The ‘systems’ approach is another strategy used to help organize treatment plans for patients with multiple ongoing medical issues. The patient is divided into individual systems: cardiac, pulmonary, renal, etc…, and the ongoing treatments outlined. Like the ‘problem list’, the ‘systems’ approach is great for charting purposes; also like the ‘problem list’, it’s a poor communication tool. Because again all those individual ‘systems’ plus undefined inputs (social support, financial challenges, to name just a few) adds up to a more complicated ‘whole’ patient.
patients are more than the sum of their ‘systems’
Mr B, 57 yrs old, with a history of coronary artery disease, hypertension, type 2 diabetes, and chronic renal failure was admitted to our hospital following an in-home cardiac arrest. The paramedics had arrived very quickly and after ~15 minutes of CPR, he had return of spontaneous cardiac activity (i.e., his heart started beating on its own). But upon arrival to the emergency room, he was unresponsive and required emergency intubation and ventilatory support.
It is now hospital day #10.
While Mr B’s cardiac function quickly stabilized, he developed pneumonia and generalized sepsis (likely secondary to aspiration during the resuscitation efforts) which resulted in acute kidney failure. Renal replacement therapy was started, and now his kidney function is showing small signs of improvement. But he remains comatose. And today’s head CT scan shows significant anoxic changes- a very poor prognostic sign. Per the neurology consultant, the likelihood for Mr B to make any meaningful neurologic recovery is minimal.
Mr B’s ‘systems’
Mr B’s is a 55yr male with cad, htn, dm2, day 10 s/p cardiac arrest
Cardiac:
- stable on current antiarrthymic medications
- blood pressure normal, off pressors x 2 days
- no evidence of ongoing cardiac ischemia
Renal:
- urine output improving.
- Still requiring renal replacement therapy
- electrolytes stable
Endocrine/nutrition:
- diabetes well controlled on sliding scale insulin,
- tolerating tube feedings.
Pulmonary:
- continues on iv antibiotics for pneumonia
- remains on vent
- oxygen requirement decreasing,
Neuro:
- no purposeful movements
- f/u scan shows evidence of severe brain injury,
- prognosis poor
the conversation
The team spoke often with Mr B’s family- and essentially used this ‘systems’ list to guide the discussion about his daily condition and planned treatments. At their most recent meeting the conversation shifted to address his ‘code status’. Despite being told by the team that Mr B’s prognosis was poor, the family wanted to continue ‘everything’. So now palliative medicine is consulted, with the concern that the family “just doesn’t get it”.
But after reviewing his record and listening to the family’s understanding of Mr B’s condition and prognosis- it’s likely that the family is seeing a different picture than the team means to convey. Looking over the list, all except one (albeit an important one) of his ‘systems’ seem to be stable or improving. Even if the team explains why they feel Mr B’s prognosis is so poor (due to the neurologic injury), is it any wonder the family wants to continue all treatments? In their mind, because his other ‘systems’ are improving, ‘he’s getting better’, so why can’t his neurological ‘system’ improve as well if given more time? Here is where hope and the equally powerful force of denial is coming into play: hope that their loved one will improve; denial of Mr B‘s current state and the fact that he will never be the same man again.
A discussion centering on Mr B’s ‘systems’ or ‘problems’- is a relatively safe, superficial discussion because each individual system or problem is at the center of the conversation. There’s little emotion evoked when talking about his kidney function or respiratory function. In contrast, there’s a ton of emotion in a discussion about Mr B as a person, now with a devastating brain injury on top of his other issues.
Patient care challenges occur because it can be tough for both the provider and the family to communicate at that deeper plane required for a big picture discussion. It can be too painful. But to counter unrealistic hope and denial, the conversation must delve into this more intimate and potentially emotional space to determine what Mr B would want given his new reality. And that’s the whole point of the conversation in the first place.
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