DNR canstockphoto4969800Code status. Do not resuscitate. Allow natural death… These can be some of the most daunting concepts for new learners to explain to patients, but they can also be the most critical. Depending on the circumstances, discussing these topics may be difficult for the most advanced clinicians.  This month’s ALiEM MEdIC series case considers how we might help a learner through a bad experience with end-of-life care discussions. Please join us in discussing the case this month, we would love your thoughts and advice.


P.S. Eve Purdy, Brent Thoma, Sarah Luckett-Gatopoulos and I would also like to invite you all to register for the ALiEM MEdIC pre-conference workshop at SMACC.  Come out and be part of a LIVE version of the ALiEM MEdIC case development and release for a special SMACC version of the case series!

MEdIC Series: The Concept

Inspired by the Harvard Business Review Cases and initially led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@Brent_Thoma), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the fourth Friday of the month, we pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses are be made available for download in PDF format – feel free to use them! If you’re a medical educator with a pedagogical problem, we want to get you a MEdIC. Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching to the next level.

The Case of Breaking Bad News Badly

by Dr. Stephen Singh (@SSingh_MD)

“I’m not sure that went so well…” William said to Sally. William was a first-year off-service resident rotating through emergency medicine. Sally, a third-year emergency medicine resident, was reviewing the case with him.

“I think…. I think the patient and his wife are upset with me…” William continued. The patient was Mr. Theodore Smith, a 78-year-old gentleman with stage four prostate cancer with metastases to the bones. He had come to the emergency department in a pain crisis, and a decision had been made to admit him to hospital to optimize his pain control.

“Why do you think that?” probed Sally, a budding medical educator. She had encouraged William to discuss the patient’s end-of-life goals, using the hospital’s ‘Code Status’ form as a prompt to open the discussion. She had even asked William if he was comfortable with the discussion, and he had stated he felt very confident, as he had just finished is in-patient internal medicine rotation.

“Like you asked, I was trying to get them to complete the code status form, to make it easier for the admitting team. But it sounds like no one had discussed this before with them,” William explained.

“How did you bring it up?”

“I asked them if they wanted everything done if something bad happened,” William explained. “They seemed confused, so I went through the checklist on the sheet, and that seemed to confuse them more. They wanted to know what this had to do with alleviating his pain, and why I was asking them these questions. Mr. Smith started to cry, and his wife asked me why I had to put him through more suffering. They then demanded to speak with the ‘real doctor.'”

Sally understood as she had had a similar experience when she was a first-year resident. Though able to empathize with William, she reflected that she was not well equipped to help sort this out now that there was clearly an issue between William and his patient. Not wanting to complicate the situation for the busy Senior Medical Resident, she and William come to you as the supervising staff emergency medicine physician and explain the situation.

Key Questions

  1. How should questions about a patient’s ‘code status’ be brought up?
  2. Who is responsible for helping to determine a patient’s goals of care?
  3. How can one “repair” the physician-patient relationship after a code status or goals of care discussion goes awry?

Weekly Wrap Up

As always, we posted the expert responses and a curated commentary derived from the community responses one week after the case was published. This time the two experts are:

  • Dr. Ashley Shreves, an Assistant Professor of Emergency Medicine & Geriatrics and Palliative Medicine, Mt. Sinai in New York City.
  • Dr. Susan Shaw, Critical care & Anesthesia physician in Saskatoon. She teaches at the University of Saskatchewan, working to improve the system in Saskatchewan, Canada.

On January 30, 2015 we will posted the Expert Responses and Curated Community Commentary for the Case of Breaking Bad News Badly. After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary which was released on January 30, 2015.  That said, we’d love to hear from you, so please comment below!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.


Image from CanStockPhoto

Teresa Chan, MD, MHPE
ALiEM Associate Editor
Emergency Physician, Hamilton
Associate Professor, McMaster University
Assistant Dean, Program for Faculty Development, McMaster University Ontario, Canada
Teresa Chan, MD, MHPE


ERDoc. #meded #FOAMed Own views expressed. Contributor to @ALiEMteam, @WeAreCanadiEM, ICE Blog, #FeminEM. @MedEdLIFE founder. Works @McMasterU & @HamHealthSci