Emergency Physicians' Role in End-of-Life Care

The idea of death, the fear of it, haunts the human animal like nothing else; it is a mainspring of human activity—activity designed largely to avoid the fatality of death, to overcome it by denying in some way that it is the final destiny for man.ERNEST BECKER As the end of the 20th century approaches, the biotechnological war so cleverly waged against cancer and other diseases by the medical profession has also created a hostage situation. Doctors continue to concentrate their efforts on providing maximal duration to patients' lives when those patients are confronted with life-threatening illness. Employing ritualistic resuscitation remains the default position of emergency medical personnel in cases in which no advance directive (AD) and its promise of legal immunity exists. If recent studies are to be believed, this reflexive activity is born out of fears of litigation and peer criticism in 94% of emergency physicians (EPs) surveyed and is independent of professional judgment of medical benefit or futility.61 Additionally, even though prehospital ADs are recognized by emergency medical service (EMS) providers to be important documents designed to limit care in the terminally ill, they are not necessarily considered routinely.73 Again, this omission stems from provider fears of legal consequences for withholding life support measures. Considering that conservative estimates of 1.9 million deaths per year in the United States are preceded by decisions to withhold or withdraw life support treatment, and that no physician has ever been successfully prosecuted for withholding or withdrawing of medical care from any dying patient in the legal history of this country,41, 100 (Annas GJ: Personal communication, 1998) one is left wondering what of substance fuels these fears of legal retribution. Equally troubling is the physician tendency to cast aside opportunities for discussion of meaningful care options at the end of life and shy away for providing patients and surrogates with honest estimates of their prognoses. A disturbing example of these shortcomings can be found in the 1995 Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). Investigators spent $28 million in a multicenter controlled trial aimed at improving patient care, only to conclude that “the care of the seriously ill or dying persons is not attractive.”101 Carefully understated but rigorously demonstrated were the physicians' failure to meet all outcome markers; failure to include patient and family in pivotal care discussions, failure to provide realistic estimates of outcomes valued by patients, failure to treat pain adequately, and failure to prevent prolonged death in patients with known poor prognoses. Where do emergency physicians fit into this indictment of systemic failure, and what can we use as guideposts to better inform our practice when death is at the bedside? In 1997, the American College of Emergency Physicians (ACEP) adopted its first code of professional conduct.4 In this code, several prioritized obligations highlight the uniqueness of emergency medical practice, its mission, environment, and committed moral responsibility its physicians have for their patients. The need for such an oath acknowledges the nature of illness, which colludes to make patients vulnerable, dependent, and exploitable by physicians.48 The document emphasized the physicians' supreme duty to embrace patient welfare, respond rapidly in delivering expert emergency medical care to all, while maintaining respect for patients' autonomy and their best interests through truthful informed communication. Notably absent from the code is any mention of liability as a motivator of professional conduct. Representative segments of this code will serve as fitting guideposts as we discuss end-of-life care issues in the emergency department (ED). (The ACEP Code is reproduced in its entirety in Iserson's article.)