This video helps us think about how to have Realistic Conversations
when making a Treatment Escalation Plan with patients
in the video Dr Chris Mcnally talks with a simulated patient called Malcolm. He is
an elderly man admitted with severe pneumonia
who has s stabilised overnight. Using the REDMAP framework Dr Mcnally
reaches a shared understanding of Malcolm's diagnosis
and expectations then he explores what's important to Malcolm.
The REDMAP framework has six steps these are Ready Expect
Diagnosis Matters Actions and Plan
Ready means preparing people for an important conversation
and also thinking am I ready too?
A realistic conversation about care planning happens once Malcolm
understands his condition, shares what's important to him now
and is ready to talk about treatment and care options.
Cardiopulmonary resuscitation could be discussed at this stage.
Look out for the REDMAP steps and see how Dr Mcnally
communicates with Malcolm as you watch the video.
Hi Mr Smith I'm Dr Mcnally. I work in the medical high dependency unit.
I've been asked to come and see you today because you've been quite unwell
when you've come into hospital. Is that okay? Absolutely doctor. Call
me Malcolm. All right I'm Chris. Okay pleased to meet
you. Malcolm what are you aware of your
condition and why you've had to come into hospital?
Uh well I know that i've been a bit unwell the last four or five days
you know I'd a bit of a cough and I didn't feel very well and i've been
like I've had quite a dirty spit
that i'm spitting up . 52 00:02:02,479 --> 00:02:06,399 Um and just a bit short of breath. Okay
um to be honest. Okay and what have you been told so far
what the reasons for that have been? Um now I think they said that it was some
sort of chest problem it could have been pneumonia
maybe. Okay Okay and can you remember
anything about the emergency department and being in the resuscitation room?
I can vaguely remember what happened everything seemed to happen very quickly.
I was in the house one minute, the next minute I was in the hospital with
doctors and nurses ... Yes you were unwell when you were in
the emergency department and well the doctors there were
concerned about you. I think it's good that you've improved
but I think it would be useful to discuss if you were to become that
unwell again which with pneumonia is a possibility.
okay. Would that be okay? Yeah that's fine. It's just the the pneumonia ... is it as
serious as i think it is? Yes pneumonia is a serious condition. It's
infection in the lungs and you've got it in both lungs and and it causes you
to feel the way that you did and um you need quite a lot
of oxygen when you've got pneumonia and yes people can die from it
okay
What did you notice the doctor saying and doing?
What was the impact of the doctor's communication on Malcolm
The doctor says I've been asked to come and see you because you've been quite
unwell since you came in. Malcolm hears this is an important
conversation with an intensive care doctor.
The doctor says what have you been told so far about the reason you had to come
into hospital? The doctors were concerned about you in
the emergency room. Malcolm now knows he has pneumonia and
starts to realise how unwell he has been. The doctor says it's good that you have
improved but it's useful to discuss
if you were to become that unwell again which
with pneumonia is a possibility. Malcolm responds to information given
clearly and sensitively by asking a direct question: is it as
serious as I think?
The doctor explains a little more about pneumonia and says
yes people can die from it. Malcolm uses the pause to think and nods
to show he understands this could apply to him.
Well about four or five months ago I had a fall
you know and I ended up with a a broken bone in my hip and I had to
have a hip replacement Prior to that I was quite an
active person you know I would go cycling a
couple of times a week and I've got a dog called Ben. I would
take him out walks regularly as well but more recently as I
say and with the hip you know I've been
having a few falls that I haven't really told anyone about.
I was just basically I'm afraid to admit you know that I'm sure I'm kind of
falling for no apparent reason but since the hip replacement I've
not really been back to my full mobility. I've been
having to use a walking aid I'm not able to walk my
dog and my son has had to take the dog.
He's been doing more for me in the house as well
and I've just quite struggled with it. I'm
I'm kinda afraid of falls again in case something
else happens. Okay it sounds as if your cycling
and your dogs are quite important to you. Oh absolutely they were the things that
kept me going since my wife passed away a couple of years ago. Okay
okay and your son Eric .. We've been speaking to him. Is that who
we should ...? Absolutely. .. discuss things with? Okay.
Okay That's really useful for getting to know
you a wee bit better, so thanks for sharing all the
problems. If we can just go back in to your
current condition just now. I think,
you know, we need to have a plan in place. Obviously
we're hoping that you'll improve with the the treatment that we're getting
just now but i think it'd be useful for us
to know what to do if you were to get unwell again.. okay
because it is a possibility all right. Have you yourself had any
thoughts on that? Yeah I have. You know I'm an 86 year old
man, I've had a good life, you know.
Yes I've been ...I have had ,that odd thought about
what's the future got for me you know, if I'm not able to do what I'm doing just
now, what's actually going to happen? Okay well the
reason I've come down to see you is if you got more unwell
should we admit you up to the critical care unit
and look after you in a high dependency or intensive care unit.
Do you know what these units mean? Not really, I mean they're all just names
to me. So some people when they've got
pneumonia their lungs begin to fail and they need quite high amounts of
oxygen and we can do that with a tight-fitting mask that blows quite a
lot of oxygen into the lungs and we can also give medications that
support blood pressure if things get worse and and
in the worst case scenario we would need to think about
placing or putting you into a coma .. putting you to sleep
and putting a tube down your windpipe and taking you through to an intensive care
unit to be hooked up to a ventilator which is
a form of artificial life support. Is that anything
you've ever thought about or discussed with anyone? Yeah I've had a
discussion with my son. I'd .. I don't know about
ventilators and I didn't really know much about all that
until you've mentioned it there but I've certainly had a conversation with my son
Eric. When my wife passed away that there's no way
that I would ever want anything like that done to me, you know,
especially having my age, you know. I'm not wanting
Tubes and that, you know, and the outcome might
not be that great and it might actually be worse than what it was before I
even went in. I think that's quite a realistic outlook that you've got
and I don't think you would necessarily benefit from
the artificial life support and things like that.. because I don't think that
you would be likely to survive that.
Okay. All right, how do you feel about that?
Well as I said you know I'm 86, you know, I've ihad a good life
you know but I definitely don't want Tubes or
anything. Okay I think that's ..well we've come to an aagreement on
that and I think we should discuss what should we do if then
that we're not doing that and I think you know we should continue with
the antibiotics, the fluids but you seem to be drinking
okay so you might not need them, and give you the oxygen just
and do all this just in the ward here .. and you know if things were to get worse
we need to think about discussing about resuscitation.
Okay and what I mean by that is if your heart and lungs were to stop.
Okay have you heard about a DNACPR form? Yes I heard .. is that the red form?
Yes.
Again it was my son that dealt a lot with that at the time but I do
recall. Do you know what what it means and what it doesn't mean? No well I know
that it means well you don't want anything but I don't
know really the ins and outs of the form. So what it means is if if your
heart and lungs were to stop there's what we do, we call it
cardiopulmonary resuscitation but in some people like yourself
and given your underlying health problems
frailty and your your age as well um it probably wouldn't be successful. It
doesn't always work, okay and i don't think based on
what you've said and what you wouldn't want done,
because if it were to work then you would need to go to intensive care and
things like that .. I don't think that that's in your best
interest, therefore I don't think cardiopulmonary resuscitation is
in your best interest okay. So what I would
so I think we should probably put that form similar to what your wife had
In your notes. But what I need to explain to you
is that it doesn't mean that we withdraw treatment from you or care.
It just means we wouldn't do treatment that we know would be unlikely to be
successful, okay? Yep, all right.
Any questions about that? Obviously you know it
makes you worry about .. but at the end of the day, as I've said I mean I'm 86
And i don't want anything like that to go
and i'd rather pass away peacefully than people running about. Okay I think we're
also useful to say and mention that if you become unwell we'll give you the
treatment to give to treat the pneumonia but we can also
treat the symptoms that come with the pneumonia
a bit better and I can see you're actually quite breathless just now
is that right? Yeah absolutely. And sometimes medications to help with that
actually make you feel a bit better, so what I mean by that is
some morphine that you take ... it's just a liquid
under the tongue that the nurses can give you
and I think you actually might benefit from that just now.
okay. Would you be willing to try that? Yeah I'll try anything.
Okay and that's a different way that we can care for you
okay and I think better I think what I'll do now is I'll
probably go and speak to your your doctors on the ward
we'll document this discussion in your notes
and then with your permission is it okay if I speak to your son Eric?
Yes absolutely. Okay thanks very much for having this
difficult conversation with me. I know it's not easy
but I think it's very important for how we care for you
in the next few days or so all right.
In the second part of the video how did the doctor find out what matters to
Malcolm and discuss a treatment escalation plan
with him? How could you use some of the effective
approaches to communication you've seen here in your own work?
The doctor says that before moving on he wants to know about Malcolm and what
matters to him in general. This lets Malcolm share information
about himself. The doctor says have you had any
thoughts on what we should do if you were to get unwell again?
Malcolm has thought about the future but would like to know about intensive care.
He's now clear icu is not something he would want.
The doctor says 'that is a realistic outlook'
I don't think you would benefit from artificial life support
I don't think you would survive that Malcolm hears that icu is not an option
that would work for him and that he's not faced with a choice to
make Having talked about what the team can do
to care for Malcolm the doctor explains what cpr is and why it would not work
for Malcolm Malcolm shares what happened with his
wife and agrees with the doctor and hears that a DNACPR form does not
affect any other treatments that can help him.
Malcolm and Chris agree on a plan including a call to update Eric
Malcolm's son ...so
in summary REDMAP is a good framework 395 00:14:22,480 --> 00:14:25,279 to structure these important
conversations. Remember ready is about preparing people
for the conversation and thinking am I ready too