My compliments to Bridget Highet, MD, on her recent article, “The Big Picture: Communicating Prognosis in the ED.” (EMN. 2019;41:20; http://bit.ly/36o9Ymd.) I recently retired after 43 years of practicing emergency medicine, and have witnessed many true miracles of medicine. One thing, however, has never changed—patients die.
The futile procedures that our patients and their families are subjected to are determined in the ED and the ICU. Way too often, there has been no previous discussion of advance directives with a primary care physician even when the patient has obvious end-stage disease from cancer, dementia, respiratory failure, cardiac failure, or other organ failure.
My last eight years as an EP were in a teaching hospital where residents always asked the patient before admission: “If anything bad happens, do you want us to do everything to save your life?” The answer was almost always yes. They marked down full code, and moved on. There was no communication about the prognosis, nor had there been from the physician before transfer to the ED. When I asked the residents, “If you had the medical morbidities your patient has, would you be a full code?” The answer was usually, “No, I wouldn't, but the patient wants to live.” Of course, everyone wants to live. What is a physician saying when he says he would be a DNR instead of a full code? He wouldn't want to die like that. Don't we owe it to our patients and their families to have a discussion about what “die like that” means?
Why do we do things to people that we would never want done to ourselves? We have to do a better job of communicating prognosis. “Dad would want to have everything done. He's always been a fighter!” How do we explain to our patients and their families that it is not a fight when you can't punch back—it's torture?
Stephen Lund, MD