Annals for Educators - 5 March 2019
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2019)

Web Exclusives5 March 2019Annals for Educators - 5 March 2019FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED201903050 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsEffects of a Personalized Web-Based Decision Aid for Surrogate Decision Makers of Patients With Prolonged Mechanical Ventilation. A Randomized Clinical TrialPatients requiring prolonged mechanical ventilation face high morbidity and mortality and frequently lack decisional capacity. Decision aids might help align understanding of patient prognosis between surrogate decision makers and clinicians to better inform discussions about plans of care. This randomized trial assessed whether a decision aid improved agreement on patient prognosis between surrogates and clinicians.Use this study to:Start a teaching session with multiple-choice questions. We've provided 2 below!Ask your learners when a surrogate decision maker should be involved in deciding about a patient's care plans. How is a patient's capacity to make decisions for herself or himself evaluated?Teach at the bedside (part 1)! Ask surrogate decision makers for patients on your service if they would be willing to discuss the experience with your learners.Ask the surrogates what they understand their role in the patients' care to be. Do they know what the patient wants? Ask whether they feel conflicted in any way. Is it difficult to separate what the patient wants from what the surrogate wants?Teach at the bedside (part 2)! Ask these same questions of patients who have the capacity to make decisions together with their designated surrogates in case of future need.Ask if your learners have encountered a surrogate whose assessment of a patient's prognosis seemed unrealistic. How was this discussed? How might your learners approach such a discussion?Why do your learners think the decision aid in this randomized trial did not improve prognostic concordance between clinicians and surrogates or alter patient or surrogate outcomes? Use the accompanying editorial to help frame your discussion. Compounded Topical Pain Creams to Treat Localized Chronic Pain. A Randomized Controlled TrialThe use of compounded topical pain creams has increased dramatically, yet their effectiveness has not been well evaluated. This trial assessed the effectiveness of compounded creams versus placebo for treating localized chronic pain.Use this study to:Ask your learners what topical analgesics are available. When are they considered for localized, chronic pain, and what are their potential advantages and disadvantages compared with systemic analgesics?Have your learners heard of compounded topical pain creams? How are they prepared, and by whom? Invite a member of your hospital's pharmacy staff to discuss with your learners whether these compounding services are provided and, if so, how the formulation is determined for a patient.Review the results of this study. Do they surprise your learners?Why do your learners think the compounded topical pain creams were ineffective in this trial? The authors provide some potential explanations in the paper's discussion.Invite an expert in pain management to review the mechanism of action of the drugs used in this study's compounded formulations. Does the expert from your center's pain service use compounded topical creams?In the Clinic: ObesityThe role of internists in evaluating obesity is to assess the burden of weight-related disease, mitigate secondary causes of weight gain (such as medications and sleep deprivation), and solicit patient motivation for weight loss. Are your learners prepared?Use this focused review to:How are “overweight” and “obese” defined? How and when should waist circumference be measured? Why is it useful?Ask your learners what the health consequences of overweight and obesity are. Use the information provided in the box. What outcomes have been shown to improve with intentional weight loss?Are your learners aware of drugs that are associated with weight gain? Are there alternatives? See Table 1. How do you decide when the risk for weight gain is outweighed by the drug's benefit?What are the secondary causes of obesity? How do the history and examination help in their evaluation? What testing should be considered, and when?Do your learners counsel patients about lifestyle modifications to achieve weight loss? What exactly do they discuss? Should the instructions be specific? How should an approach to dieting be discussed, and how should one be chosen? What are reasonable goals?When should medications for weight loss be considered? When should bariatric surgery be considered?Invite a bariatric medicine specialist to join your discussion. Which patients with overweight or obesity should be referred?Use the multiple-choice questions to help introduce discussion topics. Log on to enter your answers and earn CME and MOC credit for yourself!Humanism and ProfessionalismOn Being a Doctor: Bedside RoundsDr. Ruopp considers the relative benefits of conducting rounds in a conference room, outside the patient's room, and at the bedside.Use this essay to:Listen to an audio recording of the essay, read by Dr. Virginia Hood. Consider what rounding style you prefer, and why. Do you allow your learners to determine where and how rounds will be conducted?Ask your learners which rounding practices they have experienced and what they think are their relative benefits and problems.Do you conduct rounds at the patient's bedside? If not, why not? Should you try it?Ask your learners whether they believe there are issues that are too difficult or even inappropriate to discuss with the patient or family present. Does everyone agree? Do some members of your team think there might be value in discussing these issues at the bedside? Is there an appropriate way to do so?On Being a Patient: Regarding MarciaDr. O’Glasser asks, “How can we know what a small window of time potentially holds for a patient unless we ask?”Use this essay to:Listen to an audio recording of the essay, read by Dr. Michael LaCombe. Ask your learners what “DNR” means. Is the definition always the same?Should the definition vary? When might it be appropriate to rediscuss a “DNR” status with a patient to allow for more aggressive interventions than in the past?Why was Marcia's son upset at the idea of discussing code status again? What essential information regarding the issues and potential interventions might not have been effectively communicated to him, resulting in his anger?MKSAP 18 Question 1A 70-year-old man is evaluated before discharge from the hospital after treatment for community-acquired pneumonia. Medical history is significant for mild dementia. The patient lives alone and has a daughter who lives nearby. Remaining in his home is very important to him.The care team recommends that the patient be discharged to a short-term rehabilitation facility to gain strength and prepare him to safely return to his home. The patient refuses. Decision-making capacity is assessed; he is able to articulate the risks, benefits, and alternatives to short-term rehabilitation as well as an understanding of his current medical condition.Which of the following is the most appropriate management?A. Administer the Mini–Mental State ExaminationB. Ask the patient's