Emergency providers often misunderstand the goals of care of patients who come to the ED at the end of life, according to the authors of a recent study.1

“Particularly if it’s an unexpected visit to the ED, the patient may not have thought about or discussed end-of-life care with their own physician,” says Robert J. Hyde, MD, MA, the study’s lead author and an emergency physician (EP) at Mayo Clinic in Rochester, MN.

Even if the patient has engaged in such conversations, their wishes might not be documented (or, if so, not readily accessible). “In the ED, we are wanting to know what those preferences are. We may be making certain assumptions on our understanding of what the patients want,” Hyde says.

The ED has seen increasing numbers of geriatric patients in recent years. “We are interested in trying to improve care for this patient population,” Hyde says.

To learn how well EPs understand patients’ goals of care, Hyde and a colleague surveyed 80 ED patients age 65 years and older in 2019 about their goals of care and end-of-life preferences. They also surveyed 30 physicians (16 attending and 14 resident physicians) about which goals of care were important to their patients and which goal was the most important. “Not surprisingly, we did find some discrepancies,” Hyde reports.

Patients and attendings identified the same “most important” goal of care in only 20% of cases, and residents and patients agreed in just 27% of cases. “In our culture, there’s a presumption toward aggressive care unless someone indicates otherwise,” Hyde observes.

ED providers do not want to provide unwanted aggressive care. “We’re trying to get it right, and that can be tough to do,” Hyde admits.

Patients often arrive with a critical illness, and already are struggling with that medical problem. “We don’t have enough time to discuss the matter adequately,” Hyde says.

ED providers do their best to learn the information from the patient, align care with the patient’s wishes, and ensure the patient understands his or her options. “In some cases, they don’t know, or have misunderstandings, on what it means not to choose a treatment,” Hyde notes.

Goals of care discussions “are imperative to ensure that medical interventions received are in alignment with the patient’s values and preferences,” says Amber R. Comer, PhD, JD, assistant professor of health sciences at Indiana University in Indianapolis.

Ideally, goals of care discussions do not happen for the first time when the patient presents to the ED. When goals of care conversations are held earlier in a patient’s disease course, advance care planning is possible. “This can alleviate the use of aggressive interventions in the event that the patient decompensates or does not make a meaningful recovery,” Comer says.

If a patient is receiving aggressive end-of-life treatments that are not beneficial, ethicists can assist with engaging in goals of care conversations and advance care planning. “Additionally, ethicists can help the clinical care team implement hospital policies on withholding and withdrawing life-prolonging interventions in instances where the interventions the patient is receiving are futile and causing the patient to suffer,” Comer offers.

A case example: A frail 89-year-old patient received an emergency laparotomy, is on a ventilator in the ICU, and is not expected to make a meaningful recovery. The patient is decompensating quickly and is unlikely to survive cardiac arrest. The patient does not have a surrogate medical decision-maker, and there is no time to pursue a court-appointed guardian to make medical decisions. “Situations such as this are, unfortunately, not uncommon,” Comer laments.

Ethicists could be used to help change this patient’s code status to Do Not Resuscitate (DNR) to ensure the patient does not suffer at the end of life. Sometimes, these cases start out in the ED. Many hospitals maintain policies that allow ethicists to change a patient’s code status when it is appropriate and no surrogate is available. “Most policies have the ethicist work with the chief medical officer and legal to make this happen,” Comer says.

Eileen F. Baker, MD, PhD, FACEP, an EP at Riverwood Emergency Services in Perrysburg, OH, says the central ethical issue stems from “misunderstandings regarding the patient’s goals of care on the part of patients, families, as well as physicians.”

Some of that confusion comes from variations in terminology found in all the different end-of-life documents. These include DNR orders, Physician Orders for Life-Sustaining Treatment, living wills, and healthcare power of attorney documents. It is difficult for patients, families, and physicians to know under what circumstances advance directives should be applied.

“The ethical implication of such confusion involves patients receiving life-prolonging care they did not wish to receive, or enduring treatments that they did not foresee and would not have agreed to, with better knowledge of what such treatments would entail,” Baker says. 

REFERENCE

  1. Swenson A, Hyde R. Understanding patients’ end-of-life goals of care in the emergency department. J Am Coll Emerg Physicians Open 2021;2:e12388.