Withdrawal of Treatments in the Emergency Department
Author: Kelly Bookman, MD, Assistant Professor of Emergency Medicine, University of Colorado Health Sciences Center, Denver.
Peer Reviewers: Catherine A. Marco, MD, FACEP, Professor, Department of Surgery, Division of Emergency Medicine, Director of Medical Ethics Curriculum, University of Toledo College of Medicine, Toledo, OH; and Steven M. Winograd, MD, FACEP, Attending, Emergency Department, Horton Hospital, Arden Hill Hospital, Orange County, NY.
Emergency physicians and pre-hospital personnel are trained to intervene rapidly in critical situations. In the absence of information to the contrary, a patient's desire to be resuscitated must be assumedespecially when withholding life-sustaining procedures may result in death. Often, only after such procedures have stabilized the patient is there time to reflect and understand that patient's wishes. At the end of life, life-preserving interventions may not be wanted. While it may take several hours or days to sort out patient wishes near the end of life, it is occasionally true that the emergency physician can clearly discern the patient's desires during the emergency department (ED) stay. Honoring the patient's hope to avoid heroic but painful or non-beneficial treatments near death may involve withdrawing interventions that could not be withheld during the first few minutes of care. This article presents the legal, ethical, and practical issues surrounding the withdrawal of treatments in the ED.
Introduction
Emergency physicians (EPs) and pre-hospital providers are trained to initiate life-preserving interventions as an integral part of their job. Given the nature of emergent presentations, life-sustaining treatments often must be started without the patient's ability to consent. When patients are unable to express their wishes, these interventions are performed using the principle of preventing harm, knowing that death may occur if treatment is delayed. As a larger proportion of the population is older and lives with severe chronic disease, it is more common that life-saving procedures may be performed during the terminal part of an illness or during the process of dying. In some instances, emergent procedures performed in the first minutes of care may eventually be determined to be overly invasive or not in accord with patient's wishes near the end of life. The EP must be comfortable with the legal, ethical, and practical issues that surround the withdrawal of treatment.
Case Vignette
A female patient is found unconscious by a neighbor. An ambulance is called, and the patient is found to have no gag reflex and is therefore intubated in the field. The patient arrives in the ED intubated with stable vital signs. There are no obvious signs of trauma to the patient. A neurological examination reveals sluggish pupils, no response to verbal stimulation, and withdrawal to pain. The patient is stable enough to receive a computed tomography scan, and the results reveal a subdural as well as subarachnoid hemorrhage. The neurosurgeon on call recommends immediate evacuation of the subdural. At this time, the patient's son and his wife arrive with appropriate documentation that the son has the medical durable power of attorney. He says that his mother has a significant chronic disease burden including coronary heart disease, hypertension, emphysema, and that she can barely leave her house. He states that his mother would not wish to have the surgery and that she has stated clearly that she does not want to be "hooked up to any machines to keep her alive." Can the EP comply with the son's refusal of the surgery? Given the patient's preferences according to the son, should she be extubated? Should the EP initiate the process of withdrawal of treatments in the ED?
Background
Death and Dying in Modern Society. As complex medical treatments for chronic obstructive pulmonary disease (COPD), heart failure, cancer, and other fatal illnesses have become more successful, the number of people living with severe chronic diseases has increased. A century ago, 90% of people died rapidly of sudden cardiac death, trauma, or infectious diseases. At the beginning of the 21st century, only 10% of people in the United States die suddenly.1 Deaths in the course of these chronic diseases often occur relatively unexpectedly with acute exacerbations or complications that present to the ED. These complications occur not in isolation, but in the context of a patient's terminal or severe, progressive diseases. In such cases, they may represent the natural history of the disease or even the classic "gift" or opportunity for a peaceful death at the end of life. In fact, artificial life support may deny certain patients a dignified death. As this country ages, focus must be drawn to the nature of death and dying and gaining an understanding and acceptance of this natural process.
The ED Culture. In general, the goals of health care are to prolong life, restore health, and relieve suffering.2 One of the important principles governing emergency medicine (EM) practice is to rescue patients from acute medical crises. Often, patients present to the ED in extremis, and the EP must act urgently to stabilize or reverse acute decompensation in the face of multiple uncertainties, including the severity and overall prognosis of underlying illnesses, cause of the acute decompensation, patient's wishes, and determination of the appropriate decision maker. The patient's family or loved ones may not immediately be available and/or there may be no primary care provider or a physician who has a longitudinal relationship to aid the resolution of the these uncertainties. When there is no information available regarding a patient's wishes, it is necessary to initially act to preserve life, which will allow time for further assessment, conversation, and reflection.
