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Reserve Judgment:
Aligning with patients at the
end of life
Ashley Shreves, MD

SMACC 2019

Ochsner Medical Center, New Orleans, LA
Ms. M
Ms. M
Ms. M
What do you think of her?
Ms. M
Ms. M
• Brave
Ms. M
• Brave
• Stoic
Ms. M
• Brave
• Stoic
• Rational
Ms. M
• Brave
• Stoic
• Rational
• Accepting
Ms. M
• Brave
• Stoic
• Rational
• Accepting
• Exactly like me
Mr. B
Mr. B
Mr. B
What do you think of him?
He is
He is
• Irrational
He is
• Irrational
• In denial
He is
• Irrational
• In denial
• Frustrating
He is
• Irrational
• In denial
• Frustrating
• Desperate
He is
• Irrational
• In denial
• Frustrating
• Desperate
• NOT LIKE ME
Let’s take a survey
Let’s take a survey
• I will die like Ms. M. Yes/No
Let’s take a survey
• I will die like Ms. M. Yes/No
• I will die like Mr. B. Yes/No
Let’s take a survey
• I will die like Ms. M. Yes/No
• I will die like Mr. B. Yes/No
• I want to spend my last weeks of life in the hospital. Yes/No
Let’s take a survey
• I will die like Ms. M. Yes/No
• I will die like Mr. B. Yes/No
• I want to spend my last weeks of life in the hospital. Yes/No
• I am ok being on a ventilator in the ICU in the last weeks of
my life. Yes/No
Let’s take a survey
• I will die like Ms. M. Yes/No
• I will die like Mr. B. Yes/No
• I want to spend my last weeks of life in the hospital. Yes/No
• I am ok being on a ventilator in the ICU in the last weeks of
my life. Yes/No
• I want to die at home. Yes/No
“What’s unusual about them is not how much treatment they get…but
how little. For all the time they spend fending off the deaths of others,
they tend to be fairly serene when faced with death themselves. They
know exactly what is going to happen, they know the choices, and they
generally have access to any sort of medical care they could want. But
they go gently.”
“What’s unusual about them is not how much treatment they get…but
how little. For all the time they spend fending off the deaths of others,
they tend to be fairly serene when faced with death themselves. They
know exactly what is going to happen, they know the choices, and they
generally have access to any sort of medical care they could want. But
they go gently.”
“I cannot count the number of times fellow physicians have told me, in
words that vary only slightly, “Promise me if you find me like this that
you’ll kill me.” They mean it.”
• Inpatient hospital use last 6 mo of life: same
• Inpatient hospital use last 6 mo of life: same
• Days in hospital: same
• Inpatient hospital use last 6 mo of life: same
• Days in hospital: same
• Died in the hospital: same
• Inpatient hospital use last 6 mo of life: same
• Days in hospital: same
• Died in the hospital: same
• Days in ICU: same
• Inpatient hospital use last 6 mo of life: same
• Days in hospital: same
• Died in the hospital: same
• Days in ICU: same
• Hospice: physicians 46%, non-physicians 43%
• Inpatient hospital use last 6 mo of life: same
• Days in hospital: same
• Died in the hospital: same
• Days in ICU: same
• Hospice: physicians 46%, non-physicians 43%
• Inpatient hospital use last 6 mo of life: same
• Days in hospital: same
• Died in the hospital: same
• Days in ICU: same
• Hospice: physicians 46%, non-physicians 43%
WHAT??!!
Matlock et al. JAGGS 2016
WHAT??!!
Matlock et al. JAGGS 2016
“Fear and avoidance of dying are strong
motivators of…human behavior and perhaps physicians are
not immune to these fears of dying.”
What drives intensity of
EOL care?
Prigerson HG and Maciejewski PK. J Support Onc 2012
What drives intensity of
EOL care?
Prigerson HG and Maciejewski PK. J Support Onc 2012
What drives intensity of
EOL care?
Prigerson HG and Maciejewski PK. J Support Onc 2012
Uncertainty
Ouchi K et al. J Am Geriat Soc 2018
Uncertainty
Ouchi K et al. J Am Geriat Soc 2018
Uncertainty
Ouchi K et al. J Am Geriat Soc 2018
Towards acceptance
Towards acceptance
“It has become, in my view, a bit too trendy to regard
the acceptance of death as something tantamount to
intrinsic dignity…For most situations…I prefer the
more martial view that death is the ultimate enemy -
and I find nothing reproachable in those who rage
mightily against the dying of the light.”

