IntraOperative Death Flashcards
Key points
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An anaesthetist is likely to be involved in an intraoperative death during their career.
Guidance on practical steps to take after an intraoperative catastrophe is available from the The Association of Anaesthetists of Great Britain & Ireland.
An opportunity for debriefing the theatre team should be provided after an intraoperative death.
Debriefing skills integral to high-quality simulation education can be translated to clinical practice following an intraoperative catastrophe.
Simulation can be a useful tool for team based in situ experiential learning from intraoperative catastrophes.
Intro
The focus of an anaesthetist’s training is in the safe delivery of anaesthesia and the management of perioperative crises. Little training is received in the management of an intraoperative death. Despite this, the majority of anaesthetists will be involved in an intraoperative death during the course of their careers.1
An intraoperative death can be traumatic and stressful to the entire theatre team2 and several surveys have highlighted the need for debriefing of staff after the event.1,3 In this article, we will outline practical steps to take after an intraoperative death.
We aim to illustrate potential debriefing methods, and how simulation education can be used to train staff to both deal with the aftermath and learn together to reduce the likelihood of future intraoperative catastrophes.
Practical steps to take
- Record keeping
- The anaesthetist involved
- The anaesthetist involved
- Subsequent actions
Debriefing the theatre team
Critical incident stress management
BICEPS model
Record keeping
- Contemporaneously where possible
and any retrospective entries identified as such.
- It is difficult during a critical incident to keep track of time and we would recommend delegating a member of the theatre team to keep a record of events as they unfold
The anaesthetist involved
- If a non-consultant grade clinician is the primary anaesthetist involved, then the responsible consultant should attend in person.
- It is suggested that a consultant should also request the presence of a colleague to assist with the aftermath
- Many anaesthetists may feel their ability to deliver safe anaesthesia is compromised after an intraoperative death,
- A decision about whether an anaesthetist should continue working should be based on a discussion between the anaesthetist involved, a colleague and the clinical director
The patient’s relatives and breaking bad news
- Informing the relative of the death of one of our patient’s is extremely difficult.
- Breaking bad news should be done in person
and the relative should be asked to bring another relative,
or friend to accompany them, for emotional support.
- In recent years, medical schools have focused on communication skills with breaking bad news a key element. However, during postgraduate training, this skill is often not reinforced, particularly in specialities such as anaesthesia
- A team approach is vital, with a senior member of the anaesthetic, surgical and nursing team responsible for the patient present. Non-consultant members of the team should have appropriate consultant support
- All members of the team present should be introduced.
Delivering bad news effectively not only involves delivering the information clearly, but also providing emotional support.
Bad news should be delivered in a straightforward and honest way, avoiding medical jargon.
Apologizing is not an admission of blame.
The time should be allowed for the information to be absorbed.
Shock, denial, and anger are all natural grief reactions and the team should be prepared to deal with these. All questions should be answered honestly and compassionately, with factual reassurances and time provision for further questions emphasized.
Relatives may want to see the body and provision for this in a quiet area should be made.
A second interview may well be necessary, as questions often arise after time has been allowed for the news to sink in. These questions should again be answered openly and as compassionately as possible. Where facts are uncertain, speculation should be avoided.
Subsequent actions
A consultant not involved in the case should take responsibility for checking the patient and equipment.
Where suspicion of equipment failure or malfunction is present,
then that piece of equipment/theatre should be isolated until a formal examination can be undertaken.
In the case of an anaesthesia-related death,
then all anaesthetic equipment, drugs, syringes,
and ampoules should be kept.
The patient’s general practitioner and the coroner should also be informed.
Debriefing the theatre team
There is a lack of high-level evidence to demonstrate the efficacy of debriefing clinical staff after a critical incident.
However, several surveys have highlighted that clinicians feel debriefing would be useful and should occur.
Indeed, it is a duty of care for an employer to consider the psychological needs of personnel after a traumatic event in the workplace.
It also forms part of National Institute for Clinical Excellence (NICE) guidance that practical and social support should be provided after a traumatic incident.
illustrates the core elements of any debriefing process.
Core elements of debriefing
- Description
Identifying the salient points of the experience which
had an impact on how the incident unfolded - Analysis
Individualizes the experience,
focusing on the individuals actions and thoughts
underpinning those actions during the incident - Application
How to incorporate the learning points from the incident into practice.
This has been shown to aid closing the performance gap
in an individual’s expertise
What debriefing tool?
There is no consensus on the debriefing process after a critical incident such as an intraoperative death; however, several techniques have been described and are currently in use.
Critical incident stress management
- Defusing:
this is an informal group debriefing session
occurring within hours of the incident.
peer led, and will often take the form of an open discussion about the event
these sessions decrease tension and
help individuals gain control of their emotions.
It will also highlight key points for further critical incident stress debriefing
- CISD
It should be emphasized that CISD is not a therapy, but rather a way of identifying those in need of further counselling.
Critical incident stress debriefing
- Session type
Group session, 1–10 days after the event
- Session leader
Specially trained individuals
- Aims
Facilitate early help seeking
Identify those with an acute stress reaction
Enable early recovery
- Session structure
Introduction
i Facts—
the group is asked to describe what happened
ii Thought—
what an individual’s thoughts were during the incident
iii Reaction—
what emotions individuals have towards the event,
in particular the worst part for them.
Allowing venting of thoughts and feelings
iv Symptom phase—
the group is asked to report stress symptoms during the event, in the first few days afterwards and any continuing symptoms they may have
v Teaching—
individuals are provided with stress reduction information,
communication with relatives and
others in the group is encouraged
vi Re-entry phase—
any questions the team may have and summary
BICEPS model
This model was originally designed for use in the military for soldiers who have suffered traumatic events. It has also been recommended for use in anaesthesia training programmes7 because of parallels with an anaesthetist’s life, such as dealing with loss of life, sleep deprivation, and grief. The principles of the BICEPS model are illustrated in
BICEPS Model
1.Brevity
Dealing with the stressor will be brief and focused
- Immediacy
Feelings of guilt or grief should be confronted soon after the traumatic event, or as soon as they are recognized
- Centrality
Discussions should take place with all affected healthcare staff in a central location in an organized fashion
- Expectancy
Make clear expectations that the affected individuals will return to work
Means of returning to normal productivity are outlined
- Proximity
Discussions and treatment should take place near the place of work to maintain friendships and bonding
Forced absence from work is discouraged
- Simplicity
Discuss and treat only the current problem
Avoid complicated recovery regimens
Debriefing principles
Despite the stress associated with a critical incident, it is essential for organizations and individuals to learn from these experiences. Simulation education based on experiential learning (learning through reflection on and after doing) is a powerful educational tool, which aims to modulate knowledge, skills, attitudes, and behaviours, within a safe learning environment. The use of high-quality debriefing stimulates reflection and facilitates a guided closure of performance gaps by the participants involved in the simulation
An intraoperative crisis does not mean that such a structured approach is inappropriate. Indeed, using the core elements of a debriefing session, identified in Table 1, may help to give structure to a staff debrief after an intraoperative crisis.
A key concept underpinning successful debriefing of a team is the presence of a bubble of safety within which team members and any specific individual can speak up and voice their opinion or knowledge within the debrief as per normal, with no fear of being embarrassed, or punished.
At the start of a debriefing session, it should be made explicit why it is important for team members to voice their opinions/concerns and that blame is not being sought. This increases freedom within the group for individuals to voice their opinions or indeed admit to errors without damaging someone’s self-worth