The ED culture traditionally focuses on acute rather than chronic diseasesas does much of current medical education and practice. Indeed, in the ED or pre-hospital arena, it is appropriate to start with an interventive, acute approach to most patients.3,4,5 However, increasing numbers of ED patients have a mix of acute and chronic disease. Holman, in a recent Journal of the American Medical Association editorial, has criticized the overuse of an acute disease approach in medicine and has pressed for understanding the important differences between acute and chronic disease models.6 He brings attention to the very different role of the patient and physician in the two paradigms. In the acute disease paradigm, the patient is passive and often unable to communicate; the goal is cure or reversal of disease, and the interaction is limited and episodic. In a chronic disease model, the patient needs to be active, and the goal is to manage diseases that cannot be cured. Patients with chronic disease are often the more knowledgeable partiesonly they know the burdens, benefits, and life goals that inform how they want to be cared for.6 This means that the all-out aggressive interventive standard, while particularly tempting in the ED, may not result in appropriate care for all patients.
Initially, it often is difficult to discern patient wishes to refuse life-sustaining treatment in the ED. Many critical patients are either not conscious or are conscious, but with questionable decision-making capacity. Decision-making capacity (differing from legally designated "competence") is defined as the ability to: express oneself, demonstrate understanding of the medical options and the consequences of one's choices, and give an explanation of one's reasons for refusing "standard" resuscitative care that is consistent with previously expressed values.4,7,8 The ED "culture," with its necessary focus on "saving the patient," through-put time, and disposition, is not well-suited to conversations to determine patient wishes or capacity to make decisions. Further, sorting out the legal requirements for recognizing a proper surrogate to withdraw life-sustaining treatments once initiated is often too complex to manage in the time frame of ED care. Indeed, it has been shown that it can take several days of hospitalization before a "do not resuscitate" (DNR) order is written.9 While some of this delay may be due to lack of attention by admitting physicians, a large part is due to the complexities of discerning patients' true wishes when they are very sick but have unclear or non-existent written directives. The result of these dilemmas is that it is more common for life-sustaining treatments to be withdrawn after admission to a hospital rather than in the ED.
In some cases, however, it does become evident during the ED course that initial interventions are not in accordance with patient wishes. Given the current ED culture, it is easy to understand that, when confronted with clear patient wishes that would mean the withdrawal of life-sustaining treatment, ED physicians are less well prepared to honor these wishes because they have less experience in doing so. However, in the evolving era of successful treatment of chronic disease, ED physicians clearly need to become better prepared to respect patient choices at or near the end of life. Indeed, one resident's perspective reflects this notion, "Understanding what constitutes beneficial or non-beneficial care and knowing when to stop is an important aspect of our emergency medicine training."10
There are many reasons to try to honor a patient's wishes as soon as they are known, one of which is comforting and caring for the patient's family. In a letter to the editor in the New England Journal of Medicine, a physician's wife encapsulates the frustration of family and patients in this situation. She writes that an ED physician overrode her express wishes to withdraw care for her husband following an anoxic arrest and calls it one of the most frustrating parts of her husband's death. She asks "Why was his advance directive not respected? Why was my durable power of attorney ignored?"11
Legal Issues
A written advance directive is a statement that competent persons make about their wishes regarding end-of-life treatment.12 These directives, although not ubiquitous, have become more commonplace as a means for patients to improve end-of-life care. In fact, there is specific federal legislation (the Patient Self-Determination Act of 1990) that requires hospitals and health care providers to advise patients of their right to provide an advance directive, to inquire whether they have completed an advance directive, and to honor a patient's wishes as described in a written advance directive.7,13 While details vary and there are several types of advance directives in existence, all 50 states and the District of Columbia have legislation that says adherence to advance directives is mandatory, not optional.14 The legal requirement to follow advance directives is becoming international. In Canada advance directives are recognized as law, and the recent passage of the Mental Capacity Act in the United Kingdom reiterates this fact.12,15
Advance directives can be "proxy directives" and assign a decision maker or they can be "instruction directives" and give instructions as to the care patients would want should they become unable to speak for themselves.12 The most commonly understood advance directive is a "DNAR" (Do Not Attempt Resuscitation) or "no CPR" directive, which is issued according to state regulations to avoid initiating CPR in a patient with cardio-pulmonary arrest at the end of life. In addition to an advance directive specifically addressing a patient's desires for CPR, several other types of written advance directives also exist. A medical durable power of attorney designates a person whom the patient trusts to speak and make medical decisions when he or she is unable to do so. Wishes expressed by a designated decision-maker on behalf of the patient should be honored as if the patient were speaking. A living will, another commonly written advance directive, specifically directs the physician to take or omit certain actions should the patient become unable to make decisions. It is rarely relevant to the EMS system and the ED because it can be difficult to completely assess whether the patient is in the specific situation addressed in the living will. For example, living wills often specify instructions if the patient is in a "terminal condition" or if there has been no response to medical interventions for some number of days, both of which may be difficult to ascertain during the ED stay.
