If Emergency Departments are the end-of-life crossroads, then Emergency Physicians must become the end-of-life traffic directors

Tuesday, 11 Sep 2012 22:10

About Dr. Monica Williams-Murphy (120 Posts)

Dr. Monica Williams-Murphy is a Board Certified Emergency Medicine Physician, who practices in one of the largest emergency departments in the United States at Huntsville Hospital. Through her writing and speaking, she is devoted to transforming the end of life into a time of peace, closure and healing. Media Page

A stunning recent article officially puts Emergency Physicians (EPs) squarely in the middle of end-of-life decisions in modern America.

In the June 2012 edition of Health Affairs, I believe the most important Emergency Medicine article of our generation was published, entitled “Half of Older Americans Seen in Emergency Department in Last Month of Life; Most Admitted to Hospital; And Many Die There.” 1

This longitudinal study (1992-2006) of a large population of people age 65 and older found that:

Over 50% of those who died during the study period visited the Emergency Department (ED) in the last month of life.

• 77% of this group were admitted to the hospital during that same ED visit

68% of those admitted died during this same hospitalization

Why is this so significant?

If this data can be generalized, it means that we, Emergency Physicians, play a key role in helping to determine the end-of-life care trajectories for over half of all Americans who die every year- what we ‘say to’ and ‘do for’ these patient and their families in the ED will significantly affect their course of care, including where and ultimately, how they die. This is so important because as I have stated before, 90% of Americans wish to die at home, but nearly 80% of us die in medical institutions.

This also means that Emergency Physicians have a great deal of power over the “costs” associated with this last month of life- the financial costs (to the families) of the medical interventions initiated in the ED, as well as the physical and emotional costs to the patients and families depending on which medical interventions are selected or declined.

Alright, so we have this responsibility, as the healthcare providers standing with our patients who are probably at the last crossroad of life…but will we use this power?

Will we help them to re-direct their course of medical care, if they so desire?

Will we help those who desire a natural death to have one?

Will we choose to help transform the end-of-life experience in modern America?

Will we take the lead by doing things like:

A. Appropriately identifying palliative/hospice candidates and transitioning them to inpatient or outpatient palliative/hospice care? (This will help solve the 90-80 Dilemma)

B. Asking about code status in the ED, and documenting this officially?

-Using state approved Do Not Resuscitate (DNR) or Allow Natural Death (AND) forms should the patient go home or back to a care facility

-Using hospital approved DNR or AND orders, if admitted.

(Addressing this in the ED prevents your patients, who desire a natural death, from being coded in the hospital in the middle of the night, or being intubated by EMS at home and brought back to you later in full arrest.)


Or, will we just go about our old routine without asking questions:

• “Tubing” 90-year-old great-grannies who have advanced dementia without seeking informed consent from a healthcare proxy;

• Placing actively dying, hypotensive bed-bound nursing home grandpa’s in the ICU (where they will likely die away from their families);

• Or, calling multiple consultations for multi-system organ failure in those at the end of a terminal illness?

Will we go about these courses of action all without asking the right questions- questions that could completely re-route the final course of care for these human beings?


What are the right questions anyway?

There are lots of people willing to give you a long list of questions to ask, but I can’t remember long lists anymore and I don’t have the time to ask a lot of questions anyway. So, I have boiled this down to a simple but powerful tutorial for Emergency Physicians (or any doctors) who are willing to accept the leadership role for changing how and where Americans die.


How to be an effective “end-of-life traffic director”: It’s as simple as See, Ask, Write

1. See

You are not an idiot. You can just look at your patients and generally pick out the ones who look like they might be in the last year or months of life. They are generally wasted, weak, requiring increasing assistance with their daily activities and may have had multiple ED visits or hospitalizations recently. These are the patients and families who need you to take a moment to sit and talk with them on a deeply honest level. They need to hear what you are seeing:

“Your mother’s Alzheimer’s is very advanced and she shows signs of nearing the end of her life”


“This is your 5th visit for COPD this year, Mr. Jones. I don’t know if any doctor has ever talked to you about this before, but COPD is a terminal illness. Your increasing visits to the hospital usually means that you are coming closer to the end of your life. (Please hold his hand.) I want to help you to make decisions which will make this as peaceful as possible for both you and your family.”


2. Ask

Next, Ask 3 simple but gutsy questions (while holding your patient’s hand): Where, Who, How

1- When your time comes where do you want to be when you die?

2-Who do you want with you at that time?

3-Do you want to have a natural death or do you want artificial life support like breathing tubes or CPR? How do you want to die?

(Now, I have made up these 3 questions and recognize that I am willing to speak more boldly than many doctors. So, if you have another set of questions you’d rather ask, then please take the time to commit them to memory so that you can overcome your own personal fear and ask questions that might make all the difference in whether or not your patient has a peaceful, as-desired dying experience, or NOT.) If you are asking these or another set of questions to a healthcare surrogate or proxy, click here for a helpful tool.


3. Write

Write the answers to your questions in your medical record and discuss them with the Primary Medical Doctor (PMD) or Specialist or Caretaker who will be receiving the patient from your care. Asking the questions, “Where?  Who?  How?” brings great clarity to medical decision-making for the patient, for the family and for their healthcare providers. Writing your patient’s answers in your physician notes and verbally communicating them with everyone involved, will strongly influence all actions taken or not taken from that moment forward- as commanding as a “STOP” sign, a “YIELD” sign, or a “DETOUR” sign at a cross-road.

Your note might read like this:

“Discussed end-of-life wishes with Mr. Jones who appears to have end stage COPD. He wants to die at home, with family in attendance and wants a natural death (DNR), with comfort focused care.”

Action: Signed DNR order and discussed hospice/palliative care track with PMD


Or this,

“Discussed end-of-life wishes with Mr. Jones who appears to have end stage COPD. He wishes to die in an ICU, without family in attendance, on a ventilator (Full Code).”

Action: admitted to ICU, PMD aware of wishes.


So, you can see clearly that by asking these (or other) questions and writing our patient’s answers, we may very quickly direct or redirect their course of care (per their informed decision(s)). We can make a difference for those who come to us, Emergency Physicians, in the Emergency Department at the final medical cross-road of life. If we will accept this power, (and master the fine art of traffic-directing), then we Emergency Physicians, will become leaders in positively transforming the end-of-life experience for the majority of our fellow Americans: for our patients, for our families and ultimately, for ourselves.

Monica Williams-Murphy, MD

1. Health Aff June 2012 vol. 31 no. 6 1277-1285

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