Case: A 79-year-old woman with metastatic lung cancer presents to the ED with severe dyspnea. Assisted ventilation appears necessary. The family is in attendance and under the impression that she will benefit from chemotherapy and/or radiation. According to the family, no one has discussed her prognosis or an advance directive with either the patient or them. Should this patient be immediately intubated?

There is strong evidence to suggest that physicians have poor training in end-of-life (EOL) care discussions and that, even when they do occur, the quality of the discussions is generally poor.¹ Complicating the situation further is that patients and their families do not always absorb medical information communicated to them when patients are acutely ill. Family members frequently do not know and cannot accurately predict patients’ EOL care preferences, and patients have preferences that change over time and across differing clinical scenarios.^2-4

The emergency physician should have a candid and accurate discussion with the patient and family regardingcurrent condition, prognosis, recommended interventions, and alternatives.

Individual goals of treatment should be established. Preferences should be gathered in regard to specific interventions and procedures rather than asking if patients or surrogates want “everything done.” Many patients may choose to limit critical and resuscitative interventions at the EOL but may be concerned about symptoms, such as pain, anxiety, nausea, or dyspnea.^5,6 Establishing goals of treatment that are consistent with patients’ values is an important task when caring for patients at the EOL.

Anticipating the support needs of families of patients near or at death in the ED is important in facilitating the natural grieving process that will occur if patients die. This may have more impact than the actual medical care provided to critically ill patients at the EOL. To that end, resources such as social services and pastoral care may be helpful.

How to Approach the Case of the 79-Year-Old Woman

Rapid acquisition of information is essential. A review of the medical history, including any information that would allow the emergency physician to formulate a prognosis and understand the patient’s EOL care preferences, ideally in conjunction with the primary care provider, is important to emergency decision making. The ED presents significant challenges to effective communication about critical decisions, including time constraints, a loud and unfamiliar environment not always conducive to patient privacy, and the necessity for rapid decision making.

If possible, the emergency physician should have a candid and accurate discussion with the patient and family regarding current condition, prognosis, recommended interventions, and alternatives. In the event that information concerning the patient’s EOL care preferences is unavailable and surrogate decision makers need more time to make decisions regarding goals of therapy, the medical condition should be stabilized to provide them with the opportunity to determine the best treatment plan to achieve patient-centered goals. For the case at hand, stabilization for the purposes of temporizing may include noninvasive positive-pressure ventilation and medical therapy. If intubation is indicated, the decision to extubate can always be undertaken when further information is available about patient-centered values and goals of medical therapy.

Dr. Marco is professor of emergency medicine at Wright State University Boonshoft School of Medicine in Dayton, Ohio. She currently serves on the ACEP Ethics Committee. Dr. Baker works clinically for Riverwood Emergency Services Inc. She is assistant professor of emergency medicine at the University of Toledo College of Medicine and Life Sciences. She currently serves on the ACEP Ethics Committee.

Dr. Jesus is assistant professor of emergency medicine at Christiana Care Health System in Newark, Del. He currently serves on the ACEP Ethics Committee.

Dr. Geiderman is a professor of emergency medicine and emergency department co-chairman at Cedars-Sinai in Los Angeles. He currently serves as chair of the ACEP Ethics Committee.

References

1. Kaldjian LC, Erekson ZD, Haberle TH, et al. Code status discussions and goals of care among hospitalised adults. J Med Ethics. 2009;35:338-342.
2. Shalowitz DI, Garrett-Mayer E, Wendler D. The accuracy of surrogate decision makers: a systematic review. Arch Intern Med. 2006;166:493-497.
3. Suhl J, Simons P, Reedy T, et al. Myth of substituted judgment. Surrogate decision making regarding life support is unreliable. Arch Intern Med. 1994;154:90-96.
4. Perkins HS. Controlling death: the false promise of advance directives. Ann Intern Med. 2007;147:51-57.
5. Hamel MB, Lynn J, Teno JM, et al. Age-related differences in care preferences, treatment decisions, and clinical outcomes of seriously ill hospitalized adults: lessons from SUPPORT. J Am Geriatr Soc. 2000;48:S76-S82.
6. Marco CA, Schears RM. Societal preferences regarding cardiopulmonary resuscitation. Am J Emerg Med. 2002;20:207-211.