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1/During normal times, there's a reasonable chance 1. A health care surrogate will be at the bedside of their sick loved one in the ICU 2. Loved ones will be there as well for mutual support during talks w/ HC team. Chances of both during #COVID19 are ~0. #pallicovid #hapc #icu
2/Stress of surrogate decision making is high during normal times, and the facts listed above only serve to multiply that stress. Healthcare teams who rely heavily on communicating JUST with a surrogate need to take notice of this thread. #pallicovid #icu
3/Since we know the laws and ethics as they relate to surrogate decision-making, we sometimes oversimplify how this will go. "If only" we can identify who the right surrogate is and "if only" we can get them to exercise substituted judgment, the chips will fall into place!
4/If only it were so simple. The pace of time for surrogates of people in the ICU is not the pace of the healthcare team. For the surrogate, having THIS person in the ICU at THIS time is a once in a lifetime story. #pallicovid #icu
5/Surrogates make decisions in emotional milieu that includes coping w/ prognosis (and associated anticipatory grief), considering decisions that are often wrought with uncertainty, how decisions will impact themselves and other loved ones, and a ton of other factors. #hapc #icu
6/ I cannot count how many times I've been in a "normal time"/non-pandemic family meeting where a primary surrogate (let's say a spouse) is overwhelmed, and other family/loved ones come through with essential support for the surrogate. #pallicovid #hapc #icu
7/ Other loved ones are able to bring important patient insights about goals/values, know the surrogate's "stress" points and limitations, and more about WHY any decisions might be so hard. #pallicovid #hapc #icu
8/ Loved ones will go home with the surrogate, so there's a ton of "work" they do outside the healthcare family meeting, both during the patient's ICU stay and well beyond. It's the family's story, not just the patient or surrogate story. #pallicovid
9/ So, how do we reconstitute what often happens organically in normal times? ie Including other family members in important conversations. I think there are a couple of steps we can all take to shore this up. #pallicovid #hapc
10/ First, don't just identify a surrogate- identify who else is most important to patient and who the surrogate might lean on if faced with difficult discussions. Get names and phone numbers. #pallicovid #hapc #icu
11/ Tell surrogate you will give them daily updates, but that for significant conversations, you want to include others. #pallicovid #hapc #icu
12/ Second, know when you're about to talk about serious news and have a low thresshold to involve the surrogate's support in those conversations. This is part of the "S" in the SPIKES protocol. Pay extra attention to it. https://theoncologist.onlinelibrary.wiley.com/doi/full/10.1634/theoncologist.5-4-302 #pallicovid #icu
13/ Third, know when you're about to have a goals of care conv and include the surrogate's support/other patient loved ones. For other resources on having GOC conversations, see @vitaltalk. #pallicovid #hapc
This relies on being a bit facile with technology (not THAT hard!)
This relies on being a bit facile with technology (not THAT hard!)
14/ At my hospital, we use @avaya phones, @Webex, and @Google Duo as platforms for group communication. Sometimes, a group phone call will suffice, sometimes "face to face" via video is desired. Be flexible. #pallicovid #icu
15/ Families have been flexible with tech, and just want to talk! #pallicovid #hapc
A couple of other thoughts related to this. A few of my favorite essays on stress of surrogate dm come from #hapc colleagues. https://jamanetwork.com/journals/jama/article-abstract/184746 and OMG there's another one I cannot find.
A couple of other thoughts related to this. A few of my favorite essays on stress of surrogate dm come from #hapc colleagues. https://jamanetwork.com/journals/jama/article-abstract/184746 and OMG there's another one I cannot find.
16/ The second essay was written by a #hapc physician as he made EOL decisions for his wife in the ICU. Written circa 2007-2013, perhaps? I think I know who wrote it. It made an indelible impression on how I see these things, and I WILL find it. #hapc #icu
17/In meantime, recognize that identifying and talking to the right surrogate is not enough. Make sure you "know your tech" options to remove any barriers to supporting surrogates. See my tweet here for more on one tech option: https://twitter.com/FettigLyle/status/1252908381934964737 /fin
CODA: A few years ago, Indiana changed the healthcare consent law to create surrogate hierarchy, if no named proxy. Previously, there was no hierarchy, but only list of eligible surrogates who had "equal say." Previous law never bothered me and promoted consensus building
I'm fine with the change to create prioritization of surrogates and agree there are advantages, but worry at times that exclusive focus on "top of hierarchy" worsens stress on surrogates. It's an unintended side effect that many people overlook. #hapc
