to do is (Ethics)

24. Not just basic understanding

25. Summary Check-list Knowledge Knowledge  Ethics  Proper drug use  Accessing support systems Skills Skills  Drug utilization  Communication  Offering support to patient, family, staff

26. Final words In historical terms ventilation and other forms of life-support are recent innovations In historical terms ventilation and other forms of life-support are recent innovations As a society we have not ‘caught up’ with such 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 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 We need to work hard to figure out how best to incorporate needed training into existing curricula