The ICU might not be appropriate for some ED patients with end-of-life care directives limiting aggressive care, but that is not necessarily the case. ICU admission should be based on the alignment of uniquely beneficial treatment offered by the ICU, along with patients’ values and stated goals of care, the authors of a recent paper argued.1
“If a patient would benefit from this level of care, and they are agreeable, intensive care may be appropriate,” says Catherine A. Marco, MD, FACEP, professor in the department of emergency medicine at Wright State University in Dayton, OH.
On the other hand, if a patient has declined intensive care, an appropriate disposition might be admission to a medical/surgical bed or discharge to hospice or home. “Individual cases should be assessed based on patient wishes, the current medical condition, and proposed interventions,” Marco offers.
Ethical care of patients near the end of life should include “a team-based approach to assessment, diagnosis, communication regarding proposed interventions, prognosis, and patient wishes,” she adds.
Some patients arrive with living wills or other advance directives specifying which procedure they want. Often, this cannot be acted on in the ED. “A request for ‘Do Not Intubate’ documented in an advance directive is predicting a future hypothetical situation,” explains Jean Abbott, MD, MH, a clinical ethicist at University of Colorado Health.
Standard advance directives give an idea of what might be important to patients. “But these are no substitute for ED conversations about such things as the meaning or goal behind the written directives,” Abbott cautions.
Completed Physician Orders for Life-Sustaining Treatment forms give clearer guidance on whether the patient wants CPR, intubation, ICU-level care, or something less aggressive. “The ED provider has an ethical obligation to honor these when they are available and filled out correctly,” Abbott says.
But even so, a conversation is needed after initial stabilization. Clinicians need to know if admission, hospice care, or discharge home is desired at this particular point. ICU care remains a possibility even for patients who want “comfort-focused” care only. If the patient experiences a massive gastrointestinal bleed that cannot be managed at home or in a regular hospital bed (or experiences intractable pain), the ICU might be the best place. “Intensive management of symptoms may require intensive nursing and even physician care,” Abbott notes.
Ethics Expertise Needed
Engaging in sensitive discussions about preferences at the end of life “are tough for anyone, not just residents,” says Jan Shoenberger, MD, associate professor of clinical emergency medicine at Keck School of Medicine of USC in Los Angeles.
Emergency medicine residents are trained primarily to perform resuscitation through aggressive, life-prolonging measures. “This mindset is appropriate for the vast majority of patients we see,” Shoenberger says. “But for patients who have not much time left, the question of ‘How much, and which procedures?’ comes up often.”
This is the case when frail, elderly patients found in cardiac arrest are brought to the ED. Three ethical questions that commonly arise are: Should we keep performing CPR? Should we intubate the patient and put him or her on a mechanical ventilator? What if the family tells you to perform CPR, but you do not think it is the right thing?
“These kinds of things come up a lot in the ER, and trainees really struggle with these scenarios,” Shoenberger reports, noting that hospice and palliative medicine knowledge is needed in these cases. “This expertise brings a higher level of knowledge about the ethical ramifications of these scenarios.”
ED Is Action-Oriented
ED providers are procedure- and action-oriented. “Helping the patient and family with a terminal sepsis event is not something we are as comfortable with,” Abbott says.
If a there is a procedure or resuscitation to perform, “particularly as residents, they want to do it, rather than stopping to ask if it is appropriate to the patient’s goals and values,” Abbott explains.
However, recent lawsuits have alleged that overaggressive treatments were initiated in conflict with patient wishes. “Some have suggested that ignoring advance directives that limit the desired interventions should be treated as a medical error,” Abbott adds.
Some ED providers believe their role is strictly to keep patients alive, and patients’ end-of-life wishes can be sorted out after admission. “That is no longer acceptable,” Abbott stresses. “There is no excuse for not asking a 97-year-old who comes in septic, or their family, what their goals are and where the patient is in the arc of their life.”
Even if decisions do not happen in the ED when the patient is admitted, end-of-life decision-making still needs to be addressed. “Sometimes, one of the best roles for an ED physician is to prime the patient and family that the admitting team is going to ask some important questions in the coming hours,” Abbott offers.
University of Colorado Denver’s emergency medicine residency curriculum covers ethical issues at the end of life. The training emphasizes that patients’ priorities are different near the end of their lives. “Our role as physicians is to help people understand the medical situations they are in, their options, and respect their wishes,” Abbott says.
- Jesus JE, Marshall KD, Kraus CK, et al. Should emergency department patients with end-of-life directives be admitted to the ICU? J Emerg Med 2018;55:435-440.