Stopping the Resuscitation When Family Is Present

DEMOGRAPHICS Case title: Stopping the Resuscitation When Family Is Present. Patient name: Patricia Yu. Case description and diagnosis: A 38-year-old woman with widely metastatic breast cancer in pulseless electrical activity (PEA) arrest. Simulation scenario developers: Luke Devine, MD, MHPE, CHSE FRCPC; Laura Hawryluck, MD, MSc FRCPC; Michael D. Christian, MD, MSc, FRCPC. Target audience: Resuscitation (Code Blue) team leaders/members. CURRICULAR INFORMATION Educational Rationale The decision to terminate resuscitation efforts can be a challenging one, and the presence of family members at the resuscitation can make this decision even more difficult. Some decision aids exist to help inform the decision to terminate resuscitative efforts. It is a judgment that must take into consideration the patient's pre-existing comorbid conditions, the circumstances leading up to the resuscitation, and the resuscitative efforts themselves.1 In the 2015 American Heart Association guidelines,2,3 it is suggested that clinicians should not hesitate to cease resuscitative efforts when functional survival is highly unlikely or when return of spontaneous circulation cannot be achieved.4 Functional survival is based on many factors, including comorbid disease, initial arrest rhythm, witnessed versus unwitnessed arrest, and others. Physicians may often find it difficult to make decisions about ceasing resuscitation, especially if a family member is present, and it can be especially difficult for medical residents when they first assume the role of resuscitation team leader. The hospitalization and death of a patient have been shown to have significant physical and emotional consequences for families.5 However, having family members present during a resuscitation allows them to be present during what may be the last moments of a loved one's life. This practice also allows family members to witness the significant efforts being performed in an attempt to bring their loved one back to life.6 How to best facilitate family member presence at a resuscitation, however, continues to be the source of some debate.6,7 Allowing family members to be present during a resuscitation may have positive psychological consequences for them, and this practice often does not interfere with care from the medical team.7,8 However, in simulated practice, one study found that a family member's presence during resuscitation affected medical residents' abilities to perform key actions.9 Providing residents with simulated opportunities to lead resuscitation situations where a family member is present and in which they need to determine when to cease resuscitative efforts may help prepare them to do so in real life. We developed a simulated case of a patient with end-stage cancer, in which resuscitative attempts are designed to be unsuccessful and where a family member is present at the bedside. The simulation, associated debriefing, and teaching are used to review the appropriate Advanced Cardiac Life Support (ACLS) protocols, to teach leadership and communication skills, to discuss strategies to help determine when to cease resuscitation, and to discuss the need for emotional support for both families and team members during and after the crisis situation. Target Audience The scenario is designed for residents who are about to transition to the role of resuscitation team leader. At our institution, this is a group consists of internal medicine residents as they enter their postgraduate year 2. Based on their previous workplace and simulation-based training, it is presumed that most (if not all) participants would be able to apply ACLS skills and crisis resource management skills in the case of a “straightforward” pulseless arrest. With appropriate modifications, this case can be used to address the learning needs of other groups, such as critical care, anaesthesia, obstetrics and pediatrics residents, practicing physicians, or learners from other healthcare professions such as nursing and respiratory therapy. Regardless of the target audience, it is important to ensure that the learners have appropriate background knowledge and experience, because the other challenges in the scenario will likely introduce too much extraneous cognitive load to be a valuable learning experience for more novice learners.10 Learning Outcomes This is a challenging simulation that offers the learner the opportunity to practice teamwork and crisis management skills in a difficult situation where a family member needs emotional support. In addition, the decision to terminate the resuscitation needs to be made. This allows for a discussion on debriefing and further learning around these issues. At the end of this simulation, learners should be able to: Demonstrate the application of ACLS skills during a resuscitation [Accreditation Council for Graduate Medical Education (ACGME) core competencies “medical knowledge and patient care,” CanMEDS competencies “medical expert”]. Demonstrate effective interpersonal, crisis resource management skills as they relate to resuscitation (ACGME core competency “interpersonal and communication skills”, CanMEDS competency “communicator,”, “professional,” and “collaborator”). Identify factors that should be considered when making a decision to terminate resuscitative efforts (ACGME core competency “medical knowledge” and “patient care,” CanMEDS competencies “medical expert,” “health