Family Meetings: My Approach

Preparation:
- What information do we need from the patient/family? What are the key decisions we are helping them make?
- What key information do we need to give them? (Usually this info supports item 1.)
- What is the basic prognosis? Days to weeks, weeks to months, months to years, more? What information is essential to clarify this? Can we get the consultants to help clarify?
- Confirm who is the decider. Find the paperwork that confirms the healthcare proxy, which is crucial if the patient lacks capacity.
- Make a brief list of all major organ systems that are impaired.
- Schedule a time and place, try to set aside an hour of your time. Who needs to be there? I try to only include consultants who have known the patient a long time and who the patient identifies as their doctor. Otherwise, lots of providers can make for a confusing and long session.

Get the room ready:
- Get chairs for everyone.
- See if there is a separate room where everyone can meet in and try to reserve it.

Before going in:
- Decide who will be the meeting leader. There should be one point-person that the discussion goes through so that the important items get addressed. Others are there for supporting comments and details.
- Review with the care team what the main decision points are.

During the Meeting:
- Close the door and turn off the TV.
- Introduce everyone by relationship to the patient and by role in the care team, and shake their hand.
- Identify the healthcare proxy and verbalize this.
- Orient yourself initially toward the patient.
- Update the patient about the state of things. Review the major organ systems that are impaired, and the basic treatments in very general terms. "You have an infection in your blood and we are giving you antibiotics. Your heart is weak which makes it hard to breathe, and we are giving you medicine to dry out your lungs. Unfortunately, this medicine uses your kidneys, but they are weak too, and so we are having a hard time. And you are also unfortunately bleeding into your bowel so we are giving you blood transfusions."
- Ask if there are any questions. Answer them in the most general terms possible. Avoid getting too specific about the medical details.
- Get straight to the key question you have. Be straightforward in asking it. If the patient does not have capacity, direct the question at the healthcare proxy. "We need to talk about something we call code status. Do you recall anyone discussing this with you before?"
- Deliver the information that you need to deliver. "We have been giving you a blood thinner to protect from stroke, but this medicine makes you bleed. Since we haven't been able to fix the bleeding, we stopped it."

Closing the Meeting:
- Reassure the patient that we are doing as much as you can and want to make sure that everything we are doing lines up with their preferences and wishes.
- Thank everyone for coming and shake their hand.
- Write a "Goals of Care" progress note that includes the names of everyone present, a brief summary of the discussion, and any major decisions that were made.

Tips:
- Focus on the decider, either the patient if lucid or the healthcare proxy. A family member or friend may be the most engaging. Answer their questions briefly, but bring your attention back to the decider.
- Never argue. Give your impression and understanding and recommendation, but don't argue about details. Allow patients and family's to contradict you. Correct only when they are being disrespectful of the staff, and do so gently.
- Try to let the patient/family do most of the talking. Try to let them finish all sentences before jumping in. Let them set the pace of the conversation.
- Try not to be overly cheery. We instinctively greet people upbeat and happy, but it often doesn't match the context. Smile and be pleasant, but not joyful.

Advance Directive Discussion Tips:
I envision a ladder: Full code -> DNR/DNI -> Do Not Escalate Care -> CMO

I often use language like this:
"For most patients, at some point the burden of treatments reaches a point where those treatments are not worth it. This happens on a spectrum. For an otherwise healthy 24 year old, if they get sick we put them through a lot (machines, lines and tubes, surgeries, etc), because their organs are all healthy and they have so much potential life ahead of them. For an 80 year old with terminal cancer, we don't do that stuff. Most patients fall somewhere in between. Lots of times, patients say 'do what you can using hospitals and intravenous medicines and fluids, but don't hook me up to lines and tubes, don't put me in the intensive care unit.' We call this Do Not Escalate Care. If antibiotics and fluids don't seem to be working and the patient starts declining, we focus on their comfort and let them pass away in peace."