Medical providers often also honor verbal wishes of the patients conveyed informally by family. This is often more appropriate once there has been time to establish who will be the decision maker for the patient or when a personal physician has had prior conversations with that patient and understands the underlying medical conditions as well as the patient's overall goalsneither of which generally occur in the ED. There are many legal complexities when there is no clearly appointed proxy. Some states permit patients to orally appoint a health care proxy in conversations with a physician, but most set restrictions such as requiring that they be witnessed or limiting them to the duration of a specific hospital stay or episode of illness.13 In the absence of written designation, in some states the spouse is legally recognized as the primary proxy decision maker (followed by a prescribed hierarchy of family members); in others, all "interested parties" have a voice in deciding who can speak best for the patient in making treatment decisions.13 Since the laws about who is a surrogate vary from state to state, each EP and pre-hospital provider must know the statutes concerning proxy decision-making in their state.
Surrogate or proxy decision makers are authorized to make decisions for medically incompetent patients. In the absence of an instructional advance directive, they are expected to make such decisions based on "substituted judgment" or what the patient would want. If it is unknown what the patient would want, the surrogate should use the "best interests" of the patient or what most people in the same situation would want.7,14
Significant problems exist, both globally and in the emergency setting, with written advance directives. For instance, only 15-25% of adults even have a written directive and this number has not increased since the Patient Self-Determination Act.13,14 In one ED study, fewer than half of residents transferred from a nursing home had written advance directives, and only 12% had directives specifically addressing intubation.16 In another study, EMS initiated resuscitation in 21% of long-term care patients who had DNR orders, primarily because of concern for the validity of the DNR order.17 Although there is no expiration date on an advance directive, the health care providers must feel assured that the advance directive reflects a patient's current desires which, in the case of a very old directive, may be called into question since circumstances may have changed in the interim.10 Another problem with advance directives is that they are often directed at vague patient values such as "excessive burdens," "heroic measures," and "quality of life." These values are interpreted differently by different people and are often not helpful in directing what specific life-sustaining treatments a patient would or would not like. It should also be mentioned that the very limited scope of a DNAR or DNR needs to be understood. DNR orders do not entail other limits on treatment and should not affect other treatment decisions made when a patient is not in full cardiopulmonary arrest.18
Ethical Considerations
The perception of death as the enemy is pervasive in our culture and the concept of withholding or withdrawing technologic tools that maintain at least biological survival is often antithetical to the Western world view. Perhaps in a misinterpretation of the Hippocratic Oath, which states, "I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them," many clinicians feel a "duty to treat" or "duty to intervene" toward their patients.7 In fact, what Chan has termed our "rescue-oriented culture" leads physicians to see non-response as an admission of failure and to see withdrawal of life-sustaining interventions as "killing" the patient.19
To begin to ethically address these concerns, the concept of "killing the patient" must be recast and understood in many cases as "letting the patient die."7 The ethical distinction hinges on whether the physician in a particular situation has a "duty to treat" or a "duty NOT to treat." Respect for patient autonomy requires clarifying the patient's wishes and understanding the patient's perception of the balance of burdens and benefits of intervention or of non-intervention.7 If there is a recognition that the underlying disease state cannot be reversed, the death that ensues indicates the severity of the disease state and the limits of modern medicine to change the inevitable outcome of such a state.20 There is no "killing" here, simply "allowing to die."21
The next distinction is between the withholding of life-sustaining treatments and the actual withdrawal of such treatments. Most caregivers experience a disturbing difference between withholding and withdrawing treatments already started.22-25 The difference seems to be in the need for "human agency" in withdrawal.20 That is, someone has to actively disconnect the ventilator versus passively omitting to give any more vasopressors or antibiotics. This discomfort remains despite theoretical distinctions, professional endorsements, and legal precedents. In fact, most Western bioethics theorists assert that it is morally equivalent for clinicians to withhold or to withdraw non-beneficial medical interventions.7,23,24,25 Some bioethicists have gone even further. They assert that having no distinction between withholding and withdrawing treatments is "morally dangerous" and that the heavier moral burden should be placed on withholding treatments, rather than on withdrawing them.25 As Beauchamp and Childress have stated in their classic biomedical ethics text: "Only after starting treatments will it be possible in many cases to make a proper diagnosis and prognosis, as well as to balance prospective benefits and burdens."7 The moral dilemma can perhaps be resolved by understanding that it is respectful of the patient's autonomy and the physician's beneficence both to begin the resuscitation and then to withdraw the interventions if proper reflection indicates that this will best honor the patient.
