How To Facilitate Those Crucial
Conversations
for Critical Care Patients
Sandy Young CNS, MS
Adult Palliative Care
Sanford USD Medical Center
Early Identification of Patients on
Dying Trajectory
 ICU Prognostic Models
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Acute Physiologic and Chronic Health Evaluation (APACHE)
Mortality Probability Model (MPM)
Simplified Acute Physiology Score (SAPS)
Sequential Organ Failure Assessment (SOFA)
 All models predict rates of in-hospital mortality in
population of critically ill patients
 But differ for predicting survival for an individual patient
 Does not indicate functional status, QOL, long term prognosis
 As a single data point can help to guide patient-centered
decision-making
 As a screening tool to identify those ICU patients “in
need” of palliative care evaluation
 As a research tool to look at the impact of interventions
on mortality, morbidity and QOL
 What are the underlying chronic fatal illness diseases?
 What has been the clinical course of the chronic
illness over the past few months/year?
 What has been the patient’s functional status and
QOL prior to this admission?
Illness/Dying Trajectories
Sudden Death, Unexpected Cause
Illness/Dying Trajectories
Steady Decline, Short Terminal Phase
Illness/Dying Trajectories
Slow Decline, Periodic Crises, Death
Illness/Dying Trajectories Lingering,
Expected Death
Determine The
Surrogate Decision Maker
Advance Directives
 Durable Power of Attorney for Health Care
 Five Wishes
 Sanford has a standard form
 Living Will
 Comfort One
 POLST (Physician Orders for Life-Sustaining
Treatment - not recognized in SD at this time)
Go Wish Cards
http://gowish.org
SD Health Care Consent Act
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Court appointed guardian supersedes all of these
DPOA for health care
Spouse
Adult child
Parent
Adult sibling
Grandparent or adult grandchild
Adult aunt or uncle, niece or nephew
Friend
Identify Patient Values and Wishes
 Determine patient values.
 Keep the focus on the patient.
 “Tell me about…; what kind of things did/does he like
to do?”
 “Did you ever talk about what he would want if things
did not go the way he hoped?”
 “Based upon your knowledge of his values and
beliefs, what do you think he would do in this
situation?”
Patient/Family Meeting
 Determine if a meeting is needed
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Overall prognosis
Who is the decision maker
What s/s need management
What are the family dynamics
Clarify understanding of patient’s condition
Patient/Family Meeting
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Location
Who
Introductions
Determine what they know and understand
Review medical status and clarify understanding
Options for Ongoing Care
Code Status
Establish and Clarify Both
Short Term and Long Term Goals of
Care
Outcome of the Meeting
 Short term goals
 Time limited trials
 Is the patient making improvement, stable or worsening
 Are there clinical changes that impact the ability to meet
the desired goals
 What interventions will be needed
 What is pt/family understanding
 Long term goals
Code Status
 0% probability of success in the following clinical
circumstances:
 Septic shock
--Metastatic Cancer
 Acute stroke
 End stage diseases
--Severe pneumonia
 In other clinical situations, survival from CPR is
extremely limited:
 Hypotension (2% survival)
--Persistent Vegetative
State
 Renal failure (3%)
--AIDS (2%)
 Homebound lifestyle (4%)
--End stage diseases
 Age greater than 70 (4% survival to discharge from hospital)
Code Status Discussions
• Avoid Stating:
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“If your heart stops, would you like us to restart it?”
“Do you want us to do everything?”
“What do you want us to do if your heart stops?”
“What do you want me to do if your (mom’s) heart
stops?”
– “There is nothing more we can do.”
– “I think we should stop aggressive care.”
Quality of Life Issues
 QOL is multi-dimensional
 How has diseased interfered with ADLs?
 How have you been getting along with family and
friends as a results of your illness?
 What is your biggest concern or worry…?
 How have your religious beliefs been affected by your
illness?
 Determined by Patient
 How can we help you live well?
 What is important to you?
 What special events are you looking forward to?
“Hope” is the thing with feathers
That perches in the soul
And sings the tunes without the
words
And never stops at all
--Emily Dickenson