EthicsShould Emergency Department Patients with End-of-Life Directives be Admitted to the ICU?
Section snippets
Case 1
A 75-year-old woman with a history of severe chronic obstructive pulmonary disease presents to a community emergency department (ED) with fever, respiratory distress, and altered mental status. She is found to have pneumonia, and after antibiotics, glucocorticoids, beta agonists, and a period of time on noninvasive positive-pressure ventilation (NIPPV), begins to improve. However, she is still requiring venturi mask at 40% O2 to maintain saturations of 93%, and has an elevated respiratory rate.
Arguments Against the Exclusion of Patients from the ICU Based upon Having an EOL Care Document
For patients with advance planning/EOL care documents that express a desire not to receive aggressive interventions such as pressors or intubation, the ICU might still be an appropriate setting for hospitalization. ICU nurses and critical care physicians/intensivists might be more comfortable with, and skilled in, providing necessary doses of opioids and benzodiazepines, as well as other medications such as glycopyrrolate used in palliative care settings. The ICU also offers respiratory care
Conclusion
End-of-life care documents should not automatically exclude patients from the ICU. The key question for the emergency physician is, “Can the ICU offer uniquely beneficial treatment that would also align with the patient's values and stated goals of care?” End-of-life care documents are but one tool to help physicians understand patients' goals and wishes regarding specific life-sustaining interventions. Real-time conversations with patients or surrogates about goals of care in light of the
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Cited by (10)
Elders, triage and the intensivist
2022, Medecine PalliativeAssessment of emergency department staff awareness, access and utilisation of advance care directives and goals of care: A cross-sectional survey
2022, Australasian Emergency CareCitation Excerpt :While direct upload to electronic health records can provide the rapid access to documents, issues of validity and accuracy may be an obstacle [26] and need to be considered. Implementation of an existing ACD and establishing a GoC for a patient in the ED requires the careful consideration by emergency clinicians to ensure concordance between care offered at the definitive care destinations and the stated directives and goals of care [27]. Our study discovered staff knowledge on the VMTPDA 2016, which outlines ACD legal requirements, was lacking.
Early mortality in critical illness – A descriptive analysis of patients who died within 24 hours of ICU admission
2020, Journal of Critical CareCitation Excerpt :For this latter group, there may still be patients with irreversible and terminal disease who benefit from short-term ICU admission. For instance, some patients receive ICU support for emergency control of refractory symptoms and to facilitate palliation [32], particularly if there is difficulty accessing timely or appropriate palliative care resources [33-35]. Moreover, it may be suitable to support patients with life-sustaining therapies in ICU settings for brief periods to allow time for families and loved ones to say farewell and come to terms with a poor prognosis [36-38].
Association Between Do Not Resuscitate/Do Not Intubate Orders and Emergency Medicine Residents’ Decision Making
2020, Journal of Emergency MedicineCitation Excerpt :Surveys of ICU patient populations show that only 0.5–7% of ICU patients experience a cardiac arrest, with 1 recent study finding a 2.5% incidence (12,13). A recent statement from the American College of Emergency Physicians states that advanced directives, including DNR/DNI status, should not preclude patients from ICU admission (14). Therefore, withholding ICU admission based upon code status should be reconsidered.
The POLST Paradox: Opportunities and Challenges in Honoring Patient End-of-Life Wishes in the Emergency Department
2019, Annals of Emergency MedicineCitation Excerpt :Comfort care may require admission to the hospital to control symptoms or use of parenteral antibiotics to treat a symptomatic urinary tract infection or cellulitis.21 A recent ACEP Ethics Committee statement argued that even an ICU admission may be appropriate for a patient who wishes some limitations on interventions near the end of life if some specialized interventions reflect the patient’s goals and preferences.33 As Mirarchi and Yealy34 pointed out, “end of life and critical illness are not always the same.”