Morgenstern, J. The gamble, First10EM, April 3, 2023. Available at:
It is a gamble we all take. It is a gamble we all occasionally lose.
We don’t love having end of life conversations in the emergency department. They can be uncomfortable. They can take time that it feels like we don’t have. They don’t seem like our responsibility, when the patient has a primary physician or admitting team.
So we routinely gamble, admitting patients without having the conversation. Most of the time, we get away with it, but let’s consider what happens when we lose this gamble.
“Code blue, emergency department, bed 15
Code blue, emergency department, bed 15
Code blue, emergency department, bed 15”
Your heart drops. It’s your patient. You put in the request for an admission to medicine 5 hours ago, but it is busy (as always), so she still hasn’t been seen. She is your responsibility.
It is an elderly patient from a nursing home. She has advanced dementia, with complete dependence for all her activities of daily living. She is close to bedbound. She has multiple comorbidities. You don’t say it out loud, but her current quality of life is depressing to you. You never want to end up like that, and you sort of sense, in moments of semi-lucidity, that the patient probably feels the same way.
She was supposed to be admitted for delirium. She didn’t look that sick. Her vitals signs were normal. Her bloodwork was unremarkable. Unsure, you decided to blame it on a UTI. Of course, you wouldn’t be surprised if she died within the year, but you honestly didn’t expect it to happen today.
But it did happen. And it is your responsibility.
You know the patient won’t benefit from CPR; or intubation; or the ICU. You wouldn’t want it for yourself. Patients with her baseline condition don’t want CPR, when you actually take the time to have the conversation.
But you didn’t take the time. Faced with a busy emergency department, you skipped the conversation, as you often do.
The family wasn’t at the bedside. You weren’t sure who was the legal power of attorney . The nursing home should have done it. There were many justifications – excuses – but none help you now.
She is your responsibility, and the code has already started. CPR is in progress as you walk into the room. Family is not around, and it is now 2am. You are going to have to wake them up. This would have been a much easier conversation 5 hours ago. This would have been a lot easier if you didn’t have to start the conversation with “your mother’s heart has stopped”.
You look around the room as you dial the phone. Your colleagues are professional. They move through the resuscitation with practiced grace. But there is sadness in the room. Despite the heroic expertise, no one is proud. No one is hopeful. No one is happy. Everyone knows where this is headed.
There is profound moral distress, and that too is your responsibility.
The death occurs, despite all efforts, as it was destined to. It was only delayed by 30 minutes. But those 30 minutes were profound; profoundly harmful; profoundly sad.
It is a gamble we all take. We avoid the uncomfortable conversation; defer it to the admitting team. It is a decision that is easy to justify. The patient is stable. The conversation is not urgent. There are always 20 other things that need to get done.
So we gamble, and usually we win. But when we lose, we lose big.
The result is moral injury, distress, burnout. We feel awful about the part of our job that should make us feel the best. We have the ability to bring people back from the dead. Our jobs are miraculous. We can occasionally be heroic. But too often we practice those skills in futile situations, on patients who would not appreciate our efforts, and so instead of heroism, we feel shame. We question our commitment to this profession. We question everything.
Of course, we are not the main characters in this story. Let’s not overlook the impact on the patient and their family. The loss of dignity. The lack of respect. The family forced to make impossible decisions at impossible times. Decisions that will live with them forever, while we move on to the next patient.
It is a bet we have all made, but if we pause to consider the losses, perhaps we will stop.
6 thoughts on “The gamble”
5 hours ago you tell the physicians that you have made her not for resus and document it. Also inform the family, and do not put this person through a process that is both futile and traumatic.
Agreed. I’m not sure if this is a cultural thing, but in my (south american) country, the decision to not resuscitate relies on the assistance team, especially on the physician. We learn early on our paliative rounds that this is not a decision that should be made by the family, especially at 2 am over the phone. We have several tools that can help identifying patients benefiting from non invasive measures and this can be assessed and registered at the admission in the ED.
@ Fernanda “We have several tools that can help identifying patients benefiting from non invasive measures and this can be assessed and registered at the admission in the ED”.
That looks very interesting, can you us more about these tools?
Thank you for a useful and thought provoking piece. None of us wants to have “the conversation” with patients and their family – is it because we find it difficult to accept that people will still die in spite of everything we can do – but we need to be realistic about what is possible balanced against the wishes of the patient. You can play baseball on the freeway, but is it a good idea?
In Germany a treatment is allowed only if it does help the patient and improves the condition. A patient as described in the article does not benefit from resucitation so this makes the decision easy how to treat the lady. However you have to strong enough to do so.