Knowing whether an emergent intervention is helpful or not: that is, if a physician has a "duty to treat" or "duty NOT to treat," requires determining both whether it is medically effective and whether it is beneficial from the patient's perspective. This takes time and conversation, commodities that are in short supply in a pre-hospital response and in the first few minutes of treatment in the ED. Thus, EPs more commonly will face the issue of withdrawing than withholding treatments, even though their intellectual investment in correcting physiology may make this uncomfortable.
An extension of this discussion becomes the idea of "futile" treatment and the physician's ethical obligations to provide such care. This concept is difficult because there is controversy regarding the meaning of "futility" and who gets to decide which (or when) interventions are futile. Futile care has been defined as an intervention that provides no benefit or is only harmful.7,22,26 According to Henig et al., for treatment to be considered medically futile, the disease process must be terminal and irreversible and death should be imminent within 24-48 hours.2 The idea of "quantitative futility" implies that the likelihood of benefit to the patient falls below a minimal threshold, and the idea of "patient-centered futility" implies that a treatment won't produce an effect appreciable to the patient.27
The difficulty ensues due to the principle of patient autonomy. That is, futility can only really be determined with respect to patient goals.22 For example, even if a treatment prolongs the inevitable path toward death, the patient's desires (such as wishing to live long enough to see a daughter marry) may render that treatment beneficial and therefore not futile. There are times when the perceived quality of life of a patient is the concern that drives the physician to consider treatments futile. In these instances, the patient or the surrogate still has the right to decide whether a particular quality of life is acceptable. Further, there may be medically intangible benefits to an intervention such as allowing the family a chance to arrive before death or a chance to see that "everything was done" to help them cope with their loved one's death. There may also be medically tangible benefits to society such as organ procurement. Therefore, it has been recommended that instead of deeming an intervention to be futile, it is more appropriate to consider that treatment to be medically "nonbeneficial," "ineffectual," or having a "low likelihood of success"all of which are within the purview of the trained physician to ascertain.27 As such, if the treatment is deemed to be "non-beneficial" then the physician is well supported in not offering or not continuing that treatment.26,27
When Should Withdrawal of Life-Sustaining Care Occur in the ED?
Withdrawal of initial life-sustaining treatments in the ED requires convergence of a number of factors. Table 1 lists reasons to withdraw interventions in order of frequency cited by physicians in one study. The main acute medical disorder, the expected irreversibility of that disorder, and the level of care being maximal were the top three criteria for withdrawal to be considered.28 Table 2 suggests some of the considerations for initiating withdrawal of treatments in the ED. First, the EP needs to have a fairly good idea of the medical causes of decompensation. The EP needs to take simple, rapid steps to assess the possible causes, to estimate the chances of reversibility, to order studies needed to gain further understanding, to consider the time course for treatment and rehabilitation, and to evaluate the effort or suffering involved in a proposed intervention.22 Conversations with family don't require full knowledge of the nature of the acute problem, but a physician's medical expertise can often help the patient and family discern how the patient would want to proceed. Patients and their families may have different assessments of the relative costs or benefits of a treatment or intervention, depending on whether the deterioration is readily reversible or not. For instance, diagnosis of pneumothorax, even in the setting of advanced COPD, may suggest a simple treatment. However, chest tube placement may be too painful to consider in the face of dementia or terminal lung disease, and patients or families may prefer symptom control with morphine. Performing a CT scan to differentiate ischemic stroke from intra-cranial bleed is only useful in the patient with sudden non-responsiveness if the family would consider surgical intervention for that particular patient. In one geriatrics practice study of life support preferences for 288 elderly patients, 88% desired short-term mechanical ventilation if the chance of recovering was reasonably good, but only 3.5% would want long-term mechanical ventilation.29
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Second, the EP must have a clear understanding of the patient's wishes. These could be expressed by the patient herself, as may happen with a patient with a rupturing abdominal aortic aneurysm who can be transiently returned to alertness with IV fluids, but in whom operative repair may carry an enormous mortality or who may have refused surgery due to other underlying medical conditions. A direct patient expression of wishes could also occur when a patient with severe COPD presents with acute decompensation. Such a patient, if he or she has been intubated previously, may not wish to be intubated again and may be able to reaffirm that decision. The EP must be skilled in simultaneously expressing empathy for the reasonableness of such a decision and giving assurance that the physician's goal will be to support the patient's comfort, and, at the same time, understanding that those wishes may change, and being prepared to intubate.
