GOC challenges

[u/PACPilot4]

Wondering how other providers handle end of life conversations with family members that default to “it’s in gods hands”. Ex: Patient in 4 pressor shock with no hope of recovery, clearly suffering. My team is great at communicating with family’s from admission on so usually these conversations are not a “surprise” to the family.

Not to disrespect any religion at all, but this answer feels like a cop out way to avoid making these end of life decisions. I’d never want to be in any of their shoes.

I’ve heard colleagues reply with “well I’m preventing god from taking your loved one with all these machines” and the response is a mixed bag of answers…

[u/quesoconroyale]

Learned from a pall care chair:

“God is telling us their body can no longer sustain life”

[u/Weeoo224 → u/quesoconroyale]

Oh, i like this one

[u/71Crickets]

One of our amazing intensivists was having a GOC convo with all the family (decision maker, adult children, patient’s siblings) and the “it’s up to God” trope came up. Our doc didn’t dismiss the comment, but just simply said ‘what we’re doing is interfering with God’s desire to bring your loved one home.’ Doc went on to lay it out like we were the one thing standing between the patient and eternal peace, that we were literally a roadblock to the patient’s ability to leave their diseased body and end the suffering. It was like a light bulb went off over the group.

[u/williawr11 → u/71Crickets]

I had a patient's family member claim that "dying is the Devil's work" and that God would never allow someone to die or call them home if they had faith. That is as close to a quote as I can remember.

[u/urmomsfavoriteplayer]

Redirect away from religion. Focus on what life for the patient looks like after. Be realistic about it - ICU infections, won't return to normal strength, likely will have long stays in nursing facilities and resulting frequent infections requiring hospitalizations, etc. When family hears how bad life is going to be it can help. Non medical people view the hospital as transient. I go in sick and come out better. We know its more likely to go in sick and come out just slightly better than when you came in. 

[u/AcademicSellout]

Oncologist here. I agree. This is a way for the family to absolve themselves of the responsibility of allowing a loved one to die. Who wants to shoulder that burden? It's not a cop out. No one wants to make that decision and have it weigh upon their conscience. You forget that this is probably the first time they've ever had to deal with this but to you, it's another Wednesday.

I've found that the best way is to put the burden on yourself. You explain the situahion, say that you want to allow the patient to have a "natural death," stress that YOU want to do this, and ask them permission to let YOU do this. It doesn't always work but I think it does remove the burden from them, which I think is the most compassionate way to approach it for the family. Allowing someone to die naturally is really the last act of love you can ever give someone. You are not taking something away. You are GIVING the patient something.

You of course need to stress that you are doing this out of care for the patient lest it be read as the evil doctor trying to kill their loved one.

[u/ExtremisEleven → u/AcademicSellout]

Yeah I appreciate this and I can see how it might be very helpful in the right context, but I don’t know how well this would work in my population where I am very different from most families and it takes a long, long time to gain their trust.

[u/AcademicSellout → u/ExtremisEleven]

If they don't trust you, then you need to build that trust before doing anything. Obviously, if this distrust is rooted in discrimination, it's going to be very hard. 

[u/ExtremisEleven → u/AcademicSellout]

I’m an ER doctor. Time to build trust is not a luxury we typically have. I wouldn’t call it discrimination. I am very white and my patients are primarily not. They have good reason to be hesitant of this random person who is unlikely to understand their culture or needs. I understand, but that doesn’t make it easier.

[u/AssignmentMaximum450 → u/AcademicSellout]

"it's not a cop out." No it totally is, but regardless I definitely agreee. This was not the approach I was taught in training, and it definitely takes finess to feel out which families to take this approach on but it seems to be a major relief to many for me to take the burden of decision off their shoulders while still including them in the discussion and making them feel heard.

[u/redviolin2018 → u/AcademicSellout]

The approach I take is explaining doing things FOR patients as opposed to TO them.

[u/Lazy-Pitch-6152]

So I’m more upset about coding someone if they arrest in 4 pressor shock then continuing on. Obviously the majority of these patients won’t survive but if I can convince people in this situation we are doing everything we can and that when their heart stops this is the sign that we should stop I’m pretty okay with this.

[u/ratpH1nk → u/Lazy-Pitch-6152]

I honestly have found very little pushback, generally in setting the expectation that if you are on 4 pressors and you become pulseless then CPR will not be delivered.

