Advocacy Workshop: Death and Dying in the ED

“There is a dignity in dying that doctors should not dare to deny.” – Unknown

Palliative Care Workshop 1

How do you respond when a family member pleas, “do everything”, for a dying patient?  What do you do for a patient with profound dyspnea at the end of life?  Did you know that hospice bereavement services are available to families of deceased patients even if the patient was never in hospice?

In February 2015, the Advocacy Track hosted a Palliative Care Workshop led by Dr. Lindsay Weaver, Assistant Professor of Clinical Emergency Medicine and Palliative Care Medicine. There was a tremendous turn out for the workshop, and included representation from multiple hospitals and a wide variety of specialties/fields – RNs, faculty/resident EM MDs, NPs, SWs, CMs, CNAs, hospice representatives, and palliative care experts.

A few of the critical topics related to death and dying in the ED were covered, including:

  • Withdrawal and end of life of care in the ED
  • Code status discussions in the ED
  • Hospice resources/information
  • Discussing the results of the palliative care needs assessment
  • Aiding in the development of an action plan for end of life care in our EDs

Why is this discussion so important, and how does it relate to emergency medicine?  

As Dr. Weaver aptly stated in her powerpoint, “The Emergency Department is the safety net for the acutely and chronically seriously ill. As the population ages, ED visits for crisis events in the setting of serious, chronic illness are likely to increase. Initiating end of life conversations in the ED allow for a more patient centered, quality of life centered focus that may save the patient from unwanted procedures, avoidance of unnecessary admissions, integration into resources such as palliative care sooner, and decreased overall cost to patients and families that does not ultimately improve end of life care.

Palliative Care Workshop 3

Individual patient cases were discussed in small groups, each illuminating key points in caring for patients at the end of life. The overwhelming theme was communication. Taking the time to discuss options with patients and families with the other team members (RNs, CMs, SWs) can prove to be the major factor in providing optimal care. The consensus was that we should start these conversations in the ED, because what we do has a snowball effect for the patient’s management/testing/procedures in the hospital.

What limitations or barriers exist to limit our ability as providers to achieve this in the ED?

  • Common responses include TIME. Conversations about end of life take time, and this can be a limited commodity in the ED during a bustling shift. However, sharing with your colleagues in the department that you are going to have a conversation with a family is OK. Some thoughts were to have secretaries hold pages for 10 minutes during this time, and to make a call-back list when you are finished. We often do not like to ask for help, but in some situations, this can prove to be the difference between intubation, central lines, arterial lines, vasopressors, and a week or more on the ventilator, when perhaps all the patient or family really wants is the option to go home with hospice or focus primarily on pain control and do it well.
  • Another concern was provider/RN comfort and perceived time required in providing medications for comfort. There seems to be a educational gap regarding goals of comfort measures in the department, because it is not performed often.
  • Furthemore, lack of documentation and medico-legal concerns are another factor.

Solutions we discussed to improve Palliative Care in the ED:

  • Creating an order set for withdrawal of care/comfort measures in the ED
  • Identifying a quiet place in the ED to provide comfort care and/or arrange services, for example, the observation unit
  • A bereavement resource basket filled with information for families who have a loved one pass in the ED
  • Resource handout available in the ED for easy reference for providers
  • Educating staff/residents/RNs/ancillary staff on medications used for comfort measures
  • Carrying out discussions and plan of care in the presence of the entire team, if possible, including MDs, RNs, chaplain, SW/CM to ensure communication is consistent
  • Holding pages from secretaries and asking fellow ED colleagues for help while you have this important conversation uninterrupted

Some of the above solutions are actively being implemented in the Methodist ED, and other sites are also being considered.

A sincere thank you to everyone who participated in this important conversation, particularly to our guest speakers, our resident leaders Amber Fouts (EM PGY-2) and Anar Desai (EM PGY-3), and to our faculty leader/presenter, Dr. Lindsay Weaver.

