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joeG

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Most of the time the decisions we make are straightforward…if the patient is not sick, essentially, he or she can be discharged and followed up with a primary care physician. If they are sick–they get intubated, lines, meds, etc and admitted to the ICU–easy. Today’s patient was a 48-year-old man with gastric cancer who presented to the emergency department in respiratory distress, vomiting, heart rate 140s, blood pressure 90/50 mm Hg and no advanced directives. My first instinct as an EM physician--secure the airway and start IV fluids–basic stabilization before doing anything else. I wonder why his heart rate is so fast? Why is he hypotensive? Does he have a pulmonary embolism? Is he bleeding somewhere? CT scan time? He vomits and cannot lie down. I give an antiemetic. No change. I try an nasogastric tube. It doesn’t go and he vomits again. Desat to the 70s; I pull the tube. What next? Why don’t we intubate him then we can do all of the necessary tests.

I convince the attending that this is the right plan. I realize he is a great candidate for nasotracheal intubation so I go over to another attending who is “the queen” of nasotracheal intubation and ask, “Want to nasotracheal intubate a patient with me?” “Sure,” she says. We walk over to the patient and the first thing she asks is, “Why are you going to intubate him–that is the last thing I would do.” I was confused. The attending saw my patient differently than I had–she saw an end-stage cancer patient with little chance of survival. She saw a tube going in but never coming out. She saw a family that would spend the last days with a brother, son, father, who could not speak due to this tube in his mouth--slowly drifting towards death. What are some other options?

Supportive care.

Can we drain fluid from his distended belly to allow for better lung expansion and easier breathing? Impossible–his belly was not filled with fluid, rather it was solid tumor. What about draining the fluid that accumulated in his chest? Also impossible, a needle in his thorax had a better chance for a liver biopsy than draining fluid–his anatomy was so distorted that his abdominal organs monopolized most of his thorax.

What does the patient want? I ask him. “Lets fight a little longer,” he says. What does that mean? “Do you want us to breathe for you,” I ask. “Chances are you’ll die with the tube in you.” The patient responds slowly, “just give me the oxygen and ask my family what to do.” I asked him gently if anybody ever had a conversation with him about this momentous moment—the moment you have to think hard about how you want to die. “No,” he said. I excused myself and walked to the waiting room to speak with his family. “Your brother will stop breathing in the next 12 to 24 hours,” I said. I tried to be empathetic, but clear about his options. “We can put in a breathing tube, which will probably never come out. He will be sedated and won’t be able to speak with you. Or we can let him stop breathing on his own and make him feel good while this happens. What do you think he would want? With little hesitation, his family members say in chorus, “put him on the morphine drip.”

Five sisters, a niece, and a mother make their way to my patient’s bedside to comfort him and each other.

I just negotiated the death of another human being.

Am I trained for this? Can anyone be “trained” for this moment? Can we predict the end of life? Should we? What if I had insisted upon an intubation? Would this have changed the patient’s outcome? How would it have affected the life of the entire family?

My patient walked into the hospital a little short of breath thinking he suffered from a bad cold. He was hoping for a little relief--maybe some antibiotics and fluids. Instead he had to decide if this would be the last day of his life. He was only 48. He died at the end of my shift.

How does it feel to make such an incredible decision? How did my patient and his family make the decision so quickly? What could I have done better? How can I ever understand what that moment feels like to the patient?

Posted at: nyemergencymedicine.blogspot.com
 

DrQuinn

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Nice post. Believe it or not, I actually took the time to read the whole thing.

Not sure if teh OP is the author (as it was posted in another website). But, yes, we make these decisions. And I think (since it seems you're still a resident), over time, you will be able to eyeball these patients and know if it is "futile" or not, much like the nasotracheal attending.

I often phrase it this way to my patients:

"I can give you my professional opinion, and my personal opinion."

They almost ALWAYS want to hear both. My professional opinion is we can be aggressive as we want. Then my personal opinion, and I phrase it this way "If it were me, my father, or my wife, I would...."

That way, you give them an "out."

It gets easier, I promise.

Yet every once in a while, a patient will say something that sticks with you. I had a beautiful 32 year old female, nasty rare breast cancer that spread everywhere and cutaneously. I told her "You're one of the nicest patients I have ever had." She said to the nurse and her husband as I left the room. "He's so young, he probably hasn't had that many patients." She died the next day.


Q
 
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joeG

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I often phrase it this way to my patients:
"I can give you my professional opinion, and my personal opinion."
Q

I think that is excellent advice - from the outside, these situations may not seem so difficult - but when you are faced with the patient and their family - sometimes you can't find the right way to present the situation. Thanks, Q
 

BKN

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How does it feel to make such an incredible decision? How did my patient and his family make the decision so quickly? What could I have done better? How can I ever understand what that moment feels like to the patient?

