A Qualitative Study of Perioperative Depression and Anxiety in Older Adults.

OBJECTIVE: We had three aims 1) understand barriers to perioperative management of anxiety and depression in older surgical patients; 2) identify preferences and requirements for interventions to manage their anxiety and depression; and 3) explore the feasibility of implementing such interventions in perioperative care. DESIGN: A qualitative study using semistructured interviews was conducted. SETTING: Participants were recruited at a large academic medical center. PARTICIPANTS: We interviewed older surgical patients and clinicians to characterize their perspectives on management of anxiety and depression symptoms, with emphasis on patient needs, barriers, and potential interventions to address these needs. MEASUREMENTS: We used the Consolidated Framework for Intervention Research to guide the development of interview questions related to intervention implementation feasibility. Thematic analysis was used to analyze interview responses. RESULTS: Forty semistructured interviews were conducted. Key barriers for perioperative management of depression and anxiety included fear of surgery, acute pain, postoperative neurocognitive disorders, limited understanding of what to expect regarding surgery and recovery, and overwhelmingly complex medication management. Patients and clinicians suggested that a bundled mental health management intervention targeted for older surgical patient population comprised of behavioral and pharmacologic strategies can help mitigate anxiety and depression symptoms during the perioperative period. Clinicians emphasized the need for a collaborative engagement strategy that includes multiple stakeholders in the design, planning, and implementation of such an intevention. CONCLUSION: New care models need to be developed to integrate mental health care into the current perioperative care practice.

Breaking Bad News in the Emergency Department.

Audience: The primary audience for this simulation is emergency medicine (EM) residents, but this curriculum could also be used for EM-bound medical students. Introduction: Breaking bad news is a difficult but necessary skill for EM physicians. Bad news can range from informing family that a patient is in the emergency department (ED), to shared decision making regarding a life-threatening situation, to family notification of patient death.1 Although there are many structured approaches to death notification and breaking bad news, such as GRIEV_ING2 and SPIKES,3 EM physicians often lack confidence in their ability to effectively communicate bad news.1,4-6 Goals of care discussions and shared decision making become especially complex in the ED environment because critically ill patients often arrive without advanced directives, lack pre-existing rapport with the EM physician, and may require rapid engagement with surrogate decision-makers on emergent interventions.7 This simulation curriculum was developed to provide EM trainees with a psychologically safe environment to practice effective communication in breaking bad news, incorporating clinical scenarios commonly encountered in the ED. Educational Objectives: At the conclusion of these two simulation cases, learners will be able to 1) recognize signs of poor prognosis requiring emergent family notification, 2) take practical steps to contact family using available resources and personnel, 3) establish goals of care through effective family discussion, 4) use a structured approach, such as GRIEV_ING, to deliver bad news to patients' families, and 5) name the advantages of family-witnessed resuscitation. Educational Methods: This curriculum consists of two simulation cases. Prior to the simulation, learners were assigned pre-reading on the GRIEV_ING approach to death notification, and how this approach could translate into breaking bad news in the ED. Although we chose to implement GRIEV_ING at our institution, other structured approaches (such as SPIKES) are reasonable as well. Each simulation case was conducted using a high-fidelity mannequin capable of intubation, respiratory examination findings such as abnormal breath sounds, and dynamic vital sign changes. Both cases required a standardized patient or other case confederate. Following each case, the learners underwent a debriefing session discussing how to break bad news in a high-pressure, time-sensitive ED environment. This case was designed as a high-fidelity simulation with a standardized patient, but it can be adapted to a low-fidelity simulation with a standardized patient. Research Methods: Learners filled out a survey before and after the simulation describing their confidence in establishing goals of care with patients and surrogates, notifying family members of bad news in the ED, and their use of a consistent approach to breaking bad news. Scores were analyzed using the related-samples Wilcoxon signed rank test. Results: Learners exhibited improvement on all surveyed items, with statistically significant improvement on the survey item asking about their confidence in implementing a consistent approach to breaking bad news. Qualitative feedback was positive, with learners consistently endorsing the value of practicing difficult conversations in a simulated environment. First- and second-year residents appeared to benefit from the cases more strongly than senior residents. Discussion: These cases provided a safe environment for learners to practice a structured approach to breaking bad news. Learners tended to aggressively resuscitate the elderly septic patient and perform invasive procedures, such as intubation and mechanical ventilation, prior to contacting family or establishing goals of care, which generated good discussion points during debriefing. Topics: Simulation, breaking bad news, goals of care discussion, death notification, sepsis, cardiac arrest, family witnessed resuscitation.