Especially draining case. Anybody have any coping advice?

[YouHaveNoIdeaWhereIWork]

Hey Everybody! I made a new account to post this because at least a few people on here know where I work and I didn't want that linked to this. I'm pgy3 now and up until this point, I've never had anything that was this emotionally taxing on me. I mean yeah I've had plenty of tough cases and bad loses but this is something else.

It's a fairly complicated situation and I'm trying to keep it generic but we've had a patient under our care for awhile now. This patient is incredibly sick. The person with power of attorney and refuses to sign a DNR and keeps insisting we do everything in our power. It's a close relative and he/she wants us to do whatever we can for her (nothing at this point beyond barely keeping her alive and he knows this). I understand where this is coming from and I'm thankful I'm not in that position but the patient is clearly suffering - told the attending "let me die". But of course he won't. He can't.

I know it's crazy to say this but up until this point, I loved my job. I even loved my job as an intern. I'm supposed to hate being a resident but didn't. I do now though. I can't sleep because I know I'm going to have to go round on this patient in the morning. When I'm working on another case I can usually keep it out of my mind just because I know I have to or something bad could happen but any minute I have of down time, I start thinking about it. I'm miserable. I just feel helpless. I've been on this case since admission, I've scrubbed in every surgery, I have the chart memorized, every change in the past 2 months, yet there's nothing I can do. Nothing any of us can do.

Has anyone been in a similar situation? How did you cope?

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[FutureInternist]

This is a very common situation unfortunately
People who have not seen the pt for years suddenly come back into their lives 2/2 guilt, others keep pt alive in order to cash their social security checks etc etc

Did the pt say "Let me die" when they were coherent? If so , then you should get the ethics committee involved since the POA makes decisions when pt is unable to, although once pt is "out of it" they can do whatever the hell they want.

Did YOU do everything in your power to convince the POA? If so, rest easy & hope that the POA burns in Hell

This will happen MANY times during your career, you may think about getting Psych help (do NOT go through your residency)

 

[Gastrapathy]

This isn't an uncommon scenario in the icu. At some point, you just have to strengthen your defenses.
1. You aren't the one on the vent
2. Not your family
3. Procedure based residency so if the patient doesn't benefit and you can't fix that, at least you and society benefit by training a surgeon.
4. Ethics committees exist to take this burden off individual MDs. If your attending wants to punt, he or she can. If not, then you should try to see why this isn't such a big deal to the attendings.

 

[PteFabulous]

I totally understand that feeling of not being able to fix it. It's something we all go through, and I think as long as you are aware of your feelings, and aware of your boundaries, that's the most important thing. Take some time to think through those feelings and be okay with the reality that your pt is dying.

I would also recommend getting a palliative care consult for your pt. Palliative care has a way of approaching pts that I find really helps the paint and emotional suffering. It's a really amazing thing actually.


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[Shikima]

Ethics committee, SW, Chaplin and/or Hospice consultations?

 

[rokshana]

Ethics committee, SW, Chaplin and/or Hospice consultations?

agree with this as well...if the pt has the capacity to make her decisions, then her voice needs to be heard...and having psych and the ethics committee weigh in would be helpful...HCP is only to make decisions for the pt if the pt is unable to do so...

 

[Shikima]

agree with this as well...if the pt has the capacity to make her decisions, then her voice needs to be heard...and having psych and the ethics committee weigh it would be helpful...HCP is only to make decisions for the pt if the pt is unable to do so...

There is little psych can do in reality since it's a medicolegal issue, however, likely would be part of the ethics team for the hospital.

 

[rokshana]

There is little psych can do in reality since it's a medicolegal issue, however, likely would be part of the ethics team for the hospital.

psych can state whether the pt has capacity...medicolegally it will be important to have psych's opinion on that even if others can make that determination.

 

[Shikima]

psych can state whether the pt has capacity...medicolegally it will be important to have psych's opinion on that even if others can make that determination.

Yes and no. I don't see it going to court in all honesty, rather a lot of family meetings and drama to have care decided in committee.

 

[NotAProgDirector]

Agree with all of the above. Sometimes, what you (or the attending on the case) needs to do is say "Your loved one will not get better. Nothing we do will reverse the multiple organ dysfunction. I've discussed this with (insert all specialists involved) and we all agree. All we are doing now is causing him/her suffering for no benefit. Even your loved one recognizes this." (Note that this is paraphrased -- don't read this to them, you need to plan for a long conversation). We often create these false hopes that there is some chance of improvement, where there isn't. Often times, families are able to let go when you (and the whole team) are clear there is no chance of recovery. Sometimes, you get the "miracle defense" -- there's always a chance of a miracle, right? I point out that if that's the case, we might as well focus on comfort since the chance of a miracle would be the same either way.

 

[doc05]

why do you keep operating if it's hopeless?

 

[Doctor Bagel]

psych can state whether the pt has capacity...medicolegally it will be important to have psych's opinion on that even if others can make that determination.

It sounds like decisions are already being made by someone other than the patient, so I guess it's already determined that the person doesn't have decision making capacity. Actually any doctor can make that determination. In two of the three hospitals that I've worked at, psych will not officially make that determination on the consult service but will assist teams in knowing how to make the determination. So, yeah, I'd go for palliative care and ethics first.

