For better or for worse, a lot of our time in critical care in spent writing notes. in the US, these serve multiple purposes including communication, medico-legal documentation, and the basis for billing. But, I’ve found that the art of writing them is not really all that well taught. I can only speak of NP education first hand, first as a student and now as an educator, but anecdotally, I don’t think it’s much better in the MD/DO or PA worlds.

I was taught mostly by watching preceptors and reading their notes. That’s an OK strategy, except for 1) it places a lot of burden on the student to figure out why a note is good and how to adapt that to different situations, and 2) who’s to say that the preceptor is good at writing notes? I’ve had residents tell me before, “don’t worry about it. It doesn’t matter what you put in your note. No one really reads them.” But that’s wrong. On so many levels.

It does matter what your write (and how) and people do read your notes. for example, I read the notes of the people on my service who I’m following. I read the notes that consultants write, and I read the notes the primary service writes when I’m consulted on a patient. A well-written note is a great source of information and very helpful. A poorly written note can often me more of a hinderance than no note at all.

I’ve been wanting to write a Guide to Note Writing for a while, so I was really thrilled to see a great Twitter thread the other day from Robert Oubre covering this exact topic. I agree with everything he writes, so I’ll just let you read it for yourself. I will add this, your note is yours. There are right ways and wrong ways, but not one right way. The one constant I feel like I see (again, at least in NP education) is that people critiquing student notes often focus on the style points. The student doesn’t write the exact same way that they would. I’m always tempted to do this as well. I like the way I write and so I’d like if everyone else did the same. But, you’re a professional and should be able to find your own voice. But, this thread is gold.

In 8 years I’ve written and read >20,000 SOAP notes.

Most could be improved.

3 tips to writing better notes:

— Robert Oubre, MD (@Dr_Oubre) April 30, 2022

Previously, we discussed how to deliver bad news. I set it up specifically as a situation that didn’t require much in the way of further discussion. The example I used was telling a family that their loved one had died. But often we have to have other types of difficult conversations with families as well. The most common type of this is the Goals of Care discussion.

This is a talk where you are delivering bad news of a sort, that their loved one is unlikely to have meaningful recovery. But in this conversation, there are decisions to be made. Unlike telling a family that someone has died, there isn’t total finality to this conversation. You need to help the family decide what to do next.

Often we consult palliative care for this, but I think that that is not the best practice for 2 reasons. First, any healthcare provider, especially an ICU provider, should be able to handle a basic goals of care discussion. Palliative care is helpful and should be involved in complex situations, especially those that involve tricky ethical or legal questions. But, the palliative care team is busy and just like you wouldn’t consult cardiology for every arrhythmia, you shouldn’t consult palliative for every goals of care discussion. Most often, people consult palliative care for these talks because they’re uncomfortable and the ICU provider would rather not have them.

And that brings me to reason number 2 to handle this without consulting palliative. It’s your responsibility. They are your patient and you shouldn’t abandon them when it becomes uncomfortable. In many cases, the ICU provider probably has some sort of relationship with the family (although not always, because patients may show up to the ICU in a non-salvageable condition). It’s going to better for the family to hear this from you than from a palliative care provider that they just met.

So, how do you approach this conversation? It’s similar to the breaking bad news discussion we talked about last time, but you often have a little advantage of prior relationship. I start by prefacing the conversation like this: “I’m going to speak very frankly to you because, if I were in your shoes, that’s how I’d want to be spoken to. I apologize if anything I say comes across as harsh, that’s not my intent. But, it’s been my experience that families prefer to get the straight truth rather than beating around the bush.” In several years, I’ve never had a family disagree.

Too often, we use medical jargon and euphemisms. Or, we just skirt around the issue without addressing it head on. I’ve been in conversations where the person leading the discussion does this and then leaves the room, feeling that they’ve been understood. But the family will walk away with a different understanding. “Your husband has had a very serious stroke and he’s not progressing like we had hoped. I think that looking at everything, the odds of him coming off the ventilator are very poor. It’s likely that he will never be much better than he is right now.”

The next thing to do is to discuss what the patient would value and how he or she would define quality of life. I know how I would want to live and how I would not want to live, but that isn’t for me to impose on others. For some people, if they could recognize their families, living in a nursing home on a ventilator might be something they’d be ok with. Others wouldn’t want to go on if they couldn’t be independent.

This is where predicting the future becomes tricky, but you need to lay out the best case scenario, the worst case scenario, and what you think is the most likely scenario. In some cases, the best case (which may still be a long shot) isn’t good enough for what they patient would want.

