EMS calls ahead with reports of an adult patient in respiratory distress.  They are concerned the patient will need to be intubated on arrival.  Recognizing the name, you pull up a previous chart and review the patient’s history.  You realize this is their 10th presentation this year and on reviewing their most recent oncology note you note their oncologist has recommended they consider hospice due to end stage malignancy without further treatment options.  The patient arrives, is in distress, and does not have capacity but can be temporized by NIPPV while decision making occurs.  Their power of attorney comes to the hospital soon after but states they never got around to establishing an advanced directive. How should you approach this conversation?

Many patients who are approaching their end of life (EOL) will be seen in the ED.  Some will be critically ill on arrival, requiring decisions about EOL care to be made rapidly.  Having a toolbox for vital discussions is important for emergency physicians.  When possible, taking a few moments to establish rapport, understand a patient’s values, and making a recommendation based on those values will allow the best decision to be made in a crisis.  Here is a framework to consider:

1. Set the stage - As much as possible, find a space that is quiet where you and the surrogate decision maker can sit, focus, and talk.  It is helpful to have a pre-designated space for this in your mind.

2. Introduce yourself and your role

3. Establish common understanding - Explain that the patient is critically ill and decisions need to be made quickly.  Ask what they understand about the patient’s condition to ensure it matches your understanding.  If their concept of where the patient is doesn’t match your own, it can be difficult to find common ground.

4. Disclose your assessment - Asking permission can signpost that you’re going to share bad news.  “I met your loved one and I’m very concerned about them.  Is it okay if I share what I’ve seen so far?”  Provided the answer is yes (it usually is), continue to share your assessment that the patient is critically ill could even die from their current condition.

5. Identify the patient’s values - Explain that you want to take just a moment to understand the patient more.  What was their baseline functioning? How were they feeling prior to their presentation?  What activities did they consider the most valuable or enriching to them? Did the patient ever share how invasive they would want their care to be if their health suddenly worsened?

6. Synthesize what you learn to show understanding - By bringing together the conversation, you demonstrate that you actively listened and have created an accurate mental model of the patient’s current situation and values.

7. Make a recommendation - Instead of placing the surrogate decision maker in the hot spot (such as by asking “would they want everything done?”), or forcing decisions about specific treatments (intubation, pressors, etc.) use your medical expertise to make an actionable recommendation based on what you have learned from the patient’s values.  Typically, this is either aggressive treatment focused on comfort or aggressive treatment focused on recovery.  Focus less on offering a menu of options and more on establishing the guiding philosophy of their care.  Once an agreement is made on the philosophy you can further describe what that would mean in terms of intubating or not, using cardiac resuscitation or not, etc.

8. Open the floor - Ask “What other questions can I answer for you?”  This invites the surrogate decision maker to seek clarification for issues they may not understand.

Reference: Ouchi K, Lawton AJ, Bowman J, Bernacki R, George N. Managing Code Status Conversations for Seriously Ill Older Adults in Respiratory Failure. Annals of Emergency Medicine. Published online 2020. doi:10.1016/j.annemergmed.2020.05.039