Assess and Confirm Consensus
Important Note
Our patients need us to have these conversations — we need to let them know we are open to having difficult discussions and that we are not afraid of them. If we are too frightened to talk about these things, imagine how they feel.
Emergency physicians are often reluctant to start these conversations because they cannot be completed or resolved promptly. Like many physicians, we tend to defer them “to others” because
- We don’t want to upset patients whom we don’t know well
- We don’t feel we have the skills to have these conversations
- We’re concerned we may be wrong
- We’re uncomfortable with death and equate it with medical failure
- It is hard to be with someone who is suffering when you can’t fix it
- It makes us face our own mortality
These are complex conversations: consensus about a single clear outcome may not be possible (which is often the case in the Emergency Department.) However it is in everyone’s best interest to start the conversation as early and as openly as possible.
- Watch the video below for an example.
Discussion: Assess and Confirm Consensus
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k
92yo woman with decreased strength, increasing hallucinations, no infection detected, family wanted her in the hospital. They were just overwhelmed. Ended up keeping her overnight while they went home to sleep and they picked her up from the ED in the morning, with goals to find extra help at home and move her to assisted living for peaceful end of life.
the most recent one was a man who had a ginormous squamous cell cancer eating his face away but didnt want anything done for the cancer, just wanted pain meds, and we were able to get him in and out of ED from the WR w pain meds written and got him an outpt referral to palliative that same week. (vs sitting in our WR which has wait times north of 10 hrs some days, getting admitted and having ent and optho and all the teams see him and hem and haw about the huge mass and what it is invading and all that, none of which wouldve changed ultimate plan or outcome). feel like it was a success and i know he and his family were relieved w the expeditoius eval and dispo
Varios casos, me parece que la decisión más difícil es cuando tenemos familiares aferrados a la vida de una persona que ya es frágil con múltiples comercialidades, decirles que el pronóstico es pobre y decirles si están de acerado a que el manejo sea conservador que es el que unió recomendaría en un caso así por que no aumenta la calidad de vida
Hablar claro de expectativas
ER goals of care can be difficult because we often have limited information, the right family stakeholders are not always present, there are few quiet spaces without interruptions, and limited rapport and emotional currency with patients/families.
mostly they have preexisting care directives
he has are very difficult discussions and sometimes need to be had with the entire family and with their care provider
Conversation with husband about his wife with expanding intraventricular hemorrhage and significant frailty. Challenging since he had never discussed advanced planning with wife previously. Overall, it went reasonably, but I feel like this skill requires ongoing practice to deftly be able to navigate the myriad of possible conversations that can arise. I wish to get better at the part about giving a firm recommendation at the end.
cancer discussion
Patient had covid and was nursing home patient with multiple comorbidities. It was yough having conversation when covid was mew
AGREED
Good
It can be difficult but it helps a lot when the family knows what they want.
Participating in recommendation for discharge planning for several patients.
agreed
A
Ok
Patient with multiple episodes of CHF exacerbations, I explained that these were likely to keep happening, with increasing frequency, as patient got more frail and sick. Progressive renal failure as well. Family initially wanted full intervention until we discussed what that would mean; long time in ICU with catheter, with bipap (patient was uncomfortable) and long stay in hospital with uncertain chance of recovery/going home. Patient and family became clear that they wanted to move to comfort care and we removed all lines/tubes, kept bipap on until family could be at bedside. Removed bipap and patient passed peacefully in the ER, surrounded by family.
Had an 82 years old with new illness that changed her trajectory significantly. Patient had advanced dementia too. I had to have the tough conversation with the daughter.
AA
NERVOUS AND SCARED
I have mostly had these discussions more so in internal medicine vs in the ED. Most times, thankfully in the ED, the oncology notes are helpful re patients goals of care. Sometimes when I have had to have these conversations in the ED, I am always a bit nervous, but I know it is important because it changes whether or what tests we order / what trajectory we are headed in and the disposition.
sigmoid ca with lumbar spine mets, one growing forward and invading aorta.
