As emergency physicians, we are trained in the core procedures surrounding critical illness and resuscitation, such as endotracheal intubations, central venous catheter placement and chest tube thoracostomies. However, a critical component of the initial resuscitation that is often not recognized as a critical procedure is the rapid code status conversation. Concepts surrounding goals of care, communication of challenging news, and recognition of palliative care basics are fundamental for modern emergency physicians to practice compassionately and effectively. More than 75 percent of Americans visit an emergency department within the last six months of life.¹ As such, it is not surprising that the treatment decisions made in the emergency department affect the trajectories of care of these patients.¹ To that end, understanding the nuances and specific skills needed to care for patients at the end of life is critical for emergency physicians. This includes ending resuscitation efforts if they are not aligned with the patient’s goals of care. In addition to this being a core component of high-quality patient-centered care, there recently have also been several “wrongful life” lawsuits in which doctors did not follow advance directives (MOLST or POLST forms) or the direction of health care proxies, further reinforcing the importance of this issue.

Goals of care is a term frequently used when referring to a patient’s intubation or code status; however, the term should instead be understood more broadly and relate to every facet of care that a patient receives. Unfortunately, many patients have never had a goals-of-care conversation prior to arrival in the emergency department. Some who have cannot recall it or arrive without documentation of it. Of course, the challenge of having these conversations in the emergency department is the time-pressured environment we work in, clinical instability of our patients, and our lack of longitudinal relationships.^1,2

In addition to patient access to more “upstream” goals-of-care conversations in the outpatient setting,³ or with clinically stable patients in the emergency department leveraging the interdisciplinary team such as registered nurses or social workers, it remains critical that all emergency physicians are facile with the rapid code status conversation: a conversation that elicits the critical information we need to ensure goal-concordant care in a way that is amenable to our time-pressured environment.^4,5 However, when surveyed, 80 percent of residents expressed a need for more training in palliative medicine.⁶ Much like any other procedure taught to us in training, we have outlined the key components of a rapid code status conversation, leveraging prior work, that should only take minutes to complete.^1,2

1. Establish Urgency and Elicit Understanding

Promptly establish rapport with the patient/surrogate by introducing yourself and the situation. Establish urgency regarding the patient’s clinical condition and ask permission to discuss next steps. Before moving on, establish what the patient/surrogate already knows regarding the patient’s condition, which will enable you to be more efficient and not repeat information that is already known.