EM Reflections March 2021 – Code Discussion in the ED
Thanks to Dr. Paul Page for leading this month’s discussion.
All cases are imaginary but bring up important learning points.
Authored & Copyedited by Dr. Mandy Peach
Case
An 80 yo female is brought in by EMS in respiratory distress. There is a known history of end stage CHF. Collateral from the husband on scene was that his wife has been having increasing shortness of breath for 1 week, increased ankle swelling and was sleeping sitting up in the recliner in the living room. He called EMS today as she could not catch her breath when walking upstairs in the home.
The patient is on CPAP with EMS and has signs of central cyanosis. You direct the RT to switch her to Bipap as she is put on the monitors and a new set of vitals are obtained. You quickly examine the patient and find bilateral pitting edema to the knees and both peripheral and central cyanosis. There are audible crackles throughout both lung fields. You grab your ultrasound probe and find diffuse B-lines bilaterally in the lung fields and a cardiac view demonstrates a severely decreased ejection fraction. The IVC is dilated and not collapsing with respirations. She looks drowsy and is not responding to questions. She is not tolerating Bipap well. Her new vitals are: BP 98/62 HR 112 RR 24 O2 sat 85% on BiPAP T 37.4.
You suspect cardiogenic shock. This patient needs to be intubated. But you stop momentarily – this is an elderly patient with end stage cardiac disease. The prognosis for this patient is likely poor. Is intubation in the best interest of the patient?
This is a scenario we are often placed in as ED physicians. Just because we have the ability to resuscitate a patient doesn’t necessarily mean they will have a positive functional recovery. Here the patient is drowsy and in respiratory distress – she cannot tell us her wishes for care. In many cases, end of life care has not been discussed1 and in this situation the care decisions lie with the family/loved ones or us as physicians.
Current practice is that each patient is a ‘full code’ unless otherwise indicated2. So regardless of age, comorbidities, quality of life – if a deterioration of vital signs is seen every attempt is made to resuscitate this patient regardless of the likelihood of a functional recovery. Unlike the rest of medicine, this care is a ‘one fits all’ approach where initial efforts are carried out regardless of clinical situation. Whether or not this is the right approach is not the focus of discussion. Instead this highlights the importance of advanced care planning and goals of care discussions taking place when a patient is well and normalizing this process.
Back to our patient – they are circling the drain. You ask the medical student working with you to look up the patient chart and see if any previous code discussion has taken place. After a quick review there is no documentation of a code status. Even if there was – would this change your management?
Code discussions are not set in stone. A patient with capacity can change their mind at any time. Loved ones acting as substitute decision makers/power of attorney are also able to make decisions for the patient in the event a patient cannot make decisions for themselves.
Ideally you want to have a discussion with the family to set realistic expectations and together make an informed decision for the patient.
Luckily the husband and patient’s daughter are already in the department. You decide to have a discussion before proceeding with intubation. What are your goals for this discussion3?
- Choose a quiet location away from the patient
- Give your clear medical opinion and recommendations rather than options only, this way the family doesn’t feel the decision is completely up to them.
- Use straight forward language that is easy to understand
- “Review the risks of progressing to CPR if the patient declines including:
o Incomplete recovery
o Prolonged death
o Uncomfortable investigations and treatments
o Ventilator dependence” - Avoid a power struggle with the family if they choose to go against your recommendations.
What are some barriers we face in the emergency department when discussing and prognosing end of life care with patients or family members3?
We are poor at predicting prognosis, partly because this isn’t within our scope of care in initial resuscitation of patients, but also because there is always uncertainty in medicine – and this should be communicated to the family. As we see elderly or co-morbid patients in the department without a prior code status there may be a feeling that this should be the responsibility of the primary care provider and not the ED doc. Lastly, this is a difficult discussion to have regardless of timing and communicating prognosis may not always go smoothly. We may find ourselves in the same situation as the case above – with a crashing co-morbid patient with no clear goals of care. Unfortunately this is an especially difficult time to have this conversation, but it is a necessary one.
Since this is such a difficult discussion to have, is there any approach that might be helpful3?