Potential catastrophic rapid death from aortic lesion. Surgery potentially needed for abscess around primary, but tried to put off in favor of symptom management
With a cardiac arrest of a 65 yom, in PEA for a very long time, with metastatic esophageal cancer.
intubation
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navigating family expectation
Ok
can be challenging if you and family are starting from very different place- find it especially challenging if certain cultural beliefs, young patient, sudden decline etc
Good
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everything was made clear to her, and he made it clear to the patients wife that he will be available for her if any question came up.
discussing transferring to tertiary care center for neurosurgeon consult on a brain bleed (likely nonoperative) vs comfort care at local rural hospital
Letting a family member know that ICU is not an option for them. Prolonging life would not be in the best interest of the patient was a difficult conversation.
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none in the recent past but have had several in which I offered comfort care vs transfer to higher level of care for more aggressive treatment. Some families seem relieved to find out they “don’t have to” take what seems like extreme futile measures to prolonged their loved one’s life while others are offended that I would suggest “just not doing anything.” I typically have the same discussion but responses can differ a lot
Patient with end stage CHF, dementia, bed bound presented to the ED with worsening symptoms and early sepsis. Discussed goals of care with family. It was slightly difficult because family had gotten used to the baseline as “normal” and seemed surprised by how serious the prognosis was.
Gently telling family members of a complex medical condition that has come up unexpectedly, such as large intracranial hemorrhage from hypertension, and the huge change in their life that needs to be expected.
With chronic illnesses, it is hard to sometimes explain that you must manage the symptoms of the illness vs. providing a “cure”
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family needs to understand processes, possibilities and goals after pt is or isn’t stabilized in the ED
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end of life wishes
I had an elderly demented patient with a DNR order that presented by EMS from a nursing home after a fall and had a large traumatic subdural hematoma with mass effect. No family contacts were listed or available, and the patient’s medical power of attorney was s lawyer who did not answer repeated phone calls. I ultimately kept the patient comfortable and they passed away in the ED, which is one of the hardest things I have ever had to do.
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Goos approach
We had a known cervical Cancer patient with Mets. She had been battling for about 3 years and in recent months her visits had become alot more frequent and every time she came in a bit worse than before. When she came in for the last time, I remembered asking the Daughter if she was ready and then she began to cry. It wasn’t that end of life care had not already been discussed but the reality of it in that moment had great impact
The patient was admitted and the family stayed with her and she passed away two days prior to admission. It was sad, however I believe the fact that the family had been counciled on this made it somewhat more bearable for them
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I’ve had to do a bunch of these in the emergency department and often times people don’t really understand what a ventilator is, or what “life support” means, and the hardest part is taking the time to explain these things when you feel the pressure of a full waiting room outside. Luckily I’m still a trainee so my priority was not usually the ED flow.
I had a patient come in unresponsive, ashen, low 80s on nonrebreather. DNR bracelet was with patient, but she was not wearing it. I discussed goals with her daughter over the phone, and was able to get brief information about DNR/DNI status, as well as treatment options such as antibiotics. When daughter arrived to the ED, patient was improved, more alert, answering yes/no questions, but was very ill. She likely had an MI the night prior. Possible pneumonia on chest X-RAY. Overall, not doing well. I was able to discuss prognosis with both of patient’s daughters. I spoke with specialists in order to get there recommendations and prognosis as well. Although it was difficult to give bad news, I was careful to make sure daughters understood the severity of patient’s illness, while remaining empathetic. I also consulted with the chaplain and case management, who assisted the family. Overall, the daughters and patient were very appreciative for all the time I spent discussing treatment options and prognosis with them. We were able to honor patient’s wishes for goals of care, while making her more comfortable. Patient ended up being discharged from the ED on hospice.
