Primary prevention of ICU treatment disputes: the dinner table “bundle” for discussions regarding death

December 2, 2013

By: Gabriel Bosslet, MD, FCCP

Over the past decade or so, prevention of disease has taken a leading role in the health-care reform debate.  Screening for disease has been all but mandated by the Affordable Care Act, and new guidelines have essentially made statin drugs the fifth food group.  Earlier detection and prevention of disease has been the mantra for many public health advocates.

Management of coronary artery disease (CAD) is an informative example.  In the late 1980s, treatment shifted from primarily pharmacologic management to anatomic resolution via angioplasty—this eventually evolved into treatment via placement of stents to manage coronary disease.  Shortly thereafter, secondary prevention became a staple in management of CAD.  In secondary prevention, measures are put into place for those who are known to have a disease before it becomes symptomatic.  Aspirin, blood pressure control, and nitrates were used to ameliorate deterioration of CAD. Primary prevention, or prevention of a disease occurrence, soon followed and focused on use of aspirin, manipulation of serum lipids, smoking cessation, regular exercise, and so on to prevent first events.

Primary prevention of treatment disputes in the ICU?

Disputes regarding end-of-life care in ICUs have followed a similar trend over the past several decades.  In the late 1980s through the 1990s, “treatment” of disputes regarding life-prolonging treatments in ICUs focused on operationalizing “futility” to do the heavy lifting of resolving disputes when patients and families requested treatments that clinicians felt were not appropriate.  As many ICU clinicians can attest, futility has failed as a treatment to do the yeoman’s job it was commissioned to perform. 

As such, many have turned their eyes to prevention of treatment disputes via effective communication, mandatory family meetings, written materials for families in ICUs, shared decision-making, and use of communication consultants.  This secondary prevention model attempts to head off potential treatment disputes by managing expectations and developing clinician-family rapport at the outset of the ICU stay. 

ICU clinicians have largely ignored primary prevention of treatment disputes, and the reason is intuitive.  ICU stays are often unpredictable, unexpected, and unwanted.  Predicting those patients who (a) will require an ICU stay, and (b) will resist clinician recommendations regarding limiting treatments is difficult, at best.  Additionally, the intervention, discussion of potential outcomes and goals of care, is overwhelmingly laborious—discussing potential mortality with anyone is often seen as morbid, sad, and “giving up.”  Over the past 10 to 15 years, efforts to encourage POLST-type legislation have made some headway, but the battle remains considerably uphill.

Difficulties with these primary prevention conversations are often seen as a medical problem.  As such, they are often placed at the feet of the primary care doctor, oncologist, or other physician who cares for a person with a terminal diagnosis before they reach the end stages of disease.

Where should the discussion take place?

But the real issue begins long before the hospital is encountered. Real primary prevention for end-of-life disputes occurs outside of the health-care system, in the way that citizens discuss death and end-of-life care with their loved ones.  But how is an ICU clinician (or any clinician, for that matter) to participate in true primary prevention of treatment disputes?  There is seemingly no mechanism or platform for ICU clinicians, or any physician really, to participate in these discussions with others as citizens.

Until now.  Michael Hebb is a writer and food provocateur from Seattle who gave a TED Talk several months ago (below) in which he declared the dinner table to be the proper forum for these discussions.  He has teamed with physicians, business people, and thought leaders from around the country to create deathoverdinner.org.  For ICU clinicians, this website can be seen as an “end-of-life conversation bundle” for discussions regarding death (outside of the hospital, around a dinner table) and hopefully helps to shape how our culture views death and the circumstances in which it will (inevitably) take place. 

Essentially, the website asks you to consider hosting a dinner for family, loved ones, strangers, neighbors, biker gangs, or any group of your choosing.  Doing so, and thereby falling into the rabbit hole of the site, in no way commits one to hosting a dinner.  It then prompts you to pick a short reading, video, and audio clip from a menu of choices (I was able to watch/read/listen to all of mine in about 25 minutes). It provides a panoply of resources for hosting a “death dinner”, including:

• A suggested invitation e-mail for participants of this unique dinner event
• Links to the read/watch/listen selections you made on the site, so all guests have common substrate for discussion
• Three suggested conversation prompts (one to start the evening, one for the middle, and one for the end of the night) for discussion
• A few hosting tips
• An invitation to the “I-survived-a-death-dinner” website, with links to Everplans, a site which helps people plan for the inevitable at whatever stage of life they find themselves

The role of the clinician

This primary prevention bundle takes these conversations out of the stressful setting of the ICU and allows people the luxury of time to think and discuss with loved ones outside of a crisis moment.  As ICU clinicians, we have a unique place at this table, with our experience of being physically closer to more deaths than (almost) any other professional.  It may be time that at least some of our efforts are concentrated on true primary prevention, rather than secondary prevention.

I plan on having a dinner in the spring with members of my neighborhood community (invited via our neighborhood social network).  I see this as a relatively safe audience with which to conduct this social experiment on the feasibility and utility of a primary prevention bundle for end-of-life decision making.  I’ll report back to this blog with details on how it went.

Would you consider hosting a death dinner in your own community? What role do you think ICU clinicians can play in the community around improving and planning for a better end-of-life experience for patients? Weigh in on the American College of Chest Physicians Facebook page now.

Gabriel Bosslet, MD, FCCP (@gbosslet) is the Associate Fellowship Director for the Pulmonary and Critical Care fellowship at Indiana University.  He is an ethicist with an interest in end-of-life care and social media in medicine, and his clinical interests include neuromuscular pulmonary disease and general pulmonary and critical care medicine. Dr. Bosslet completed his residency in internal medicine and pediatrics at The Ohio State University and completed his fellowship training at Indiana University.