When the patient cannot participate in decision-making, the EP can get an understanding of patient wishes via an advance directive. The EP must understand the various types of advance directives pertinent to the acute situation and, if the advance directive is available, it must be honored. In addition, the physician must know the state laws that recognize legally authorized proxy decision makers or wishes expressed through the patient's personal physician. Since it is known that advance directive wishes can change over time and can be revoked by patients at any time, confirmation that these wishes are still in force is very helpful. The help of family members is invaluable in affirming patients' values and wishes as expressed in their written advance directives or conversations with loved ones or primary physicians. When there is conflict about the patient's wishes, admission often is required to allow time to clarify these issues.
Third, the EP must be cognizant of procedures or treatments that he or she is instigating that may be somewhat less emergent or may have less invasive substitutes, which buy time to collect information about patient wishes. This is especially true when the physician has a suspicion from physical findings, medical history, or input from family that the burden of chronic disease is heavy or that the patient is terminal. Table 3 lists some of the treatments commonly initiated fairly automatically in the ED that may have temporizing substitutes (e.g., crystalloid instead of blood, biPAP instead of intubation) or could wait a few minutes until the overall situation is clarified (e.g., antibiotics).
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Fourth, the EP must be comfortable with and knowledgeable about withdrawal of care. Physicians may not have been faced with this scenario before and may feel uncomfortable with the required discussion, unfamiliar with the comfort-based treatments required to support the family and patient and therefore feel compelled to transfer the patient out of the ED. By thinking through a case such as this and by learning the skills required, EPs will be able to provide better service to their patients at the end of life.
Finally, practical considerations vitally influence whether a withdrawal procedure can be initiated in the ED. These are also listed in Table 2. When patient wishes are unclear or when family members and others who care about the patient (including their physician) are not available, admission may be indicated. When the family has not had prior discussions about these circumstances, they may not be ready to witness the patient's death. While some emergency physicians feel at ease with helping family to understand the fact that this death is inevitable and natural in the course of the patient's illness, some will not be comfortable with allowing the patient to die in the ED in the absence of clear, unanimous decision-making from the patient or the patient's loved ones. Withdrawal of treatment may also not be possible if the ED is busy and cannot accommodate a prolonged patient stay or if staffing is short and there is no one who can attend to the patient and family needs during withdrawal. A contingency plan, shared with patient (if possible) and family, should always be in place to allow admission if the patient stabilizes after the treatment is withdrawn or if the dying process is prolonged.22
There are, however, a number of good reasons to attempt to comply with the patient/family wishes or written advance directives in the ED rather than sending the patient to the intensive care unit (ICU). Most importantly, the patient may be suffering from the intervention. Second, it avoids subjecting the family to a new team and new surroundings if death is imminent. Third, if admission does occur after withdrawal, the patient can be transferred to the floor instead of to the ICU, and an ICU placement can be avoided for a patient not desiring ICU-level interventions.22
What is the Protocol for Withdrawal of Life-Sustaining Treatments in the ED?
The ED literature contains very little about how to withdraw interventions in the ED. Table 4 lists elements in the process of withdrawal of treatments in the ED. The first step is to find out what the family (and patient, if able) understands about the patient's medical illnesses (severity and prognosis) and the acute problem that is threatening the patient's life at present. Takayesu and Hutson, in a recent review, discuss some techniques for communicating about life-threatening diagnoses that are made in the ED.30 While their discussion does not involve patients in whom death is occurring imminently and who are being kept alive with medical intervention at the moment, their points about skills needed to initiate difficult conversations are important. Despite the fact that the EP does not have an established relationship with a patient and family, the physician needs to clarify their understanding of the situation rapidly and to understand if this is an expected or unexpected emergency. The EP needs to share the understanding of the gravity of the situation and explain the option to withdraw medical interventions. Language must be plain and the EP should prepare the family or patient for the criticality of their situation.22,30 Specific family needs should be recognized, such as the desire to have another family member present or a clergy person to deliver final blessings. The feasibility of initiating withdrawal in the ED should then be explored. In some cases, the resuscitative measures performed emergently clearly will be unwanted and the family will be very ready to reach closure. These are the cases for which ED withdrawal of life-support is indicated.
