The Respect Project

Scott Schmidt, MD, Kaiser San Rafael Emergency Department Palliative Care Pilot

The Emergency Department is a busy place where patients at all stages of illness go when they require immediate attention. A small but very important group of ED patients are gravely ill or in cardiopulmonary arrest and end up dying there. It is our responsibility and privilege to care for these patients and their families with dignity and respect at this profound and difficult moment of their lives. The experience they have will remain with them for the rest of their lives. It is for these patients and their loved ones, as well as their healthcare providers, that the RESPECT project was conceived.

R: Restore Order (and prepare loved ones for coming to the bedside): • Clean blood or other body fluids from around patient’s face and mouth • Cover patient with a clean sheet • Remove extraneous medical equipment • Put patient in a private room if possible • Death disclosure should occur prior to bringing family to the bedside

E: Explain: What happened and who was involved in patient’s care • Introduce the team that cared for the patient: names vs roles vs ‘this is the team that took care of your dad’ kind of introductions will vary depending on the situation • Describe what happened briefly and in simple terms � Some information may be given at the time of death disclosure, but it is also important to name and identify medical equipment that may still be attached to the patient’s body � If family is present during resuscitation, this can occur while events are unfolding or after resuscitation is concluded. � In either situation, it matters less what you say than how you say it. If providers are able to communicate compassionately and empathically, it will be of lasting benefit.

S: Stop and Set Aside Other Duties:

• Other things can wait. • RN other patients to be reassigned or covered by charge or break RN • Physicians are encouraged to hand off spectralink to a colleague

P: Be Present

• Caring for patients and their families at the time of death can be overwhelming and emotionally challenging.

Sometimes it’s helpful to check in with our selves first.

Am I feeling anxious, irritated, sad? Take a couple breaths to feel it and know it, then let it be and turn your full awareness toward what’s unfolding before you.

E: Empathize

• Take a moment to acknowledge that someone’s life has just ended. Whatever she was doing, whoever he was sharing his life with, it’s over now. • Loss is a shared human experience that transcends all roles. • Providing empathetic presence, quietly allowing ourselves to imagine what patient’s loved ones are going through, can often be more comforting than words.

C: Chaplain/Clergy

• Spiritual support is of critical importance to some families. • Our Chaplain is in house five days a week and can come to the bedside when available or make bereavement calls to families of patients that have died in the ED if requested. • Families may be connected to a specific religious community or spiritual support system that we can offer to contact.

T: Time:

• Allow family some time with their loved one • After approximately 30 minutes or when family shows signs they are ready, gently ask “would it be ok to talk about some logistics now?” When they feel ready and only then, begin to work on the other items that need attention such as mortuary plans, death certificate etc. • Caring for dying patients and their loved ones can be very satisfying for providers, but it can be emotionally and psychologically burdensome as well. Thus, it is essential that we take care of ourselves and each other along the way.