If physicians don’t help patients and families make these tough decisions, soon enough the government will be doing it for them.

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ACEP News: Vol 30 – No 03 – March 2011

Too many times to count, I have had discussions with families about a moribund nursing home patient who has no designated code status. I try to present the situation to them objectively to help them understand prognosis and chance of success. Sometimes families choose to proceed with treatment and sometimes they decide to allow a peaceful death. This is the way it should be. These are decisions that should be made by patients and their families, not the government. We are less likely, however, to be providing futile care if these discussions are not held in the shadow of a pending crisis.

What I find most frustrating is when a DNR Comfort Care patient is sent by EMS from the nursing home for emergency care. According to the statute in Ohio, these patients are not to receive monitoring, resuscitative drugs, or an IV line. These are the expressed written wishes of patients and families, and yet nursing homes routinely send these patients for treatment that is not appropriate or desired.

I make these patients as comfortable as possible, talk to the family, and then return them to the extended care facility. The vacuum of common sense in these places could suck a satellite out of the sky.

Every day we see examples of futile and very expensive care. Ancient and demented patients receive dialysis, surgery, and positive pressure ventilation when there is no hope for any meaningful long-term success.

It is easy for doctors to say that we will “try everything” to prolong life. What takes courage and a sound moral compass is to sit down with a family and explain that sometimes the most loving thing you can do for a relative is to acknowledge that the end is nigh and to allow death to happen in a comfortable setting free of contraptions best used elsewhere.

On the day I write this, there is an AP article in the Toledo Blade about oncologists and end-of-life discussions. It reports that the American Society of Clinical Oncology says that fewer than 40% of patients with advanced cancer have a realistic discussion about what to expect and what choices they have in end-of-life care.

This is astonishing. If the oncologists are not getting this right, I expect that few other specialties are doing any better. Patients need our guidance in these important matters. Television and movies have conditioned the public to expect miraculous cures from interventions such as CPR for traumatic arrest and aggressive chemotherapy for late-stage cancer. Patients need us to put their condition into perspective and help them make sound decisions. Physicians must take the initiative in these difficult discussions.