Geriatric Case 3: Termination of Resuscitation

This case is the third in a six-part mini-series focusing on the management of geriatric patients in the ED. This series of cases was written by Drs. Rebecca Shaw, Nemat Alsaba, and Victoria Brazil.

Dr. Rebecca Shaw is an emergency physician currently working as a Medical Education Fellow within the Emergency department of the Gold Coast Hospital and Health Service in Queensland, Australia. Dr. Nemat Alsaba (@talk2nemat) is an Emergency physician with a special interest in Geriatric Emergency Medicine, medical education and simulation. She is trying her best to combine these interests to improve Geriatric patient care across all health sectors. She is also an Assistant professor in medical education and simulation at Bond university. Dr. Victoria Brazil is an emergency physician and medical educator. She is Professor of Emergency Medicine and Director of Simulation at the Gold Coast Health Service, and at Bond University medical program. Victoria’s main interests are in connecting education with patient care – through healthcare simulation, technology enabled learning, faculty development activities, and talking at conferences. Victoria is an enthusiast in the social media and #FOAMed world (@SocraticEM), and she is co-producer of Simulcast (Simulationpodcast.com).

Why it Matters

Deciding when to terminate CPR is a very delicate moment in a patient’s care. It is literally the determination of possible life vs. certain death. There are clear guidelines for when to terminate resuscitation in certain contexts, but for patients who are brought to the ED by EMS, there is no true objective measure of when to terminate CPR. This is where determination of quality of life is important. In the elderly, the likelihood of a meaningful quality of life after a CPR-requiring event is quite low. Recognizing this futility is an important and challenging skill to learn. Being able to debrief with your team and discuss these events further is another essential skill that is often not practiced. This case gives the opportunity to learn and enhance these skills.

Clinical Vignette

ED RN to inform team prior to patient’s arrival: “We have an out of hospital cardiac arrest coming in with an unknown downtime and unknown past medical history. He is an 89-year-old male coming from home. He has had no shocks and CPR is in progress. They are one minute away.”

Case Summary

An elderly male is brought in by ambulance from home with CPR in progress. He collapsed in front of his son/daughter who commenced CPR. His rhythm has been PEA throughout and his downtime is 20 minutes. Participants should assess the patient, gather information about his background and determine that CPR is futile. They should decide to cease CPR and inform his son/daughter in a sensitive manner that their father has died. They will also debrief the team following the termination of resuscitation.

Download the case here: Geri EM Termination of Resuscitation

U/S for the case found here:

(U/S courtesy of McMaster PoCUS Subspecialty Training Program)

Debriefing Techniques – the Art of Guided Reflection

Simulation without debriefing is really just an expensive way of either making learners feel badly about themselves or allowing learners to practice performing poorly. This is why the theory behind debriefing is so important.

Debriefing is one of the most amazing teaching tools available to an instructor. Debriefing allows insight into a learner’s thought process such that an instructor can tailor teaching to a learner’s specific needs. Kolb’s learning cycle1 and Schonn’s description of the Reflective Practitioner2 allow us to see why debriefing is such a useful tool. We must actively reflect on an experience to learn from it; debriefing allows educators to help guide that reflection.

PEARLS Framework

While debriefing is arguably the most important component of simulation education, it is also a difficult skill to acquire. Eppich and Cheng3 have published an excellent approach to debriefing that reviews many of the key steps a novice simulation educator should aim to follow. They have called it the PEARLS approach (Promoting Excellence and Reflective Learning in Simulation). We will review its four phases here.

1. Reactions Phase

This is where learners are invited to express their raw feelings about the case. Often, learners will do this without a formal invitation (for example, you may hear initial reactions while walking from the simulator to the debriefing room). It is important to invite all learners to have a chance to vent during this stage.

2. Description Phase

This phase begins by asking a learner to describe what they think the case was about. This allows the educator and the learners to see if they are on the same page. Often, this leads to important issues for discussion during the next phase.

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3. Analysis Phase

Here, the educator must tailor their style of debriefing to suit both the learners in the room and the time available for the debriefing. This phase is what educators often think about when they envision debriefing. Essentially, the analysis phase is where learners can go through guided reflection.

+/Δ Method

There are two common styles of guided reflection described. The first is the +/Δ method. This involves probing learners as to what went well (the +) and what could be improved or changed for the future (the Δ). Many who are new to debriefing find themselves turning to this style at first.

Advocacy/Inquiry Method

A second, commonly used style is called advocacy/inquiry.4 This approach leads to incredible insights into the knowledge and performance of the learners. It can be somewhat more challenging to execute well. The basic premise is that one must first describe a noted performance gap. This is followed by a question as to the learner’s frame of mind at the time of the performance. The learner’s answer leads the instructor as to what learning points may need to be addressed. Sometimes, the entire room of learners is unsure of a next appropriate step in management. In this case, the debriefer must simply provide directed teaching. In other cases, the learner has made a slight cognitive error. Often, these can be addressed through facilitated discussion with other learners.

4. Summary Phase

Once the group has gone through all the desired learning objectives in the analysis phase, it is imperative that the instructor guides a review of key points related to the objectives. If time is short, the instructor can provide the summary himself. If time is more abundant, it can be useful to have the learners go through their key learning points.

As we can see, a fair amount of effort is required to facilitate an excellent debrief. With frameworks like the PEARLS approach, experienced and inexperienced educators alike have a practical means upon which to build their debriefing skills.

What tips and tricks do you use in your debriefing?

References:

  1. Kolb DA. Experiential earning: experience as the source of learning and development. Englewood Cliffs, NJ: Prentice Hall; 1984.
  2. Schon D. The Reflective Practitioner: How Professionals Think in Practice. New York: Basic Books. 1983.
  3. Eppich, W., Cheng, A. Promoting excellence and reflective learning in simulation (PEARLS). Simul Healthc. 2015:1. doi:10.1097/SIH.0000000000000072.
  4. Rudolph, JW., Simon R., Rivard P., Dufresne RL., Raemer, DB. Debriefing with good judgment: combining rigorous feedback with genuine inquiry. Anesthesiol Clin. 2007;25(2):361-376.