"We think Mr. Smith is at the end of his life. Some people in this situation want as many days as possible. They are willing to go through anything: 'Keep me in the hospital, poke me with needles for labs and imaging, do procedures, hook me up to lines and tubes and machines. Whatever it takes, even if it means I'm in pain and uncomfortable at the end. Other people would prefer a period of calm and some clarity at the end. They want to focus on maximizing the quality of the days remaining, rather increasing the number of days. They say 'Stop checking labs and vitals, stop with the treatments. If something happens, just let it take it's natural course and carry me off.' We call that Comfort Measures Only. The team that makes this happen is called hospice."

We often focus on "making the person DNR" or otherwise getting them to change their code status. This is the wrong approach. It's most important to give the proper information and get a clear decision that the whole family acknowledges.

Uncomplicated Gram Neg Bacteremia - I can do oral antibiotics for how long?

Someone finally studied it! There's decent evidence that you can switch to oral antibiotics with good bioavailability (in this study they primarily used Bactrim or quinolones for UTI bugs) when patients with gram negative bacteremia become clinically stable and get the same outcomes as with IV therapy. It's not an RCT, but it's almost 5,000 patients at several centers in a cohort that is closely matched with controls. And it's for hospitalized patients.

 

Association of 30 Day Mortality with Oral Step-Down vs Continued Intravenous Therapy in Patients Hospitalized with Enterobacteriaceae Bacteremia

 

Even better, an actual RCT of 600 patients with gram negative bacteremia, uncomplicated (ie- good source control, no mechanical valves or anything like that), which compared 7 to 14 days of antibiotics and showed no difference.

 

Seven versus fourteen Days of Antibiotic Therapy for uncomplicated Gram-negative Bacteremia: a Non-inferiority Randomized Controlled Trial.

 

It's a good case for doing what feels reasonable - start with IV antibiotics, once patient has been afebrile ~48 hrs and feeling better (no renal failure or stuff like that) and you have sensitivities, then switch to levofloxacin or Bactrim to complete 7 days. No PICC. BAM!

 

Ward Expectations

Disclaimer: These are my personal expectations and may not overlap with other attendings. I offer them more as a learning tool to see what an experienced clinician considers good performance.

Work hard:
- Show up on time, don't leave until your work is done or handed off.
- Do what you say you are going to do, update your team when you make changes to the plan.

Take Ownership:
- Act like you are the main doctor taking care of this patient, and that all patient problems are your problems.

Medications:
We are internal medicine, we own the med list, and we are responsible for an accurate list for any of our patients. This responsibility is easy to dodge by simply importing the existing list, and since we often care for patients for whom we did not do the initial med rec, that means assuming the list is wrong until we have checked it ourselves.
- Double check the following home meds against pharmacy records or patient/family report.
     - Anticoagulation
     - Antiplatelet (clopidogrel)
     - Diuretic
     - Immunosuppressives
     - Any other drug that is critical

Interacting with patients:
- Introduce yourself in terms of your role in the hospital in terms the patient can understand.
"Hello, I'm Dr. Stupple. I know you have seen a lot of doctors. I'm taking over from Dr. _____. I'm your main doctor right now. I'm on a team that includes Dr. _____. You have gastroenterologists and surgeons who are seeing you as well, so there's three teams. My job is to coordinate everyone."
- Be respectful of everyone. Patients that trigger anger and resentment are often the most vulnerable and suffering the most.
- Give them time to feel heard. Letting someone speak uninterrupted until they get out everything they want to say is maybe the most powerful way to communicate compassion.
- Explain to them what is happening and update them when things change. Ex- if you order a CT scan, tell them why it's happening rather than letting the nurse or transportation tech do it.
- Discuss medical issues at a 6th grade level of language and understanding.
- Speak with the healthcare proxy or close family once every day or two.

