By Bethany Wood Harvey
I think it’s a fair assumption to say the Trauma ICU is a bit different than anywhere else in the hospital. Our patients are often in our care unexpectedly; they are ‘healthier’, working, and independent just hours before arriving in the TICU. Moreover, they are acutely sicker -their status is often tenuous and can decompensate quickly. In these situations, families are often thrust into the position of being surrogate decision makers, being faced with questions they had never previously considered. These family members look to the team to help guide and support them through this process. Although as surgeons we have 9+ years of medical education, often less than 1 month of that time is dedicated to how to effectively have difficult conversations.
While scrubbing for a trauma surgery, you may not know exactly what you will encounter, but at the sink, you rehearse the steps in your head. One needs to treat these conversations as if it were a case and prepare as such: know the history of the patient, the details of their prognosis, their treatment thus far, and anticipate complications that may arise. One way to accomplish this is a pre-meeting discussion with all of the services involved in the patient’s care, as trauma is a multidisciplinary field. Making sure everyone is on the same page with realistic goals, expectations, and treatments that may or may not be indicated helps to present a united picture for the already overwhelmed family.
Now, to the nuts and bolts of the family meeting. For some residents and attendings alike, I’m sure just the thought of running a family meeting induces palpitations. Thankfully, there are tools which provide a framework for surgeons to effectively elicit a patient’s goals and values: The Serious Illness Conversation Guide and the REMAP Framework for Difficult Conversations being the most frequently used. I encourage you to try both and see which is naturally easier for you!
For myself, I tend to use REMAP:
M:Map out a plan
A:Align with patient values
P:Propose a plan
I could dedicate an entire blog post to each step, but for myself as a surgeon in the TICU, learning to comfortably navigate the “reframe” and “expecting emotion” have been critical.
Reframe – In this step, the surgeon assesses the patient/family’s understanding of the patient’s medical course/prognosis and then helps them take a step back to see the big picture. “Unfortunately, we are in a different place than we were X days ago” is one of my go-to phrases. Many TICU patients were healthy, independent individuals and it can be extremely difficult for families to comprehend the new reality. “Although I’m hopeful your loved one may ___, I’m worried that they may not ___ (regain their independence, breathe without the help of machines)”. The reframe statement sends a ‘warning shot’ to the family and often elicits an emotional response.
Expect emotion – in this step one must recognize that the statement from the patient/family after the reframe is typically an emotion, despite sounding like a factual question: “Are you telling me there’s nothing more you can do?”,“Is my mom dying?” It is critical that the surgeon responds to the emotion first before continuing the conversation. “I can’t imagine how overwhelming this news must be” or “I wish there was a treatment that could fix this, but the team is here to support you”. This step has been the most uncomfortable adjustment for me. Physicians feel safe in numbers, percentages, and factual responses and therefore want to answer the factual question. It feels awkward to respond to a factual question with empathy or naming the emotion rather than an answer, but trust me it works! This allows the patient/family to process the reframe and move forward to collaboratively work on a plan.
This framework can be applied to any situation where you are breaking serious news; whether it is your vascular patient who has failed multiple revascularizations now needing to discuss amputation, or your surgical oncology patient with tumor progression despite neoadjuvant chemotherapy. Navigating these conversations requires deliberate practice, and I encourage you to review the referenced articles and begin to integrate them into your discussions.
Bethany Wood Harvey, MD, MHS, is a general surgery resident at the University at Buffalo, currently completing a fellowship in Hospice and Palliative Medicine at the University at Buffalo. She received her MD from Tufts Medical School and her MHS from the Johns Hopkins Bloomberg School of Public Health. She lives with her husband, 3 kids, and 2 dogs in Buffalo NY and plans on pursuing a Surgical Oncology fellowship after graduation. You can find her on twitter at @bdwood62.
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