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All can not be done in once:
bad news and managemnt, specifical end of life management should not be done in once and with relative alson specificaly if she/he have somebody to consult. this docotr done very well askin patient to talk with relativess, her GP…
I do practice the same in ED if we have a time
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nice set goals
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Occasionally a patient will tell me they are so sick of coming to the hospital. That is a perfect segway to talk about hospice or palliative care.
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Discussing MOST/GOC any time a patient is admitted to hospital or critically ill is a challenge when you have just met the patient and are forced to work in a rushed environment where critical treatment steps may be needed on an urgent basis for that patient or another in your department. I have found using terms such as “allow natural death” to be effective in helping family and patients understand that we are not causing the patient to die by withholding invasive treatments that may not be effective such as CPR/intubation.
Discussing goals of care/end of life
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It is hard in the ED setting. It is a more acute setting and sometimes the reality has not sunk in for families or patients yet.
At times its hard to talk about but it needs to be done.
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yes i’ve had these discussions
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Supportive care measures for patients who have progressive chronic diseases are always emphasized. Getting a palliative care team to help the patient make informed decision is also valuable.
OK
One difficulty situation I had during residency is a patient on hospice who was in respiratory distress and family wanted to overturn DNR and advance directives to have “everything done” in the ER because they didn’t want him to die at home, which was the patient’s wish. It was hard to get all the family together to discuss the patient’s end of life goals, which were opposite of the family’s.
patients and families react differently when given difficult information/ news, which can make our jobs very difficult when talking with them
Difficult to have the conversation in face of new acute change where family is not ready to hear that this change may not be fully reversible. It was made more challenging by having some family members on board with a palliative approach while others were not ready to step away from active management.
Doctors usually start the conversations and nurses have a tendency to explore more on patient’s feelings and desires.
hard
poor prognosis in a young patient, asking for their hopes and goals especially when prognosis is poor is difficult
k
I had to inform a patient with their relatives that she had cancer of the ovaries. My senior and had went step by step and the patient left hopeful, although was tearful but hopeful
good
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organ donation. family distracted with death. achknowledge and ask again.
okay sounds good
Sometimes the discussion is very straightforward, other times it is difficult due to time constraints, unrealistic expectations, or because you know a pt well. It is never easy to tell someone that they are dying. I’ve had both good and difficult encounters in the ED, but I always try to approach the discussion with compassion and best wishes for the pt and their family, and people usually know and appreciate this.
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Many end of life conversations had in the ED are limited by a lack of common language and understanding of prognosis.
recently had very elderly pt that presented with STEMI. Family wanted everything done even though pt had a signed MOST as DNR M1. Family did not agree with it. We ended up doing imaging and IV’s which caused much discomfort. Family was not hearing what info the staff was providing and it became very frustrating for staff and family. Very unfortunate situation
very clear instruction
very good
elderly dementia patient. discussion with family. Always goes better if I lead with empathy and ask questions.
Allowing for other support from family or faith leader good idea, gives some say and control over a difficult situation
these are always difficult
very good
The most difficult situations are patients with advanced cancer whose oncologist continues to give them hope although they are deteriorating rapidly.
Pt was on Medical care, constantly expressing that she “doesn’t deserve this”, and is “ready to day”; discussed whether she would like to talk about comfort care measures instead
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maid
great learning experience
Having end of life discussions with patients families that are not ready to let go of loved ones
Sometimes difficult to get at what the patient actually wants and not what the family wants
difficult also when the family doesn’t want the patient to know the severity of the cancer and the prognosis
Having to choose MAID and determine if that is what the patient wanted, as he is in ltc and was slowly going through the dementia and end of life trajectory
Difficult situation when family disagrees with the patient’s desires.
haven’t had to have one yet
difficult to discuss mental health in a busy ER, important to provide a safe, inviting environment for the patient to discuss a sensitive topic
frequently start the conversation for any patients that are elderly, being admitted, or have had a change of trajectory/new comorbidity. use the critical illness conversation guide as a framework in the back of my head – which is a lot more conversational than other approaches. although it may feel difficult at the time, it almost universally allows them to see that you want to care for them in the best way possible, that you are open and honest, and listening to them
great work!