Nursing and other staff:
- Be respectful. Among other things, control the urge to be dismissive- when nurses are concerned, patient mortality reliably increases.
- Be approachable.
- Respond to pages quickly, regardless who they are from. It's easy to say you respect everyone, but actions speak louder. Responding quickly to pages tells the recipient that you value their concerns. Think how much you appreciate it when someone "important" gets back to you immediately. It's gold.

Workflow:
- Top priority is generally to call consults, then submit orders, talk to patients and families, and finally get notes done.
- Be skeptical of all incoming information. Double check important vitals, confirm history with the patient or close family.
- Don't dismiss incoming information. Treat emergencies and urgencies as such until you know they are resolved.
- Don't delay placing diet orders.

Presenting:
- Start with chief complaint or one-liner to orient the team. (This is an excellent habit because it teaches you to prioritize and summarize.)
- Save the discussion for the assessment/plan, don't editorialize the data.
- On rounds, take a guess at a diagnosis, list alternatives, and look for tests you could do to make things clearer. Don't obsess about trying to get the diagnosis right, just tell us what you're thinking, including "I don't know."
- Master the problem list. Have a problem for each medication the patient is on at home, including meds that are on hold, and each med in the hospital.


Master Level:
- Focus on solving problems for patients, rather than simply getting your job done. Ex- A patient admitted with CHF can be rapidly improved with IV lasix and tempting to discharge. But focusing on their problem of volume overload and frequent admissions, we can diurese them to their dry weight.
- Prioritize items that will impact care, such as delaying diagnosis and treatment or prolonging hospital stay. This requires good medical knowledge as well as....
- Maintain situational Awareness: Outmaneuver the bottlenecks, such as PICC lines and IV access, procedures, consents.
- Extend your plan all the way until discharge. Clarify what conditions need to be met before you will discharge.
- Speak definitively when you are definite about what you are telling them. Avoid using qualifiers like "we might have to do an LP" or "it looks like you might have bacteria in your blood stream."

Personal Extras:
- I avoid maintenance fluids. If a patient needs fluid, I make an estimate of how much and write to give that amount over a period of a few hours. Then I reassess and consider more fluids. Maintenance fluids are hard to know how much they received and can easily be forgotten about over a period of days.
- I never order colace since several RCT's show it doesn't work.
- With exceptions, I rarely alter patient's diet from home because their treatment should be tailored to what they usually eat, not a special in hospital diet.

Assessing Adrenal Suppression while on Steroids

Assessing adrenal function is challenging because false positives and false negatives in the testing is common, particularly when a patient is actively receiving steroids.

A high-normal serum cortisol essentially rules out adrenal suppression. However, normal values, even in the morning, are inconclusive. This is because physiologic cortisol varies widely throughout the day, making the test inherently unreliable. Furthermore, suppressed adrenal glands can nonetheless produce a baseline cortisol level that falls in the normal range, even though the adrenals are not communicating with the pituitary and therefor not responding to ACTH. Therefore, the stimulation test is preferred.

There's no role for simply checking serum cortisol in patients on steroids.


UpToDate Approach

Step 1- Assess their risk of adrenal suppression.

If high risk (taking 10-20mg pred daily for three weeks or more), then you simply assume they are suppressed and treat them accordingly. Basically, the treatment is gradual, careful weaning of steroids.

If low risk (getting steroids for less than 3 weeks), assume not suppressed.

If someone is moderate risk or you're unsure, THEN assessment of adrenal axis is warranted. Go on to step 2:

Step 2- Assessing adrenal suppression

Ideally, start with a low dose ACTH stimulation, 1 mcg cosyntropin (which is synthetic ACTH). Measure serum cortisol immediately before the dose and 30 minutes after. This test is more sensitive because it uses physiologic levels of hormone, and it's faster because it can be completed in 30 minutes (as opposed to an hour with the high dose test).

If the serum cortisol is >17 mcg/dL, they don't have suppression. If greater than 25, their adrenal axis is intact. See below for between 18-25.

