PACES MRCP UK - Where MRCPians Meet Since 2006

MRCP is well establised as an entry exam for advanced specialist training in many countries including Malaysia. It consists of 3 paper i.e. Part1, Part2(written tests) and PACES. PACES in full means Practical Assessment of Clinical Examination Skills. It is the third part and the candidate is assessed by fellows of RCP. I passed my PACES in 2005. I am glad that many seniors had guided me throughout my preparation for PACES and I wish to share my experiences with PACES candidates via this blog.

Friday, April 27, 2007

Breaking Bad News 1

Inform brain death and withdrawal of treatment

Mr Smoki is a 65 y.o. gentleman admitted 3 days ago for acute exacerbation of COPD. He has been getting dyspneic for past few days, with fever and increased sputum production but has refused for admission. He was found collapsed by her daughter, but resuscitation team has managed to resuscitate him and was sent to hospital. He has history of recurrent admission for COPD. For the past 1 year, his COPD symptoms worsened, and he required 5 x admission for the past 1 year. He has been stopped smoking 3 months back due to progressive worsening dyspnea. He has been staying with his only daughter, and his wife has passed away due to myocardial infarct. His daughter Miss Norsmok has been quite supportive of her father so far, and has been spending her time all along during these hospital stay.

There has been no improvement in his father’s condition throughout the ICU stay. He has spiking fever and it was complicated by septic shock and multi organ damage. His blood pressure has been low, an now require inotropic support. The ICU team has discussed poor prognosis to medical team. Brainstem test was done, and Mr Smoki was confirmed brain death. Therefore, withdrawal of treatment is imminent.

You are the senior medical officer in charge appointed to meet Miss Norsmok. Your task is to explain braindeath to her and discuss the issue of withdrawal of treatment.

1) Introduction
Dr: Im Dr X, im here to discuss with you about your father’s condition. Do you have anyone coming along for the discussion?

Miss Norsmok: No, I came alone.

2) Explore how much she knows about her father
Dr: How do you feel about your father’s condition? Did anyone tell you about your father’s condition before?

Miss N: Nobody so far tell me in detail. But I was told that my father is critical. Doctor, did anything go wrong?

3) Explaining general condition
Dr: Im afraid we have bad news for you. Your father has been admitted with severe lung disease. We have to protect his lung into rest. His breathing is supported by our machine. It has been hard for your father to recover in view of his severe lung disease. Your father’s condition was worsened by multiple organ failure due to severe infection. We have been trying our best but we failed to do so. (give a pause…)

Miss N: What do you mean? Fail?

Dr: Yes. The fact is hard to accept, but we have perform a test and have found that your father has brain death, in other word, your father has passed away. We are sorry.

Miss N: It can’t be. He is still breathing, and he still have pulse..Are you sure my father has died?

Dr: Yes. Your father would not be able to breath by his own. It is the machine which help his breathing. And his pulse is due to medication, which temporally make his heart beat. Without artificial support, his heart will stop beating, and he would stop breathing. Therefore, your father has passed away.

Miss N: I can’t believe it…(pause…)

4) Discuss withdrawal of treatment

Dr: You seems upset by the news. I could understand that. It is difficult for us to discuss this at this moment, but I need to tell you that we are going to withdraw treatment to your father. How do you feel about it?

Miss N: Are you going to give up on my father? Do you mean you want to let my father stop breathing?? Don’t ever mention it!

( Do not be panic as most family would think that we are going to let the patient die. We need to confer to them that her thought is incorrect)

Dr: Miss Norsmoke, we never give up treating your father. It is however not appropriate to continue treatment in your father, as he already passed away. I’m sorry about this, and I know that you need time to accept.

Miss N: …What are you going to do Dr?

Dr: We are going to stop the medication that support the heart as well as stopping the machine. Your father would stop breathing and his heart beat would stop in a short moment. There would be no suffering to your father as he has already passed away. (Mention the word “passed away” few times to remind the family about the death)

5) Explore reason if disagree
Miss N: No, I don’t want you to do that. You cant stop the treatment.

