The EM physician is often seen as the doctor who aggressively treats.... and gets the adrenaline rush from performing CPR, intubating and performing life saving procedures. However, with the evolution of medicine, life expectancy is increasing and in developed countries such as Singapore, we are left with a large proportion of elderly patients.
What is then saving a life? Is saving a life about reviving a heart beat whilst the patient remains on a ventilator for the rest of his life? Is saving a life about doing everything that is possible because we have the technology and means to do so just to sustain a heart beat while the patient ends up in a comatose, 'vegetable' state for the rest of their lives?
This is even trickier for the Emergency Physician as we are trained to treat and reverse any irreversible causes. Furthermore our initial point of contact is brief, where we have to make a decision based on the snapshot of the patient's clinical presentation, their quality of life as painted by their family members and their pre-existing medical conditions. And when the medical decision is made, we have to communicate it with the relatives as well as the medical/ICU team we would be admitting the patient to.
The grey area- We have to treat the reversible causes!!!
How far do we go in treating a reversible cause? Do we intubate a 45 year old active lady with metastatic lung carcinoma presenting with drowsiness from respiratory failure and massive pulmonary embolism, where the goals of treatment hasn't yet been addressed? Do we intubate a very well 90 year old with only hypertension and diabetes who goes on daily walks and still sends his grandchildren to school everyday? Is age itself an independent factor in determining if a patient gets sent to ICU? Something to think about...
End of life (EOL) discussions and pathway in the Emergency Department
On the other hand, we EP have recognised that there are a group of patients where their extent and goals of treatment is clear. Such as:
1) EOL issues being established on previous admissions, advance care planning being present
2) When there is advanced cancer or terminal illnesses
3) Advanced dementia with instability
4) Advanced age, multi organ failure, instability
In such cases and after discussion with patient and relatives, a decision is made to treat the patient in the most dignified and beneficial way possible. Keeping them comfortable takes precedence and such a pathway acts as a guideline in doing so.
Hence much thought and discussion goes into making such a decision and implementing it. And Emergency Physicians play a crucial role in doing so as we are the first point of contact.
A patient is not just a diagnosis. Our job is not over once the diagnosis is made and medical treatment is initiated. It is about recognising that the patient is a person with a family, a job, a hobby, a pet dog and a whole life behind them.
When these people arrive in the ED, they are at their most vulnerable and possibly at the lowest, darkest moments of their lives. They may not feel the immediate beneficial effects of the antibiotics or the ABG we have just done. But they will feel the cold because we have removed the blanket to examine them.. they may feel the pain... they may feel the breathlessness... and above all, the uncertainty of what may happen and the loneliness.
Hence especially in EOL care, it is important to communicate with the patient and relatives, control the symptoms and most importantly, to let their loved ones be with them. What we say and do in these darkest moments, will have an impact on them and their family for the rest of their lives.
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Here are some links that physicians may find useful in dealing with EOL patients.
How to have an EOL discussion- Do listen to the podcast as I found it extremely useful.
http://emcrit.org/podcasts/semantics-end-of-life-discussions/
http://emcrit.org/podcasts/end-of-life-care/
Singapore Lien centre resources
https://www.duke-nus.edu.sg/lcpc/sgpallebook
Center to Advance Palliative Care (CAPC)- American based website with resources
https://www.capc.org/providers/palliative-care-resources/quick-links/
End of Life guidelines by NICE- UK based
This is interesting as the UK was one of the first to start and EOL pathway, called the Liverpool Care Pathway (LCP). However, the LCP was not used appropriately and had caused controversies. (I had personal experience with using it while in the UK myself) Hence they have revised their guidelines, which is now found under NICE.
https://www.nice.org.uk/guidance/ng31
https://soundcloud.com/nicecomms/care-of-dying-adults-interview-with-professor-sam-ahmedzai
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