Submitted by: Kyra Reed, PGY-3 EM/Pediatrics


IUEM Christmas Family 2014

Christmas Family IUEM 2014 group

Each year, the Emergency Medicine/Pediatrics Residency and the Advocacy Team through Indiana University Emergency Medicine Program takes part in the United Way Christmas Service. The United Way pairs volunteers or groups with an underserved family in the community, with the goal being to provide gifts to a family that otherwise would be unable to do so. Volunteers are given the names, ages, sizes of clothes/shoes, and the desired gifts for each family member.

This year, the Advocacy Team provided gifts to a family of seven – five children (ages 1, 6, 11, 14, 17) and two parents. We are excited to share that well over $500 in donations were provided from the IUEM Residency Program! Volunteers helped wrap gifts and deliver them a few days before Christmas to the family. Shoes, clothes, winter coats, family games, a basketball, and a variety of Ninja Turtles toys were just a few examples of the gifts provided to the family. During delivery, the family was ecstatic about the donations, and extremely thankful. The mother shared that with a family member currently in hospice, they are going through a financial and emotional rough patch, and without the donations, they would have not been able to celebrate the holidays at all this year. The children stated happily that they plan on sending hand drawn thank you cards to the residency. Look at those smiles!

Christmas Family IUEM 2014 kids

Christmas Family IUEM 2014, wrap

Christmas Family IUEM 2014 wrap 2

Thank you everyone for your generous donations and for those that helped wrap and deliver the gifts! We look forward to continuing this annual tradition.

More about the Christmas Service:

Submitted by:  Kyra Reed, PGY-3 Emergency Medicine/Pediatrics

Infant Mortality Summit 2014

Kyra Reed, PGY3 Emergency Medicine/Pediatrics

infant socks mort conference

“Preventing infant death is EVERYONE’s responsibility”.
This recurrent message from the 2014 Infant Mortality Summit resonated deeply with the audience as we gazed upon the 654 pairs of infant socks arranged on the stage. These socks represent the number of infants that do not survive to see their first birthday in Indiana each year. The issue surrounding infant mortality is multifaceted and complex, spanning a variety of socioeconomic, cultural, and geographic lines. The goal of the summit was to educate on facts, inspire, share innovative ideas/solutions, and to bring together resources to combat this public health concern in Indiana.

Reflecting on the conference, this message definitely included Emergency Medicine in my mind. We can all strive to find a teachable moment or provide a small intervention with families in the ED, such as information on safe sleep, injury prevention, and coping with parental stress. This just might save a life.

A few highlights from the summit:

infant mort summit safe sleep book

Charlie’s Kids Foundation is an organization created in memory of Charlie, son of Maura and Sam Hanke, who died from SIDsS in 2010. The book above, “Sleep Baby, Safe and Snug”, was written to educate families about safe sleep through vivid illustrations. Each page displays the AAP’s guidelines for safe sleep and early literacy in a creative and beautiful way. Perhaps a future project could be to pass out books to parents/guardians/foster parents of infants from the ED? Find out more:

Non-accidental trauma is an unfortunate reality, and this is part of what we see in the ED. Dr. David Olds with the Nurse-Family Partnership found that with the institution of home visiting nurse programs, the incidence of NAT and pediatric injuries substantially decreased.

— CVS announced that all tobacco products have been removed from their shelves. A win in the effort to decrease smoking rates.

— The afternoon breakout sessions also proved equally enlightening. A variety of important topics were covered, including approaches to addressing infant safe sleep, pregnancy and prescription drug abuse, delayed cord clamping in premature infants, smoking cessation in pregnancy, infant mortality in Burmese Chin population, strategies to address disparities in rural areas, postpartum contraception in urban adolescents, breastfeeding improvement strategies, simulation for obstetric/neonatal emergencies to improve outcomes in rural areas, and innovative technological mobile applications to improve education and access to resources. Some specifics from the sessions I attended:

Reducing Infant Mortality in a Vulnerable Burmese Chin Population, with Panel Discussion
– Burmese refugees represent the largest proportion of immigrants to Indianapolis, and numbers are increasing drastically every year
– Culture: Pregnancy is expected shortly after marriage. A larger family represents the strength of the family and provides increased support in times of need.
– Mothers often feel that prenatal vitamins lead to maternal weight gain, which results in large infants and therefore a high risk delivery
– Thus, providers need to encourage vitamin use and nutrition while explaining benefits
– Little to no prenatal care available in home country, all health costs paid out of pocket. No insurance, no blood banks. Most deliveries occur in the home with the assistance of female elder of the community.
– Initial screening for refugees upon arrival to U.S.: CMP, CBC, Hep A/B, UA, UPT, TB, syphilis, HIV
– Ways the community is attempting to improve education include: Educational programs on nutrition, health, and navigating healthcare in U.S., going to apartment communities where large number of Burmese live to provide resources
– Currently, group is working on providing genetic counseling and mental health resources
– Suicide risk in this population 4 times higher than general population

Wabash Valley Healthy Moms and Babies Initiative
RHIC picture
– Rural Health Innovation Collaborative (RHIC) in Terre Haute, IN: Learn more
– “It’s about connecting people out of their silos,” explains Stephanie Laws, Executive Director of RHIC.
– Goal is to learn from communities and identify priorities of the community
– Striving to promote development of community-based prevention and intervention strategies
– It is a broad spectrum of community participation that leads to sustainability
– Rural culture often does not support asking for help, which impacts health
– Enacting Community Health Advocacy Leaders (evalueLEAD) for Pregnancy Peer Support Program, which creates social networks to provide emotional and instructional support for mothers
– The importance of community leaders in identifying issues and promoting change is undeniable
– The project has observed the immense power that social determinants have in overall health

Training Rural Providers to Save Infants Using Simulation
sim baby
– Large number of OB units throughout rural Indiana are closing
– Many residents of rural Indiana travel >30miles to access care
– Now have increasing number of deliveries occurring in rural EDs
– This is a low volume yet high risk situation for providers, mothers, and infants in this setting
– RHIC created simulation center to train rural providers for these OB/neonatal emergencies in order to reduce infant mortality
– Simulation scenarios are also brought to rural EDs unannounced to assess preparedness and what resources are needed for these situations
– Most rural providers have never seen an OB/neonatal emergency or it has been >9mo since being involved
– Critical Access Hospitals are eager to learn, and this training has been implemented successfully
– More about

Overall, a moving and educational conference. Thank you to the Indiana State Department of Health, Summit Speakers, and Breakout Session Speakers/Panelists for all of your hard work and inspirational comments!

On Back Pain and the Discipline of Empathy

Samuel Locoh-Donou is an IUEM PGY-2 resident and part of the IUEM Avocacy Track.

“Let ME tell you how to do this dance, doc. First, I want an American doctor who speaks good English and who knows what he is doing. Second, I want my brother to get an MRI today, instead of a goddamned rectal exam. Nobody is getting a rectal exam! I have a slipped disk, so I know how you guys operate. Always trying to line your pockets by billing for unnecessary procedures!”

How did we get here? I recall vividly an angry man standing in front of me, eyes blazing, with his index finger pointed in my face. He must have been in his late 50’s, and had tobacco stains in his beard and moustache, and a hunting cap screwed on his head. His brother, who actually was my patient, was resting on the ER room’s bed, in his mechanic dark blue overalls, looking very uncomfortable with the unexpected turn of events.

I was in shock. Over the course of my clinical training, I had yet had to encounter this level of disrespectful and prejudiced speech. In the space of two seconds, this family member had made allusions to my ethnicity, my accent, and my treatment plan in a way that made my blood instantly boil. This was new for me. My experience as a healthcare practitioner in this country has always been a very positive one. My French accent and a bit formal English vocabulary (conditioned by my schooling in the British system) was generally welcomed with an initial wide-eyed curious surprise on behalf of my patients, quickly replaced by a smile and a heartfelt, mindful conversation on what brought them to the hospital.

