Turn Emergency Docs Into End-Of-Life Experts

My first introduction to medical futility was as an intern in Chicago in the late 90s. I was working on a medical floor when a code blue was called overhead. I responded to find the nursing staff attending to an elderly male. As I started CPR and called out orders, I inquired as to what his medical conditions were and started looking at this shell of a man.

The nurse reported, “He is a 99-year-old male with diabetes and cardiovascular disease.” I realized the man was blind, had above knee amputations to both legs and also had bilateral arm amputations. He was a full code. I am not sure if that was because there was no family to make him DNR (do not resuscitate) or he had chosen to “have everything done.”

Futile medical care is the continued provision of care when there is no reasonable hope for recovery or cure of the patient. It is surprisingly quite common. There are many reasons for this.

The Pew Research Center just released its newest study that looks at current attitudes toward end-of-life care and provides comparisons to show changing attitudes from previous studies. It is clear that culture plays a role, as Hispanics are less likely than whites to choose to say they would halt medical treatment when facing these situations. There are some differences by religion and age noted in the study, as well as a growing percentage of the population that feels “doctors should do everything possible to save the life of a patient in all circumstances.”

Another reason identified was lack of a discussion or planning for end-of-life care. The Pew Research Center’s study showed that even as our population is aging, less than half of those aged 75 and older have given a “great deal of thought” to end-of-life wishes. If there is no documentation present and no family around to state a patient’s wishes when they arrive in the emergency department, everything gets done, including emergency surgeries, procedures, admissions and transfers.

Not only does this cost a significant amount of money but it also does not change the outcome in many cases and may not be what the patient actually wanted. Without thoughtful preparation, discussion, documentation and communication the medical team and family will not know what the patient really wanted.

Many emergency physicians are not comfortable discussing end-of-life issues with patients and families. First, it was not taught during medical school or residency training. As emergency physicians we are trained to save lives, treat acute emergencies and deal with complications of chronic illnesses.

However, as a specialty, we are present at the end-of-life for many patients. This provides emergency physicians a real opportunity to educate and provide advice to patients and family on the dying process. Not only should we be experts on saving lives and treating acute conditions, we also should be experts on end-of-life issues.

Not too long ago, I took care of a man who had severe dementia and was living in a nursing home. He presented to the ED with a brain bleed and was not doing well. I knew that even if I stabilized and intubated the patient, his long-term prognosis would be very poor. Decisions on feeding tubes, tracheostomies and further nursing home care would be needed. His wishes were already made known as he was DNR and the family reaffirmed this wish. Instead of admission to the hospital, we worked with case management and hospice to arrange a private room back at his nursing home so the family could spend his last moments on this earth with privacy and dignity.

The American College of Emergency Physicians has joined the Choosing Wisely Campaign with one of the recommendations involving “engaging available palliative and hospice care services in the emergency department for patients likely to benefit.” EDs around the country should seriously consider implementing end-of-life strategies given the resources available, encourage physician education in this area, and provide resources to patients and families on this topic.

By developing our end-of-life expertise, we can help patients and families make more informed decisions at this crucial and inevitable event in their lives. While we cannot change cultural or religious beliefs toward end-of-life care, we can be an expert resource to those seeking our advice and have a plan in place for those who choose palliative or hospice care from the emergency department.

This post originally published by Hospital Impact.