Dr: It must be hard for the decision. But can I ask why do you think in such a way? Do you have any religious believe in this matter? Did your father ever express his will about how he would be treated before this?

Explore the reason and sort out any misconception is utmost important. Decision of the relative must be regarded important, although decision of withdrawing treatment lies in the hand of clinicians.
Miss N: No, there is no specific reason. I don’t accept that my father be treated as such.

Dr: Withdrawing treatment may be unfamiliar to most people. I would address the issue to my consultant. In a short while, we would have another discussion with my consultant. Do not hesitate if you have any question regarding the problem. See you again.

Issue and Discussion:

Distributive justice

Why withdraw treatment?
1) Withdrawal of treatment is an issue in intensive care medicine because it is now possible to maintain life for long periods without any hope of recovery.
2) It is often easier to withhold a treatment than to withdraw it once it has been instituted. Ethically, however, there is no difference between withdrawing a treatment that is felt to offer no benefit and withholding one that is not indicated.
3) About 70% of deaths in intensive care occur after withdrawal of treatment. This is not euthanasia. The cause of death remains the underlying disease process, and treatment is withdrawn as it has become futile.
4) In general, treatment is withdrawn when death is felt to be inevitable despite continued treatment. This would typically be when dysfunction in three or more organ systems persists or worsens despite active treatment or in cases such as multiple organ failure in patients with failed bone marrow transplantation.

Patient autonomy
1) Autonomy is another of the basic precepts of ethical practice, but there are problems with its implementation in the intensive care unit. Most critically ill patients are not competent to participate in discussion because of sedation or their illness.

2) in the United Kingdom relatives do not have legal rights of decision making

3) Another difficult issue occurs when a patient may survive but with a poor quality of life

4) Relatives must be kept fully informed about the patient's condition, in particular regarding issues of limiting and withdrawing treatment.

5) Although decisions rest with the medical staff, it is unwise to limit or withdraw treatment without the agreement of the relatives

1) The referring team request continued futile therapy
This can usually be resolved by explaining the rationale and offering a second opinion from another intensive care consultant. If conflict still remains, treatment cannot be withdrawn. The family should not be informed of a decision to withdraw that is then rescinded because of interteam conflicts. It will reduce their faith in subsequent decisions and undermine confidence in the predicted outcome.

2) The patient's family requests continued futile therapy
Guilt usually plays a part in the family's request to continue treatment, although religious and cultural factors may also contribute. Agreement can usually be obtained by explaining the rationale again and offering a second opinion from within or outside the intensive care team. It is best not to withdraw treatment if there is conflict. However, the final decision rests with the intensive care team. This underlines the need for good communication.

3) The family requests inappropriate discontinuation of therapy.
The rationale behind the therapy and the reasons why continuing treatment is thought appropriate should be explained. The duty of care is to the patient, not the family. Again, a second opinion can be offered.

4) The patient requests discontinuation of therapy.
Explain to the patient the rationale for the treatment and that, in the opinion of the intensive care team, a chance of recovery exists. It may be appropriate to offer a short term contract for treatment (for example, 48 hours then review). Ultimately, the competent patient has the right to refuse treatment even if that treatment is life saving.



At 4/29/2007 09:10:00 AM, Blogger Dr. David Teoh (eMRCPian) said...

Explaining of brain death is difficult. Sometimes, we might need to explain organ donation at the same setting. That is even more difficult.

Looking forward for your 2nd part!

At 4/29/2007 09:17:00 AM, Blogger Dr. David Teoh (eMRCPian) said...

There is some comments in MMR website.

At 5/13/2007 01:09:00 AM, Blogger Chris said...

I think it's also important to say that the patient has died/is dead and to try and avoid using jargon like 'passed away'.

It just helps clarify the situation and leaves no room for ambiguity.

At 1/26/2009 04:29:00 AM, Anonymous AMER said...

it is very beautiful contribution


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