Rob Orman steers a conversation on skillful ways to discuss code status, comfort care, intubation, and whether or not dying debilitated patients should go to the ICU.
For more of the amazing Rob Orman, check out the Stimulus Podcast.
- When family members have to make decisions for their loved ones, you can minimize their guilt by being clear what you think is medically inappropriate.
- In an ideal world, a DNR order would only affect what you do when a patient’s heart stops.
- When having a comfort care conversation, Scott uses the dichotomy of two goals: curative care vs. dignity.
Tips and tricks for having a conversation with a patient and/or their family about plan of care:
- If you don’t have time for the conversation, then reconsider having it.
- You still must make the initial foray to find out if they have preexisting wishes and if the pt's condition is dire, then you have no choice.
- Deferring the conversation to the ICU is an option.
- A slapdash conversation is worse than no conversation at all.
- Create a space where everyone feels comfortable.
- Provide chairs so people can be seated.
- Reassure the family that this is a discussion you have with EVERYBODY who enters the hospital system.
- Feel out the situation and try to understand one another.
- Your job is to translate the medical realities in a way the family can understand.
- The family’s job is to translate their wishes, desires, and belief structure to us in a way we can understand.
- 5-10% of people are “vitalists”. They want anything done to bring back whatever form of life possible, no matter the predicted quality of that life. You’re not going to get what you feel is medically appropriate in those cases.
- Pick your own philosophy that fits with your strategy and psyche in medicine.
- Weingart has learned to be medically paternalistic and socially completely open.
- Inquire: has the family had prior end-of-life conversations with their loved one?
- It makes everything easier if they have.
- If they haven’t, ask them to put themselves in the mindset of their loved one. By asking the family to be a channeler of what their loved one would want, you minimize their guilt.
- If you feel something is medically inappropriate, state it clearly.
- This transfers guilt to yourself.
- In many countries (ie. Canada, Australia, New Zealand), CPR is not offered if it’s felt to be medically unacceptable.
- Avoid being manipulative when describing CPR.
- Don’t tell them chest compressions might break ribs or cause organ damage.
- Instead, concentrate on the end game and what you could get out of CPR.
There are 3 tiers of care: DNR (do not resuscitate), DNI (do not intubate), and comfort care.
- In an ideal world, DNR would only apply when a patient’s heart is about to stop.
- While DNR is not supposed to affect the rest of the care we provide, it often does.
- Being DNR may have significant effects on the willingness of physicians to provide aggressive care, even when the patient is not at the point of imminent cardiac or respiratory failure.
- Once a patient has opted for a natural death at the point of heart cessation, the next decision about critical care aggressiveness is whether he/she wants intubation.
- Patients who opt to be DNI make a real statement about their choice of dignity-preserving care over aggressive critical care.
- Explore the DNI decision, especially if the patient’s decision is incongruous with your medical opinion.
- Short-term intubation is different from long-term mechanical ventilation.
- Many don’t understand that a short trial of intubation could be terminated (and the patient extubated) if the patient is no better or worsening.
- DNR and DNI are linked; it’s not possible to be DNI but not DNR.
- If you’re going to do CPR, you have to be able to intubate.
- Many think that if intubation is allowed, that means they’re agreeing to the potential for being on a ventilator chronically. Make sure the family understands that you can remove an endotracheal tube after 3-4 days if there’s no signs of improvement.
- Comfort care
- This is the next decision point for patients who opt to be DNR and DNI. If you can’t intubate, a lot of critical care no longer makes sense.
- Varies between hospitals, but in general it means NO: artificial nutrition, ICU, dialysis, vasopressors, intubation, or aggressive measures. Weingart recommends against talking about individual therapies because it dissolves the conversation.
- For Weingart, the dichotomy is cure vs. dignity, since every aggressive curative treatment (ie. Foley catheters, IV lines, feeding tubes) steals some of the patient’s dignity. You either optimize dignity at the end of life, or you optimize the attempts to bring them back to where they were before the illness.
“When the curative care doesn’t have a hope of bringing the person back to a function of life they would actually want, then stealing their dignity becomes unacceptable.”
- Comfort and end of life care can be provided on a medical floor ward, but the ICU is often the better destination for those likely to die in 12-24 hours in order to get the close attention they deserve.
4 end-of-life illness trajectories:
- Sudden death — when someone with a high level of function dies unexpectedly
- Terminal illness — a relatively healthy person has an illness resulting in a sharp decline over months to a few years
- Organ failure — the general gradual slope is downwards, but there are periods of sharp decline followed by improvement, but never to the level quite as high as before the decline
- Frailty — At baseline, these patients have a very low level of function and difficulty managing ADLs. They have a continuous decline with no periods of getting back to their prior low level of functioning. For these patients, we need to really channel the patient’s voice to see if they would truly want aggressive medical measures.
Shownotes edited from ERCast
- Lunney JR, et al. Profiles of older medicare decedents. J Am Geriatr Soc. 2002;50(6):1108-1112. PMID: 12110073
More on EMCrit
- Podcast 165 – The Semantics of End of Life Discussions with Ashley Shreves
- Podcast 93 – Critical Care Palliation with Ashley Shreves
- EMCrit Podcast 25 – End of Life and Palliative Care in the ED
- EMCrit 276 – The Rapid Code Status Conversation with Kei Ouchi
Now on to the Podcast…
- EMCrit 290 – Decompensated Hypothyroidism and Myxedema with Dr. Arti Bhan - January 23, 2021
- EMCrit 289 – Ketamine Only Intubation Paper with Brian Driver - January 12, 2021
- EMCrit 288 – Neurogenic Shock & Should we be Using Vasopressors for Hemorrhagic Shock? - December 29, 2020