Case: A 79-year-old woman with metastatic lung cancer presents to the ED with severe dyspnea. Assisted ventilation appears necessary. The family is in attendance and under the impression that she will benefit from chemotherapy and/or radiation. According to the family, no one has discussed her prognosis or an advance directive with either the patient or them. Should this patient be immediately intubated?
There is strong evidence to suggest that physicians have poor training in end-of-life (EOL) care discussions and that, even when they do occur, the quality of the discussions is generally poor.1 Complicating the situation further is that patients and their families do not always absorb medical information communicated to them when patients are acutely ill. Family members frequently do not know and cannot accurately predict patients’ EOL care preferences, and patients have preferences that change over time and across differing clinical scenarios.2-4
The emergency physician should have a candid and accurate discussion with the patient and family regardingcurrent condition, prognosis, recommended interventions, and alternatives.