•
-Jay Gould “The Median isn’t the Message”
Towards compassion
Towards compassion
• “Our brokenness is…the source of our common humanity,
the basis of our shared search for comfort, meaning, and
healing. Our shared vulnerability and imperfection
nurtures and sustains our capacity for compassion.”
-Bryan Stevenson, Just Mercy
Translation at the bedside
Translation at the bedside
• Offer guidance, balance with humility
Translation at the bedside
• Offer guidance, balance with humility
Translation at the bedside
• Offer guidance, balance with humility
• Acknowledge uncertainty
Translation at the bedside
• Offer guidance, balance with humility
• Acknowledge uncertainty
Translation at the bedside
• Offer guidance, balance with humility
• Acknowledge uncertainty
• Be the doctor you will want when it’s your time

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Reserve judgement: aligning with patients at the end of life

  • 1. Reserve Judgment: Aligning with patients at the end of life Ashley Shreves, MD SMACC 2019 Ochsner Medical Center, New Orleans, LA
  • 4. Ms. M What do you think of her?
  • 8. Ms. M • Brave • Stoic • Rational
  • 9. Ms. M • Brave • Stoic • Rational • Accepting
  • 10. Ms. M • Brave • Stoic • Rational • Accepting • Exactly like me
  • 11. Mr. B
  • 12. Mr. B
  • 13. Mr. B What do you think of him?
  • 14. He is
  • 17. He is • Irrational • In denial • Frustrating
  • 18. He is • Irrational • In denial • Frustrating • Desperate
  • 19. He is • Irrational • In denial • Frustrating • Desperate • NOT LIKE ME
  • 20. Let’s take a survey
  • 21. Let’s take a survey • I will die like Ms. M. Yes/No
  • 22. Let’s take a survey • I will die like Ms. M. Yes/No • I will die like Mr. B. Yes/No
  • 23. Let’s take a survey • I will die like Ms. M. Yes/No • I will die like Mr. B. Yes/No • I want to spend my last weeks of life in the hospital. Yes/No
  • 24. Let’s take a survey • I will die like Ms. M. Yes/No • I will die like Mr. B. Yes/No • I want to spend my last weeks of life in the hospital. Yes/No • I am ok being on a ventilator in the ICU in the last weeks of my life. Yes/No
  • 25. Let’s take a survey • I will die like Ms. M. Yes/No • I will die like Mr. B. Yes/No • I want to spend my last weeks of life in the hospital. Yes/No • I am ok being on a ventilator in the ICU in the last weeks of my life. Yes/No • I want to die at home. Yes/No
  • 26.
  • 27.
  • 28. “What’s unusual about them is not how much treatment they get…but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.”
  • 29. “What’s unusual about them is not how much treatment they get…but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.” “I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it.”
  • 30.
  • 31.
  • 32.
  • 33.
  • 34.
  • 35. • Inpatient hospital use last 6 mo of life: same
  • 36. • Inpatient hospital use last 6 mo of life: same • Days in hospital: same
  • 37. • Inpatient hospital use last 6 mo of life: same • Days in hospital: same • Died in the hospital: same
  • 38. • Inpatient hospital use last 6 mo of life: same • Days in hospital: same • Died in the hospital: same • Days in ICU: same
  • 39. • Inpatient hospital use last 6 mo of life: same • Days in hospital: same • Died in the hospital: same • Days in ICU: same • Hospice: physicians 46%, non-physicians 43%
  • 40. • Inpatient hospital use last 6 mo of life: same • Days in hospital: same • Died in the hospital: same • Days in ICU: same • Hospice: physicians 46%, non-physicians 43%
  • 41. • Inpatient hospital use last 6 mo of life: same • Days in hospital: same • Died in the hospital: same • Days in ICU: same • Hospice: physicians 46%, non-physicians 43%
  • 43. WHAT??!! Matlock et al. JAGGS 2016 “Fear and avoidance of dying are strong motivators of…human behavior and perhaps physicians are not immune to these fears of dying.”
  • 44. What drives intensity of EOL care? Prigerson HG and Maciejewski PK. J Support Onc 2012
  • 45. What drives intensity of EOL care? Prigerson HG and Maciejewski PK. J Support Onc 2012
  • 46. What drives intensity of EOL care? Prigerson HG and Maciejewski PK. J Support Onc 2012
  • 47. Uncertainty Ouchi K et al. J Am Geriat Soc 2018
  • 48. Uncertainty Ouchi K et al. J Am Geriat Soc 2018
  • 49. Uncertainty Ouchi K et al. J Am Geriat Soc 2018
  • 51. Towards acceptance “It has become, in my view, a bit too trendy to regard the acceptance of death as something tantamount to intrinsic dignity…For most situations…I prefer the more martial view that death is the ultimate enemy - and I find nothing reproachable in those who rage mightily against the dying of the light.” • -Jay Gould “The Median isn’t the Message”
  • 53. Towards compassion • “Our brokenness is…the source of our common humanity, the basis of our shared search for comfort, meaning, and healing. Our shared vulnerability and imperfection nurtures and sustains our capacity for compassion.” -Bryan Stevenson, Just Mercy
  • 55. Translation at the bedside • Offer guidance, balance with humility
  • 56. Translation at the bedside • Offer guidance, balance with humility
  • 57. Translation at the bedside • Offer guidance, balance with humility • Acknowledge uncertainty
  • 58. Translation at the bedside • Offer guidance, balance with humility • Acknowledge uncertainty
  • 59. Translation at the bedside • Offer guidance, balance with humility • Acknowledge uncertainty • Be the doctor you will want when it’s your time