When talking about treatment plans with patients in the emergency department, as physicians 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.
Why 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?”
Discussing 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 discussed separately.
Physicians 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.
Our 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.
By exploring these questions with the patient and family you will most often come away from the conversation with a code status, without ever asking the 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.
Physicians 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 example:
“From 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.”
Does 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.