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Neurointensivist and palliative care physician Jess McFarlin (@JessMcFarlinMD) walks us through a case of catastrophic intracranial hemorrhage, with a focus on goals of care, family interaction, prognostication, and other end-of-life aspects.
See Part 2 here.
Takeaway lessons
- We can undo most things except death, so in most cases, a short trial (perhaps 3 days) of fully aggressive care after an ICU admission is reasonable to help clarify the eventual prognosis. Set clear guideposts for when you’ll regroup to make more decisions about the direction of care.
- The ICH score is a helpful guide for early prognostication in spontaneous intraparenchymal hemorrhage.
- When prognosticating, express the range of outcomes in terms of three possibilities, as determined by the currently available data: the best case, the worst case, and the most likely case.
- Useful questions for families:
- If your [loved one] could hear this prognosis, what would he/she say is most important to him/her?
- What’s most important to you at this stage? What are you most afraid of?(Many are more concerned about discomfort, pain, or “struggling” at the end of life than about the prospect of death itself.)
- When you’re asked, “What would you do if it were your mom?” the question is not really about your mom; it’s a request for a recommendation about theirs.
- Transition from open-ended questioning, and translate their values/goals into an actionable plan, by using alignment statements: “What I’m hearing you say/it sounds like…” leads to “Hearing that, may I make a recommendation?”
Resources
References
- ICH score: mortality prediction score for spontaneous intraparenchymal hemorrhage
- Vital Talk: training resources for the skills of executing palliative and end-of-life conversations
[this episode was reposted on the website 4/27/2020 due to a database reversion after an unfortunate system breach —ed.]