advocate,” “professional,” “communicator”). Implement strategies to involve a family member during a resuscitation without it affecting the quality of the resuscitation (ACGME core competency “interpersonal and communication skills,” CanMEDS competencies “communicator”). Guided Study Questions What are the considerations that inform a decision to terminate resuscitation efforts? What are the potential benefits and drawbacks of family member presence during resuscitation? What strategies can be used to facilitate family member presence during a resuscitation without their presence adversely impacting the quality and duration of a resuscitation? What strategies can be used to explore divergence of team opinions on when to cease resuscitation, listen and receive feedback as team leader during the resuscitation, improve collaboration, and support team members (as a team leader) when ceasing resuscitation in the presence of distraught families? PREPARATION Personnel/Roles Patient's mother (confederate). Ward nurse (confederate). Respiratory therapist (RT, confederate). Spiritual care/social worker (confederate). Resuscitation team leader (learner). Resuscitation team members—intensive care unit nurse, anesthesia MD, resuscitation team junior resident, resuscitation scribe (optional roles for other learners). The number of learners can be varied on the basis of availability and local resuscitation team composition. The scenario can involve a multidisciplinary group of learners or participants from a single discipline assuming the various resuscitation team member roles. In settings where a spiritual care or social worker is not part of the resuscitation team, their role in supporting the family member can be assumed by the ward nurse or can be assigned to one of the participants during prebriefing. Equipment Required High fidelity mannequin Noninvasive blood pressure cuff Three-lead electrocardiography (ECG monitor) Pulse oximeter, capnography Intravenous pole, saline bags, syringes, connecting tubes, facial tissue box. Not in simulation room (available outside room) Airway supplies: ambu bag and mask, nonrebreather mask, oral and nasal airway, endotracheal tube, laryngoscope(s), and oxygen supply (wall, tank, or simulated) ACLS medications: including but not limited to epinephrine, amiodarone… Resuscitation cart with defibrillator We have successfully run this scenario substituting “lower-fidelity” equipment when necessary and using appropriate prebriefing to maintain realism. For example, an empty syringe has been used to simulate any medication required, as long as the team clearly specified what and how much medication was being administered. A simple compression mannequin and patient monitor can also be substituted for the high-fidelity mannequin. Duration Prebrief: 3 minutes (longer if participants are unfamiliar with the simulation environment and principles). Simulation: 15–25 minutes. Debrief: 20–30 minutes. Room/Mannequin Setup The scenario begins with the mannequin lying in bed on a medical ward with no monitors attached. The patient has 100% fraction inspired oxygen by nonrebreather facemask on at the start of the scenario. The mannequin is unresponsive, has no pulse, and is in sinus rhythm at 105 beats per minute. The patient is on continuous oxygen. Two peripheral intravenous lines are in situ. The resuscitation cart is available outside the room. The patient's mother and the ward nurse (both confederates) are present in the room at the start of the scenario. The mother has a fearful and panicked look on her face. Prebrief Our typical participants have had significant previous prebriefing regarding the simulation center and simulator function and principles. These include the establishment of a safe learning environment where assessments are formative, performance is confidential, and mistakes are seen as learning opportunities.11 Cognitive aids are allowed to be used because their use is also encouraged in the clinical setting as a potential means to improve performance.12 This scenario is often incorporated as part of a simulation half-day. The orientation to the half-day outlines that the scenarios will require the residents to demonstrate appropriate application of ACLS skills but will also require the application of higher level skills, such as leadership and other crisis resource management skills. To prevent loss of psychological fidelity, participants are aware that time telescoping (where the scenario is “fast forwarded” by several minutes) may occur and have experienced this in other scenarios. Stem for the Learners You and your fellow residents are on your internal medicine rotation and are participating in morning signover. You are the members of the Code Blue resuscitation team. A “Code Blue” is called overhead directing you to a wardroom of a patient you do not know. Background and Briefing Information for Facilitator/Coordinator's Eyes Only The resuscitation leader (learner) will arrive at the code along with the other resuscitation team members. The roles of the patient's mother, ward nurse, spiritual care/social worker, and RT will be played by confederates (see text, Supplemental Digital Content 1, https://links.lww.com/SIH/A321, information for confederates). All other resuscitation team member roles will be assumed by participants (this can be done before the start of scenario or roles can be assigned by the team leader). Cardiopulmonary resuscitation (CPR) will have been started by the ward nurse. The