Today’s Special: CPR with a Side of Fries? - How to Talk About End-of-Life Decisions
are not waiters. When talking about treatment plans with patients in the emergency
department, we lay out our concerns, the pros and cons of different options,
and why we recommend one over the other for the particular patient. We do not
ask patients which antibiotic combination they would prefer.
is it different when we talk about resuscitation or end-of-life wishes? Why do
we suddenly ask patients “what they want” with no context or recommendation? We
sound like waiters: “Do you want shocks with that CPR?” “What about
intubation or pressors?”
end-of-life options is a skill, like intubation or placing a central line, one
that requires just as much preparation and practice. These options must be
discussed in the context of the patient’s illness and his personal goals.
Resuscitation should be discussed as an entity – not parsed out as individual
selections. The only exception to this is in patients with a primary
respiratory illness. In these cases, such as COPD patients, intubation may be
must think about this discussion as a fact-finding mission to uncover what the
patient and family understand about three things: What is going on with your
body? What do you understand about what the doctors are telling you? What
is your understanding of resuscitation? We listen, and when they are finished,
we educate, give a prognosis and outline our recommendations.
recommendations are based on two facts: Whether what brought them to the emergency
department is reversible or not. If it is not clear, we can offer “time-limited
trials” of aggressive interventions including intubation. The family should
understand that if the patient’s condition does not improve over the next
several days, then we would withdraw or stop the aggressive treatments. And
second, we consider the patient’s trajectory of illness and his prognosis. This
includes an assessment of his disease progression and functional status.
exploring these questions with the patient and family you will most often come
away from the conversation with a code status, WITHOUT EVER ASKING SPECIFICS!
Of course we clarify at the end of the discussion: “If, despite everything we
are doing, you were to stop breathing or your heart was to stop and you were to
die, we will allow you to die naturally and not attempt resuscitation.” If the
conversation devolves, that usually means the patient is not ready and needs
further intervention from a palliative care team.
are not there to judge the patient and family’s response, only to educate and
support. We can make recommendations based on our workup and conversation, for
what you have described, your condition is worsening despite aggressive medical
treatment. Your goal is to spend whatever time you have left with your family
and be free of pain. I would recommend at this time to talk with hospice.” OR
“It sounds like you are willing to continue treatment for reversible
conditions, but if you were to die you would not want resuscitation.”
this conversation take time? Yes. Is it time well spent? Yes. This is the heart
of medicine - charting and other administrative tasks, while necessary; do not
directly help the patient or your career longevity. Conversations like this
will help the people who matter. We will have their trust from listening and
then making clear to them their condition and its likely course. We will also
have a clear plan and most likely a “code status”. If we do not, we will have
set the stage for future conversations.
the Author: Kate Aberger, MD, FACEP is
the Director of the Palliative Care Division of Emergency Medicine at St. Joseph’s
Regional Medical Center in Paterson, New Jersey. She is also the Chair of the Palliative
Medicine Section for the American College of Emergency Physicians.