Moving session coming up now post morning tea about oncology and end of life. @docranjana chairing a multidisciplinary panel - anaesthetist, palliative care physician, surgeon, Intensivist, geriatrician.

I absolutely adore a de-silo'd panel like this.

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Taking a moment to acknowledge and think of our colleagues in India dealing with the covid humanitarian crisis.

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This panel has no slides. @docranjana is channeling her inner Tony Jones!

Going through a case and we will ask questions and discuss as we go.

Oooh this will be a live-tweeting challenge.

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Here's the case:
74 yo man retired cleaner. 2 previous strokes (nil residual), severe osteoporosis with crush fractures and walking issues, postural hypotension, depression, CRF eGFR33, BMI 40, ex-smoker, AF, on a blood thinner.

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Asks the panel their view of this person.

Irene (geriatrician) - patient is vulnerable: brain issues, renal, lung, cardiac, difficulty walking
Won't take much for him to become disabled.

What would happen if he went to ICU? CC Don't know - could go well or badly.

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CC says not a 'nightmare patient' - would likely surprise us if he had an operation and came to ICU. This is a middle grade patient.

(agree with CC this sounds like a very routine patient for us, and most do well).

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Should we offer surgery?

VM (surgeon) says need to look at the patient journey right from beginning to end.

Says single most important thing is: don't make a decision with one consultation and one person.

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How do you decide if this patient is suitable for a long operation? A short operation?

DL (Anaes) The thing that stands out about this patient, is that nothing stands out. This profile is v standard. (agree). Need more information, including the person behind.

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Can the patient medically cope, plus the other discussions we should be having about the patient themselves. What are his values and goals?

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More history. SOCIAL.

Lives with unwell elderly sister, indep ADLs, continent, single level rented house, drives short distances, manages banking, sister organises online groceries.

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Geriatrician IW: Who is caring for who? How long have they lived together? Could they cope if he was unwell. Are they codependent. Not going out shopping is a concern (no socialising).

Side note IW is worried about older people stuck at home ATM with pandemic.

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Do you take a social history?
VM (surgeon) - says yes it is a routine part of his practice, social aspects very important.

(BTW surgeons I work with are terrific at knowing the patients social situation - it's a falsehood that surgeons don't care about this stuff).

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Ooooh @docranjana comments to VM that she hasn't read any surgical note which lists the patients children and the grandchildren. VM notes the importance of involving the whole team, especially at the MDT. @docranjana says info at MDT can be incorrect.

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Is a social history important for anaesthetists? DL: productive conversations about preoperative risk require a social history. Gather as much information as you can, before you start giving information. (This reminds me of the listening infographic I saw last week .)

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Gathering social information is also a time efficient way for the anaesthetist to develop rapport with the patient DL.

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Presenting hx: presented with lethagy and weight loss (attracted to poorly fitting dentures)

CT: 1cm LUL lung nodule, no nodes, bilateral pleural plaques, basal at FEV1 60% FVC 88% TLCO 64%
PET: 1 cm lesion post seg LUL, nil distant
R frontal lobe cortical stroke

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Decision to proceed to cardiothoracic surgery. Heart tests were not too bad.

Are we at a crossroad here?

VM (disclaimer he works below the diaphragm). Surgery is like a bus hitting you but oncology is like a minibus hitting you for a long period of time.

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VM says it's ok to re-discuss cases in MDT's - sometimes decision makers have received the wrong information, or different people present. Hard to know the functional decline after proposed surgery. What are the risks of biopsy?

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Most of us emphasise the options we are most familiar with. Have we checked that we have considered all of the options?
One interview skill is the hypothetical enquiry with the patient - what if this, what if that? We should share this more commonly with the patient.

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This patient had no documented discussion of any other non-surgical options, this may have happened but hard to know as not documented.

Consent form signed for left upper lobectomy.

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Once patient is consented and booked for surgery, how can we intervene if we think there is an alternative way?

IW says patient needs a support person in view of their comorbidities. Are there cognitive issues? Can the patient understand what is being proposed.

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ICU usually only hears about the patient from Anaes/surg that bed needs booking. CC worried now that this will go badly post-op. In particular who will make decisions if he can't? Is his sister up to it? We don't know about his wishes and goals.

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Is the patient thinking that the system is the patient advocate, not just an individual?

CC (intens) quite rightly notes that undoing things (esp if have been through MDT) is really difficult.

(I've tried this ...not easy ....esp when I've only just met the patient)

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CC notes chance of delirium post-op extremely high. Wants to find a decision maker at least.

Is ICU the 'innocent bystander'?

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Can anaesthetists 'push back' against a surgical decision to operate?

