Step 3: Knowing your patient’s values, you can move on to the most difficult question you never wanted to ask:
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ACEP Now: Vol 39 – No 05 – May 2020“If you are so sick that you are unlikely to recover and would require artificial life support during the time you have left, would you prefer to continue on artificial life support, or would you prefer to allow a natural death?”
Everyone may have a different answer. Some may say, “I prefer nature to take its course. I want to die naturally.” Others may say, “Keep me alive at all costs, no matter what. I can’t bear the thought of dying.” What is most important is that the decision is based on the patient’s values, not what their family or even you as the provider prefers.
Step 4: Offer a recommendation. Language is everything. Studies indicate that what listeners understand often differs from what physicians intend. Certain phrases can lead families to feel abandoned and forced to choose between aggressive curative care and giving up.4 As emergency physicians, we should propose realistic goals. Here are two examples, and more are listed in Table 1:
- “Given that you said you most value being at home and hugging your children, I suggest home hospice.”
- “I recommend we accept that he will not live much longer and allow him to die peacefully.”
Planning for end of life is not a new phenomenon, but the presence of COVID-19 has made all of us a little more aware of our own mortality. None of us want to contract the virus and potentially die from it. However, that may be a reality for many people in this country. We are all hoping for the best outcome—that is, very few people falling ill and dying—but we must be practical and prepare for the worst.
Table 1: End-of-Life Conversation Suggestions
| Instead of Saying… | Try Using This Language |
|---|---|
| “Do you want us to do everything possible?” | “Would you like us to initiate artificial life support, or would you prefer to allow a natural death?”
“This virus is so deadly that no matter what we do given her age and comorbidities it is not clear she’d survive.” “What do I need to know in order to do a better job taking care of you?” |
| “We’ll refrain from extraordinary measures.”
“I’m going to make it so he won’t suffer.” |
“Your comfort and dignity are my top priority.”
“Can we agree not to escalate care, which will prolong the dying process?” |
| “It’s time we talk about pulling back.”
“Will you agree to discontinue care?” “I think we should stop aggressive therapy.” |
“I want to help you live meaningfully in the time you have left.”
“What can I do to help fulfill your wish to be at home with your family?” “Let’s concentrate on improving your quality of life.” |
References
- The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19)—China, 2020. China CDC Weekly. 2020;2(8):113-122.
- Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72,314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020;323(13):1239-1242.
- Emanuel LL, Ferris FD, von Gunten CF. EPEC. Education for physicians on end-of-life care. Am J Hosp Palliat Care. 2002;19(1):17-18.
- Angus DC, Barnato AE, Linde-Zwirble WT, et al. Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med. 2004;32(3):638-643.
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