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.
Pearls:
- 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.
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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.
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- DNR
- 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.
- DNI
- 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.
- DNR
“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.”
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- 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
References:
- 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
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Great conversation here, well done. I recently watched a New York Times feature on Dr Nadia Tremonti (pediatric palliative care physician). She talks about empowering families to “make good choices when everything seems bad.” Really thought provoking stuff…
(The video is called “this doctor wants to humanize death | Op-docs” on youtube if anyone is interested.). Anyway, thanks for the podcast
I would somewhat disagree about not having a social worker present during discussion in ICU about DNR/comfort care. I was 25 years with VA hospitals during which my assignments included ED and ICU’s. (I have an MSW & am a licensed clinical social worker). MICU attendings often involved social workers for these sit down discussions with family. I didn’t usually have much to say during the discussion but since I have heard the discussion, I could continue to be involved with the family about the issues. After MD’s left or even later in the day or other days, I continued… Read more »
entirely different world in the ICU and the ED. When I had these discussions as an attending in the SICU, social work would always be there. Has not yet been adopted by many ED social workers.
Scott, thanks for another great post and podcast episode. I’ve been an EMCrit fan ever since I started working in the ED and ICU as a nurse. Now I’m a palliative care NP, and my wife is an EM resident. I have come to understand and respect that these conversations often have to be executed much differently in the ED. I completely agree with your criticism of the “curative vs. comfort” dichotomy. I’ve grown tired of hearing comfort as a concept being vaguely juxtaposed against curative or survival-prolonging treatments, since it is still our moral duty and a basic competency… Read more »
Alex–very thoughtful response! I believe the terms as you define them are not perfectly aligned with the situation. Curative therapies do not offer a cure. They make a cure more likely than without them. If we choose a curative path, we are attempting to maximize cure without any guarantee we will get there. Dignity-impediments make maintaining dignity more difficult. They do not guarantee that a patient will be stripped of dignity–they make maintaining dignity harder. I believe the ALS patients you mention would have no disagreement with this, while at the same time they would assert their dignity is intact.… Read more »
Great podcast – but the speaker sounds very pressured and forceful in their tone. I would not want to have goals of care conversations with a provider with such pressured rushed speech.
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