The trouble with the low dose version is that you need an IV (which is not usually a problem in the hospital). The other difficulty is that the cosyntropin dose needs to be mixed--the vial contains 250mcg, and must be appropriately diluted. If pharmacy or nursing can do this reliably, you're in good shape.

If low dose is not feasible, use the high dose test. This involves 250mg cosyntropin (entire vial) and measuring cortisol immediately before, 30 min, and 60 min after. This high dose is intended to be able to use IM or IV. The serum cortisol cutoff is the same >17.

Alternatives are the 8 hour and 48 hour stimulation tests. These are rarely used. The 48 hr test may be useful to distinguish secondary from tertiary adrenal suppression.


COMPLICATORS:
- If cortisol is 18-25 after stimulation, it is unclear what to do. I would repeat the test.

- Cortisol testing in the ICU is difficult to interpret and controversial, with no clear guidance on how to assess.

- Birth control can falsely elevate serum cortisol levels (because estrogen increases cortisol binding globulin).

Managing noninfective interstitial lung disease in the hospital

Pulmonary fibrosis, or idiopathic interstitial lung disease, is challenging to manage in the hospital, largely because of the alphabet soup naming system, the constantly shifting classification system, overlapping diagnostic criteria, and the lack of effective therapies. Below, I try to simplify these diseases by focusing less on diagnostic criteria and more on therapies. As you'll see, we generally use steroids, with only expert opinion to guide us.

The below diagram places pulmonary fibrosis and idiopathic interstitial pneumonias in context with other noninfective diffuse lung diseases.

Diffuse parenchymal lung diseases (From UpToDate)

IIP: idiopathic interstitial pneumonia; LAM: lymphangioleiomyomatosis; PLCH: pulmonary Langerhans cell histiocytosis/histiocytosis X.

FDiagnosis is driven by high resolution CT. Treatments for Idiopathic Interstitial Pneumonias are largely based on expert opinion.


Idiopathic pulmonary fibrosis:
Most common, it's a chronic progressive disease with flares, median survival 2-3 years.

Acute presentation/flare: treat underlying cause, can try steroids (not studied)
Chronic: Nintedanib (tyrosine kinase inhibitor to block fibrosis), lung transplant.


Idiopathic nonspecific interstitial pneumonia:Less common, usually associated with connective tissue diseases or toxic exposures, when alone it is classified as “idiopathic.” Disease course is chronic progression with waxing and waning.

Acute presentation/flare: High dose steroids (weakly studied)
Chronic: Treat underlying disease, add steroids, then add immunosuppressants

Cryptogenic organizing pneumonia:Less common, can have single onset and resolve, or waxe and wane. Can be fulminant, behaves very similarly to pneumonia.

Acute presentation/flare: Steroids (weakly studied, but have a strong observational effect)
Chronic: Lower dose steroids, possibly adding immunosuppressants


Acute interstitial pneumonia:
Rare, fulminant disease with 50% in hospital mortality on initial presentation. Difficult to diagnose. Acute presentation: High dose steroids, lung transplant.



BOTTOM LINE:
The most important condition to look out for, in my mind, is cryptogenic organizing pneumonia. It behaves the most like an infectious pneumonia, presenting with fevers and often a focal infiltrate. However, in my clinical experience, and that of the pulmonologists I hear from, it really does often respond well to steroids; two thirds of cases resolve with initial steroid treatment. This disease can fool you by resisting antibiotics alone, making you think it is a resistant organism, or by vanishing when steroids are used adjunctively.

Overall, it helps to be suspicious when pneumonia isn't responding to the usual therapy. Have a low threshold to get a high resolution CT, and keep cryptogenic organizing pneumonia in mind in particular because it is easier to modify its disease course. Unfortunately, the other conditions are less important to identify because they usually have a slower onset, giving clinicians enough time to diagnose in the early stages. Acute flares of all of these tend to get the same basic treatments, and, with the exception of cryptogenic organizing pneumonia, the disease course is difficult to modify.