Palliative Care Pro-Tips

Goals-of-care conversations in the emergency department can prevent nonbeneficial intubation, CPR, and ICU care that lock patients into outcomes they would not have chosen. Cardiac arrest survival is limited, and many survivors have poor neurologic function, making plain-language discussion of CPR, ventilators, and acceptable quality of life essential.

Emergency Department Goals of Care

• High-risk ED populations: Critically ill patients near intubation or arrest, those with advanced chronic disease, and patients with repeated admissions without benefit should trigger an early goals-of-care discussion.
• Interventions shape trajectory: Intubation and other critical care interventions can commit patients and families to a harsh hospital course, so the key question is whether that path matches the patient's goals.
• Plain-language framing: Avoid the term code status and talk instead about CPR and ventilators, because most patients do not understand the jargon and often overestimate what resuscitation can achieve.
• Outcome reality check: Only about 10-20% of patients survive cardiac arrest to discharge, and 30-60% of survivors have poor neurologic outcomes that may mean loss of independent living.
• Patient-defined line in sand: A useful anchor is asking what abilities matter so much that the patient cannot imagine living without them, which clarifies whether CPR could deliver an acceptable quality of life.
• Conversation setup matters: Sit down, normalize the discussion as routine care, and ask permission before going deeper; that small shift often gives patients and families more control in a chaotic moment.

DNR Orders and Medically Futile Care

• Valid DNR confirmation: A DNR should be on a signed order sheet, but if the form is unavailable the patient's or surrogate's verbal confirmation still matters and should be verified carefully.
• Dynamic code decisions: Code status can change at any time, and even a prior DNR may be challenged during crisis, so clinicians need to revisit the patient's stated wishes rather than treat the order as static.
• Surrogate revocation nuance: If an obtunded patient has a prior DNR, a medical power of attorney or legal guardian may attempt to revoke it, and the driver is often fear rather than a true change in values.
• Unreasonable request limits: Requests like CPR without ventilation may be medically unrealistic, and physicians can refuse interventions judged futile if they clearly document the specific treatment and rationale.
• Two-attending futility standard: When declaring medical futility, documenting the decision with two attending physicians strengthens the record and helps align the plan with defensible emergency practice.
• Reversible supports distinction: DNR does not automatically mean no treatment; central lines and vasopressors are often appropriate because they are more readily reversible than CPR or intubation.

References:

1. Crispo AE, Strout T, Bunting S. Older adults’ knowledge of code status and perceived outcomes after cardiopulmonary resuscitation. Ann Emerg Med 2023;82:S161.