Often find that there are elderly patients who have never even engaged in these types of conversations despite having multiple comorbidities – sometimes, it’s not the first time presenting to hospital with an exacerbation. For the people who are thrown off guard, I frame it as a normality in my practice that I do with patients at any age who are admitted so we can have clear documentation going forward (in the cases where I do not expect them to die in this visit).
Often difficult if patient is in a grey zone age/disease wise, ie 70 years old with mild comorbidities, as they are often caught off guard by these conversations even if you preface them. Also can be difficult the more people are involved.
discussion making is hard
discussions can be difficult sometimes
I find the most difficulty in having a goals-based conversation with the patient and family during a sensitive period of time where they may simply just wish to be with their loved ones and grieve. Additionally, in a environment like the ED where the environment is fast-paced, the turnover is quick, and the acuity is high, it can be difficult to alot the appropriate amount of time necessary to have this conversation. Involving IDT members such as SW or chaplaincy are good ways to involve the team and achieve a well-rounded approach to EOL care.
instead of them addressing her questions and asking her questions he passes on the responsibility to someone else
Whether to move the patient into a setting they were unfamiliar with, but where better options were available.
palliation vs rehabilitation…. it is a hard conversation
bad prognosis, a patient with a few hours to live. disseminating information when the family is very emotional and have not come to terms with the current situation, makes it difficult. but there is often one member that sees the situation in a logical way
Trying to configure patients and their families expectaations as everybody seemed to be on a different page.
Patient with organ failure and multiple recent hospitalizations, becoming more symptomatic. Wanted to focus on comfort measures and said “I don’t want any machines to keep me alive”
The plan of care, what pt will want…
difficult conversation and is time consuming
tough conversation. give time
communication issue
difficult to discuss
often the families are unavailable in ED so family discussion is often challenging
Patient came in with CHF, respiratory distress and it was fairly evident that no matter what we did, his outcome was going to be death. We were able to have a conversation with the patient, his sisters and his fiancé. We determined that the patient did not want intubation or anything “heroic”. His main goal was to marry his fiancé. While we could not manage a legal marriage, we were able to get a chaplain to bless them and had a makeshift ceremony for them right here in the ED, even with some cake from the cafeteria and flowers from the volunteer office as a bouquet. It helped to make a difficult time for the patient and family more meaningful and fulfilled his wish to “marry” his fiancé.
ED marriage! wow
often in emergency department family (all of family or even one representative) is not available to make these decisions and if it has not been discussed before it can be hard.
Pt with stage IV SCLC who the day prior had meeting with oncology and with wife (an RN) present. had acute decompensation and wife brought into ED via EMS and was requesting intubation. Long discussion including telling her spouse had made goals of care clear when he was competent to decide day before. After long talk wife came around to comfort care and he was admitted to an inpatient hospice bed.
Mother of a colleague had stage IV breast cancer and multiple admissions over 2 weeks prior to this final admission. She presented with delirium and acute SOB, likely secondary to pneumonia sepsis, and hypotension refractory to IVF. We had an early discussion about prognosis and determined what she wanted to have done as well as the families wishes. She died approximately 7 hours after admission however the family was very thankful for the early discussion about goal directed therapy.
conversations go well if sympathetic
give time
I find most of these discussions go well…. if they are properly done. Patients just want to be listened to and want OUR opinion, as the doctor, of what is the best thing to do. Honest discussions, albeit difficult, are the most useful and productive.