My 55-year old male patient had actually come in for back pain, like one of the thousand others who walk into our emergency room every day with the same complaint. He worked as a mechanic, and had developed instant back pain 3 days ago when bending over the hood of a truck he had been working on. His symptoms included lumbar pain so severe that he could not sleep at night, as well as shooting pains radiating from his lumbar area into his L. calf. He had no history of recent back trauma, IV drug abuse, cancer, or chronic steroid usage. When I asked about cauda equina symptoms, he denied saddle anesthesia, but endorsed 3 recent episodes of urinary incontinence and 2 episodes of weakness in his bilateral lower extremities that had caused his legs to buckle at the knees. The patient was unable to tell if his legs gave away because of pain or because of pure weakness. His past medical history was positive for hypertension and hyperlipidemia. He had undergone hernia repair surgery in the past, and smoked 1.5 pack of cigarettes a day.

My patient was clearly uncomfortable, but pleasant and calm during the interview. As I proceeded to the clinical examination, his brother walked into the room and sat silently on a chair in the furthest corner, watching us warily. Since it is my habit to acknowledge every person in the room, I greeted the family member, and earned a grunt for a response. As I focused back on my clinical examination, it struck me that my patient was very tender to palpation in the paraspinal lumbar areas, and had difficulty with proximal and distal bilateral lower extremity strength testing. When I asked why he was weak, he said he was actually too in pain to move. His lower extremity sensation and reflexes were normal. Given his story of urinary incontinence and the findings of weakness (possibly due to pain), I decided to check for a rectal tone for my own peace of mind. I explained to the patient what I wanted to do, and the reasoning behind a thorough physical exam for the type of symptoms he was having. The patient flat out refused, and the brother erupted from his corner with his index finger pointed to me.

I maintained an attitude as professional as possible, attempted to explain the indications for an emergency MRI and the required physical exam components to precede the actual MRI, but every single word I calmly uttered only further aggravated the family member. He screamed that he wanted a different doctor for his brother, so I excused myself and stepped out of the room. I closed the door with shaking hands as I tried to quell the anger storming inside. My female staff ended the visit after walking in the room alone and getting a better history of the episodes of urinary incontinence (more related to inability to get to the bathroom in time) and lower extremity weakness more related to pain than actual weakness. The patient was discharged with pain control, return precautions, and a physical therapy referral.

As I reflected on this incident in the following days, I realized that the outburst directed at me by the angry family member was actually rooted in the love the man had for his brother, and a fear that his brother would have to suffer unnecessarily because of perceived inadequate care. Since no man is perfect, the family member’s emotions could not be detached from his personal socio-cultural canvas, and his perception of a different skin tone and accent in a healthcare provider only heightened a sense of unfamiliarity and insecurity already ignited by a loved one’s suffering. I came to terms with my initial feelings of anger and indignation, by applying to my patient’s brother the same principles of empathy I apply with all my difficult patients.

According to a 2007 study, the development of clinical empathy by physicians is key in managing difficult patient-physician encounters, and clinical empathy was defined as the ability for physicians to be emotionally engaged during conflicts with patients. In a nutshell:

– Physicians should accurately acknowledge their feelings and negative emotions as they occurred;
– Physicians should take the time to consider the meaning of their negative feelings and how they may relate to the patients’ feelings;
– Physicians should attempt to discern the emotional issues that underlie the patients’ negative reactions;
– Physicians should be sensitive to the patients’ body language, as the patients’ nonverbal cues will require the provider to adjust their own nonverbal signals accordingly;
– Finally physicians should accept patients’ criticism and negative feedback without falling in the trap of getting defensive.

I believe that the disciplined application of these key principles to not only patients, but patients’ families as well, is a healthy technique for healthcare providers to engage in a conflictual conversation with emotional intelligence and without compromising themselves. The discipline of clinical empathy goes beyond the simple doctor-patient relationship, as a provider is also engaged in some type of therapeutic communication with a patient’s loved ones. And this is the challenging beauty of the art of medicine.