If the family indicates that the patient would not want to continue, this is when I lay out the options for end of life care. “We can transition to a different type of care in that case. One focused not on cure but on providing comfort and allowing a natural death.” I then will ask them if it’s ok for me to share with them what that looks like. This is all a lot to take in. Some families may need time to process. Simply hearing the poor prognosis may be enough. They may need time to come to grips with that before they’re ready to discuss comfort care.

Goals of care meetings may be one meeting where everything is decided, or they may take multiple days. You’ll need to gauge what they can handle. If they decide they want to continue, I describe the process of comfort care. “We stop doing tests and giving medicines that are not aimed specifically at comfort. Then, when you’ve had time to spend with them, the last step is to remove the breathing tube and take them off the ventilator.”

At this point, I usually ask if they’re waiting on other family members to arrive. If there are others coming within a reasonable amount of time (a few days), I suggest that we continue minimal life support (mechanical ventilation, vasopressors) to keep the patient stable until everyone has had a chance to arrive and say goodbye.

These are some of the most difficult conversations to have and can easily be the most exhausting part of your day. Despite what I said earlier, if you’re not comfortable with this conversation, call your palliative care team. But, use that as an opportunity to learn so that next time, you don’t have to call them. Once you do this a few times, you’ll get comfortable with it and it can become a very rewarding part of working in the ICU. If we only seeing curing patients as wins, then we lose a lot. And that can lead to burnout. However, if you take the view that we did everything we could and now we can focus on keeping them comfortable and allowing them to die with dignity, it can help turn what would normally be perceived as a negative outcome into a positive one.

Having difficult conversations is probably the most overlooked, underappreciated skill in all of healthcare. Very few providers are taught this skill in any sort of structured way. It’s often something that they learn by watching others more senior to them. The problem with that is, those people learned it by watching people more senior to them, who learned it by watching…well, you get the idea. If whoever started the chain didn’t know how to do it, then bad habits kept getting passed down.

As a critical care nurse practitioner, I’ve been involved in hundreds of these conversations. And many of them were very poorly done. And it’s not just trainees. Some of the worst conversations were led by attending physicians with years of experience. And it’s not totally their fault. They were never taught how to do this.

I’ve had the good fortune to learn this skill from some excellent teachers. In school, during my trauma rotation, Dr Cindy Talley taught me how to deliver bad news to a family in a specific way, citing actual research in the field. As an NP, I’ve been fortunate to learn from some great palliative care providers like Dr Jessica McFarlin and see how to expand those principles into leading a goals of care discussion. Here’s how I approach the difficult conversation.

Delivering Bad News

This is the hardest conversation to have. When a patient has died, or is in a position where they are not going to survive, despite our best efforts. Often the difficulty is compounded by shock. Rarely are these expected.

Step 1: Just say it. In most of these cases, a family has been gathered together and placed in a room. They know very little except that their loved one is hurt or sick. Something bad has happened and they’re waiting to find out. The biggest mistake people make at this point is going into all the details. They won’t hear any of that because they’re waiting for the other shoe to drop. I quickly introduce myself and get right to the point.

“Your son was involved in a very serious car accident. He was brought in very badly hurt. We did everything we could. I’m very sorry, but he died.”

You have to say “died” (or “won’t survive if it’s imminent but hasn’t happened yet). Too often, we try to soften the blow by using euphemisms like, “passed” or “gone.” Although we know what we mean, in their worried state, the family can misunderstand that. There is a definite finality to the word death.

Step 2: Sit. This is when you need to shut up and resist the urge to say things or the (overwhelming) urge to leave). It will be uncomfortable. They may cry, they may scream. They will grieve and it will be awkward. But this is what they need to do right now. Let them.

Step 3: Questions. This is why you can’t run away during the grief. Because at some point, they will come around and they’ll be ready to hear all those details that you wanted to give at the start. They’ll have questions and it’s only after they’ve dealt with the initial shock that they can ask them.

That’s the basics of how to deliver bad news to a family. Next time, we’ll talk about how to have a goals of care conversation.

A lot of people are now working from home quite a bit due to the pandemic. It can be great at times (you can wear your pajamas! But, I guess most of us wear pajamas (aka scrubs) to work every day…) but there are definite challenges as well. I’m not great at it, but I’m getting better. For me, the biggest challenge are those days when the rest of my family is home as well. Jennifer Kanapicki Comer, MD wrote a really great piece for the Academic Life in Emergency Medicine (ALiEM) blog recently called The 1440 Doctor: How to Unplug While Working From Home. She discusses the challenges of working from home and how to deal with them (who knew that the lack of a commute could be a problem?). I’m trying to implement a lot of them (including implementing the WFH Commute) on days when I’m at home working on fellowship stuff, or teaching stuff, or this blog for example. Check it out, I think you’ll find it helpful!