You are working a shift in your emergency department (ED) when an 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 and unable to provide any further history. 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 see that her daughter lives out of state but is available via phone. Have you been here? Seen this patient? If you have worked 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) .
Even among survivors, the long-term survival is dismal. Over 80% of survivors would go to the skilled nursing facility or a long-term acute care hospital, and overall median survival is only 164 days after leaving the hospital (under peer review). The functional outcome is expected to be worse among survivors. For older adults with mild to moderate physical disability admitted to the ICU, 26% would die, and among the survivors, 54% would develop a severe disability . In light of this poor outlook, emergency physicians must consider what these patients would be willing to live for. More than 70% of older adults prefer quality of life rather than life extension . Furthermore, ≥ 60% of older adults consider “cannot get out of bed” or “rely on breathing machine to live” as equal to or “worse than death”. The vast majority (87%) of seriously ill older adults who are hospitalized express that they would even trade one year of a 5-year lifespan to avoid dying in ICU . At this clear turning point in older adults’ life, emergency physicians are tasked to delineate patients’ values and what they consider “worse than death” in the context of best possible outcomes to provide goal-concordant care.
Why rapid code status conversations?
To help emergency physicians navigate these emergency code status conversations, we developed the rapid code status conversation guide. The guide was developed based on best communication practices in the palliative medicine literature and refined by a panel of experts in serious illness communication and emergency medicine. It was further adapted by emergency physicians specifically for code status decision-making [8,9].
How does it work?
Focus the conversation on ascertaining the patient’s baseline function and desired outcome rather than wishes around a particular procedure (e.g., intubation). Through an organized series of steps and suggested phrases (outlined in the chart below), the rapid code status conversation guide allows emergency physicians to succinctly obtain patient’s baseline function and outcomes that patient may consider acceptable for living in the time-pressured ED settings and make recommendations around intensive care focus on recovering from respiratory failure (i.e., intubation) or focused on patient comfort (i.e., no intubation). Standardization of the code status conversations by emergency physicians is of paramount importance in our current COVID-19 pandemic.
Thanks to our expert panel: Kei Ouchi, MD, MPH (emergency medicine/internal medicine), Naomi George, MD (emergency medicine/critical care), Rachelle Bernacki, MD, MS (palliative medicine/geriatrics), Susan Block, MD (palliative medicine/psychiatry), Erin Clarkson, MD (palliative medicine), Esme Finlay, MD (palliative medicine), and Joshua Lakin, MD (palliative medicine).
Table 1: Version 04/03/2020 v2, created by Kei Ouchi, MD, MPH and Naomi George, MD
- Ouchi K, Jambaulikar GD, Hohmann S, et al. Prognosis After Emergency Department Intubation to Inform Shared Decision-Making. J Am Geriatr Soc. 2018;66(7):1377-1381. PMID: 29542117
- Smith AK, McCarthy E, Weber E, et al. Half of older Americans seen in emergency department in last month of life; most admitted to hospital, and many die there. Health Aff (Millwood). 2012;31(6):1277-1285. PMID: 22665840
- Platts-Mills TF, Richmond NL, LeFebvre EM, et al. Availability of Advance Care Planning Documentation for Older Emergency Department Patients: A Cross-Sectional Study. J Palliat Med. 2017;20(1):74-78. PMID: 27622294
- Ferrante LE, Pisani MA, Murphy TE, Gahbauer EA, Leo-Summers LS, Gill TM. Functional trajectories among older persons before and after critical illness. JAMA Intern Med. 2015;175(4):523-529. PMID: 25665067
- Steinhauser KE, Christakis NA, Clipp EC, McNeilly M, McIntyre L, Tulsky JA. Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA. 2000;284(19):2476-2482. PMID 11074777
- Rubin EB, Buehler AE, Halpern SD. States Worse Than Death Among Hospitalized Patients With Serious Illnesses. JAMA Intern Med. 2016;176(10):1557-1559. PMID: 27479808
- Rubin EB, Buehler A, Halpern SD. Seriously Ill Patients’ Willingness to Trade Survival Time to Avoid High Treatment Intensity at the End of Life. JAMA Intern Med. 2020. PMID: 32250436
- Vital Talk Quick Guides. https://www.vitaltalk.org/resources/quick-guides/. Accessed 4/11, 2020.
- Communication Skills. https://www.capc.org/training/communication-skills/. Accessed 4/14, 2020.