The emergency department is a setting in which medicine is practiced with limited time and information and where relationships with patients are stressed and fleeting. By themselves, these variables present significant challenges to patient-physician communication regarding outcomes of critical interventions. This is especially true of the critically ill patient, who may or may not have the cognitive capacity and wherewithal to meaningfully participate in conversation.
There are numerous challenges to communicating realistic outcomes of critical, often end-of-life (EOL) care interventions. Initial patient expectations of treatment benefit may be wildly inaccurate, with one study reporting patient estimate of survival after cardiopulmonary resuscitation (CPR) as high as 60 percent, closely matching the survival rates of patients after CPR on television. 1,2 Moreover, physicians are generally poor prognosticators, particularly in the terminally ill population. For example, physicians are generally far too optimistic about their patients’ chances of survival.3 It should then come as no surprise that physicians are inadequately trained to make prognoses and have EOL care discussions and frequently avoid the discussion altogether.4–6 When providers do approach patients, they often do so by asking about lifesaving interventions it has taken health care providers years of professional development to understand, without assessing patients’ goals of care, sometimes leading to discrepancies between patient preferences and the care provided to them.6,7 Finally, if patients lack decision-making capacity, there is no guarantee family members can represent the patients’ preferences, which they do accurately just 68 percent of the time.8
For those critically ill patients who arrive with an advance directive, physicians might be inclined to believe that communication regarding EOL care interventions and their potential outcomes ought to be straightforward. Unfortunately, that assumption is often wrong and the situation more complex. Assuming for the moment that the advance directive has actually been transported with the patient, filled out correctly, and signed by the patient, the documents themselves have significant limitations and flaws. They assume incorrectly that patient preferences are stable over time.9 Furthermore, patients and their families frequently misunderstand their meaning or how they will be applied to specific scenarios.10 In fact, evidence suggests that patients’ preferences for CPR and intubation, even those with do-not-resuscitate/do-not-intubate (DNR/DNI) documents, are highly dependent upon the perceived reversibility of their condition.11,12 As such, advance directives and DNR/DNI documents may not provide the guidance clinicians would like concerning the content of the EOL care discussions in the emergency department.
The Ethics of Transparency
Many physicians and ethicists cite transparency as the main tool used in order to better communicate realistic outcomes to patients and their families when choosing to perform or withhold critical interventions in the emergency department. It is the physician’s duty to explain both treatment goals and expected outcomes, particularly in the case of the resuscitation of the acutely decompensating, terminally ill patient. Without transparency, it is impossible to have adequate consent to or refusal of medical treatment, either by patients or their families. Physicians must describe their thinking, including the expected outcome, in order for patients and their families to truly be able to choose what the next steps will be.13,14