haven’t had the opportunity to have that experience yet
discussion provides opportunity to obtain consent
interesting
give time
discharge plan
making sure they understand
difficult conversation
Did not have this experience yet
give the family and patient family enough time to consider all options
agreed
helpful
k
I have not had this experience yet
supportive hcp
Start conversations early to give family enough time to consider all options
I Always feel inconfortable having to give a prognosis to a patient and family
Always afraid I might be wrong
important to start these discussions early
Tricky
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Very important to start these discussions early
These conversations have been necessary on so many occasions. What I find most difficult is finding/taking the time to do so. I think these conversations require a variable amount of time, sometimes it’s relatively quick and very doable, but in some cases, it could take up to a few hours! It can, in these cases, be hard to do in an emergency setting and sometimes is seems worse to do it half way than not do it at all.
difficult but a necessary convo to have
met wife of a patient with dementia, decreased ADLs independence, who came from states away for hope of a cure. Listening and acknowledging the caregiver burnout and stress was a major part of the conversation. In the end she heard the recommendations and still wanted to continue seeking alternate opinions.
now that I am confident at having these discussions and making recommendations, I feel capable and that they are clear and smooth most of the time, mostly because in the conversation I like to check in “does that make sense? do you have questions?”
When a patient/family disagreed with my recommendation, I used to find it very challenging. I no longer stress about it. The reason being that now I have an approach that is comfortable for me and reasonably direct and clear, so I feel whatever the choice, they are making a clearly informed decision (even if I don’t think it is medically appropriate).
difficult discussion but at least help patient and families to talk and think about these things
tough conversations
difficult but important
I find it challenging because I don’t want my patients to think I feel they are going to die and am not trying to help them anymore.
I find it hard to be realistic about the prognosis of heroic interventions because I am new to medicine and don’t feel confident making that assessment.
I find it hard when I don’t know the patient well.
difficult and emotional situation
Difficult conversation
Have these conversations on a regular basis. Frustrating when the SDM is making decisions based on what they want, and not speaking as if they were the patient’s voice where they are unable to speak on their own, even though they know the patient’s wishes. Also difficult to have the discussion multiple times every time a new family member arrives in the ED.
Giving family time to discuss options, and offering to go over it with them again if necessary
always difficult conversation, it’s very important to listen to family
Difficult situation, compassion and empathy are important. Having a clear understanding of the situation before the talk.
Often we look for guidance with respect to directives of care, considering how far patients wish to go ie. comfort measures only, symptom management only, more advanced procedures like Bipap, dialysis, transfusions, life saving treatments such as infusions to maintain BP, and of course CPR and intubation ultimately. I find most of the trouble revolves around the fear that if a patient or family member agrees to a DNR that we as care providers will make them “a do not treat”, so a lot of education has to be done to ensure that they understand that we will accommodate their wishes and just don’t want to go beyond what they would consider acceptable.
Letting the patient know you are available and open to discussion and planning for end of life care is important.
One of my most recent interactions involved a man who had previously refused management for his cancer and had recently deteriorated. You could sense his relief in being able to talk about dying with me – he hadn’t been able to say the same things in front of his family. They heard what he wanted at the same time as I did – they were upset but supportive
hard to have those conversation in the ED
I have had may questions about goals towards ne dog life
Pastoral are should be there as well.
its difficult for the family to understand
goal must be clear with patient and relatives
Held a Goals of Care Discussion with a patient diagnosed with terminal cancer. Patient was surprised to have this discussion in the ED as their oncologist had never brought up the topic.
Overall, the discussion went well and the family was appreciative of the time spent on discussing the care available to the patient. They were also relieved that the decision made could be changed at any time depending on how well the patient was doing.
I currently work as a geriatric emergency registrar so find myself having these discussion nearly daily – some with patients who are near death and also those who are cognitively intact with minor issues. One i had recently involved a lady who had iatrogenic hyperkalaemia and had no advanced care plan. Whilst very elderly she was very independent and whilst normally i would advocate for NFR in cardiorespiratory arrest this was difficult in this instance as the likely cause of her arrest would be reversible.
