Tuesday, November 3, 2009

On teaching EKG's and family meetings

On my last day of ward attending, I handed out an EKG that resembled the Dow Jones industrial average over the last 10 years (not pictured). The normal pattern of an EKG was completely disrupted: ST segments were markedly elevated, P waves were hidden, and beats were grouped in odd patterns. My medical team laughed and shook their heads. I asked why. A brave intern responded that he was completely at a loss. Over the previous two weeks, our teaching rounds began with an EKG every day. We had developed a structured approach to reading EKG’s, albeit with simpler tracings. Someone finally said, “OK, let’s start with the first step – what is the rate: normal, fast, or slow?” Immediately, the focus shifted, from fear and doubt to problem solving. Patterns emerged. Small details contributed to a cohesive understanding. And the students and house officers realized that they could do this. By breaking a seemingly insoluble problem into smaller, more manageable steps, these trainees succeeded in interpreting an EKG that would have challenged a cardiology fellow.

We moved on to discuss a challenging conflict that occurred during a recent family meeting. The patient was in her 80’s, had advanced dementia, and had experienced a precipitous decline in her health status since suffering a compression fracture one month prior to admission. She no longer walked due to back pain. She had developed bedsores. She was admitted to our service with urosepsis, her third admission in the last month. In the family meeting, the patient’s husband agreed to the suggestion that she not be resuscitated in the event of a cardiac arrest. The patient’s son and daughter, however, strongly opposed a “Do-Not-Resuscitate Order,” saying, “We want everything done for our mother.” I asked the intern, who ran the family meeting, how he felt when this conflict came up. He said that while he wanted to support the husband, he didn’t know what to say to the adult children. He felt he had lost control, as family members had begun talking over each other and the medical team, and tensions were rising. I passed out an article published in the Annals of Internal Medicine by Quill et al., “Discussing Treatment Preferences With Patients Who Want ‘Everything.’” This terrific article describes a structured approach to addressing these issues with patients and families, beginning with an examination of the underlying reasons and emotions behind the request, an exploration of the benefits and burdens of treatment options and their alternatives, and culminating with a recommendation for care that encompasses what is known about the patient’s values and preferences. We role-played the family meeting, with the other house officers playing the part of family members. The intern used the suggested structure and his own words. He still struggled, and we had to rewind a few times to play parts over, but ultimately he learned, and felt more prepared to run a “real world” family meeting.

Before rounds were over, we compared the two experiences: the EKG and the family meeting. In each case, my trainees had felt at a loss, inadequate to the task, not knowing where to begin. In each case, a structured approach had helped them work through the problem. In the case of the EKG, however, a structured approach was more familiar to the trainees, whereas a structured approach to communication challenges was novel. The contrast to them was striking. It was the juxtaposition that brought the message home to my trainees: fundamentally, communication is a skill that can be learned, in the same structured way that performing a lumbar puncture, or interpreting an ABG, or reading an EKG can be learned.

6 comments:

Diane Keefe said...

My mother had Alzheimer's. I was up visiting her in Toledo and had noticed during the 3 days that I was there, she had become more and more tired. At lunch her head just about dipped in her plate. I accompanied her back to her room where she laid down on the sofa with her hands folded peacefully over her middle.

The intake nurse came in for the new Long Term Care Facility to which we were preparing to send her. She told me that my mother's blood pressure was 80/40. I asked what that meant. She said protocol was that I should call 911 so I did. My mother went off to the hospital where it was determined that she had pneumonia. There had been no outward symptoms. When she was better, they transferred her to the Long Term Care Facility. I remember saying to her, "I just need to know that you will get better." The truth was that she would only get worse as she was in her final stage of Alzheimer's. If I had known then what I know now, I would have called all of my brothers and sisters and asked them to come say their goodbyes.

What happened was that she had a massive stroke one week after she arrived at the Long Term Care facility. She became comatose and had to be turned every two hours to prevent pressure sores. She had asked for no feeding tube or hydration so we swabbed her mouth every little bit. It was anything but dignified. The one day when everyone was exhausted from being there every day, she passed away.

Many times family members are not ready to say goodbye. The older adults are ready to go and have stated it on a number of occasions. When your parent has Alzheimer's, it is a progressive, degenerative disease. It will not get better. I always share this with families who have someone in a terminal condition. Be prepared to let go. In fact, tell them you love them and give them permission to go. It will be the most loving thing you can do for them.

Diane Keefe
Geriatric Care Manager

Jerry said...

Thanks for pointing me to Quill's piece. It's an excellent companion to Rebecca's JAMA essay.

It certainly makes sense to approach a family meeting with the same level of structure and preparation as is done with other tasks.

It also makes sense to a)reach a level of common understanding as promptly as possible; b)frequently ask questions like "What do you understand from what we just discussed?" to avoid misunderstandings; and c)avoid badgering patients and families once their wishes have been clearly expressed.

It all makes sense. It's all pretty simple.

But it sure ain't easy.

Anonymous said...

I have ordered and look forward to reading this article. I currently have some colleagues that have difficulty with this same scenerio and frequently change the care plan and treatment course on their rotation. Often this negates a whole weeks worth of communication with the patient and family. Unfortunately, it often escalates cost of care as well without changing outcomes.

Anonymous said...

I have ordered and look forward to reading this article. I currently have some colleagues that have difficulty with this same scenerio and frequently change the care plan and treatment course on their rotation. Often this negates a whole weeks worth of communication with the patient and family. Unfortunately, it often escalates cost of care as well without changing outcomes.

ken covinsky said...

Both Alex's and Diane's stories are very poignant. I am sure the nurses and doctors taking care of Diane's mother cared deeply about providing the best possible care. While they were undoubtedly taught how to treat pneumonia, they probably were never taught how to talk to families about prognosis and the limits of "curative" therapy.

Alex's trainees will certainly have other attendings who teach them about EKG reading. But it is highly likely that his sessions will be the only time an attending teaches them how to run a family meeting or how to handle a difficult communication problem.

We can all hope for the day when teaching the art and science of communication becomes as important as the art and science of EKG reading. There are certainly major cultural issues in medical education we have to overcome. But we should also recognize that our disciplines have a lot of work to do in developing effective teaching methods.

Quill's article is a great step forward, but our disciplines really need to recognize that it is not enough to have a few palliative care and geriatics specialists with these skills. Our disciplines really also need to develop the art and science of teaching these skills.

ken covinsky said...

See KevinMD for additional comments on this post:

http://www.kevinmd.com/blog/2009/11/learn-conduct-family-meeting-structured-approach.html