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Monday, March 18, 2019

Doctor on Video Screen Told a Man He Was Near Death, Leaving Relatives Aghast

Hmmm...something is amiss with this situation. Terminal lung disease rarely sneaks up on anyone. Terminal lung conditions tend to be chronic and progressive over years. So, either the patient didn't present to medical attention until the very end (unlikely) or we never had a serious illness conversation with the patient and family about the expected progression of the lung disease. Having an initial serious illness conversation during an acute hospitalization is not the ideal circumstance as studies have shown increased patient and family anxiety and PTSD-like symptoms even when a live human-being trained in palliative and hospice care does so face to face. Thus, the response this family had to such news from the tele-ICU doctor is the same type of reaction experienced with an in-person conversation. For serious, progressive health conditions from which one may succumb, the serious illness conversation is best initiated in the outpatient setting. The inpatient conversation should be a continuation of the outpatient conversation (not a newly initiated one). Simple outpatient questions such as: 1) Have you considered your wishes if your disease progresses despite ongoing best medical treatment? 2) What goals and objective do you have for the remainder of your life? 3) How much independence are you willing to give up and how much suffering are you willing to endure in order to meet those objectives? 4) Would you wish to be intubated and kept alive on a mechanical ventilator? 3) Would you desire nutrition via an artificial feeding tube if you are no longer able to feed yourself? 5) How long are you willing to try "heroic" life support measures before determining a different focus and strategy would be appropriate? The answers to these questions aren't really the issue. It's the consideration of the questions which is meaningful. The patient may go home and ruminate on these questions. They may discuss with family members. If and when they are finally hospitalized due to progression or sequelae of their disease, the continued seriously illness conversation will not be psychologically or emotionally shocking.
from Rajesh Harrykissoon, MD

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