Indepth Interview

06182019_CriticalCare1
June 18, 2019

Interviewer: [Side Conversation] By way of background, one of the challenges is that I’m trying
to make it so like oncologists, hospitals and critical care people could always see
themselves and then, they’d all have some role in seeing the patient. You’re asked
to see a 60 or 70-year old woman with myelitis prostate syndrome diagnosed two
months prior to admission. This was monitored as an outpatient but [it all starts
from her] PMD with worsening cytopenias and there’s a suspicion of transformation
to AML. She’s awaiting the results of her bone marrow biopsy and she’s had bouts
of fever [Unintelligible] and she has right lower [Unintelligible] pain and has
[Unintelligible] too. Her urinalysis has pyuria bacteria. She’s started on antibiotics
but her systolic blood pressure is in the 70s. They’re about to see her. She appears
ill with right side tenderness. As [Unintelligible] there was a man and a woman
arguing outside of the hallway. The nurses are supposed to be her adult son and
daughter or her next set of kids. Tell me what your initial thoughts about this case
are.

Respondent: Clinically, I called to see her because she’s hypotensive and she sounds like she’s in
sepsis, septic shock so my role, as a critical care, at least, is to establish how can I
stabilize this patient and in the back of my mind, I do want to think about what is
her prognosis? What can I offer her?

Interviewer: Cool, you already said this a little bit but can you tell me more about your initial
priorities with the patient?

Respondent: Initial priority, in her case, because she is in shock, I want to get her blood
pressure better, raise her blood pressure, establish how aggressive does our team
need to be involved and she sounds like it’s a brand new diagnosis. She hasn’t
received any treatment. It sounds like she’s someone who probably can have a long
term treatment course so what’s killing her right now is the sepsis and the shock
that I could do something about. Does that make sense?

Transcripts@civi.com | www.TranscriptionWing.com | 888-223-9488

The only transcription company with ListenLinkTM!

Interviewer: Totally, anything else that’s come into your mind?

Respondent: I think the vignette also mentions this family fighting outside but it’s not my issue
at this time just because I have a more critical care thing that I need to deal which
is her blood pressure but recognizing that, as a consultant, I could ask him to step
away and not have to luckily deal with their fights.

Interviewer: Just for right now.

Respondent: Yes, I’m being honest. [Laughter]

Interviewer: Yes, part of it. It’s [Unintelligible]. Part of it is I don’t want cases where everybody
would say, yes, definitely you would discuss [rules of caring] now.

Respondent: It’s the fact that she has a shock and it sounds like she’s [Unintelligible] to
treatment so what’s killing her is the shock, not the cancer, so I should focus on
the shock.

Interviewer: After initial stabilization, how likely would you be to discuss rules of care at this
moment in her disease trajectory?

Respondent: Meaning if she had an ICU or she’s still being taken care of by the medicine and
oncology so I think that makes a difference to me as well. If I become the primary
team, then I’ll be the one. If she’s still someone else’s care, I don’t want to see
someone else’s problem but if they’re still a primary team, I would oftentimes
recommend have a goals of care discussion and see what’s the trajectory but,
again, she sounds to me not that sick.

Interviewer: So it sounds like there are factors related to her clinical presentation and are also
related to your role?

Respondent: Yes, I think for me to want to start a conversation right away without being the
primary team usually is when I’m called to the ED and there is no real primary
team. I assume that role and if the person is imminently dying and I need to know
how aggressive I need to be, that’s when I take over my role but, in this case, it
sounds like there are people taking care of her. Her situation, in the vignette, did
not sound as dire to me as some other cases.

Transcripts@civi.com | www.TranscriptionWing.com | 888-223-9488

Page 2 of 18
Interviewer: So maybe that’s alright then.

Respondent: Yes.

Interviewer: Okay, what other aspects of the case make you less likely to consider goals of care
right now, anything else that you haven’t mentioned yet?

Respondent: She’s under someone else’s primary care. I do make the recommendation about
goals of care discussion in my recommendation but I don’t personally have the
conversation. Clinically, I think she is stable enough that it could be a longer
discussion than an urgent discussion.

Interviewer: Can you think of any aspects of the case that would make you consider more
strongly? You said that if you felt that she was really at the end of life, effectively
dying, you would bump that into consideration, anything else?

Respondent: In her case, if I had resuscitated her and she’s still refractory in terms of blood
pressure, her acid is still rising and I can’t control the underlying cause of the
sepsis, urgently, then I’ll have this discussion. If this is her fifth round of treatment
for her AML and that there is no prognosis in terms of her cancer side, then I’ll
have this discussion earlier. If she had previously already made her wishes known,
saying that she would not want aggressive care and she’s someone who’s never
seen a doctor and behavior-size proved to me she doesn’t want any of these done,
then I would have that discussion earlier because there are people who just don’t
want to have anything done to them. It doesn’t matter how old and how sick or not
they are.

Interviewer: That’s great. When you think about goals of care, just to be clear because
sometimes it’s a little vague, what specific things would you want to discuss?

Respondent: Discussion for me also has to with the actual clinical presentation and how urgent
things are. I find it most difficult to discuss goals of care with the patient him or
herself. It’s easier for me to talk about goals of care with a family member, right?

Interviewer: [Laughter] Yes.

Respondent: It’s so weird to say and what was the question again? I’m sorry.

Transcripts@civi.com | www.TranscriptionWing.com | 888-223-9488

Page 3 of 18
Interviewer: What would you include? Most people would say, obviously, [good status] but are
there things that you would include?

Respondent: What are the things that you would want and then, I also would want to include
comfort and pain relief type discussion in it.

Interviewer: I know that this is limited information that I’m giving you but, just off the bat,
what is your estimation of this person’s survival?

Respondent: Probably 75% through septic shock, a quarter of patients don’t survive.

Interviewer: Okay. [Laughter] That’s great.

Respondent: I literally was just discussing my [Unintelligible] going to the shelf. That’s why. I
think they’re 70%.

Interviewer: You just told me you use a sepsis estimation of survival. Anything else that you use
typically for prognosis?

Respondent: Co-morbidity, she has pancytopenia which has probably put her mortality to be
higher than someone who is not immune suppressed. Her age, to me, sounds like
she’s a younger person and I think relative age which means I age as well but, to
me, 67 sounds like you’re a young person. She has no other medical problem than
this transformation AML and she’s crushing the course. She hasn’t shown me that
she’s in a refractory AML. It’s just she hasn’t been treated yet. We give hope.

Interviewer: Would you be surprised if she died in the next six months?

Respondent: No, I would not be.

Interviewer: What social features are you considering when you think about discussing goals of
care?

Respondent: What does that mean?

Interviewer: Is there anything else you would want to know about her, her family or her family
structure, anything like that?

Transcripts@civi.com | www.TranscriptionWing.com | 888-223-9488

Page 4 of 18
Respondent: I want to know what she would want. If I had to discuss goals of care with her and I
think this could be a decent time if she has a good mental status even without low
blood pressure, I usually would ask her what she wants. I would prefer the family
members are around so that they could hear from the patient herself what she
would want when she cannot make a decision. That’s something that I try to do
especially before I intubate the patient. I am just imagining in the emergency
department that the family’s around. You’re stable right now. You’re very sick.
Things could get better. Things could get worse in this situation like have you
thought about how aggressive do you want the doctors to be? Do you ever want to
be on a machine? Do you want peoples test on your chest? Sometimes, the patients
can reflect that and can say it in front of the family which, oftentimes, in my field,
are the people who end up having to make the decision later on.

Interviewer: Excellent, any other things or pieces of information you would want if you were
thinking about discussing rules of care?

Respondent: For this patient?

Interviewer: Yes.

Respondent: Really just her previous decisions and beliefs, if I were having [Unintelligible] have
you ever had this discussion? Have you ever thought about this? Were there any
documentation in the system that she’s already made decisions on those?

Interviewer: That would make you more likely to want to discuss and clarify things?

Respondent: That’s one of my pet peeves. I feel like if someone has already explicitly made a
decision, I hate it when residents have to reconfirm, triple confirm and then,
reason everything because I think the more you ask people, the more confused
people can get and like “Why are you asking me again? Am I making the wrong
decision?” Do I clarify? There’s a situation where I need to clarify the goals and
what the actual decision but I don’t think I need to keep –

Interviewer: [Unintelligible]

Respondent: Yes, there’s a different level of asking and asking. Does that make sense?

Transcripts@civi.com | www.TranscriptionWing.com | 888-223-9488

Page 5 of 18
Interviewer: Yes, got it. I can imagine a situation where the patient is DNR and that might
prompt you to say “Do you want us to place a central line?,” have a further
conversation or the patient’s in respiratory failure and are DNR-DNRA. You
wouldn’t necessarily revisit that while they’re gasping for air.

Respondent: I wouldn’t in some way. If I have a discussion with someone who’s DNR-DNI, in
respiratory distress, respiratory failure, I usually would have had the discussion
earlier on and say things like “This could happen. If this happened, I would try to
make sure you’re comfortable and not gasping for air. I even actually –

Interviewer: [So you really] –

Respondent: Yes, that’s crazy. I even sometimes establish a patient and family that if we get to
that point and that person doesn’t like to have a BiPap on, I’m not going to do that
because it’s uncomfortable and if the person’s dying, don’t try to prolong
something that’s not helpful to the patient so I’ll make sure the medication is
we’ve used that. There was another point I wanted to say. I think it goes both
ways. The full code, we’re asking “Are you sure you want us to do everything?” It’s
the same annoyance as “Are you sure you don’t want us to do this?”

Interviewer: [Unintelligible] – the timing.

Respondent: There’s no point of pushing the family to make someone DNR if they cannot make
that decision in my opinion. I don’t know how we got to that.

Interviewer: [Laughter] I think that was very clear, issues like whose job it would be to discuss
goals of care and who’s responsible for the patient.

Respondent: Would you consider palliative care at this juncture in this person’s trajectory?

Interviewer: I think in this hospital, I always do. Part of it is because I don’t sometimes trust a
primary team to make that call. They are busy taking care of many people and
sometimes, you’ve got to call the professional especially on the medicine service
when I’m consulted or a PA hospital is serviced, I would say “Please consult
palliative care.” I do that in the ED as well when they’re not critically crashing at

Transcripts@civi.com | www.TranscriptionWing.com | 888-223-9488

Page 6 of 18
 the moment. I don’t need to be the one having that discussion. I usually
recommend calling palliative care.

Interviewer: I should let you know before we go on that. In addition, to using this
[Unintelligible] vignettes, I may use this and may try to publish separately these
two, if that’s okay with you.

Respondent: Confidentiality, I saw that somewhere in that form I signed.

Interviewer: We didn’t record your name on that. It doesn’t matter. Do I try another one?

Respondent: Go ahead.

Interviewer: Alright, so [Unintelligible]. This is a 70-year old man with widely metastatic
prostate cancer and peripheral vascular disease and diabetes. He’s admitted with
an infected [Unintelligible] heel and his prostate cancer was metastatic and he’s
initially treated as for life and he progressed. His PSA rose and he was treated with
– how do you say that?

Respondent: I get it.

Interviewer: He –

Respondent: [Unintelligible]

Interviewer: The idea that the oncologist was [Crosstalk]. He recently developed debilitating
pain and was treated with Strontium-89. His pain is better controlled but because
of his PBD and increasing time spent with that, he developed a heel ulcer for the
past few weeks. His MRI shows evidence of osteo. I bolded [Unintelligible] question
for you. Would you get called on this patient or is there something that we could
write in this case that would make it more like critical care would be involved but
he’s stable.

Respondent: Critical care would get involved in this case if they can’t get a peripheral IV and
then, whenever I’m on, I would have a hissy fit because we’re non-IV service. I
would tell the fellows to tell them to get a pick line or they need to keep trying.

Transcripts@civi.com | www.TranscriptionWing.com | 888-223-9488

Page 7 of 18
 It’s not fair for a team to keep calling us for central lines for IVs or blood draw that
they need to be able to deal with that.

Interviewer: This hinges on [Charles and that man]. What kind of situation would it be
appropriate for you to be involved?

Respondent: With this guy?

Interviewer: We’d have to make him somewhat unstable, right?

Respondent: He has to be unstable or you know what? You could just say he’s allergic to
penicillin and the only sensitive thing is penicillin so they need ICU for
desensitization.

Interviewer: Awesome, thank you so much. [Laughter] That’s why I need smart people to help
me so you’re saying they need ICU but for desensitization. Anyway, he’s a widower.
He has eight children. He has a nephew who lives in [Unintelligible] [Weird Noise].
Same question, what are you thinking [in this story]?

Respondent: He’s a stable patient so I think for him if they [Unintelligible] tell me that they do
not want resuscitation and they don’t want intubation, he’s not someone that I’ll
actively pursue the goals of care discussion. Again, because he’s here for a heel
ulcer and he’s a stable patient, it’s not going to interfere with this very limited life
span because he’s metastatic and he’s 80. The things that make me feel like that’s
going to kill him is his metastatic prostate cancer and maybe his age or his
osteomyelitis but osteomyelitis is a chronic thing that [Unintelligible] stable so
from my perspective, he’s not someone that I’m going to go ahead and push for
discussion. I assume, by this time, he’s in the ICU and that’s why I’m involved. It
would be not the priority for –

Interviewer: For the ICU side.

Respondent: Yes, but if he became unstable, then he’ll be discussed.

Interviewer: Do you think of this quite in this trajectory, not maybe you, but goals of care, in
general, would be a preference? Who would you think would be doing that?

Transcripts@civi.com | www.TranscriptionWing.com | 888-223-9488

Page 8 of 18
Respondent: Who is his primary doctor? Is it the oncologist?

Interviewer: So it sounds like it would depend on who’s primary care.

Respondent: Who has had the longer relationship with him?

Interviewer: So an oncologist could be an appropriate person or a PMD?

Respondent: Yes, so someone like him, I would ask him goals of care also not just DNR-DNI.
When I first meet him, I would ask him “You’re stable right now and you’re making
your own decision,” and, actually, I do ask this to everyone that I admit or I see. In
the case where you can’t make a decision, who do you want us to talk to? I would
have asked the first patient this as well in front of their family so everybody hears
it from the patient. Especially him, he has a nephew. He has others. He has no
children but there are other people involved so does he want us to talk to the
nephew or they’re actually friends who he preferred to make decisions for him so I
think that would be something that I want to address with him. Not necessarily “Do
you want resuscitation? Do you want life support?” but more as a healthcare proxy
decision and I think that’s appropriate for someone like him who’s stable.

Interviewer: So maybe not like a full goals of care.

Respondent: Because maybe he becomes delirious and choke.

Interviewer: You mentioned especially because he doesn’t have a lot of close relatives so does
that make you what kinds of [Unintelligible]. What kinds of family factors in that
case make you more or less likely -

Respondent: More to ask that question?

Interviewer: Yes.

Respondent: To be honest, I don’t think there is a factor that would make it more or less likely I
would ask because even if someone has 20 relatives in the room, I need to ask
those because I don’t want all 20 people telling me to do when this person can’t
make decisions and if there’s no one in the room, I also need to know who to call
when this person can’t make decisions so I don’t think there’s any particularly

Transcripts@civi.com | www.TranscriptionWing.com | 888-223-9488

Page 9 of 18
 strong factor. I think part of what’s important is I need to have an identified
person. Can I tell you an adult story when I was a resident? There was a young guy.
He was 67 years old. Where I train, our residents basically have to do everything so
I was admitting this guy in the ICU. He was in respiratory distress. I was examining
him. I saw thrush in his mouth. No history of anything and literally we were about
to intubate him and before he got intubated, I was like “Please tell me who I
should call and who can help make decisions when he can’t make decisions.”
Luckily, he told us someone because, otherwise, it’s going to be another three days
before we find someone. We found his Mom and she was able to consent for HIV
and everything so it helped. That’s one of the things that always reminds me to
establish who to contact and I think -

Interviewer: [Crosstalk] goals of care.

Respondent: Not necessary the DNR/DNI but I think healthcare proxy and surrogate decision
makers, identifying those people is very important.

Interviewer: I’m just jotting this down because when I make the eventual scale, it might make
sense to ask a series of questions more specifically, not just goals of care in general
but what do you ask about the healthcare part? Would you ask about some of those
so I can think about whether I should need to test [Unintelligible] so that’s very
helpful. Would you ask for a palliative care consultation for this dude?

Respondent: No.

Interviewer: I’m just going to go very corny. I called him a dude. [Laughter]

Respondent: Not at this juncture.

Interviewer: Okay, because he’s stable.

Respondent: Yes, stable-ish, he has metastatic cancer but that’s not the reason why.

Interviewer: Anything else that you’re thinking about that?

Respondent: I’ll tell you when I think of it.

Transcripts@civi.com | www.TranscriptionWing.com | 888-223-9488

Page 10 of 18
Interviewer: [Laughter] Okay, I think that was pretty straightforward.

Respondent: Good, do you have more time? I could do another one if you need.

Interviewer: Maybe one more?

Respondent: Give me a sick patient. [Laughter]

Interviewer: Yes, I’ll give you guys a sick patient. I’ll give you another one that’s –

Respondent: Crashing, [Unintelligible] of 12.

Interviewer: [Laughter] No, I didn’t take any of them crashing stuff.

Respondent: Yes.

Interviewer: I didn’t want to be like three [pressers] and TBBA. Obviously, I would - [Crosstalk]
have dialysis. Yes, everybody would be like [Unintelligible]. This one is sicker.
She’s 43 years old. She’s with breast cancer diagnosed three years ago.

Respondent: Which one are you on?

Interviewer: This one.

Respondent: Okay.

Interviewer: I won’t bore you with the details but it was - [Crosstalk]

Respondent: She was treated multiple times. She declined [Unintelligible] radiation and
chemotherapy.

Interviewer: But was treated with [Ajumen] and Anastrozole but then, she stopped because she
lost the follow-up. She didn’t have insurance anymore and now, she’s presenting to
the ED with shortness of breath and pleuritic chest pain. She’s intubated for
respiratory failure, hypoxia and she has pulmonary embolism and she also has a
probable [Unintelligible] lumpectomy and her partner is [Unintelligible]. What is
your first clinical impression of this patient.

Transcripts@civi.com | www.TranscriptionWing.com | 888-223-9488

Page 11 of 18
Respondent: She’s sick. She will die. Her cancer sounds aggressive. She also has PE probably
because she’s high risk with the cancer. I’m glad there’s someone on her bedside
who could help us guide how to manage this patient. That’s where I am.

Interviewer: After your initial stabilization, how likely would you be to discuss goals of care at
this moment and her trajectory?

Respondent: Very likely, she’s someone that I most likely would have a discussion myself with
the partner at that time. I don’t trust the ED to have that kind of discussion with
them, sorry.

Interviewer: It sounds like from your previous thoughts because she also, right now, doesn’t
have anybody else taking care of her.

Respondent: Yes, because I think that ED can have a discussion but there are different arts of
having this discussion like do you know that? There are ways to be like “Do you
want us to do this?” then, have to go into patient’s value and beliefs and then,
guide the decision making.

Interviewer: What things would you specifically discuss with the partner?

Respondent: For her, I would talk about her cancer course. The last two follow-ups make me
very sad. First, she had refused certain treatments. She had opinion of what she
wants and doesn’t want. The [loss to fog] due to endurance is very sad. Is it
intentional or is it more she really lost it and she just couldn’t get herself together
to get it or she’s more like “Oh well, then I don’t need to get treated.” I
understand –

Interviewer: So you want more information - [Crosstalk]

Respondent: Exactly, and so what is her opinion on life support and chest compression and
resuscitation? I think, for me, part of what I would tell the family is what’s the
underlying reason of her crashing? Right now, it’s PE. Can I treat the PE? If she’s
bleeding at the same time, she’s clotting. What are some of the things that I could
reverse in her course and what are some of the things that I cannot? PE is the only
reason and she does not have any bleeding anywhere else. I could safely treat this

Transcripts@civi.com | www.TranscriptionWing.com | 888-223-9488

Page 12 of 18
 PE, then maybe give her a course versus just comfort at this point or do a full
course. I think, for her, there’s a lot of information I need to get from the family or
the partner to help guide our discussion and I don’t trust the ED.

