Innovations in End-of-Life Care
an international journal of leaders in end-of-life care

© 2002 Eric J. Warm, MD. Published here with permission.

[Citation: Warm EJ, Romer AL. Introducing end-of-life care into the University of Cincinnati Internal Medicine Residency Program: An interview with Eric Warm. Innovations in End-of-Life Care. 2002;4(5): www.edc.org/lastacts/]

ROLE PLAYS

Role Play Case One:

• Physician: You are an oncologist treating a 68-year-old male with pancreatic cancer. You have taken the patient through multiple rounds of chemotherapy, and the tumor has become resistant. At today’s office visit you need to tell the patient this news, and suggest stopping the chemotherapy.

• Patient: Your partner, in the role of the physician, will break this news to you. Please try to react as if you were really given this news.

• Observer: Please observe and reflect what you see and hear, and when prompted, provide feedback to your classmates.

Role Play Case Two:

• Physician: In your office today is a 55-year-old woman with severe bullous emphysema. She has been hospitalized 6 times in the past 18 months, twice requiring intubation. She is becoming more and more bed bound each day. Today you decide to discuss DNR issues. How will you do this?

• Patient: Your partner, in the role of the physician, will discuss DNR issues with you. Please try to react honestly.

• Observer: Please observe and reflect what you see and hear, and when prompted, provide feedback to your classmates.

Pearl 1

Do not put the following words into your vocabulary: "There is nothing more we can do for you."

It is, of course, the major tenant of palliative care that there is always something more to do. This includes attention to symptom control, remaining life goals, spirituality etc. What we say defines and determines our reality. As a physician, saying the words "there is nothing more I can do for you" indicates a sense of failure. If we fail at something (physicians do not like to think they fail at anything!) we tend to avoid it. Often times the patient for whom curative therapy has failed is left until last on rounds, seen in a rush before morning report or conference. It is difficult to stand with a patient when you feel you have nothing to offer him or her. This attitude, conscious or not, will be picked up by the patient, creating a sense of abandonment. A dignified and gentle death should be seen as a true medical accomplishment, and a bad death should be seen as medical emergency.

Unfortunately today, we do not have many role models to support these ideas. Often the third year medical student, the person with the least experience (and therefore the least amount of cynicism) recognizes a bad death prior to anyone else on the team. So, finish the sentence: "There is nothing more we can do to cure your disease, but there is still much we can do for you." Remember that no one is going to love you for what you don’t do. If you only discuss treatment withdrawal ("we will be stopping the chemo, the IV’s, the monitor…) you may trigger abandonment anxiety. Make sure that you discuss reasonable and caring alternatives, and tell the patient and family what you will be doing to help them. I like to think of programs such as hospice as a basket or cushion to catch us when we fall. Many patients and families see hospice as a sign that we are giving up entirely, and many physicians unconsciously perpetuate this idea. Ignoring the fact that a patient is dying, however, and not using the palliative care resources available, is giving up entirely.

Pearl 2

Do not put the following words in your vocabulary: "Do you want us to do everything?"

Discussing code status and DNR issues is one of the most difficult things we do as medical professionals. And though almost all of us have to do it as some point in our careers, almost none of us have any formal training in it.

At this point, I pass out two Fast Facts which address how to engage in a DNR discussions.

References

von Gunten CF, Weissman DE. Fast Facts and Concepts #23a Discussing Do-Not-Resuscitate orders in the hospital setting: Part 1. Journal of Palliative Medicine. 2002;5(3):415-417.

von Gunten CF, Weissman DE. Fast Facts and Concepts #24b Discussing Do-Not-Resuscitate orders in the hospital setting: Part 2. Journal of Palliative Medicine. 2002;5(3):417-418.