daughter to make a decision on his behalfC. Discharge the patient home with home care servicesD. Obtain a court order for the patient to be discharged to a rehabilitation facilityE. Refer the patient to a psychiatrist for a capacity assessmentCorrect AnswerC. Discharge the patient home with home care servicesEducational ObjectiveEvaluate decision-making capacity.CritiqueThe most appropriate management is to discharge this patient home with home care services. Patients should be presumed legally competent to make medical decisions unless found otherwise by judicial determination. However, in the clinical setting, physicians must frequently determine a patient's decision-making capacity by assessing the patient's ability to understand the relevant information, appreciate the medical consequences of the situation, consider various treatment options, and communicate a choice. Decision-making capacity should be evaluated for each decision to be made, and frequent reassessment is necessary to confirm prior determinations of capacity. Patients with depression or mild dementia may retain decision-making capacity; however, in such circumstances, the capacity assessment should be performed more cautiously, particularly when a decision may result in serious consequences. Validated tools, such as the Aid to Capacity Evaluation, may be useful for capacity assessment in the clinical setting. In this situation, the assessment reveals that the patient demonstrates sufficient capacity to make decisions; thus, he should be discharged home with appropriate services to ensure his safety. This patient's choice is also consistent with his previously expressed wishes, which lends validity to his decision. Cognitive evaluations, such as the Mini–Mental State Examination, do not assess capacity; rather, they are used to detect cognitive impairment.This competent and autonomous patient is able to make his own choices; therefore, the patient's daughter should not be asked to make a decision on his behalf.Formal assessments of competence require judicial determination, although a competency hearing is not usually required for clinical decision making. In this case, a court order for the patient to be discharged to a rehabilitation facility is not required because he demonstrates decision-making capacity.A psychiatric consultation is unnecessary to determine a patient's decision-making capacity; any physician can perform this assessment. However, some hospitals may suggest a psychiatric evaluation in high-stakes situations, such as when a patient requests to leave against medical advice.This content was last updated in January 2018.Key PointIn the clinical setting, physicians must determine a patient's decision-making capacity by assessing the patient's ability to understand the relevant information, appreciate the medical consequences of the situation, consider various treatment options, and communicate a choice.BibliographyPorrino P, Falcone Y, Agosta L, Isaia G, Zanocchi M, Mastrapasqua A, et al. Informed consent in older medical inpatients: assessment of decision-making capacity. J Am Geriatr Soc. 2015;63:2423-4.MKSAP 18 Question 2An 81-year-old woman was admitted to the ICU 8 days ago for multisystem organ failure associated with a severe episode of multilobar pneumonia. She has required mechanical ventilation since admission. Efforts to wean the patient from mechanical ventilation have not succeeded, and the patient remains somnolent and unresponsive to verbal stimuli. Medical history is significant for dementia, diabetes mellitus, COPD, chronic kidney disease, and heart failure.The care team concludes and shares with the patient's family that she will not have a meaningful recovery; however, the patient's children request continued ICU-level care. The patient does not have an advance directive, and her wishes are unknown. After a family meeting with the care team to discuss the patient's prognosis, the children continue to request all treatment.Which of the following is the most appropriate management?A. Consult with the hospital ethics committeeB. Discontinue ICU care in 48 hours if there is no improvementC. Transfer the patient to another institutionD. Continue current level of careCorrect AnswerA. Consult with the hospital ethics committeeEducational ObjectiveManage a request for potentially inappropriate treatment.CritiqueThe most appropriate management is consultation with the hospital ethics committee. A recent policy statement from the Society of Critical Care Medicine recommends that appropriate treatment goals of ICU care include treatment that provides a reasonable expectation of survival outside of the acute care setting with sufficient cognitive ability to perceive benefits of treatment, or palliative care through the dying process in the ICU. Because conflicts between the desire to provide benefit to the patient and the desire to minimize the burden of treatment can be very difficult, one of the most important skills of the physician is the ability to communicate and negotiate a reasonable treatment plan with the patient's family. If these situations become intractable, many organizations recommend initiating a process to resolve the disagreement, including notifying surrogates of the process, seeking a second medical opinion, obtaining review by an interdisciplinary ethics committee, offering the surrogate the opportunity to seek care at another institution, and implementing the decision of the resolution process. This patient's family is requesting treatment that the care team does not think will achieve reasonable goals, and an ethics consultation may lead to conflict resolution.In some situations, the physician and the patient's family may mutually establish a time frame in which care will be withdrawn if there is no improvement; however, these decisions should not be made unilaterally by the care team.A physician should not provide treatment that conflicts with professional obligations and will not meet the goals of care. However, often by communicating his or her concerns, a physician is able to help a family understand the burden of continued, ineffective treatment. If resolution is not possible, family members may seek transfer to another institution; however, the physician is not obliged to initiate such arrangements.This content was last updated in January 2018.Key PointA physician should not provide treatment that conflicts with professional obligations and will not meet the goals of care; when the physician and the patient (or family members) have conflicting goals of care, an ethics consultation may be beneficial.BibliographyKon AA, Shepard EK, Sederstrom NO, Swoboda SM, Marshall MF, Birriel B, et al. Defining futile and potentially inappropriate interventions: a policy statement from the Society of Critical Care Medicine Ethics Committee. Crit Care Med. 2016;44:1769-74. doi:10.1097/CCM.0000000000001965Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Associate Dean of Graduate Medical Education and Affiliations, Thomas Jefferson University. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 5 March 2019Volume 170, Issue 5Page: ED5KeywordsDementiaDrugsIntensive care unitsObesityOverweightPatientsRandomized trialsVentilatorsWeight gainWeight loss ePublished: 5 March 2019 Issue Published: 5 March 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...