Messed Up Seven Ways To Sunday: Communication About Course and Prognosis

I was reminded the other day about the importance of narrative storytelling and theory of mind in communicating with patients' families.  A good storyteller, say Stephen King, has theory of mind - he can see into the minds of his readers and anticipate how they are going to react to what he writes, to the story he's narrating to them.  He knows full well that if he uses a vocabulary that they don't understand that they can't possibly engage with his story.

So if you EVER use the word "intubation" while talking to a family, or "mesenteric ischemia" or "lumbar puncture" or similar technical jargon, you are not going to engage them with your story, and you are going to confuse and frustrate them.  You must use your theory of mind to infer what parts of your medical vocabulary that laypeople do not understand (most of them).

Next, you cannot enter the room of a patient who, say, crumped from flash pulmonary edema and was intubated, and start talking about "mitral stenosis" and "wedge pressures" and "diuresis".  They have NO IDEA what those things mean.  A better narrative would be:

"She had rheumatic fever when she was a child, right?  Well rheumatic fever injures and inflames the heart valves and over the years they can stiffen from that inflammation and injury.  It's just like a guy who injures his knee playing football in high school and then years later has arthritis in the area of that injury.  Same thing, basically.  Anyway, the heart compensates for that stiff or constricted valve over the years by building up pressure behind the valve, just like pressure builds up behind the kink in a garden hose.  You can live like that for a long time because the heart and body are good at compensating, but there comes a point where the pressure behind the kink in the hose or the stiff valve causes fluid to leak into the lungs and then it's hard to breathe with the lungs wet and heavy.  This is essentially what's happened to her - she came in with low oxygen and trouble breathing from fluid in the lungs caused by a stiff valve in the heart.  So we have to remove fluid with water pills to get her breathing without the assistance of the breathing machine, and then she's going to need surgery to replace that valve at some point, which will be determined by the surgeon."

No Code, Slow Code, 45 Minute (Purgatory) Code: Responsibility and Accountability in Attempted Resuscitation from Death

Physicians can abdicate their responsibilities as reasoned guides for patients making decisions at the end of life and as gatekeepers of resuscitation practices in many ways:

• By failing to address "Code Status" at all, letting patients be "Full Code" by default (and by failing to work as a profession to reconsider or change the default)
• By asking, in a matter-of-fact manner, "if your heart stops, do you want us to do CPR to try to restart it" without discussing the probability of success and the likely outcomes, both immediate and longer term, in the (often unlikely) event of success
• By failing to probe the reasons why a code status election that is at odds with their (and/or the nurses') judgment has been made; i.e., taking for granted the legitimacy of a Full Code declaration when doing CPR will clearly or likely be futile
• By discussing the issue of code status solely from an agnostic position, as though there is no right or wrong election, when in fact the physician has a strong belief about what is appropriate and what is not (such as Full Code nonagenarians, elderly patients with hemorrhagic stroke, those on the ventilator with multisystem organ failure, those with metastatic cancer, etc.)
• By defaulting to a Slow Code as a dissimulating compromise for the conflict between the documented code order and their sense of what is medically appropriate
• And the topic of this post:  by conducting a 45 minute code without reevaluating, during that time interval, the premises upon which the Code Blue was initiated, and without integrating the new information that accrues during the resuscitation attempt

Rage, rage against the dying of the light: The Fighter and the Pyrrhic Victory

It's only been two days since my last post on prognosis and end-of-life care in the ICU, and I'm anxious to blog about today's NEJM article on low tidal volume in the operating room on the Medical Evidence Blog, but the happenings around me already today mandate another post about realistic prognostication and it's effective communication.

When I make an assessment of a patient in the ICU, my list of summary conditions and conclusions often looks something like this:




ASSESSMENT:

1. Advanced age
2. Poor Functional Status
3. Malnutrition/Cachexia
4. Swallowing dysfunction
5. S/P fall and hip fracture
6. Aspiration pneumonia
7. Congestive Heart Failure
8. Respiratory failure
9. Renal failure
10. Poor Prognosis for both survival and return to independent livinng
    

This is not the norm.  The norm is to methodically list all of the acute and chronic medicalized and pathophysiologically interesting diagnoses.  In that vein, obvious things that can't be traced to a medically interesting and well delineated disease cascade are left out (such as advanced age and poor functional status.)