If you die, do you want to stay dead? • LITFL • ER Doc Walkabout

American ER Doc Gone Walkabout Episode 025

I recently listened to Rob Orman interviewing Dr Jean Abbott. They carried on a conversation about end-of-life discussions in the ER. It’s nice to know some of the options, but some of us need a bit of a script to help us – we may not want to re-invent the wheel every time we carry on one of these discussions.

Rather comparable to the medical student who might “know” a lot about DKA, but as a practicing house officer needs a plan of action for treating DKA.

I don’t like the kind of script where we memorize the exact words, but a script in the sense of a general guideline as to how we carry on the discussion.

What do we want from the guideline?

For me, it should be something that I can use with the patient, or with the family. It should be adaptable depending on how sick the person is: some people will have a problem where death is near certainty and only the timing is uncertain and the interventions to be provided are up for discussion. Others may have a potentially survivable “bump in the road”, but because of pre-existing disease, age, and frailty, there is real potential for a fatal outcome (think pyelonephritis or pneumonia, even in a “healthy” 95 year old). And, it should fold in together a variety of invasive interventions, including chest compressions in the event of cardiac arrest – it seems, to me, that CPR as a separate category generates a weird scenario.

In the same way that a Doctor would have a guideline – either written, or in his head – to help with the management of a difficult case, a Doctor might wish to have a pre-determined scenario in his head to help with some of the most difficult professional conversations that he will ever carry out: the introduction, the points to be covered, the phrases that get the point across without being frightening or offensive (Mrs Jones, if you die, do you want to stay dead?).

Veterinarians have an advantage over human docs here:“Mrs Smith, your ferret is very, very sick. Do you want to have a ferret, or do you want to have this ferret?”

Acceptable in the Doggie ER, but probably suboptimal phrasing for the human ER.

The following proposed conversation wouldn’t be appropriate with a healthy, or at least not too unhealthy, person with a severe illness or injury, but for the infirm or elderly or chronically ill, here’s a pair of proposals: the first for someone who is right near the end with no realistic likelihood of survival.

“Mrs X, with this illness you may be reaching the end of your life. At this stage of your (life, or illness) we know that some of the treatments that might have been helpful at an earlier time are now unlikely to be helpful. In fact, because of how (frail, old, weak, far along in your illness) you are, these treatments are more likely to have complications that are very serious, and could shorten what remaining life you have.

And, some of those treatments will remove the ability of you and your family to be together and interact towards the end.

Mrs X, treatments such as tubes in your lungs, breathing machines, potent drugs to keep your heart beating, intravenous lines inserted from your neck and threaded right down to your heart, and cardiac resuscitation are examples of this type of treatment.

Because these treatments may be harmful, and have little chance of success, we should talk about how much of our treatment now should be trying to improve your health and get you back to where it was a day or a week ago, and how much should be oriented to keeping you comfortable and free of complications and pain in what time you have left.”

For the individual with a treatable bump in the road (pneumonia in the infirm elderly, for example), the conversation can be modified:

“Mr Y, (or family) you have a problem that may respond to a straightforward treatment such as antibiotics. However, we know that at your (age, frailty, state of illness) things don’t always go as well as expected. We should talk now about how to proceed if things don’t go well – even if things go bad suddenly, so that we don’t have to make snap decisions at a time of crisis.

If you don’t respond to basic treatment, and things go badly, we know that some of the treatments that might have been helpful at an earlier time are now unlikely to be helpful ……………”

…continue as before.

Having a bit of a script helps me be prepared for these conversations, maybe a few ideas in my script that others can use.

Thanks to Dr Jean for all the ideas that she gave me (yes, we are acquainted.)

Next time: EBM and the rule of thumb