Alumni Essay by Anand S. Iyer, MD

Dr. Anand IyerI arrived at the medical emergency call to a familiar situation, a man in his 60s with respiratory distress. The record confirmed he had an end-stage lung disease, and after stabilizing him, I braced for something I have become too accustomed to doing in recent years--emergency advanced care planning.

I couldn’t get a solid answer about his code status when I asked the residents, yet every note since admission ended in, “Code Status: Full.” Clearly, the most important discussions had not occurred.

Earlier this year, I wrote about the case of a patient with metastatic lung cancer and acute respiratory failure.¹ In that piece, I described how I had worked to "Do right by mama." Writing about it gave me the opportunity to reflect on an endless supply of similar cases during fellowship where I arrived to the bedside of a decompensating patient and instead of reflexively reaching for the endotracheal tube, I instead engaged in meaningful goals of care discussions about the end of life near the end of life.

I learned to prioritize goals of care as a pulmonary fellow and asked nearly every patient I saw in the emergency room or on the wards about their code status. Unfortunately, nearly half of older adults with a serious illness who present to the emergency room lack an advanced directive.² Several explanations may exist for this gap in care, one of them being insufficient training of primary and subspecialty physicians on engaging patients in tough conversations. Residents in particular express internal conflicts about this.³ 

Another reason may be lack of time on busy rounds or packed clinics. This will only get worse when already overloaded physicians at UAB begin to triage the additional 50,000 Alabamians in the ambulatory setting this coming year. When that happens, I worry that values-based discussions will be lost in favor of improving access to care. Given these barriers and concerns, what are ways to proactively prioritize patient values in the clinic and on rounds?

For starters, just do it. We can all practice embedding a few minutes for conversation with our patients and their family caregivers about their wishes alongside medication reconciliation and illness education. Additional solutions include modeling or simulating advanced care planning for learners, which is already occurring at UAB. Alternatively, we can try something simpler: flipping the checklist.

The daily rounding checklist we piloted as interns includes items that if missed could lead to a longer stay or an increased risk of mortality: antibiotics, steroids, nutrition, intravenous access, and others. Adherence to checklists seems to improve outcomes⁴ and reached peak popularity a few years ago.⁵ However, checklist fatigue has set in, and implementation has dwindled. Now, in the rare instance that the daily rounding checklist is performed, it is oftentimes incorrectly reported, with inconsistencies copied forward in the electronic medical record for days. Furthermore, the current checklist prioritizes code status last. To me, code status extends beyond resuscitation preferences. It is a surrogate for goals of care and patient values.

To respond to the epidemic of emergency advanced care planning, the time has come to flip the checklist and place patient values first. Residents who round with me in the ICU become accustomed to discussing patient values and goals just before completing the checklist. As the attending, I challenge members of my team to answer questions such as, “Who is this person to you?” or “What are the goals?” We may not solve these deep questions on rounds, but the mental exercises jumpstart the conversation and help us build an arch for the patient’s hospital stay that carries far beyond that admission.

Flipping the checklist to prioritize goals of care acknowledges that each patient we admit to the hospital has a serious illness and deserves meaningful discussions about their wishes. Doing so reserves a place on busy rounds and hectic clinic days for values. Our patients and their family caregivers deserve this.

References

1. Iyer AS, Bakitas M. Early Palliative Care in Advanced Illness: Do Right by Mama. JAMA Intern Med. 2017;177(6):761-762.

2. Elsayem AF, Bruera E, Valentine A, et al. Advance Directives, Hospitalization, and Survival Among Advanced Cancer Patients with Delirium Presenting to the Emergency Department: A Prospective Study. Oncologist. 2017;22(11):1368-1373.

3. Deep KS, Green SF, Griffith CH, Wilson JF. Medical residents' perspectives on discussions of advanced directives: can prior experience affect how they approach patients? Journal of palliative medicine. 2007;10(3):712-720.

4. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491-499.

5. Gawande A. The checklist: if something so simple can transform intensive care, what else can it do? New Yorker. 2007:86-101.