End of life discussions are a very difficult yet important facet of being a physician. This week we take a look at an article from Annals of EM that does a great overview focusing on respiratory failure.
Article: Ouchi K, Lawton AJ, Bowman J, Bernacki R, George N. Managing Code Status Conversations for Seriously Ill Older Adults in Respiratory Failure. Annals of Emergency Medicine. 2020 Aug 1;76(6):751-6.
What: A short but valuable review article that covers prognostic information for intubation and a clear step-wise approach for handling code discussions in the emergency department, specifically focusing on respiratory failure.
Why: Emergency medicine is rife with scenarios where we have to intervene, sometimes with invasive measures, to prevent a patient’s demise. The incidence of intubation for older adults has doubled between 2001 and 2020, but the majority of our patients do not have advance directives or any similar formal declaration of their desires. We’re often left in a difficult situation, navigating a critical clinical trajectory without information about the patient’s desires for their own care. Rather than simply summarize the article, I wanted to share some highlights.
One in 3 older adults (65 years or older) will die in the hospital after intubation, affected by age and co-morbid conditions. There is an estimated mortality rate of 50% for intubated patients over 90 years. Of the surviving intubated patients, approximately 80% will be discharged to places other than home. For older adults with mild to moderate physical disability who are admitted to the ICU, one quarter will die and more than half of the survivors will develop disability worse than their baseline. For some patients, the risk of severe disability or a prolonged course in the ICU are seen as equal to or worse than death. Therefore, it’s important to utilize this information to help guide patients and their families as they make critical decisions about their care. The graphic below highlights this prognostic information in a straightforward manner.
Click to enlarge
As the COVID-19 pandemic rages on, we will certainly continue to encounter many patients in respiratory failure. As clinicians, we should be aware of a patient’s prognosis and work to be effective communicators with patients and/or their family to rapidly delineate their wishes. Navigating these conversations effectively is a skill that requires thoughtful practice, similar to any other procedure. This paper offers a solid framework (included below) to approach these conversations and even covers some common pitfalls that we may fall into. It’s a short read and well-worth rehearsing, as we will all continue to encounter this scenario throughout our careers.
The Stepwise Approach:
1. Establish Urgent and Elicit Understanding
2. Break Bad News
3. Develop Therapeutic Alignment
4. Ascertain Baseline Function
5. Explore the Patient’s Values and Goals, and Then Summarize
6. Summarize
7. Make a Recommendation
As always, read for yourself and discuss with your attending and colleagues.
Written by:
Jorge Aceves, MD
Chief Resident, PGY-4
Cook County Health
Twitter: @joaceve91
Reviewed by:
Neeraj Chhabra, MD
Attending Physician
Cook County Health
Twitter: @neerajBC