Posted at: nyemergencymedicine.blogspot.com

Good post and good replies:

I didn't understand this either when I was a 26 yo h.o. How could my patients be so calm when I gave them terrible news?

Usually the patient
1) is older than you,
2) has lost loved ones, usually parents and often his life partner,
3) and has thought about death far more than you have,
4) He may have chronic pain and,
5) He has noticed his faculties deteriorating
6) and it wasn't really news anyway.

Here on the border, family often asks us "not to tell Grandma". Grandma already knows.

The point is the patient is ready to die, but you are not. At 56 I'm different than at 26. I'm in no hurry to die, but I've done everything I set out to, so if it comes. . .

My mother, who was kind of a depressive, wanted it for the last 15 years before it happened. I hope I don't feel like that at 86, but I don't think I'll fear it.
 

met19

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BKN makes some excellent points.

From a medical student/family member perspective:

I was my grandmother's health proxy during her last year (had major cardiac surg and had trouble coming out- long story). Anyway, at multiple points during her care I had tough decisions to make regarding how much further should care go and eventually she passed on. This allowed me to "see" the other side (e.g. family member) of things and in my opinion, has given me a clearer picture of end of life care in the hosp (vs not having this experience) and how tough it is on families and health care workers.

During my pallitave care rotation, the attending did a role play with me, where I would break bad news to a patient's family. It was extremely tough and half the time I felt out of control. I asked her how does she do this regularly. Her response, "1) Role playing allows us (the md's) to explore different options to use prior to speaking to the family. and 2) I have more experience in these type of discussions that you do at this stage of your career." The more sympathetic one is to the patient and/or family, the easier it is (my opinion).

While its hard to say whether I would want to place the Nasotrach or not, I know that helping the patient and the family thru their last days, experiences, and/or issues is as important as placing the tube. I think the major issue is the ability to feel comfortable with discussing or negotiating death, which only comes (as BKN correctly pointed out) thru experience.

P.S. Notice BKN is more often right than wrong-must be those years of experience :)

after all he diagnosed my matchitis and I didn't even know there was a name for my diseased state.
 

docB

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Interesting thread. It highlights the fact that in EM we deal with death and perimortum situations all the time but without any of the support mechanisms of other fields. EMS and fire often have stress debriefers, chaplains and at least get to go back to a firehouse and informally debrief. In the ED if I get tied down with a delicate situation I have nothing but a full rack when I'm done.
Good post and good replies:

I didn't understand this either when I was a 26 yo h.o. How could my patients be so calm when I gave them terrible news?

Usually the patient
1) is older than you,
...
That's true. I still remember the first time I coded someone younger than me.
 

joeG

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It highlights the fact that in EM we deal with death and perimortum situations all the time...

With the population aging and more baby boomer's presenting to the ED, these decisions are going to increase. When you think about ethical care of end-stage patients - we are usually the physicians who decide whether or not to put these people on life support (i.e. we are the ones to intubate). The ethical dilemma on the wards is usually around "pulling the tube". Once again, like so many other issues, I see emergency medicine at the forefront of the ethics debate on end-of-life care.
 

docB

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True but unless they fix the litigation crisis most ethical crises in the ED will take a back seat to CYA. For instance who's going to risk a lawsuit by saying that care is futile. I know that everytime I hold off on a patient because the family wants nothing done I have in the back of my mind that there may be some estranged loved one with an axe to grind down the road.
 

BKN

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True but unless they fix the litigation crisis most ethical crises in the ED will take a back seat to CYA. For instance who's going to risk a lawsuit by saying that care is futile. I know that everytime I hold off on a patient because the family wants nothing done I have in the back of my mind that there may be some estranged loved one with an axe to grind down the road.

Right, but some things are scientifically futile. Specifically brain herniation at the midbrain or lower level, and cardiac arrest in a patient with metastatic cancer.

The law does not demand that we provide "futile therapy". In fact it defines it as "not therapy" correctly. I think most courts would take the judgement of the EP in these cased. But gosh knows you would like not to be bothered with fighting such a suit.

In any case, where it's not completely clear, one should try to determine what is known about the wishes of the patient. If nothing known, I guess the tube is going in.
 

step1

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Am I trained for this? Can anyone be “trained” for this moment? Can we predict the end of life? Should we? What if I had insisted upon an intubation? Would this have changed the patient’s outcome? How would it have affected the life of the entire family?
As a med-std, I was always "pro-life"- do everything we can in our power to keep the patient alive. And I've heard many younger physicians are this way.

I still am, but approach it differently after a similar situation happened.
This was a patient with met lung CA with massive pleural effusions s/p pleurodesis the prior day.

Patient was DNR- until he became SOB then was debating his code status. When the family saw his suffocating state (they were in the room) despite all measure we had taken... there was debate about tubing him.

