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I do have an interesting case, basic and not a lot of flair, as I am working my shift tonight in a single coverage ED with a 17,000-patient volume with periodic PA coverage. We were busy up until about 3am when things are starting to run together, just getting my last patient out of the ED, except my 18-year-old who ingested 10gms of tylenol and just finished his 15,000mg of “Acetadote” awaiting psyche eval. I figure if I could just get 1/2 hour, maybe even a 45-minute power nap, I would be good. Two phone calls later, I look at my watch after tossing and turning (for no good reason, except it’s not my bed and I’m not at home), and it’s 3:30. I am finally feeling like I could doze off and suddenly a knock on my door and it’s Tim from Cardiopulmonary who says “…we’re intubating in the unit, do you want the Glidescope?” and I said yes, grab it. As I am walking back to the ED to tell them the plan, I get a little history, “…he was admitted at 5pm with respiratory problems and he’s a full code!” I arrive to our 4-bed unit, 2 nurses, a clerk, a tech and Tim from Cardio are there. They tell me he was on the floor, originally on BiPAP in the ED but “weaned off” to go to the floor on Telemetry. He was found by the tech to have a temp of 33 C, HR 30’s, BP 50/30 and a SaO2 of 60%. He was moved to the unit and the hospitalist on call from home (1 hour away) said “…intubate him, give him fluids and call the ER doc…” in that order, I am told. I arrive to find a pale, very diaphoretic and cachetic eldery male with agonal respirations. He was on BiPAP, barely moving any air, still hypoxic, hypotensive and unresponsive. The nurse yells to me his wife is on her way, he’s a DNR in our computer, but she is the “Durable Power of Attorney” and wants everything possible done, except “…unless it is going to prolong his suffering and he’s not going to get better….” Of course I have the crystal ball to determine that.
I made the “executive decision” to give fluids, atropine, increase O2 and NOT intubate. The wife arrives shortly thereafter, she rushes to the bedside, teary-eyed, to hold his hand. She sees he is not responsive to her and his vitals on the monitor are “in the toilet” (a medical term of course). I tell her I thought this was a terminal event and he was not going to recover (.but who gave me the crystal ball). I did sneak in 2 rounds of atropine, a little diluted epi, a liter of NS with no response. She tells me he has really deteriorated over the past several weeks to months. He stopped eating 6 weeks ago, was hospitalized twice for pneumonia and never has really been the same and was sent to our local skilled nursing facility. Because he was found hypoxic with an altered LOC he was sent to the ER and admitted a few hours before I arrived. By now, their 2 pastors arrived (not at the same time of course) and the wife wanted me to explain what was going on. Just as I finished telling the first pastor, the second arrives and so I repeat it. She again asked if I thought there was anything that could be done. And of course I said no; “it’s between he and the man upstairs,” but I will make sure he is comfortable and not suffering.
I bounce back and forth between the ED and the ICU over the next hour. Now a little after 5am his HR is 20’s, BP 30/20, SaO2 is still hanging on at 97% but he’s still on BiPAP. I return at 5:30am, HR single digits, BP still 32/20 (obviously from several minutes ago). I ask to stop the BiPAP, HR 0, and I ask to turn the monitor off. I go through my normal routine and pronounce him at 0535, 10 minutes before writing this sentence. As I offer my condolences, the wife crying, gives me a hug and says , “thank you,” the pastors shake my hand; I ask if there is anything I can do, or if they have any questions I can answer. I tell them the nurse will have certain questions, the state of Michigan mandate we call “Gift of Life” and funeral home, etc. The nurse tells me, “thank you, I wish they all went like this!”
Now the punch line. It is well published that the last 6 months of life utilizes the highest percentage of health care dollars, also, that ED docs are expected to participate in comfort or palliative care in the ED, with increasing frequency. While ED patient volume is increasing, there are the same number of ED beds and staff, decreasing reimbursements (ie, we all are expected to work harder, more stress with less compensation). We are expected to maintain an excellent attitude to keep our Press Ganey scores up and improve our “…likelihood to recommend,” keep patients happy so they don’t sue us, while all along optimizing patient safety and quality of care. This while spending quality time at home with family and somewhere in there getting enough sleep before our first night shift and thereafter.
Now that I have reiterated the obvious to all of us, this is what we do day (or night) in and day out. I am going to ask yet one more thing of all of us. We are on the front lines and are responsible for a significant expenditure of health care dollars. We spend billions of dollars on defensive medicine and doing what is “expected” versus what we “should” be doing. I do have a strict adage, “…no one should ever die alone or in pain!” I was all ready to intubate my 82-year-old cachetic dying pneumonia patient ( and believe me, I am all about procedures) and even though he was initially a full code, it just wasn’t the “right” thing to do. After seeing both my parents die a similar death; one at a tertiary care center in Los Angeles and my father at home; it was just nice to have someone there who “cared.” This is what I think society wants at end of life, not to suffer, and someone there who cares. I think if we explain to families, DPOAs, etc, what we do to prolong the inevitable they would opt not to do it. That being said, there is definitely a fine line sometimes at end of life. What is “terminal” and what is not may be difficult. But after almost 20 years of doing this, I think we have a pretty good idea. Sir William Osler had it right too, and it still applies!
I would ask that we be cognizant not only about the health care dollars we spend not only at end of life but every day, and after quality of life has passed that we emphasize the “quality of Death.” We as physicians can impact the cost of health care the most by using our judgment of what we expend at end of life and before. This should be a judgment made by the family and physician at the bedside (not at home on the phone). And if this takes us out of the ER and into the ICU then so be it! If we are the only physicians in house then it is incumbent on us to be there for the patient and their family. Our government is doomed to fail (even more), if health care spending is not controlled, and we can control it on our terms and not theirs!
We as physicians are blessed to be in the position we are in. We have a lot of influence on everything. We should use that influence to benefit every aspect of our lives and the lives of others.
Harold K. Moores, MD, FACEP