The Most Difficult Emergency Procedure

When I graduated residency and started my first job, I walked around the ED confidently, chest slightly pumped up at all times. I knew I was well-trained. If there was a sick patient, I was going to resuscitate them. If there was an impossible central line that was needed – I was going to get it. Difficult intubation? No problem. There was no procedure that was too difficult for me. 

Many Emergency Medicine graduates probably walk around with a similar sense of confidence today. Most know that when it counts, their expertise will  be life-saving. It’s at the core of why they chose to enter emergency medicine to begin with.

As I have progressed in my career, though, my perspective has changed a bit. I still love performing the life-saving procedure and resuscitating the critically ill patient. However in recent years I’ve also realized it is often the procedures that we don’t do and the conversations that we must have that are the most difficult. And no conversations are more difficult than the ones we are sometimes compelled to have regarding end-of-life care.

Last week I was working a night shift in the ER, and an 89 year-old chronically ill woman presented in severe distress. Her skin was cool and cyanotic and she was complaining of shortness of breath. Her blood pressure was extremely low and she had an elevated pulse.   It soon became apparent that she was having a massive heart attack that was causing her heart to fail, and her body to go into a shock state. Without urgent intervention she would die. Her son soon arrived to the bedside and was hysterical. “Doc, do whatever you can to save my mom,” he said.

In the past this statement would have been my green light to do any and every procedure that promised a chance of saving this woman. This time though I paused. This was an 89-year old woman that was already bed bound and didn’t have much quality of life. What were we going to accomplish with these heroic measures? I realized that this woman’s life was not likely to be significantly improved even if the treatments worked, and in fact the most likely outcome, in my medical judgement, was that we would only succeed in prolonging her pain and suffering.

I spoke to her son: “Sir, I’m going to be very honest with you. Your mother doesn’t have very much time. We can try a few heroic measures which may prolong her life. In all likelihood though she will never walk out of this hospital alive and if she does her long term quality of life will be very poor.”

He looked at me astonished at my bluntness but still wanted to continue. “Do what you have to do to save her doc.” I tried again. “Sir, if this was my own mother I wouldn’t put her through this. It would be cruel.” He stopped this time and responded. “Doc, I trust you to do what’s right.” I said, “I think we should keep her as comfortable as possible right now, but realize that she doesn’t have much time.”

The son was overcome with emotion but quickly began to come to terms with the fact that his mother would soon be dead.  He stayed at the bedside for the next two hours until she finally passed away. He thanked me for being so frank with him at the end.

I left that shift that day with a good feeling. As unfortunate as it was for the son to lose his mother, I felt that I had done the right thing for this patient. The conversation I had with the son, though difficult, allowed him to come to terms with her passing. I knew that day I had successfully performed the most difficult of all emergency procedures.