By Kei Ouchi, MD
“I need a doctor in here!”
As I walk into the resuscitation room in the emergency department (ED), I see Mr. G, a cachectic elderly gentleman barely holding onto his breath. After a rapid assessment, it is clear that he is tiring and cannot maintain breathing on his own for much longer. “We need to secure his airway” – with my command, the resident applies an oxygen mask, cracks open the airway box and prepares to intubate Mr. G, a respiratory therapist rushes in to assist the resident, and two nurses insert IV lines and gather medication. As the team gets ready for my signal to proceed, I review the record for advance directives and try to call the family members since the patient is too ill to tell me whether he wants to be intubated, sedated and have mechanical ventilation. No records of his wishes are available. In the middle of the night, we are not able to rapidly get in touch with his two children. As I run through the procedure safety list in my head to perform this procedure succinctly and safely without failure, I also have a parallel concern – “I really hope that this is what he would have wanted…”
With no family or advance directive, we secured his airway without difficulty and started the trajectory of care to place him in intensive care unit (ICU) for his later found aspiration pneumonia. After Mr. G is stabilized and I re-examine him very carefully for any additional information, I realized that I had met him a few months earlier. As he was wheeled up to ICU, I was left wondering – “Could I have made a difference in his care a few months ago — when I thought this might happen?”
Can we do better to ensure that our care aligns with patients’ preferences in the ED?
Three of four of U.S. decedents visit the ED 6 months before death. The percentage of inpatient care increases as they approach death. Many ED visits by seriously ill patients represents an inflection point in their lives. As an emergency physician, I encounter these visits daily and worry that the patients and their caregivers may not anticipate the likelihood of decline in the near future. Even though I am highly trained in delivering state-of-art medical care to critically ill patients when they need me the most, I know that many such seriously ill patients never had the chance to discuss what their goals and preferences would be if faced with the decision around end of life resuscitative care. How can I be sure that my highly trained skills align with patients’ goals and preferences?
Emergency physicians can make a difference in the value of ED end of life care.
Emergency physicians are expert in the decisions and procedures to rapidly extend life. Yet, in my experience, many emergency physicians are hesitant to have a conversation to elicit patients’ personal goals and fears in the context of their serious illness in the ED when not immediately necessary to make acute decisions. We are often meeting these patients for the first time and do not feel that it’s “our place” to intervene. However, as a physician who has training and practiced in both emergency medicine and internal medicine, I believe that emergency physicians are versed in making an objective prognostic assessment of patients with serious, life-threatening illness presenting to the ED on daily basis. One of our obligations as physicians is to inform our patients about what we think will happen in the future. The ED is an important clinical setting to initiate such a vital conversation. By creating a tool to empower emergency physicians’ ability to prognosticate and initiate discussions about goals of care, we can improve the value of end of life care delivered in the ED.
In my innovation, we will ask emergency physicians to identify patients with serious, life-threatening illness by asking them one simple question – “Would you be surprised if this patient died in the next 12 months?” If the emergency physicians answer “No,” we ask them to consider discussing hopes from the medical care and tradeoffs that patients are willing to make towards the end of life using a check list to facilitate conversation and notify the patient’s primary outpatient provider. We will then follow up on patients to determine the accuracy of emergency physicians’ prognosis. By determining emergency physician’s ability to accurately determine prognosis, we will help engage emergency physicians to begin conversations with seriously ill patients, their caregivers, and their physicians that ensure that the patients’ preferences are honored towards the end of life.
Kei Ouchi, MD is a Health Policy Research Translation Fellow at Brigham and Women’s Hospital, an Instructor of Emergency Medicine at Harvard Medical School, and an Associate Faculty at the Ariadne Labs. He was also part of team that was a Bright Ideas winner in the 2nd Annual Teaching Value and Choosing Wisely Challenge.