 

[dpmd]

why do you keep operating if it's hopeless?

Attending that doesn't give a rat's ass about end of life care (which might be why they don't have the balls to just go by the patient's request to be let go)? I had to deal with the issue a few times where the attending was the one who wouldn't accept the futility of the situation despite the patient and or family wanting to let go. I would enlist the help of the nurses who have the ability to call for an ethics consult themselves so that I could go around the attending without getting into trouble. They are also helpful for when the family just isn't being realistic. If you have palliative care bring them in too. Even if the outcome doesn't change, those folks were always really supportive and helped me cope a little better (or just cry on their shoulder for a little bit).

 

[rokshana]

It sounds like decisions are already being made by someone other than the patient, so I guess it's already determined that the person doesn't have decision making capacity. Actually any doctor can make that determination. In two of the three hospitals that I've worked at, psych will not officially make that determination on the consult service but will assist teams in knowing how to make the determination. So, yeah, I'd go for palliative care and ethics first.

that is not always the case...especially if the pt is saying something that the attending does agree with...we tend to believe people can make decisions when they agree with us and only call consults for capacity when the pt doesn't agree with out idea of how they need to be treated.

and interestingly enough my experience has been that psych will not make a determination that a person does not have capacity when most people feel that they don't (lots of negatives there i know!)...but the family and the court puts greater weight when psych gives an opinion, even if other physicians can make that decision...sounds like your psych consultants want to pass the buck...

 

[doc05]

Attending that doesn't give a rat's ass about end of life care (which might be why they don't have the balls to just go by the patient's request to be let go)? I had to deal with the issue a few times where the attending was the one who wouldn't accept the futility of the situation despite the patient and or family wanting to let go. I would enlist the help of the nurses who have the ability to call for an ethics consult themselves so that I could go around the attending without getting into trouble. They are also helpful for when the family just isn't being realistic. If you have palliative care bring them in too. Even if the outcome doesn't change, those folks were always really supportive and helped me cope a little better (or just cry on their shoulder for a little bit).

if that is what the OP has encountered, then he needs to confront the attending. these situations get ridiculous. remember the attending is not always right.

 

[dpmd]

if that is what the OP has encountered, then he needs to confront the attending. these situations get ridiculous. remember the attending is not always right.

Confronting the attending is not always a good idea. Sure you can advocate for your viewpoint but when they shut you down (like what happened in my situation) then pushing further will piss them off and get you in trouble, whereas if ethics gets called by the nurse and they get overruled they might get mad but you don't get in trouble. Although my problem staff wasn't because she didn't care, she cared a lot but just didn't believe in dnr/comfort care in almost all cases. With someone who really doesn't care then a confrontation might work.

 

[NotAProgDirector]

Attending that doesn't give a rat's ass about end of life care

This is the worst. Best you can make of a situation like this is promising yourself that you'll never let this happen when you're in charge.

 

[caffeinatedresident]

Been involved in a somewhat similar situation with a PICU patient (although pt intubated and unable to verbalize anything). Palliative care was involved for months and there had been frequent end of life conversations for months yet family member was consistent and very firm in continually pushing for the full spectrum of intervention. After the pt passed away, there was concern that the family member would actively self-harm. Very much a situation of "nothing I can do. Nothing any of us can do."

If everything else that others have mentioned has been done, and there literally is nothing that any provider can do to fix the situation (i.e. every resource has been involved, every discussion has been had), here's some possible ideas for how to cope with the situation.

1) Are you the sole resident on the service? If not, can you switch with a different resident in order to stop being this patient's primary resident? Even if it's highly disproportionate trade that's not in your favor (from a workload standpoint), having a break to gain some emotional distance would be beneficial. If you can't sleep and if you can't break these thought/frustration spirals, you won't be able to be a very effective provider for this patient or for your other patients (eventually). It's not abandoning this patient. Sometimes you need to be able to put up emotional boundaries for self-preservation. If there is truly nothing that can be done, can you absolve yourself of some of the emotional responsibility?

2) If your work environment / colleagues seem conducive to it, discussing this with others who are involved and sharing the same frustrations can be helpful and cathartic; sometimes just knowing you're not alone helps. Wouldn't do this if there is conflict w/in the provider team though.

3) Sleep is good and getting more of it might help with increasing emotional "reserve." Try exercise, melatonin, doing distracting things before bed to keep work out of your brain to maximize potential for getting rest.

4) Intentionally seek positive reminders of life / signs of thriving. This may sound silly, but I sometimes go to a local park and just sit in the sun (possible on a post-call morning), and watch kids & dogs play, and moms out w/ babies. It provides a visible contrast to death & suffering & visceral grief expressed by people...and is a reminder that life and joy can exist. Even better is actually getting to interact with babies or puppies Find your version of this.

Just some thoughts based off of what I found helpful in coping with numerous deaths in the NICU, PICU, and peds heme/onc this year.

I hope things get better for you.

 

[WinslowPringle]

Is the situation any better?

Have you yourself sat down with the family and explained - in great detail - the risks/benefits to surgery and the prognosis and goals of care? If you have been having that much contact with the family, you might be in a good position as a liaison to make a difference.

Had a similar situation first weeks of internship this year, too. It stinks.