J. Halpern, “Empathy and Patient–Physician Conflicts,” Society of General Internal Medicine 22 (2007): 696–700

Rachael’s First Week


Thanks to everyone who participated in Rachael’s First Week today! We hope that our experiences we shared with you will help you in this exciting time starting college. We’re always here to help. If you have any questions at any time please feel free to contact us through the form below. You can be sure they will stay private.

These will be some of the best years of your life. Enjoy them and remember to watch out for each other.

Carl’s Story

Terez Malka is a 5th year EM/Peds resident at Indiana University School of Medicine. She will be a faculty member at Carolinas Medical Center, working in both the pediatric and adult emergency departments, starting in July. Check out Terez’s fantastic, previous post, The Challenges of Foster Care.

“Carl,” is a 10 year old boy diagnosed with autism at 18 months, and recently discharged from an inpatient psychiatric stay after a three week history of escalating violent behavior towards himself, schoolmates, and his parents and siblings. His parents are at their breaking point as they describe how he screams and hits himself, or anyone who comes near him, for hours at a time. He has not been able to attend school for weeks due to his violence towards classmates. He seemed to have some improvement during his brief hospitalization, but his behavior became unmanageable shortly after discharge home. They apologize for bringing him to the Emergency Department. “We just didn’t know where else to go.”

The following is directly paraphrased from “Carl’s” admission note:
“Father called [facility 1] and asked “what do we do?” and was told that they could not provide any assistance as patient was not followed in their outpatient program. Father states that he was told that patient was not a candidate for the outpatient program at the time of discharge. Father then called patient’s pediatrician, who advised them to call their behavioral pediatrician. At that number, they received a recorded message advising to contact the crisis center. At the crisis center, they were told that no providers were available who specialized in autism. At that point, family was afraid of patient’s behavior and had nowhere else to go, so presented to the Emergency Department.”

Most physicians who have cared for patients with psychiatric illness are well aware of the limitations and difficulties in obtaining timely and comprehensive care for our patients in crisis. Recent national events of violence perpetrated by those suffering from psychiatric illness highlight the devastating results when we are unable to provide them support, monitoring, and crisis respite they require. In my area of the country, pediatric patients requiring psychiatric admission can wait up to 72 or more hours in a general medical unit awaiting placement. These children may require phsyical or chemical restraint during that time period as the hospital floor is not fully equipped to support an agitated child, or one at risk of harming themselves or others. While the topic is widely discussed and lamented, no viable solutions seem to have come to light.

In our ED, Carl quickly requires physical restraint and then sedative medication in order to complete his exam and assessment. We are fortunate enough to have an in-house psychiatrist, who agrees that Carl represents an immediate threat to himself and others and requires inpatient psychiatric care. She sets off to secure an appropriate placement for Carl. But even after arriving at a large tertiary care pediatrics center, securing care for Carl is not seamless.
Below are direct quotes from the psychiatry resident’s phone notes:

“Facility 1: Discussed this patient with a social worker who stated that he will accept the patient. Received a call back and was told that the case was staffed with a non-physician, their administrator. Patient will be declined as he “reached maximum potential” from previous hospitalization that happened two weeks ago. I asked for definition of maximum potential, and was unable to get an answer.

Facility 2: Stated that all of their beds were full

Facility 3: Initially stated that they would accept the patient, then updated that they could not open up any new beds. Tomorrow there may be a bed if others are discharged.

Facility 4: Stated might take minimum 4 hours to staff, never heard back from them.

Facility 5: Physician declined patient as the patient would not be appropriate to their milieu.”

Right now, Carl is admitted on our general pediatric ward, restrained in a netted bed, with scheduled antipsychotic medications, awaiting placement. It has been 24 hours…

2014 IUEM Bike Safety Fair

With mother nature giving us sunshine recently, May 1 was a perfect day for the Bike Safety Fair! The IUEM Advocacy group, with support from Women for Riley, Riley and Methodist Trauma Services, I-EMSC, Free Wheelin’ Community Bikes and Indy Cog, were able to help protect the noggins of 1300 kids! Check out how much fun we had in the process: