Counseling scenario : Counsel a relative of a critical patient regarding his critical condition and plan of management.

Counsel a relative of a critical patient ( Advanced Congestive Cardiac Failure ) regarding his critical condition and plan of management.

You are a junior doctor working on evening cover for a General Medial / Acute Medicine Ward.

Mr H is a 76 year old man who has been admitted 6 days ago with exacerbation of congestive cardiac failure.

He was started on treatment with oxygen , diuretics , and vasodilators .

However there is little response and he stays short of breath ad hypoxic despite being given supplemental oxygen.

His GCS has dropped to 7 and he appears drowsy.

The consultant on call reviewed him during ward round and decided that in the event of a cardiac arrest , he should only be treated conservatively and no CPR / cardio pulmonary resuscitation should be provided.

This was discussed with his son who also agreed.

At night his daughter arrives and speaks to you saying she wants her father to be resuscitated and transferred to ICU / intensive Care unit.

Your task :

Explain to the daughter that shifting the patient to Intensive care unit would not be appropriate and CPR would be ineffective as well.

Main points to explore :

What does the daughter believe will happen to her father ?

Why does she want her father to be transferred to the Intensive Care Unit ?

Main points to establish :

What does she know about her father”s condition and his previous state of health.

She does not live with him and may not be aware of his previous condition.

Explain to her what treatment has been given to her father.

He has been treated actively with oxugen , vasodilators and diuretics but has deteriorated despite this.

Be clear and explicit about his prognosis:

Tell her , her father is dying and there is no treatment that can reverse his condition or improve his prognosis. Not even ITU intervention or CPR in case of cardiac arrest.

Tell her about the management plan / ceiling of Care :

Her father will be given treatment to alleviate / relieve his symptoms and keep him pain free and comfortable and dignified.

This includes ward based care such as oxygen and diuretics.

Remove the misconception of the relative that no  treatment will be given at all.

Daughter may ask:

Why are you not admitting my father to the ITU :

Explain I am sorry to say your father has advanced Congestive Heart failure.

We have given him treatment with Oxygen , Diuretics and medications in order to help his heart beat more stronger and take the fluids out of  his body to reduce the pressure on his heart but it seems like these treatments are not working and his heart is continuing to fail.

Any intensive treatment such as intubation and CPR will most likely not work.

So we will continue to give him best medical care and keep him pain free.

Any intensive treatment and CPR would unlikely to succeed but will give more distress to the patient.

Address her concerns and be polite and give her time to understand the situation.

Daughter may ask : 

Is there nothing else you can do for him / Do to help him?

Tell her that we can make his breathing easier for him , make sure he is comfortable , dignified and pain free.

Daughter may say :

You are doing this because that’s what my brother / other relative wants,

Explain, this is not the case . This is a medical decision and has been made by the medical team headed by an experienced Consultant.

Although we have told your brother about this and he has agreed to this plan of action.

Relative may ask : Can I speak to someone more senior about this ?

Explain : The consultant who had made this plan of management for your father may not be available at this time , but I can arrange for the Registrar to speak to you or someone from the ITU team.

But they are most likely going to tell you the same plan which I have already told you.

However if you need to ask anything which I have been unable to answer , we can arrange your meeting with them.