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.
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.
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
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?
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.
- 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.
Prebrief: 3 minutes (longer if participants are unfamiliar with the simulation environment and principles).
Simulation: 15–25 minutes.
Debrief: 20–30 minutes.
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.
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, http://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).
When 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? Should we call it? I think we should stop it, we have been running the code for 20 minutes, I think we should stop.” If the code team leader decides to continue, the facilitator will stop the code 5 minutes afterward and debrief. The RT emotionally suggests that resuscitative efforts should continue because the patient is so young and has young children.
This scenario is used formatively. Instructors are offered ACLS-based checklists and teamwork checklists as aids to assist in identifying performance gaps. Example checklists can be found in the supplementary digital content (see figure, Supplemental Digital Content 2, http://links.lww.com/SIH/A322, ACLS checklist). A specific checklist to assess performance in facilitating family member presence at the resuscitation is not used. We consider the family member to be part of the “care team” and that interactions with the family member can be assessed as part of the global assessment made. The Ottawa Global Rating Scale may be used to assess performance of crisis resource management skills.13
We conduct our debriefings with critical care physicians who are both trained debriefers and content experts, to ensure that they are able to provide supplementary teaching when appropriate. The debriefer generally uses an advocacy-inquiry approach but will employ other techniques when appropriate.14 The confederates participate in the debriefing to provide insight into how they felt the team interacted with them during the scenario. Because adherence to ACLS guidelines is only one of the learning outcomes of this scenario, the debriefer must ensure that an inordinate amount of time is not spent debriefing only about this. However, if significant performance gaps occur, they should be specifically addressed.
The following questions can be explored during the debriefing, after allowing the leader and team to discuss what happened. They give the debriefer the chance to provide supplementary teaching when appropriate and, for the group as a whole, the opportunity to explore any emotional reactions to the scenario:
- How do you decide when to terminate resuscitative efforts? What influence does the presence of a family member have on this decision? How does the patient's prognosis and previous end-of-life discussions impact this decision?
- What, if any, is the hospital/institution's policy on the presence of family members during resuscitation (facilitator to review in advance)? What are the potential benefits and drawbacks of permitting family members to be present?
- Were the needs of the family member appropriately attended to during the resuscitation? How was the family member kept involved and informed? How did her presence impact the resuscitation? What strategies can be used to facilitate and support family member presence without it impacting on the quality of resuscitation? What do you do if their presence is negatively impacting resuscitative efforts?
- How do resuscitation team leaders and members cope with the emotional and psychological toll difficult resuscitation experiences can have? How do you go back to your “usual” work after a resuscitation? What supports are available after a particularly impactful experience?
- What responsibility do you have as the resuscitation team leader to establish a shared mental model and to facilitate collaborative efforts during a resuscitation? How do you ensure that other team members' voices are appropriately heard during a resuscitation? How do you address conflicting opinions on when resuscitation attempts should cease?
SUMMARY AND COMMENTS FROM PREVIOUS SIMULATIONS
This case illustrates some of the challenges that can arise when a family member is present during resuscitation and some of the difficulties associated with deciding to terminate resuscitative efforts within a resuscitation team itself. This scenario serves as a stimulus for debriefing and future learning about these complex issues. Residents who participated in this scenario have found it to be very realistic and stressful, stimulating learning in a way that a simple discussion would not. They almost universally felt better prepared to deal with these complex issues in real life. The performance of residents in the scenario varies considerably, potentially because of previous experience, but always leads to valuable debriefing discussions. Many residents continue resuscitations for longer than the supervising critical care physicians would if they were the team leader, and some do not cease resuscitation before the simulation “times out.” The ability to appropriately attend to the family member's needs and to demonstrate good crisis resource management skills also varies considerably. Infrequently, residents have strong emotional reactions after the scenario. Although these have usually been sufficiently explored during the standard time allotted for debriefing, the debriefer is asked to be available to explore further at a later time if needed and notifies participants about how to cope with strong emotional reactions after running a resuscitation.
This case allows the learner to practice running a resuscitation with a distraught family member present. We discuss that in general, family member presence should be facilitated, even if the patient is a child or pregnant woman, as long as their presence is not impeding resuscitative effort or as long as emergent procedures, such as emergent cesarean section, are not being performed. If family members are aggressive, extremely unstable emotionally, cannot be calmed, or are suspected of having been involved in abuse of the patient, they should not be permitted to be present.15 As previously mentioned, there has been conflicting data about whether family members affect the quality of care delivered during resuscitation.7,8 In previous studies, it may be that experienced code leaders are able to provide high-quality resuscitation while facilitating family member presence, whereas residents struggle to do so.7,9 We believe that by allowing residents the opportunity to practice leading a resuscitation with family members present in a simulated environment, we may better prepare them to perform an effective resuscitation in real life, while allowing family members to potentially accrue the benefits of being present during resuscitation. In our experience, well-trained confederates and pilot testing of the scenario have been very effective at creating an appropriate amount of realism and emotion.
Although it has been debated if the simulator should be allowed to die during a simulation, we feel that it is essential in this scenario to provide an opportunity for residents who are or will become resuscitation team leaders to explore these difficult issues.16 Evidence exists to suggest manikin death during simulations is acceptable to residents.17 This scenario portrays a patient where ongoing resuscitation is futile given her underlying widely metastatic cancer, prolonged asystole, and an EtCO2 of less than 10 mm Hg for approximately 20 minutes.18–20 Because the patient also had metastatic cancer, the chances of survival to discharge of hospital are lower, with one meta-analysis showing an overall survival to discharge of 5.6% without factoring in additional variables such as prolonged asystole or low EtCO2.21
Allowing the learner to work through a scenario where they will need to decide to cease resuscitative efforts provides an opportunity for the learner to discuss what influences their decision in this scenario in particular and to also discuss what influences decisions regarding when to cease resuscitative efforts in general. This scenario allows them to debrief about the challenges associated with making such a decision, how to best deal with family member presence, and how to effectively lead a resuscitation team.
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