Interviewer: Yes, because you’re thinking about the benefits and burdens of various treatments
and this is not going to be Davidson saying it but it’s value-sensitive and how much
you would want to - [Crosstalk]

Respondent: Yes, how much does she want and how much does her partner want for her.

Interviewer: It would be reasonable to go either way.

Respondent: At this juncture, I think it could go either way. I don’t need to push one way or the
other.

Interviewer: Cool, any other thoughts about that?

Respondent: No, I think more information about her values and some of her treatment
trajectory is important in helping me frame a discussion with the family.

Interviewer: Palliative care for her right now?

Respondent: Sure.

Interviewer: It’s pretty - [Crosstalk]

Respondent: There is no reason not to. [Laughter]

Interviewer: Any other thoughts about this case and anything else come to mind?

Respondent: The other thing for me when I recommend palliative care in the ED or primary
team, it’s not necessarily I want the family to make the patient DNR or have the
patient make themselves DNR/DNI. There are others like providing support to the
family, providing support to the patient and other management things that I’m now
thinking of like pain control, what are the better regimens, secretion and all that
stuff. I think that’s why I would recommend, especially with her, when the patient
to be palliative.

Transcripts@civi.com | www.TranscriptionWing.com | 888-223-9488

Page 13 of 18
Interviewer: Yes, it seems like from a palliative care perspective no matter what this hospital
[Unintelligible] for this dude who’s her partner so they’re going to need something.

Respondent: Should I have called palliative care for these two?

Interviewer: I rate them to be ambiguous where some people would and some wouldn’t. That’s
my overall goal. I don’t see that they’re separate. For me, going [Unintelligible]
it’s an art to know exactly what the right involvement to do it so trying to create
cases where there is some ambiguity about it. This one probably has less ambiguity
[Unintelligible].

Respondent: Have to.

Interviewer: - but my goals because it’s like, for this guy, somebody should talk about goals
because he’s got metastatic cancer but is the moment that he’s in the ICU -
[Crosstalk]

Respondent: There are times I’d be like “You’re [Unintelligible]. Have you ever had this
discussion? Think about it. Talk to your family about it. You don’t have to make any
decision.” Maybe, plant that seed sometimes but not necessarily establish a
decision.

Interviewer: [Unintelligible] This one was supposed to be ambiguous because it’s just as you
said. She’s recently diagnosed. She doesn’t have a treatment plan so you could
make an argument –

Respondent: She didn’t seem like she was in pain. He maybe in pain so he probably should get
some help with pain management and wound care as well. How about this one? I
knew this one is not unambiguous.

Interviewer: This one?

Respondent: This one.

Interviewer: [Crosstalk] I haven’t finished writing. [Laughter]

Respondent: Everybody has cancer in your thing.

Transcripts@civi.com | www.TranscriptionWing.com | 888-223-9488

Page 14 of 18
Interviewer: Yes, because I’m trying to make it applicable to oncologists. That’s true because I
want it –

Respondent: Because I feel like sometimes people forget that there are patients who need
palliative care even if we don’t have [Unintelligible].

Interviewer: Right, it just depends.

Respondent: Like the chronic respiratory failure patient who’s intubated 10 times in the past
two months. Someone needs to do something about that but if you’re asking the
oncologist. I’m going to mention this to [Unintelligible]

- End of Recording -

Transcripts@civi.com | www.TranscriptionWing.com | 888-223-9488

Page 15 of 18
Transcripts@civi.com | www.TranscriptionWing.com | 888-223-9488

Page 16 of 18
Transcripts@civi.com | www.TranscriptionWing.com | 888-223-9488

Page 17 of 18
Transcripts@civi.com | www.TranscriptionWing.com | 888-223-9488

Page 18 of 18