We were only a few minutes into rounds that morning in the intensive care unit when a nurse urgently interjected: “Mrs. D is unresponsive.” The overnight resident on call had admitted her a few hours earlier, and we had just begun discussing the key elements of her presentation with our team of residents, interns, a pulmonary critical care fellow and an attending physician.
From our discussion so far and my brief scan through her admission notes and blood work, the essentials were clear: she was an 84-year-old woman who had been diagnosed with metastatic ovarian cancer only a few weeks earlier and had now been readmitted with fevers, low blood pressure and likely infection. Her laboratory data confirmed new and profound kidney and liver failure. My experience as a resident immediately told me that she was actively dying and, irrespective of the medical aspects of her illness, the key issues for her and her family would be how they spent what little time she had remaining and how much control they would have over the circumstances of her death.
Reflexively, I turned to the overnight resident and asked, “What’s her code status?” With palpable regret, he replied that his efforts to engage Mrs. D in a conversation about her care last night were futile. She was too somnolent to participate, and none of her family members were reachable. Moreover, she had only seen her outpatient oncologist once, and they had not yet broached a discussion about goals of care. A sinking feeling filled my chest as we walked briskly to her room.
The existing large body of medical literature provides many important insights about Mrs. D’s presentation and general issues surrounding end-of-life care and the care of geriatric patients. Studies demonstrate that most people would prefer to die at home, surrounded by loved ones, instead of at a hospital, and most do not want intensive life support or other aggressive interventions used for a prolonged period of time. Studies also demonstrate that people generally want the opportunity to make decisions about their end-of-life medical care before they become sick and with the input of their loved ones and longstanding physicians. These conversations formally fall under the domain of “advance directives.” Despite these well-documented preferences, only about one in 10 patients—and only half of advanced cancer patients—have an advance directive.
Discussions with family members and doctors about a patient’s goals of care are infrequent, and the naming of health care proxies (individuals empowered to make medical decisions on the patient’s behalf if they become debilitated) is not the norm. Finally, the majority of patients in the United States pass away in a hospital or facility instead of at home.
Entering Mrs. D’s room, we encountered the scenario I feared most. Her heart had slowed to only a few beats per minute; she had no palpable pulse; and, in the most natural way, she was dying in front of our eyes. We initiated CPR, however, since we were largely obligated to resuscitate her because of the ambiguity surrounding her goals of care. I led the code, but privately felt deep grief and regret for Mrs. D, as her frail body became subject to our powerful chest compressions and attempts to gain venous access with needles and catheters.
“Call her daughter now!” yelled one of the residents. We learned a few moments later that she was already on her way to the hospital. When she arrived in the ICU, she rushed to her mother’s room, and her face filled with all the sadness, shock and fear I could imagine. Our attending physician had the foresight to take her aside, and they had a conversation about her mother’s condition. While I was not present in that conversation, I cannot imagine that its contents strayed much from the overall futility of our actions. They reemerged a few minutes later, and she requested we end the code. She didn’t want her mother to suffer any further, and had Mrs. D been able to engage in a conversation about her goals of care prior to her rapid decline, I suspect she might have felt similarly.
Angela Botts, a geriatrician at Beth Israel Deaconess Medical Center and an HMS instructor in medicine, is an expert on goals of care discussions and end-of-life issues. “Patients overwhelmingly want to discuss goals of care with their primary doctors— someone who knows them and knows their families. They feel less comfortable having these discussions with someone they have just met for the first time in the emergency room or when they are admitted on the medical floor.” She also highlights how current health policy may be a barrier to initiation of these important discussions. “Overall, the statistics regarding the number of people who have a health care proxy or have discussed goals of care with their physicians are very low. It’s not that these are negligent physicians. The discussion is time consuming, and it doesn’t have the same importance in terms of insurance reimbursement.”
With an aging population, the importance of discussing goals of care prior to acute illness will grow—as will the costs of neglecting this critical conversation. Mrs. D and her family were fortunate, I believe, in that our efforts ended shortly after initiation, and her life was not artificially prolonged. However, countless examples of the opposite scenario exist, and when a patient’s goals are not aligned with their care, harm is caused, resources are wasted and both patients and their families needlessly suffer.
Joseph Ladapo, HMS ’08, is a resident in internal medicine at Beth Israel Deaconess Medical Center.
The names used in this column are pseudonyms, and the opinions expressed are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.
