MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center...

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MDs Perspective on MDs Perspective on Working with Working with Families after Families after Trauma in Grief Trauma in Grief Lydia Lam, MD Lydia Lam, MD LAC-USC Medical Center LAC-USC Medical Center Division of Acute Care Division of Acute Care Surgery/Surgical Critical Surgery/Surgical Critical Care Care April 12, 2010 April 12, 2010

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Transcript of MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center...

Page 1: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

MDs Perspective MDs Perspective on Working with on Working with

Families after Families after Trauma in GriefTrauma in Grief

Lydia Lam, MDLydia Lam, MDLAC-USC Medical CenterLAC-USC Medical Center

Division of Acute Care Division of Acute Care Surgery/Surgical Critical CareSurgery/Surgical Critical Care

April 12, 2010April 12, 2010

Page 2: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

ObjectivesObjectives

Discuss how to approach the familyDiscuss how to approach the family Discuss how it affects staffDiscuss how it affects staff Discuss how it affects the physicianDiscuss how it affects the physician

Page 3: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

UNOSUNOS

Over 115,000 on the wait listOver 115,000 on the wait list 2009--- 14,631 donors recovered2009--- 14,631 donors recovered

28,464 transplanted28,464 transplanted 21,854 from deceased donors21,854 from deceased donors

Page 4: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

TraumaTrauma

Number one cause of death in those Number one cause of death in those 3-44 years old3-44 years old

Blunt trauma remains the majorityBlunt trauma remains the majority

Page 5: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

Surgical Surgical Intensivist/TraumaIntensivist/Trauma

Encounter those who are youngEncounter those who are young Patients you cannot resuscitatePatients you cannot resuscitate Caring for traumatic brain injuryCaring for traumatic brain injury

Understand the shortage of organsUnderstand the shortage of organs Understand your patientsUnderstand your patients

Page 6: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

TraumaTrauma

Unplanned admissionsUnplanned admissions YoungYoung No advanced directive or living willNo advanced directive or living will

Important to try to identify early Important to try to identify early patient’s wishespatient’s wishes

Page 7: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

Family Perspective Family Perspective ImportantImportant

Attitude of news delivererAttitude of news deliverer Well informed, knowledgableWell informed, knowledgable PrivacyPrivacy Clarity of messageClarity of message Clergy Clergy Autopsy informationAutopsy information

Jurkovich GJ. J Trauma 1999

Page 8: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

Family PerspectiveFamily PerspectiveLess importantLess important

Rank or seniority of care giverRank or seniority of care giver Attire of news delivererAttire of news deliverer Physical contactPhysical contact

Jurkovich GJ. J Trauma 1999

Page 9: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

Advanced DirectivesAdvanced Directives

Written statement of your wishes, Written statement of your wishes, preferences and choices regarding preferences and choices regarding end of life health care decisionsend of life health care decisions

Tool to help you think through and Tool to help you think through and communicate your choicescommunicate your choices

Only used:Only used: If you are seriously ill or injured ANDIf you are seriously ill or injured AND Unable to speak for yourselfUnable to speak for yourself

Page 10: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

Advanced DirectivesAdvanced Directives

State specificState specific Living willLiving will Medical power of attorney (MPOA)Medical power of attorney (MPOA) Do not resuscitate (DNR) ordersDo not resuscitate (DNR) orders Out of hospital DNROut of hospital DNR

Not transferrable state to stateNot transferrable state to state Need to execute by stateNeed to execute by state

Page 11: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

Living willLiving will

Legal document with your wishes Legal document with your wishes about medical treatmentabout medical treatment

You choose:You choose: What you wantWhat you want What you don’t wantWhat you don’t want

Page 12: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

MPOAMPOA Legal form that states who you want to Legal form that states who you want to

make decision about medical caremake decision about medical care Person is authorized to speak for you Person is authorized to speak for you

ONLY if you are unable to make your ONLY if you are unable to make your own medical decisionown medical decision

May also be:May also be: ‘‘health care proxy or agent’health care proxy or agent’ ‘‘health care surrogate’health care surrogate’ ‘‘durable power of attorney for health care’ durable power of attorney for health care’

(DPOA)(DPOA)

Page 13: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

MPOAMPOA

Power to make decisionsPower to make decisions Receive/review medical informationReceive/review medical information Discuss with medical teamDiscuss with medical team Consent to or refuse proceduresConsent to or refuse procedures Authorize transfersAuthorize transfers

If you are MPOA, make sure you If you are MPOA, make sure you understand what patient wantsunderstand what patient wants

Page 14: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

Advanced DirectivesAdvanced Directives

AdvantagesAdvantages In charge of making your own decisionsIn charge of making your own decisions Documents can change anytimeDocuments can change anytime You do not need an attorneyYou do not need an attorney Document can help you express your Document can help you express your

wisheswishes

Page 15: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

Advanced DirectivesAdvanced Directives

ExecutingExecuting Do not need lawyer to completeDo not need lawyer to complete Decide what type of life sustaining Decide what type of life sustaining

treatments you do not wanttreatments you do not want Discuss/inform with family and primary Discuss/inform with family and primary

doctordoctor If you change your wishes, complete a If you change your wishes, complete a

new advance directivenew advance directive

Page 16: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

Advanced DirectivesAdvanced Directives

DisadvantagesDisadvantages Not available to transfer between statesNot available to transfer between states