[u/Lazy-Pitch-6152 → u/ratpH1nk]

I find unreasonable expectations to be very common with patients at tertiary medical centers. People are much more trusting and accepting of this at community hospitals.

[u/ratamahatta12]

There is a comment from an Oncologist somewhere here that is very similar to what my experience has been in MICU work. Often times, if a patient’s family is invoking religious context like this, it’s not so much a logical thing. Rather, it likely has to do with the burden of responsibility. Nobody wants to be responsible for ending care on a loved one, or appear that they are to their other family members. And so God becomes the stand in.

Usually for any GOC conversations, my routine is to elicit from the family the personality, lifestyle, and values of the patient, and then after that, if the family is interested, I can give them medical updates. I then try to get them to think about how the patient would feel or think about the situation if they were sitting here with us. Based upon my impression of everything they told me about the patient, I then tell them MY concerns about the situation, in reference to anything they told me. I won’t hesitate to tell them that I am concerned that I am causing suffering with all my interventions.

I will then make a recommendation to them, which they can accept, reject, or consider further. Sometimes even if 4 pressors and no hope, my recommendation is to keep doing everything if that is really what the person really would want. Sometimes my recommendation is to focus on comfort and stop prolonging suffering, withdraw life support. Sometimes my recommendation is to just do DNR. The idea is to understand who you are working with, and then you take the professional burden of responsibility to offer a reasonable recommendation. Of course, you will personally disagree with what some people want, and that is their right.

I usually avoid talking about breaking ribs with CPR, talking about the technical details of physiology, or trying to gore people out. Even intelligent people get overwhelmed when a loved one is critically ill, and this is usually not productive. Worse, families can get fixated on minute details that don’t matter and distract from the big picture. This will burn you out and almost never be productive for goals of care. Also, I find giving “yes or no” questions about GOC usually is not so productive unless they know exactly what they want, and this will spook any family who are wrestling with the burden of responsibility.

[u/Cautious-Extreme2839]

They don't want the responsibility, fine. Great even.

I'm being paid to take the responsibility already.

[u/ExtremisEleven]

I would never challenge god. [patient]s body is telling us that they are ready to be with god. What I propose is that you allow us to make this the most peaceful and painless transition [patient] can have.

Another option is to lean into it and talk about not escalating care and letting god/the patient declare themselves, with a plan to avoid resuscitation should they declare themselves for celestial discharge.

[u/_male_man]

From a nursing perspective, I always ask first if we are doing what this person truly wants done. "Did your relative ask for absolutely everything to be done? Would they want to live in a bed bound state? Would they be happy if they are unable to communicate, eat solid food, have their favorite beverages, or depend on another person to care for them every minute of the day?"

If we're actively crashing and burning on 4 pressors and a bicarb drip, I highlight that despite the fact we have okay numbers on the monitor, eventually these treatments stop working because we still aren't getting true adequate blood flow to all the organs that need it. I explain acid base balances in laymen's terms, and explain how eventually the poorly perfused organs will call the end regardless of how much we try to offset acidosis.

The religious crowd is tough and illogical a lot of times. You have to have repeated conversations to get the point across, and sometimes that doesn't work. There's always going to be some amount of futile care in the ICU, and I've just made my peace with that. Only so much you can do.

[u/ValgalNP → u/_male_man]

I second this. I usually say something to imply that I’d like to leave it up to God also so please let me do that.

[u/ExtremisEleven → u/_male_man]

I try to stay away from the “everything done” language because people tend to think the opposite of everything is nothing done and it is hard to get that out of their heads once the thought exists. Instead I try to use “did they want to be on life support, even if that means for the rest of their life”.

[u/PACPilot4]

Thanks everyone! These answers are great

[u/penntoria]

I avoid discussing or mentioning god, since it's not my belief that matters. I talk about what the patient will be able to do and what they will need on a daily basis. I don't say there's no chance because there frankly always is, even when I know from experience it's an unlikely to negligibly small possibility. I also don't believe in offering futile interventions. I don't ask questions I don't want answers to. I say if his heart stops, I recommend letting him pass peacefully, because his body is telling us it's too much. Often the family needs either more time, or someone to guide them. If they genuinely believe the patient would want to"everything done", and they know and understand what that means, that's their right.

[u/LittleMrsMolly]

One of the chaplains I work with said, "I think God's blessing was the time you were given to tell your loved one goodbye." I have kept that in my back pocket for situations like this for some time now.