Poorly informed family seeing mom for first time in 6 months and finding she is in res. failure and cognitive decline. Began conversation of severity of symptom, nut family did not want to have it. Did open the door to discussion and they approached the admitting attending the next morning about comfort measures
Main difficulty is the time it takes, very difficult to sit down and have the conversation without interruptions.
Many patients are relieved that someone is being honest with them and offering them a choice.
young patient with terminal cancer presented with confusion and a septic leg
wife however had hope of full recovery
was challenging setting the goals of care discussion
initially met with resistance
possibly was in denial
I met a pt last week who was at end-of-life but her son (her sole immediate family member) felt she was able to go home soon. ‘Home’ was a regular condominium (not a retirement home, assisted living – just a regular building). She was emaciated, not eating or drinking – she was smiling but she at the end of her life. She wasn’t going home and she knew it, the son however……
My palliative nursing care experience has helped me to feel comfortable discussing death and end of life. These conversations are difficult, but family need HC providers to initiate the discussion as they may be unable to do so.
these are hard topics but need to be discussed ASAP
It is not ideal to address these topics in the “heat of the moment” in the ED but unfortunately it happens often. Most people are very reasonable and responsive
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i’ve had to approach the subject carefully as emotions are high at times along with family tension as members may not share the same ideas. ultimately once the situation is presented and information has been processed patient/family are thankful for the honesty.
Finding the time to have a complete conversation is tough. I’ve had several instances where there is miscommunication of what I have discussed with one family member with others, which results in anger and outrage. Ideally the conversation is had in real time with a/ the close relative(s) so that everyone is on the same page and understands the goals.
most patient with advanced disease are open to discussion about end of life, and speaking to families is usually more challenging
I’ve had successful and not so successful conversations in the ED
Sometimes the less successful ones were because the family or caregiver was ambushed or swamped with new information
They also can be emotionally overwhelmed and unable to understand new information or unable to put it into context
assessing where the family is really important
Usually these discussions go fairly well. However, there have been many times when clients change their mind about goals of care, especially if they feel there is a crisis situation
I had a patient who was very frail from a LTC facility who came to the ED with a N/V and stool incontinence who was found to have a bowel obstruction (likely due to a malignancy). A CT scan was arranged to see if it was surgical, I spoke with the family about the patients prognosis and their wishes, and a mutual agreement was decided that the patient would not have the CT scan and we would transfer her back home to allow a natural death to occur.
Speek with clarity
Less frequent in ER than perhaps it should be.
I have not had this experience yet
Pt. with advanced cancer who had not discussed end-of-life care. Palliative care was consulted and patient was transferred to their facility.
Elderly patient with a massive haemorrhagic stroke. The patient was not conscious, and there was no consensus between family members. However, we brought them together to talk, and with the help of one of our bereavement nurses we were able to come up with a plan that was appropriate for the pateint.
We had a young patient with metastatic gastric cancer who was receiving palliative care prior to presentation. He likely developed aspiration pneumonitis and his shortness of breath was becoming progressively worse. Goals of care were discussed with his mother and wife who both had a difference of opinion in terms of his management. His mother wanted him to be kept comfortable and didn’t want any aggressive treatment while his wife wanted every possible intervention that would prolong his life. The patient was too dyspnoiec to make a decision. They all sat down and spoke with our team of doctors and we explored all options and also counselled them on prognosis with or without intervention. Eventually they came to a mutual decision to make their relative comfortable without aggressive measures of treatment.
I feel this is a much needed conversation for the good of the patient although at this time very difficult. I think discussing it with the family openly addressing their goals of treatment with what may be best for the patient is imperative.
hay que ser claro y directo sin ocultar información
sometimes its difficult to explain clearly
no siempre es fácil lidiar con los familiares o cuidadores
I have heard some more experienced physicians will often frame the goals of care discussion in such a way that does not really give families the option of choosing unreasonable interventions. For example, in the elderly, frail LTC patient with advanced dementia, they would not even mention the possibility of doing chest compressions, or admitting to ICU, but would discuss things like IV fluids and antibiotics if needed. It seems like it would make the discussion easier, but I wonder whether this would come back to bite you in the end if the outcome wasn’t good…
Concensus should be made and goals be clear.