Living willsLiving wills May not be specific enoughMay not be specific enough May be overridden by a treating doctorMay be overridden by a treating doctor Does not immediately translate into Does not immediately translate into

doctor’s orderdoctor’s order

Page 17: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

TALKING IMPORTANTTALKING IMPORTANT

Honest discussion, reflection and Honest discussion, reflection and planningplanning

Opportunity to discover important Opportunity to discover important information on family and patientinformation on family and patient

Most important gift you can give to Most important gift you can give to prepare for the end of lifeprepare for the end of life

Page 18: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

Trauma SurgeonTrauma Surgeon

ABCDE of traumaABCDE of trauma

Page 19: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

AA

Advanced preparationAdvanced preparation TimeTime PrivacyPrivacy No interruptionNo interruption Review informationReview information Mental rehearseMental rehearse Prepare yourself emotionallyPrepare yourself emotionally

Page 20: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

BB

Build a therapeutic Build a therapeutic environment/relationshipenvironment/relationship How much do they need to knowHow much do they need to know All family presentAll family present Introduce yourself to everyoneIntroduce yourself to everyone Warn of bad newsWarn of bad news

Page 21: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

CC

Communicate wellCommunicate well What do they already knowWhat do they already know No medical jargonNo medical jargon TranslatorTranslator Frank but compassionateFrank but compassionate Allow for silence/tearsAllow for silence/tears If appropriate, repeat their If appropriate, repeat their

understandingunderstanding Follow up planFollow up plan

Page 22: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

DD

Deal with family reactionsDeal with family reactions Be empatheticBe empathetic Do not argue or criticize colleaguesDo not argue or criticize colleagues

Page 23: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

EE

Encourage and validate emotionsEncourage and validate emotions Use interdisciplinary resourcesUse interdisciplinary resources What does this mean to familyWhat does this mean to family RN, clergy or SW follow up after you RN, clergy or SW follow up after you

leaveleave

Page 24: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

FamilyFamily

AngerAnger Shock or numbnessShock or numbness Searching for any hopeSearching for any hope Disorganization and despairDisorganization and despair ReorganizationReorganization

Page 25: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

Stages of GriefStages of Grief

Kubler-Ross Stages of Dying (1969)Kubler-Ross Stages of Dying (1969) DenialDenial AngerAnger BargainingBargaining DepressionDepression AcceptanceAcceptance

Page 26: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

Stages of GriefStages of Grief

Engle’s Theory (1964)Engle’s Theory (1964) Shock and disbeliefShock and disbelief Developing awarenessDeveloping awareness Reorganization and restitutionReorganization and restitution

Page 27: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

Trauma SurgeonTrauma Surgeon

Feeling of failureFeeling of failure Fear of approaching topicFear of approaching topic Constraint for timeConstraint for time

Page 28: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

Trauma SurgeonTrauma Surgeon

Important to take controlImportant to take control Leader of the teamLeader of the team

Know your resourcesKnow your resources Recruit your resourcesRecruit your resources

Take a moment for yourselfTake a moment for yourself Review events in your headReview events in your head Remove signs of resuscitationRemove signs of resuscitation

Emotionally not drainedEmotionally not drained

Page 29: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

Trauma SurgeonTrauma Surgeon

Develop a rapport with family early Develop a rapport with family early TrustTrust SinceritySincerity EmpathyEmpathy

Page 30: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

Trauma SurgeonTrauma Surgeon

Stand firmStand firm Ultimatum sometimes necessaryUltimatum sometimes necessary Offer evidence of finalityOffer evidence of finality

Page 31: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

Approaching the familyApproaching the family

When death is imminentWhen death is imminent Maximizing comfortMaximizing comfort AcceptanceAcceptance TimeTime Saying good-byeSaying good-bye

Page 32: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

Approaching the FamilyApproaching the Family

Prepare info, location, settingPrepare info, location, setting Find out what they already knowFind out what they already know Ask how much they want to knowAsk how much they want to know Share informationShare information Respond to family’s emotionRespond to family’s emotion Negotiate concrete follow-up stepNegotiate concrete follow-up step

Page 33: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

Approaching the FamilyApproaching the Family

Avoid rote responsesAvoid rote responses Each family is differentEach family is different

Be genuineBe genuine Express your true feelingsExpress your true feelings Admit you don’t have words if you don’t Admit you don’t have words if you don’t

know what to sayknow what to say Avoid common greetingsAvoid common greetings

Hi! How are things going?Hi! How are things going? Don’t be afraid to discuss deathDon’t be afraid to discuss death

Page 34: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

Approaching the FamilyApproaching the Family

Don’t preach or lectureDon’t preach or lecture ListenListen

Let them talk and express their concernsLet them talk and express their concerns Ask what you can do. Keep the Ask what you can do. Keep the

promisepromise Be aware of the tone in your voiceBe aware of the tone in your voice

Avoid being condescending or pityingAvoid being condescending or pitying Check in on the family frequentlyCheck in on the family frequently

Page 35: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

Approaching the FamilyApproaching the Family

Offer ClergyOffer Clergy Time of stress, needed more than Time of stress, needed more than

people might realizepeople might realize Explain the need for autopsyExplain the need for autopsy

Page 36: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

ConclusionConclusion

Delivering bad news is difficultDelivering bad news is difficult Not well trained in medical school or Not well trained in medical school or

residencyresidency

Form relationshipForm relationship ClearClear PrivacyPrivacy EmpatheticEmpathetic

Page 37: MDs Perspective on Working with Families after Trauma in Grief Lydia Lam, MD LAC-USC Medical Center Division of Acute Care Surgery/Surgical Critical Care.

THANK YOU…….THANK YOU…….


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