spiritual care worker and RT arrive 1 minute after the code has been called. The patient will not improve despite resuscitative efforts. The scenario is designed to anticipate the team leader and team members' responses to the distraught family member's presence. There is also tension within the team as the ward nurse, who has previous critical care experience, recognizes the futility of further resuscitation, and pushes the team leader to consider stopping. The RT, however, has an emotional connection to the patient and finds it difficult to accept the idea of ceasing resuscitation. Despite this, the RT will make several comments during the resuscitation that the patient's end-tidal carbon dioxide (EtCO2) never rises greater than 10 mm Hg. PATIENT DATA BACKGROUND Patricia Yu, the patient, is a 38-year-old woman who was admitted from home 2 weeks ago after a seizure secondary to brain metastases. She has a history of widely metastatic breast cancer, to the lung, brain, and bone, which was already metastatic at diagnosis 1 year ago. Her disease has recently progressed despite third-line experimental chemotherapy. She has received 5 doses of low molecular weight heparin for a deep vein thrombosis/pulmonary embolism that was diagnosed 5 days ago and was empirically treated with ceftriaxone and azithromycin for a possible superimposed pneumonia. Before her recent acute decline, she has had worsening respiratory function secondary to progression of her underlying lung metastases and had been requiring 50% fraction inspired oxygen for the past 7 days. Patricia has been struggling overnight with increasing shortness of breath. The team was called several times; a chest x-ray was done that showed no change compared with one performed a day earlier. She was given a dose of furosemide without improvement in her dyspnea. She has continued to worsen and has been on 100% oxygen for the last hour. Suddenly, she has become nauseated and has started to retch. Her eyes rolled back in her head and she became unresponsive. The registered nurse who was in the room with her could not get her to respond. She could not feel a pulse, called a Code Blue activating the hospital's resuscitation team and started CPR. SCENARIO PROGRESSION AND FLOW The resident should start initial management of the resuscitation with focus on appropriate application of ACLS skills (Table 1).TABLE 1: Scenario EventsWhen asked, the ward nurse will provide a history for the patient (or if not asked after three minutes, they will provide further information without prompting). The learner should ask about advanced directives (ie, “code status”), which have been under discussion but have not yet been determined or documented. The details of these discussions are not immediately available to the resuscitation team. The mother mentions that the patient's husband is en route from home and is not answering his cell phone. After 2 minutes of CPR, where the patient has organized electrical cardiac activity but no pulse (pulseless electrical activity), the patient deteriorates into asystole. The team will continue to run the resuscitation. The patient will remain in asystole until the code is stopped. If the patient is not intubated in the first 5 minutes, the RT will suggest intubation and successfully intubate the patient. Continuous EtCO2 monitoring will be initiated, and it will not rise greater than 10 mm Hg. As the simulation progresses and it becomes increasingly clear that attempts at resuscitation are not working, the scenario is built to anticipate the code team leader's responses. Two minutes into the scenario, the patient's mother will become increasingly distraught and begin to speak louder saying “Patti, hang on, Patti wake up, Patti why won't you wake up? Think of your children… You have to try Patti you have to try.” The resident may ask the family member to leave. If this occurs, the spiritual care/social worker will say, “I will calm her down, let her stay.” The spiritual care/social worker will then talk to the family member quietly, and the family member will move into the corner still sobbing. If the resident persists in wanting the mother to leave, the mother will yell and scream on their way out, “You have to save her, she is all I have, you have to save her!” “How could you do this?” If the resident does not ask the family member to leave and does not ask a team member to attend to the mother during the resuscitation, she will continue to intermittently use the lines, “You have to save her!” “She has to get better…She is so young! She is my only daughter!” She becomes increasingly more distraught and obstructive, impairing the resuscitation. If a team member is assigned to explain the situation and the ongoing resuscitative efforts to the mother, she will quietly interact with them and not impede resuscitative efforts. Depending on the time available for simulation and debriefing, the time is often accelerated (ie, at 10 minutes, it is announced by the ward nurse that resuscitation has been taking place for 15 minutes, and at 15 minutes, it has been taking place for 20 minutes). If/when the resident decides to stop the resuscitation, the family member will say pleadingly (to nobody in particular), “No! What am I going to do, I can't lose her. There must be something somebody can do?” At this point or after 15 minutes (real time), the ward nurse will ask the code leader, “What do you want to do? 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