End Of Life Discussions in ED
• Dr Hassan Zahoor.
• Emergency Department SCGH.
Talking about death and dying
is not easy.
CPR Decision making is a
clinical skill, and requires a
systematic approach to
communicate choices to
patients or to patients carers.
• Better Prognostic models
• Specialized training
• Structured approach to decision making
• Infrastructure, information and planning ahead.
• Evidence based research on EOL care in ED.
• 89 years old male, with severe Parkinson's, and multiple other co morbidities,
wheelchair bound at home , was brought to ED post collapse at home an hour ago.
SJA staff found him in cardiac arrest and started CPR at scene ( down time 10-15
min) at least. Initial 2 shock able rhythms and then asystole. Total of 6 doses of
adrenaline given pre hospital and was intubated by SJA staff
• On arrival in ED asystole on rhythm check and then had ROSC at second rhythm
check after total of 1 hour 15 min resus. BP 60 systolic, HR around 50. pupils
dilated non reactive, no spontaneous breathing effort. BP 2 min later 45 systolic.
Family are 15 min away from ED.
• What will you do next?
Breaking Bad news and determining Goals of
• Establish what patient or family knows.
• Assess willingness to hear information
• Deliver Medical information
• Respond to emotions
• Establish goals of care.
You can Say
• Your loved one is dying and we expect at some point her heart will stop.
• Due to her severe illness, it is our recommendation that we allow her to have
natural death rather than trying to restart her heart.
• It is very unlikely that any resuscitation attempt will be useful, in the rare
instance if her heart starts again she would most likely have prolonged dying
experience in ICU.
• As an alternative we can focus on maximizing our efforts towards keeping her
comfortable, and treat SOB with medications.
Do Not Say
• We need to talk about your wife's code status.
• Do you know what's going on with your wife.
• There is nothing more we can do.
• Does she want everything done.
• Does she want chest compressions.
• Do you want us to resuscitate her, intubate her.
• Lets just keep her comfortable.
• Would she want chest compressions.
• An Advance Health
Directive (AHD) is a
document that contains a
consumer’s decisions about
their future health care
• Treatment includes:
• other health care.
• Patients can make an AHD
in which they provide
consent, or refuse consent,
to future treatment.
Capacity is the cognitive ability to
understand and appreciate the context,
choices and consequences of our
decisions. It is also a person’s performance
on measures of decision making ability.
Competency differs as it is determined by
courts and tribunals and is the legal
judgment that a person’s capacity is
adequate to make the decision in question.
It is clinical construct. Legal decision.
Person may have no capacity if they have
dementia, critically unwell, intoxicated
• 90 years old female , back ground of COPD, on home oxygen with exercise
tolerance up to 20 meters, presenting with URTI and sob for last 2 days and today
found to be drowsy and reduced GCS. In ED poor resp effort, GCS 12, PCO2 110,
PH 7.19. HCO3 30.
• You have started initial treatment and NIV . Family arrives in cubicle and you have
to talk to them about further management and goals of care.
Things to Remember
• Involve HDU, ICU , inpatient home patient team in decision making in difficult
• Utilize observation ward when we can.
• Make sure PRN medications are charted for comfort measures.
• Social workers are great help in this situations, in after hours leave referral details
and ED clerk desk.
• Document everything in your notes.