#SimPall: Having The Conversation
#HaveTheConversation is an online campaign to remind people to start having the conversation with their loved ones about what they want for their death. Over the past several months we have been developing and trialling a series of in situ simulations based around End of Life, Frailty and Uncertain Prognosis with the aim of making clinicians feel more confident having these conversations in the emergency department.
The Scenario
Mr Green has been generally unwell for the last few days, more confused when usually able to communicate well and intermittently drowsy. He has a slight cough and reduced oral intake. Smelly urine, low grade pyrexia and no falls. Today he has been very drowsy, pyrexia 39°C, breathless and his heart rate is high. The GP was called who advised a 999 ambulance. Family are present. No DNACPR or ACP.
His recent discharge summary has little information – several admissions with pneumonia, falls and poor intake…
PMH: Stroke 2012 (old L sided weakness), HTN, IHD (previous NSTEMI 2014), T2DM on insulin, hyperlipidaemia, CKD 4, mild vascular dementia.
DH: Clopidogrel 75mg OD, Bisoprolol 5mg OD, Atorvastatin 40mg ON, Pregabalin 150mg BD, Amitriptyline 10mg ON, Losartan 50mg OD
Allergy: ACE-I (cough)
SH: Unable to mobilise unaided but transfers with rotunda + 1. Incontinent and wears a pad. Needs assistance with personal care but usually able to communicate well and feed herself (should identify CFS 7)
Initial assessment
Airway (A)
Own, no airway compromise
Breathing (B)
RR 24 SpO2 88% on air
Right-sided basal crackles
Circulation (C)
HR 130 irregular BP 89/50 CRT 2 seconds centrally but hands feel cool to touch
HS 1+2+0
JVP not visible, looks dry with no peripheral oedema
Pad moist, dark, strong smelling urine
Disability (D)
GCS E3M5V5=13/15 BSL 10.2
PERLA 3mm
Left-sided facial weakness
Left-sided hypertonia with contractures. Right side normal tone but unable to complete full neurological examination due to confusion/drowsiness
Exposure (E)
Pyrexial 38.5°C
No rash
No evidence head injury or other injury
What happens next…
This is a gentleman who is frail with many comorbidities. Some initial investigations suggest a pneumonia again.
After starting some fluids and antibiotics the scenario progresses to the point where the family ask: “What is the point in the antibiotics they never seem to work?”
The participating clinician should be thinking: “Is this the best for the patient? Does he need an escalation plan or DNACPR?”
If the participant hasn’t expressed these thoughts – the family member will continue with prompts until the nurse mentions it.
Learning Outcomes
These can be a challenging conversation to have. We all know that with a clinical frailty score of 7, 8 or 9 the risk of mortality increases. Healthcare professionals need to be able to #HaveTheConversation about what patients want for when they die.
Take-home messages from staff
“Warning shots, colleague support, being honest, and avoiding jargon/euphemism with DNAR discussions” – FY2 doctor
“Discuss DNAR and choices regarding CPR” – Nursing student
“In elderly frail people with multiple comorbidities, initiate DNACPR conversation” – Nursing student
“To have discussion with the family in a suitable environment. Could be distracted in resus cubicle with patient adjacent to them.” – GPST doctor
References
- Kojima G, Iliffe S, Walters K. Frailty index as a predictor of mortality: a systematic review and meta-analysis. Age and Ageing. 2018 Mar 1;47(2):193-200. doi: 10.1093/ageing/afx162
- Krawczyk M, Gallagher. BMC Palliative Care series. Communicating prognostic uncertainty in potential end-of-life contexts: experiences of family members. 201615:59 doi: 10.1186/s12904-016-0133-4
