A few months ago, the father of a primary care physician came into the emergency department with syncope. He was 102 years old. His age was more than double his heart rate. That may or may not be bad but it certainly is often a reason for more testing. The senior resident seeing the patient ordered an EKG, a battery of labs, a head scan, and anticipated admitting the patient as he had been taught to do: old person, syncope, bunch of tests, admit — pretty bread and butter case. Or was it?
Over the past several years, I have been thinking about issues facing our health care system including cost, access, ethics, end of life care and how these considerations might affect the teaching of emergency medicine residents. It has given me pause in situations like this and so I ordered a “clinical timeout.” We have procedural timeouts during surgery or invasive actions and they are meant to prevent error; not operating on the wrong limb or sedating the wrong patient. It’s taking a pause and, amidst all the complexity and haste, stopping and asking a few, simple questions. This seemed a good time for a clinical timeout; a time to really think about what we were doing and what we hoped to accomplish. Emergency medicine can be fast paced and teaching efficiency is important. Get things done, get them done quickly, get them done right, and move on. This situation, however, seemed to illustrate the need to slow down, even for just a few minutes, and reassess.
The patient did not want anything done, particularly, anything invasive like getting a pacemaker. He had been telling his family that he wanted to die. All his friends were gone. He had lived a good, long life and he was tired. He wanted to go home. He wasn’t depressed, he was just worn out. And so I canceled all the tests. His wife, however, was somewhat uncomfortable with him at home (she was in her 90s). She did not know what to do if he passed out again and so I called her physician son hoping to get some reassurance that he could arrange appropriate home care. After a brief introduction, the conversation began accordingly: “Dad’s 102, he’s lived a good life, he’s saying he wants to die.” Great, I thought, we’re on the same page and can start arranging discharge. Then came the zinger. “Why don’t you just admit him overnight?”
It happens all the time. It often doesn’t make sense and the cost isn’t inconsequential. It’s frustrating professionally, but personally I knew what he was thinking. At that particular moment the physician son just wasn’t ready to throw in the towel on his dad. He wasn’t ready to completely stop the fight. He was doing what he thought was best. He didn’t want to leave any possible benefit on the table. And so we admitted the patient.
That moment does call people out. I get it. I had been there myself several years ago with my mother. She had survived a respiratory arrest during her last stages of lung cancer. She then went into atrial fibrillation with a rapid ventricular response. Should we do something? Should we start diltiazem? Everyone looked to me. I guess it wouldn’t hurt and so we did and then she died.
I want to die outside. Most people want to die at home. The overwhelming majority of us die in an institution: a hospital or nursing home. It’s often awful and ugly. If we define quality of care as that which we would want ourselves or our family to receive then we need to take a serious look at what message we’re conveying to our residents and students regarding end of life care. We need to take more time considering (and sorting out) what patients want, what good are we doing, how we sometimes reflexively order tests and make dispositions, how we use resources, and how we communicate. This guy had a chance to make it out and to get back home. It’s what he wanted.
I suspect you may be wondering if he died overnight or made it back. I’m not saying. It’s not the point. I’m not sure what the resident thought of all this either. Should we really even consider sending home a 102-year-old with syncope? There was a lot to discuss but not the time to discuss it as is typical in the ER. Or so it seemed. But now I think it was really important and I may not only have blown it with the patient but with the resident. The point to me is this. We need more clinical time outs. Time outs with our learners, time outs with our patients, time outs with families, and maybe most importantly, time outs with ourselves.
David Schlueter is an emergency physician.