Sunday, April 30, 2017

The Difficult Situation

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     Author: Thomas Hull, MSIV
     Loyola University Chicago SSOM

I remember trying to take my first history and physical as a first-year medical student when a middle-aged man came into the emergency department (ED) with transient ischemic attack-like symptoms. With the encouragement of my preceptor, who was the attending emergency physician, I went to do a full interview history and physical. After spending almost 45 minutes learning about this man and his life in friendly conversation, I exited the room to see my preceptor with a somber face. The patient’s head computed tomography revealed numerous scattered round tumors at the gray-white junction, likely metastases from melanoma, which I’d just heard had been treated years ago and he considered “past” medical history. My preceptor apologized for such a first encounter, though confessed she was relieved to have a partner in delivering the news. I welcomed the role, willing to employ whatever emotional capital I’d just established, and confidently planted myself at his bedside as she began to tell him. But when he started crying, I knew that there was no good response – I stood there speechless.

Currently I’m on a 4th-year medical student palliative care elective in which such encounters and family meetings are our specialty. Like the application prompt, that first encounter has stayed with me, though as much for the behavior of my preceptor as for my own revelations. Seeing the seasoned delivery of “bad news” on a regular basis, I can in hindsight now appreciate her subtle tact. Many of us probably have heard the acronym “SPIKES” and, although I’m outlining maturation away from analytical generic approaches to mortality, I’ve seen its utility. What I’d largely perceived as empathetic skill, in contrast to my na├»ve speechlessness was my preceptor naturally employing the SPIKES technique: [1]

S: Setting – physical positioning in a quiet place, seated preferably next to rather than across from.
P: Perception – beginning by asking them what their understanding of the situation is.
I: Invitation – waiting for the moment when they invite you to share information.
K: Knowledge – imparting information in a non-technical fashion, clearly, directly, and step-wise.
E: Emotion – empathizing with their emotions/concerns/fears and validating them.
S: Summary – summarizing/strategizing, ensuring their understanding, involving them in the plan.

Every step has its purpose, but in my opinion and experience, “Setting” and “Perception” are especially vital. Establishing a good initial relationship and knowing their understanding is crucial in having a meaningful and mutual dialogue. Though seemingly formulaic, SPIKES can provide a basic framework for dealing with the many poor prognoses commonly experienced in the ED. An NCBI meta-analysis done in 2013 revealed that “many physicians trained in emergency medicine (EM) report that they received very little training on coping with patient death. Since many EM residents lack the training to deal with the intrinsically difficult and stressful task of notifying the family about the death of a loved one, they may be ill-prepared.”[2] It outlines the numerous ramifications of unpreparedness: measurable physiological stress, overall reported sadness, and increased burnout. The review illustrates multiple curriculums being implemented in residency training to counter this dilemma. Ultimately, emergency physicians usually don’t have the luxury of time to prepare for difficult situations during their shift. The ability to respond and react naturally with limited time under stress is often expected of EM personnel, but death cannot be glossed over.

Mortality should neither be minimized nor aggrandized. Just as the emotional toll on relatives cannot be ignored, neither should our own. EM personnel repeatedly witness tragic events, and in our current system there is already little time available for one to take for oneself in the moment (whether institutions should do more is a topic in and of itself). A recent practice has caught on in some hospitals, and is gaining recognition: taking a uniform pause after all resuscitations, as a group. After seeing the calming effect of a Chaplain’s prayer following a death, a trauma nurse at the University of Virginia decided on the next patient “to be bold and stop people from leaving and it just came to me. I said can we just stop for a moment, can we take a moment to stop and recognize this person in the bed […] just take a moment as a group of people and just stop and just recognize this person in our own way and in silence, just take a pause, take a break and just do this together, but in silence.”[3] Jonathan Bartels describes how his practice is spreading amongst services in his hospital and to ED’s far and away. He states; “hospital workers processed death and dying in two main ways – they either became emotionally numb or they were unable to disconnect the patient’s death from their own life experience. Both ways are unhealthy and lead to burnout.” But, he believes this pause provides a sort of “permeable membrane,” which allows both connection and protection.

I won’t recommend any specific coping recipe, because I can’t. Everyone in medicine has their own way of balancing professionalism and empathy while grappling with the mortality of patients. We learn from lessons, from allegory and religion, and we learn from each other and from experience. Returning to that first encounter, as I stood there silent next to the bedside, I eventually just put my hand on his shoulder. I learned that silence is sometimes the best answer, because it is just your presence that matters. That despite SPIKES, or NURSES (another useful acronym for difficult conversations), the most important thing you can bring is your presence. Because, despite as solipsistic as our generations continue to become, there is one truth about this “difficult situation” – we are in it together.

“The word hope first appeared in English about a thousand years ago, denoting some combination of confidence and desire. But what I desired – life – was not what I was confident about – death.”

-Paul Kalanithi, When Breath Becomes Air

References:

1. Kaplan M. (2010). “SPIKES: A framework for breaking bad news to patients with cancer.” Clinical Journal of Oncology Nursing. 14, 514–516

2. Shoenberger, Jan M. et al. “Death Notification in the Emergency Department: Survivors and Physicians.” Western Journal of Emergency Medicine 14.2 (2013): 181–185. PMC. Web. 6 Feb. 2017.

3. Lofton, Kara. "Emergency Medical Workers "Pause" After Traumatic Death." WMRA and WEMC. N.p., n.d. Web. 18 Aug. 2015. <http://wmra.org/post/emergency-medical-workers-pause-after-traumatic-death#stream/0>.

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