Lesson I Learnt from Jefferson -- End of Life

Person attending: Patient's wife

Patient's info
Name : Mel Voight
Age : 55
Gender : Male
Diag & Rx : Adenocarcinoma of lung, underwent resection of lung mass followed by chemotherapy and radiation.
Comments : Recurrence of cancer after vacation and metastasize to lymph nodes, brain and lung

History of Presenting Illness
Time : One week ago
Last activity : Gardening
Comments : Patient tachycardic and hypotensive. During transport to ED, patient became pulseless and CPR initiated. Arrival to ED, PEA was reported. Epinephrine and atropine was given, CPR discontinued and intubation started. After 25 mins of ACLS protocol, patient regain spontaneous circulation and was transferred to MRICU on respiratory and BP support.
Patient condition: Stabilized, remain ventilator dependent and failed all trials to wean him from ventilator. Remained unresponsive to voice, touch, painful stimuli.
CT of head : Negative for hemorrhagic or ischemic stroke
Enlarging metastatic lesions spotted.
Comments : Patient diagnosed with severe anoxic brain injury due to prolonged resusucitation effort
CT of chest : Recurrent rapidly progressing adenocarcinoma
Comments : Bad prognosis

Your task as an attendant of MRICU, talk to Mrs Voight as she wishes to talk to you about the events that have occurred since last week and inform her about what his chances are for survival after the event. She has been told briefly about the code blue by the covering intern.

My own personal experience
It's really bad to make patient's relative or spouse to be left in a blank or confused state. I need to be confident in delivering the news and don't be afraid to mention the word "death", but mention them in a correct manner. The phrase here as quoted in my OSCE book: Assure the iwfe of the certainty of her husband's diagnosis and prognosis. [2]I give an example of how to start the conversation, (you can actually ask anything you want since you are the creator):

Physician: Good morning. How are you feeling today?
Patient: Better than I did a week ago.
Physician: I'm glad of that. We have some very serious matters to discuss regarding your health. Do you feel ready for this discussion?

The aforementioned dialog [1] is a nice approach to prepare patient, as in to prepare the patient of the information he or she is going to hear. One can also try to offer a conclusion or the details first. "Do you want the big picture first?" is a nice phrase to be used.

A good handshake (you can use both of your hands to hold their hands) can mean a difference. Even a tap on shoulder or if you want to offer a patient a hug can help the patient, at least to let them feel that death of the loved ones is inevitable and that they need to overcome them. "We really try our best" should be mentioned. Mind you that everyone deep down wants the truth no matter how bad a situation is.

Talking about overcoming them, it's nice. Ask them what else can be done to help, e.g. access to phone to contact family members or access to clergy[2] and always offer support or help. Words like "My doors are opened to you. If you have any questions, you can consult me." If patient's relative still can't make any decision, it's fine mainly because they are shocked about the bad news.

There are a few points mentioned in the handbook. Just act according to situation, and as Dr. Majdan said, "Treat your patient not by your brain, but by your heart."

Correct me if I am wrong in any part of my article

Reference:
1. P Gordon, J Marsh. Crash Course: History and Examination. Philadelphia: Elsevier| Mosby; 2005, p.14.
2. Katrina F Hurley. OSCE and Clinical Skills Handbook. Toronto: Elsevier | Saunders; 2005, p.362.