Discussing end-of-life care in the emergency department : to attempt resuscitation or allow a natural death

Abstract

Patients on a known dying trajectory quite frequently present to the emergency department (ED), unprepared for some of the common and inevitable crises related to their disease process, and most of them have not prepared an advance directive. Near end-of-life (EOL) patients who present to the ED with an emergent need for symptom management may instead be faced with an incongruent treatment plan focused on lifesaving interventions. Time constraints, lack of prior patient-provider relationship, vague and misleading terminology, and patient misconceptions about attempted resuscitation interfere with discussions about EOL care preferences in the ED. Questions sometimes posed by ED providers such as "If your heart stops beating, do you want us to try and start it again?" or "If you stop breathing, do you want us to put in a breathing tube?" or the more loaded question "Do you want us to do everything?" are problematic because patients are offered no tangible alternatives; in essence, the choice they are presented with is between doing everything and doing nothing. Realistically, who will choose nothing? There is a growing movement toward using more precise language to discuss attempted resuscitation and allowing natural death. The purpose of this project was to explore the language used during patient-provider conversations about attempted resuscitation versus allowing natural death. A case study was used to interview emergency department physicians, nurse practitioners, and physician assistants. Twelve topics emerged during the interviews regarding how providers discuss attempted resuscitation versus allowing a natural death. The interviews revealed areas where patient-provider communication may be improved, and highlighted the need to replace ambiguous language with more frank and detailed discussions of EOL care options. ED providers need to become more comfortable discussing EOL care, and give patients and families the full benefit of making informed decisions in line with their goals of care.