Welcome to the Intensive Care Unit, where end of life conversations will happen almost daily.
The ICU is stressful for so many reasons, and you deal with a lot of scared and grieving patients and families. One thing I've done really well during intern year helping people cope with death and dying.
Here's what you do:
1. Ask the patient or family what they understand about their illness and current state of health. Some people might think they're going to die from a GI bleed that just needs close monitoring, and some family members might not have had anything explained to them about why their family member is so sick after chemotherapy.
If you're sure the patient's dying from sepsis on 4 pressors despite all efforts, you need to communicate it at the earliest moment possible to give the family time to grieve and get ready for death.
2. If someone has failing/failed organs, tell them their organs are failing or have failed.
Be realistic and honest, but not callous. Many people don't fully understand their diagnoses or what's going on in the hospital and it's your job to inform them. Inform them each time an organ fails.
Some people might not know they can choose comfort care and that they don't have to spend the rest of their life in an ICU getting dialysis dying slowly and uncomfortably.
I'll paraphrase conversations. Mechanical support doesn't "cure" anyone the way antibiotics might.
In a case of ESRD from hypotension/shock/long code:
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"..What is that..the dialysis, doctor?"
"Dialysis is a treatment that uses a machine to help get rid of extra fluid in the body and helps remove toxins in the body, which the kidneys do on their own. The kidneys help filter the blood.
The reason your dad needs dialysis is because many times, when someone's heart stops, many organs in their body don't get enough blood, and they don't work the same as before. Since your father has been here, we've been doing everything we can to help his kidneys, heart, and blood pressure, but his kidneys won't be able to recover on their own. The dialysis machine is doing the work for his kidneys right now."
Or in the case of an AKI being managed with dialysis:
"The job of the kidneys is to help the body get rid of extra fluid and help clean the blood. We've found that your father is very sick and needs help cleaning his blood and help getting rid of the extra fluid. We've been able to use this dialysis machine to help take off some of the work from your father's kidneys. We hope it can help him get through this stage of his illness. It's too early to tell if he will keep needing dialysis while he's in the hospital or for the rest of his life. So far we've been able to control his fluid well and have seen him responding well to the filtering of his blood with the dialysis machine."
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Ventilators:
"Many patients get so sick that they can't breathe well on their own and they need help with a ventilator. Right now, the ventilator is doing the breathing for your mother because she's too sick and weak to breathe on her own. We watch her everyday and check the ventilator to see if she's recovering. We'll be making small changes day by day and see how she does."
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"Will she be able to come off that machine..?"
"Your mother is very sick right now and needs help breathing right now. I know you're worried and the machine might look scary. I can't promise you that she'll come off the ventilator at this point, but we'll keep doing everything we can to take care of her."
3. Go back to the symptoms. Families and patients are scared and don't interpret signs and symptoms the same way we do. They're not as familiar with death as we are.
"Doctor, he's not feeling any better. He keeps getting more and more short of breath. Is the medicine not working? Is he going to die soon? How is his heart now?"
"I know it's hard for you to see him like this. I know you have been going through a lot seeing your father so sick. We've been supporting him with medicine as much as we can but his heart has become so weak. In a heart like yours or mine, it's strong enough that it keeps fluid from building up in our lungs. His heart isn't as strong as it used to be, so we're using medicine to help keep the extra fluid off, and using medicine to help boost his heart function."
4. Preparing for the end. Show your human side while spelling things out so you don't give false hope. Here's a paraphrased conversation of mine.
"So how long does he have left, doctor?"
"It's hard for me to say exactly how long your husband has left. We know he's been very sick for a very long time, and his health has gotten worse since he came into the hospital. He requires dialysis because his kidneys have stopped working. The ventilator is doing the work for his lungs now because has become too weak and too sick to breathe on his own. We've been taking the best care of him night and day."
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Giving short, direct sentences minimizes confusion and helps get everyone to understand what's happening. When you read what I wrote, it might sound pretty callous and maybe condescending, but I actually have a great bedside manner and everything is in my body language and voice.
If you're "good" at giving bad news, you will project warmth, concern, and comfort. It's easy to tell who is genuine and who isn't.
Always have tissues ready for people, listen closely, don't interrupt, and communicate your understanding.
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