We invited the wife to watch the resuscitation, and together with her, we decided to intubate the patient in order to obtain the CT scan. The scan showed a large left-sided bleed with 2 cm midline shift and herniation. This confirmed the prognosis, which had already been shared with the wife based on our clinical findings: this type of injury to the brain is not survivable. She told us to stop everything that could possibly prolong his suffering. We moved him to a special room in the ED, turned off the monitors, and called the chaplain at the family’s request. The wife called in her family, and when everyone was present, we extubated him. He lived for two more hours, during which time we treated his dyspnea with morphine and his secretions with sublingual atropine drops, plus answered all of his family’s questions. We admitted him to a hospice room on the floor. He died in the ED just as a room became available.

Case 2: The Game Changer

A 59-year-old woman with colon cancer metastasized to the liver, pancreas, lung, and brain presented to the ED with shortness of breath for one day and abdominal pain. On exam, she was in moderate respiratory distress with tachypnea, tachycardia, hypertension, and hypoxia. Her lungs were clear, and her abdomen was diffusely tender with a hard palpable mass. Her daughter was with her at the bedside. Per her daughter, the patient had been feeling short of breath all day and then syncopized (without head trauma) trying to get back to bed from the bathroom.

1. Standard approach: Labs, chest X-ray, CT angiography of the chest for possible pulmonary embolism, and admit to ICU.
2. Palliative approach: Symptom management, goals-of-care discussion, work-up, and disposition.

On further history, we found that the patient had extensive chemotherapy and radiation, most recently whole brain radiation two months ago that shrank the tumor briefly, but a recent scan showed tumor recurrence. Her oncologist had stated that there were no further chemotherapy options but discussed possible experimental treatment. She suffered constantly from abdominal pain, and she was treated with both long-acting morphine and short-acting morphine. However, upon further questioning, the patient admitted she was not taking any opiates, only the occasional Tylenol because she did not want to feel “drugged.” The patient was essentially opiate naive. She was given 5 mg morphine, 4 mg ondansetron, and 25 mg Benadryl. After a half hour, the patient was resting comfortably and was able to walk with assistance to the bathroom. Her vitals normalized, and her chest X-ray and labs were all essentially normal.