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It is absolutely difficult to go back to the start of decision making once it has been decided.

We can however confirm decisional quality. Surgical, pall care, geriatrician, intensive care etc and for the patient. Is their care structured for the best outcome.

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How do we balance the need to cure, with functional outcome. Palliative care, geriatricians etc see the functional outcome later. Is there a disconnect? Is 'cure' the only point?

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How can you carefully bring up concerns with colleagues and still preserve relationships?

(this reminds me of @mlanefall speaking about relationships between us during the deteriorating patients).

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Pall care PM

I need to ask you something difficult. (prepare them for what's coming)
I need to talk to you ask you something difficult and it may be scary.
If we have the op and you don't wake up well, what would that mean to you? What would it mean to your sister?

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SPIKE protocol for difficult decisions.

Setting
Perception
Invitation (what matters to them)
Knowledge
Empathy/ respond to emotional q
Summary/strategy

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Average clinician interrupts the patient at 9 seconds ...

We need to listen more, talk less.

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VM @Murali_HPBSurg says patients wishes change during their journey. Might begin with 'I want to live', and then become different as the different treatment options are explained, and the patient has a deeper understanding of what is involved.

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Intensivist CC quite rightly says most patients just want the cancer removed, no complications, and go home. Pretty hard to convince patients to not have operations or chemo ....

Says he is often surprised how well many high risks patients have gone (me too).

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CC says most people want to have a go, and it may or may not work. They want to be fixed. (I agree).

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OK, now back to the story.

Intraoperatively - cancer more extensive, Lobectomy is now a pneumonectomy.

Big ethical dilemma v stressful for surgeon ... decision making is not easy. How do you deal with this @Murali_HPBSurg ?

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VM notes that this unexpected difficulty (of more advanced ca) is within the realm of possibility. Notes in pancreatic ca surgery there are points where he would not proceed, it's understood that not all will be known before. This should all be discussed before.

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Rapid shared decision making relieves us of the burden of terrible decisions we have to make immediately when the patient has unexpectedly deteriorated says DL anaesthetist.

(Agree with this, works really well when you work in a high trust high functioning team).

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VM says he will ask his fellows to help with decision making, advocates 'call a friend'. Has 6 surgeons who would all come at the drop of a hat.

(Good relationships are everything in patient care, rudeness and incivility means that we won't call others for help).

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How does intensive care define recovery?

CC says it used to be leaving ICU, Now @anzics data looks at hospital discharge. Increasingly looking at longer term outcomes.

RS notes ICU full of patients who are frail with poor functional outcomes.

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On one hand, ICU full of patients with frailty and poor functional outcomes, on the other side, CC notes everyone angry with ICU if they won't take a patient. (They are damned if they do and damned if they don't).

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Back to the pt.. survived pneumonectomy.. not great at home.. declining ... sister didn't want carers .. residential care.... off to see oncologist for chemo! Decisional regret .. 'had I known, I would never had said yes to the operation'.Died in hospice months later.

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How can we empower doctors to ask more questions about appropriate treatments for those who are frail?
PM:
PROMPT and PREMS will drive culture change.
Equip with communication skills.
We need to be brave
Note about wellbeing impact for clinicians (moral injury)

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Who should be the gatekeepers of decision making?

Decisions should be made in groups.
Head of palliative care attends @Murali_HPBSurg 's cancer MDT's.
And of course it's one thing to invite others, but also listening to their expertise (diversity AND inclusion).

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Gosh Prof Peter Martin runs a palliative care obesity clinic ... palliative care isn't just end of life care.

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Great q from the audience about consent and risk communication.

A big list of risks perhaps isn't impactful to our patients (mi, stroke, infection etc).

What about a narrative ... what if you couldn't live at home anymore, would you regret your decision?

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Notes that we should perhaps move from a quantitative risk discussion (x % chance of y) to a qualitative dis which is more tangible for the pt.

DL notes however that no matter how the decision is made, most will want surgery. As clinicians we should accept that.

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It's not true that shared decision making will stop patients from having surgery, but we will sleep better at night knowing that the patient is truely informed. Bad things will still happen.

Decision regret with both commission and omission. (DL)

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Wrapping up now. Clearly shared decision making is very complex. Preoperative medicine can help us with all of this (I'm looking at you @VBeavis @PMbloke) .

Patients aren't distressed by the complication, it's that they weren't informed. PM

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Ultimately it's all about high trust between us as treating clinicians, and with our patients.

Don't forget a patient advocate to help pt's with their decisions.

Give pt's a narrative of their journey:
Best outcome satisfies hope
Worst outcome satisfies reality

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