Think SILVER
“Seeks Information:
- Elicits information regarding baseline level of function, behaviors, and symptoms that suggest progressive decline
- Elicits information regarding current diagnosis, prognosis, and treatment plan
- Elicits information regarding key players in decision making, including family and health care workers
- Elicits information regarding previous end of life discussions, including advance directives
Life Values:
- Elicits information regarding the patient’s personality and approach to life
- Elicits information regarding how the patient views death and dying
Educates/Extends Care:
- Pr0vides information regarding the patient’s disease process, current condition, and treatment options
- Explains how end of life decisions will impact further treatment
Responds:
- Solicits questions from family and offers continued support and availability for further information.”
You have a discussion with the family keeping in mind the above approach. You clearly lay out the poor prognosis and that you would suggest palliating the patient and avoiding any aggressive resuscitation. The daughter is upset and states “So you’re going to do nothing for my mother?”
This is a common misconception – that ‘do not resuscitate’ is the equivalent of doing ‘nothing’. Choosing not to do compressions or intubate a patient is the decision when an arrest or peri-arrest situation arises. However, patients can still receive medical care with goals in mind depending on the clinical situation. For example, using antibiotics in a patient with metastatic cancer who has pneumonia and who is clinically stable. Or in this situation – providing medications and oxygen to ensure a patient is comfortable and without suffering as they near the end of their life.
One approach could be to positively state all the things you will do for her mother, as oppose to what you will not be doing3.
Wording surrounding code status has also moved towards “allowing natural death” instead of “do not resuscitate” – again moving away from the idea that we are not providing a medical service.
You lay out your plan and positively reinforce the care you can provide for the patient. They agree that aggressive care would not be what the patient wanted and they agree to proceed with palliation. The husband asks you how much time she has left, and if they have time to call in family.
What are signs that help predict timing of death3?
“Delirium with hypotension and tachycardia: median survival 10 days
Death rattle: medial survival 1 day
Respirations with mandibular movement: median survival 2.5 hours
Cyanosis to extremities: medial survival 1 hour”
Your patient is cyanotic and essentially crashing. You again express that predicting is difficult, but you anticipate she may die soon and you suggest calling in the family.
You discuss interim management of the patient’s symptoms while you await palliative care. As the patient is quite short of breath one of your recommendations is opioids to help. The husband says he does not want opioids given as they will ‘kill her sooner’. How do you respond?
Opiods can help with the sensation of shortness of breath. The doses used for dyspnea are smaller than the doses used for pain.
“Studies have shown that O2 and CO2 levels stay the same despite the decreased respiratory rate associated with opioids. Opioids in the palliative patient are appropriate and ethically permissible as long as the intent is symptoms relief.”3
See the infographic below for symptom management in palliative care patients3. Being familiar with palliative care is pertinent – these patients are ours until consultants take over care, and in current climate often we end up palliating patients.
The husband agrees with your plan. They stay with the wife in the ED and within a short time a bed is available in palliative care. The patient dies comfortably that night. What about if the family wasn’t there? And we had to choose to resuscitate the patient or not?
There is no right answer. Choosing to intubate the patient and have the discussion with family after the fact is one option. Choosing not to intubate the patient and provide conservative management until a discussion can be had is another option. Sometimes these will be patients with end stage disease but the presentation may be a reversible one. Sometimes these will be healthy patients with irreversible presentations.
Regardless, clearly documenting on the chart your rationale and approach can be helpful in laying out your thought process.
These are difficult situations, and at the end of the day you have to be ethically comfortable with your decision. Having open, honest conversations with family/loved ones as outlined above can certainly help us feel at ease with our decisions and help families and patients come to terms with worsening conditions.
References and further reading:
Dong, K. CanadiEM Frontline Primer – Advance Care Planning and Goals of Care Review. CanadiEM. 2020. https://canadiem.org/canadiem-frontline-primer-advance-care-planning-and-goals-of-care-review/ (Assessed April 25, 2021)
Kwok, E. From Full Code to No Code. CanadiEM. 2012. https://canadiem.org/from-full-code-to-no-code/. (Assessed April 25, 2021).
Greewal K, Helmin A.Episode 70 End of Life Care in Emergency Medicine. Emergency Medicine Cases. Sept 2015. https://emergencymedicinecases.com/end-of-life-care-in-emergency-medicine/. (Assessed April 25, 2021).
