The rapid code status conversation guide for seriously ill older adults in acute respiratory failure
You are working a regular shift in your emergency department (ED) when a 85 year old female presents with a complaint of altered mental status. She comes from an extended care facility, where paramedics are able to tell you “they called us to come get her”, you are handed a stack of paperwork, given some vital signs and you notice the patient is altered beyond being helpful to you. You dig a little in the paperwork and note a history of dementia, as well as a long list of other medical problems, you notice no known advanced directive and a number to speak with her daughter who lives out of state. Have you been here? Seen this patient? IF you have work in emergency medicine long enough you certainly have. The tool outlined below is designed to help you know what to do in these difficult situations.
Emergency physicians are responsible for setting the trajectory of hospitalization for seriously ill (terminal illness with less than one-year prognosis) older adults . 75% of older adults (≥65 years) visit the ED in the last six months of life . More than half of such patients lack advance directives . Emergency physicians are tasked with completing the hardest conversations in medicine – helping patients determine their goals-of-care and making rapid decisions regarding the use of life-sustaining therapies. The importance of this task has been amplified during the COVID-19 pandemic. Emergency physicians must recognize that the best possible outcome after survival may be “worse than death” for seriously ill older adults. One in three older adults die in the hospital after intubation, and most survivors would go to places other than home with limited life-expectancy. Among decedents, the mean time to death is three days. These overall survival characteristics are influenced by age (e.g., 50% in-hospital mortality for those above age 90) and comorbid conditions (e.g., 40% increased odds of death for those with Charleson Comorbidity Index >4) .