Difficulty with communication skills
errr
Even when you explain to family about prognosis it’s like they have this barrier and keep coming back to ask the same questions over and over again. This is difficult because you are busy and have a lot of other sick patients that you need to attend to.
goals of care that I have discussed in ED include: keeping pts comfortable,Curative treatments and so on and difficulty often has been when family members are not on the same page in regards to their loved ones goals of management.
usually its relatives who have not been that involved who make unreasonable demands
These are difficult discussions to have however, the pt. and family that have never heard this kind of information usually appreciate that someone cares enough about them to be honest and direct their train of thought to end of life issues.
haven’t had the chance to raise this type of discussion yet – good strategies from the module for future though
A patient came in with a massive ICH and we felt intubating the patient was to no avail. We had a discussion with the family (which had to be done as soon as the patient arrived) about goals of care given her now futile situation. It was the first time I’ve had this type of scenario happen in the ED.
concensus
dd
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frequently it is difficult when involving the family, especially for end of life
In the ER, I have not had many “goals of care discussions” but have had to broach the issue of poor prognosis in patients with organ failure where this has never been brought up. In some ways it is easier to be the bearer of bad news if you are not the regular physician but it is frustrating that so many physicians have been dealing with the patients before and no one appears to have broached the subject. When I supervised chemotherapy I always made it clear to the patients, especially as many were young, that ventilation/CPR would be “off the table” and this seemed to make patients much more relaxed. People can accept death,but they don’t want it to be awful.
recent patient who was going to die any hour. Family understood the options and valued the patient’s wishes. The patient died peacefully within the hour
Always important to discuss with pts and their family what they want to know about current and future situations regarding patient issues.
It is always difficult- often these things have not been discussed among the family before hand. It can be a reality check to the family who may not be aware how seriously ill their family member is.
Great rapport by offering more time for the patient to reflect and re-discuss it with him!
nice touch compassion, patience and empathy is key for these conversations
The ER doc supported the wife and said he would be available to talk to her and her family for further discussions about what is best for the husband. This is a difficult conversation to have. I think having the social worker present is a good idea to provide supportive care especially if the ER doc is not comfortable with having this conversation alone.
I have had numerous discussions with patients and their families. I have found that, in the case of sudden/new illness, starting the discussion with the family and stating this is not something I need an answer to right now but that it is important that you as a family start to have a conversation about it seems to work. I hope that I am assisting my medicine and ICU colleagues by having started the discussion.
And even more importantly you are assisting your patient and his family! Establishing goals of care is a process not an event. It’s never the wrong time to start the process. Emerg physicians have a big role to play in that process. We can’t be critical of other people for not participating if we do not play our part too.
Must admit I have avoided these conversations. Tend to try to give as much hope as possible, rather than seek their goals
I have an 85 yr old woman in LTC with advanced dementia (total care, non-verbal) whose family still insists on “full code” despite discussions. I think I did a good job, with an approach similar to the one outlined here, but they remain insistent. Having seen these examples, I feel motivated to try again…
96 yr old still a category3 at the nurseying home at the family’s request to be transferred to the emergency dept for rehydration fluids when the patient stopped drinking and eating. we had a family meeting that this constant transfer was not providing any comfort and was a strain on this patient to be shunted in an ambulance back and forth . The IV may prolong life but showed no quality of life at end stage.It was the patient’s choice even in her demented state if she ate or drank and they agreed to leave in the nurseying home and let nature take its coarse.
recently I had a patient who had been demented and had a metastatic cancer after assessment it was apparent that he had become bedbound, incontinent and in pain, his wishes were to not prolong his life but allow him to die pain free wife agreed he was given rx for pain, nausea and died peacefully a day later