Each person has their own unique set of values, beliefs, and goals that together shape their personal philosophy about life and death. Individuals, therefore, have a distinctly different set of measures that they use when determining their opinions and desires surrounding EOL medical care.15 This only makes transparency about EOL care and prognosis from treating physicians that much more important. Physicians must be as accurate as possible when discussing both the expected quantity and quality of life (QOL) that patients and their families can expect. Ethicists have tried to create tools to aid them in the complex endeavor of these factors, though statistically they are often vastly incorrect about the time patients have left to live. Also, some ethicists argue that QOL is impossible to measure without knowing the individual patient on a familiar basis and therefore are typically useless to emergency physicians.16 QOL to a professional musician may involve fine motor coordination of both hands and to a young mother may mean the ability to carry and see her child.
Patients and families experience uncertainty and anxiety near EOL. They are often scrambling for hope and looking to the physician as the care team leader to give them some hope for meaningful survival. It is humane to offer hope. We have all seen the anecdotal patient who has meaningful survival against all odds, and we want the best for our patients. As our patients navigate through this painful and impossibly difficult process, we must be transparent in our medical advice and opinion, particularly when it comes to EOL expectancy and disability.
Identifying the Terminally Ill Patient
The identification of patients who would benefit from EOL evaluation and/or intervention is the largest obstacle for emergency physicians. Recognizing when to focus on QOL and comfort rather than life-prolonging treatment is particularly challenging for physicians, patients, and their families.17 Triggers for assessment of palliative and EOL needs may include:18
• Diagnosis of a progressive or acutely life-limiting illness;
• Critical events or significant deterioration during the disease trajectory;
• Significant change in the patient’s or caregiver’s ability to cope and need for additional support;
• The clinician not being surprised if the patient were to die in the next 12 months; and
• Onset of the EOL phase; all curative therapy has been exhausted for a progressive serious disease.
Perhaps the simplest method of identifying EOL patients is answering the question, “Would you be surprised if this patient died during this admission?” If the answer is no, the patient would likely benefit from an EOL evaluation and/or intervention. Although various screening tools exist, understanding various trajectories is beneficial in transitioning to EOL care and in communication strategies.19