I tried to be professional, but my personal opinion was to tube. When the son/wife saw some passion in me to keep the patient alive and tube, the code status was changed to FULL.

He goes to the ICU per medicine resident and codes before intubation. I get yelled at by the ICU resident for bringing such a decomensated patient to the ICU... and how I "should have brought him earlier". I tried to explain the code status was changed... but there was so much commotion she didn't listen.

2 days later after developing ARDS, he dies. I spent some time talking to the family each day and after his death. I felt that prolonging his death just made his family suffer longer. They waxed and waned from hope to despair.

We knew the patient would die fairly soon before tubing. My idea as a 3rd year med student was to keep EVERYONE alive as long as possible.

You did the right thing by making the professional but a logical personal decision.

I learned my lesson... so now in addition I discuss what could be the consequences to the family themselves if heroic measures are taken in a dire situation.
 

beyond all hope

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We make them every day. Some stick with you more than others. Especially end of life discussions.

The first patient I had that conversation with was a seventy year old drag queen who presented with chest pain and had a huge lung mass. I spent a half an hour during a busy shift talking with him. He regretted being estranged from his son and told me to live every day to its fullest.

Agree with Quinn: Give professional and personal opinion. I've made the mistake of holding back my personal opinion out of fear of lawsuits/biasing the family/whatever and the family can always tell when you're not being honest with them.

Agree with BKN: The patient already knows the prognosis before they arrive. If they don't, break it to them gently.

The reason that doctors haven't been replaced by computers is because we are human beings. If you genuinely care about the patient and families' well-being and autonomy and you're honest than the decisions you make together will ultimately be the right ones.
 

BellKicker

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What does the patient want? I ask him. “Lets fight a little longer,” he says. What does that mean? “Do you want us to breathe for you,” I ask. “Chances are you’ll die with the tube in you.” The patient responds slowly, “just give me the oxygen and ask my family what to do.” I asked him gently if anybody ever had a conversation with him about this momentous moment—the moment you have to think hard about how you want to die. “No,” he said. I excused myself and walked to the waiting room to speak with his family. “Your brother will stop breathing in the next 12 to 24 hours,” I said. I tried to be empathetic, but clear about his options. “We can put in a breathing tube, which will probably never come out. He will be sedated and won’t be able to speak with you. Or we can let him stop breathing on his own and make him feel good while this happens. What do you think he would want? With little hesitation, his family members say in chorus, “put him on the morphine drip.”

Five sisters, a niece, and a mother make their way to my patient’s bedside to comfort him and each other.

I just negotiated the death of another human being.

Am I trained for this? Can anyone be “trained” for this moment? Can we predict the end of life? Should we? What if I had insisted upon an intubation? Would this have changed the patient’s outcome? How would it have affected the life of the entire family?

My patient walked into the hospital a little short of breath thinking he suffered from a bad cold. He was hoping for a little relief--maybe some antibiotics and fluids. Instead he had to decide if this would be the last day of his life. He was only 48. He died at the end of my shift.

[/URL]

Joe, I think you did the right thing. In fact, it sounds like it ended really well.

However, there's gotta be an oncologist somewhere who has dropped the ball in a serious way. At the end of a cancer patient's life, the oncology department should "do everything" or make damn sure the patient has a palliative care doc or hospice nurse to call with questions.

The ICU docs always say that 100% of people will want to be intubated if they are SOB enough. And 100% of people on the vent will want the tube out if you were able to ask them. That's why these end-of-lie questions should have been dealt with long before you got into the picture. This guy was way beyond any meaningful conversation.

What would you have done if his family hadn't been there? Or if they didn't agree? What, in that case, if you couldn't reach his oncologist?

Speaking of oncologist, was anyone from oncology called? From the history, it sounds like an aggressive radiation oncologist could easily be convinced to radiate the poor guy's chest. I once admitted someone quite similar to your patient. He had SVC syndrome along with massive tumor burden in his chest. He actually got radiated and went home on hospice.
 

joeG

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However, there's gotta be an oncologist somewhere who has dropped the ball in a serious way.

Yes there was -- the patients oncologist was contacted - however he was not on call that day...I spoke with someone from the office who said to "just get the patient to the ICU and they'll take care of him."

The patient's regular oncologist, I was was told, does not believe in "giving up" and therefore rarely has end-of-life discussions with his patients.
 

BellKicker

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The patient's regular oncologist, I was was told, does not believe in "giving up" and therefore rarely has end-of-life discussions with his patients.

Talk about torture.

It sounds like you guys saved this poor guy from a miserable last few days/weeks.

The sad part is that it takes LESS work for an oncologist to be aggressive with treatment; and it pays better, too, since palliative care is so poorly reimbursed.
 
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