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Protocols for withdrawing ventilator support are available in many intensive care units and can be adapted for use in the ED. There are also algorithms for medical management of withdrawal of ventilator support in the ED in the recent literature.22,31 It is recommended that once the decision is made to withdraw life-sustaining treatments, all interventions should be stopped at once, including antibiotics, vasopressors, and ventilator support.2 It is especially important to discontinue paralytics and assure that neuromuscular function is restored prior to initiation of withdrawal unless there are specific extenuating circumstances.32 If possible, all monitors should be turned off, and the patient should be monitored directly for signs of distress. Narcotics and anxiolytics should be used to manage pain and respiratory distress. Ventilator support can be withdrawn in a rapid, stepwise fashion starting with setting the fraction of inspired oxygen (Fi02) to room air and turning off all positive end-expiratory pressure (PEEP). Volume or pressure support can likewise be reduced in a graded fashion. Decreasing the ventilator support in this manner should be done over an hour or so. The goal is the equivalent of T-piece or the expiration of the patient.2
Conclusion
A simple "duty to treat" model of emergency interventions is insufficient in an age where people live for many years with chronic diseases that may be accompanied by significant suffering and in a culture in which patient autonomy is so revered. The ultimate goal is to care for patients (and their families) and help them achieve their goals. Physicians have the responsibility to give their patients every chance to live, and, when the emergency has passed, need to learn to listen and reflect on how this event is situated in the course of a patient's life. End-of-life wishes should be honored, when possible, even in the emergency department. This can influence both the quality and the quantity of patients' final hours or days. The compassionate EP must know the laws regarding decision-making in his or her state, must be comfortable with the ethics behind withdrawal of treatments, must develop the skills to have conversations with patients and families near the end of life, and must learn techniques for withdrawing unwanted interventions to honor a patient's final wishes.
In the original case vignette above, it becomes clear that the patient's wishes are known and there is a designated medical durable power of attorney who is present. This situation represents a perfect scenario to consider the withdrawal of life-sustaining treatments, and the attending EP should feel comfortable legally, ethically, and practically initiating the withdrawal in the ED.
References
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17. Becker LJ, Yeargin K, Rea TD, et al. Resuscitation of residents with do not resuscitate orders in long-term care facilities. Prehosp Emerg Care 2003;7:303-306.
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23. Schwarz JK, Del Bene ML. Withdrawing ventilator support for a home-based amyotrophic lateral sclerosis patient: A case study. J Clin Ethics 2004:282-290.
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25. Iserson KV. Withholding and withdrawing medical treatment: An emergency medicine perspective. Ann Emerg Med 1996;28:1:51-54.
26. Non-beneficial ("futile") emergency medical interventions. Policy Compendium. American College of Emergency Physicians. Dallas, 2007; 45.
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28. Le Conte P, Baron D, Trewick D, et al. Withholding and withdrawing life-support therapy in an emergency department: Prospective survey. Intensive Care Med 2004;30:2216-2221.
29. Murphy DJ, Santilli S. Elderly patients' preferences for long-term life support. Arch Fam Med 1998;7:484-488.
30. Takayesu JK, Hutson RH. Communicating life-threatening diagnoses to patients in the emergency department. Ann Emerg Med 2004;43:749-746.
31. Schears R. Emergency physicians' role in end-of-life care. Emerg Med Clin North Am 1999;17:539-559.
32. Truog RD, Burns JP, Mitchell C, et al. Pharmacologic paralysis and withdrawal of mechanical ventilation at the end of life. N Engl J Med 2000;342:508-511.
33. Emmanuel LL, von Gunten DF, Ferris FD, eds. The Education for Physicians on End-of-Life Care (EPEC) Curriculum. Robert Wood Johnson Foundation, The EPEC Project, 1999.
Emergency physicians and pre-hospital personnel are trained to intervene rapidly in critical situations. In the absence of information to the contrary, a patient's desire to be resuscitated must be assumedespecially when withholding life-sustaining procedures may result in death.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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