With this initial rapid palliative assessment completed, the expected outcomes of various medical interventions can better guide the emergency physician in a discussion with the patient or surrogate on the patient’s priorities and goals. For example, if the emergency physician recognizes that the patient is likely to die during this hospitalization, regardless of critical interventions, it would be reasonable to express to the surrogate “worry” about how dire the situation appears. It is also reasonable in such a situation to ask the surrogate about whether the patient had expressed, or if the surrogate has an understanding of, the patient’s goals, values, and perspective on medical priorities near the end of life. Had the patient talked about whether “dying on machines” was acceptable or unacceptable? Does “being comfortable in a peaceful situation if I am dying” sound more consistent?

These ideas may well be clear already in the mind of the surrogate, even in the absence of an advance directive. If the goals are already clear under the medical circumstances described, then the interventions are dictated by those goals. If physiological support through the end of life is the priority, regardless of the patient’s prognosis, or if the discussion is not possible and the goals cannot be reasonably discerned in those brief moments when physiological intervention is critical, then the emergency physician will intervene appropriately, of course. Having opened the discussion about the value of these interventions, the emergency physician will have initiated an essential and time-sensitive dialogue with the family as they consider the role of ongoing critical interventions while the patient’s condition evolves in the intensive care unit. If comfort is the priority, then hospice involvement or a palliative care consultation might be the most important intervention.

Dr. Jesus is attending physician at Augusta Medical Center in Fishersville, Virginia and subcommittee chair for publications of the ACEP Ethics Committee.

Dr. DeSandre is the chief of Palliative and Supportive Care at Grady Memorial Hospital; and the program director of Fellowship in Hospice & Palliative Medicine and assistant professor of emergency medicine at Emory University.

Dr. Fairbrother is assistant director of undergraduate medical education at the Ronald O. Perelman Department of Emergency Medicine at New York University School of Medicine in New York.

Dr. Rosenberg is chairman of emergency medicine at St. Joseph’s Healthcare System and associate professor of clinical emergency medicine at New York Medical College.

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