The Tsunami: Neither Hasten nor Postpone Death

The Centers for Disease Control reports that 8.7% of all ED visits in 2001 were by patients aged 75 and older.[1] At Maimonides Medical Center 16% of our patients fall in this age group. Though I’m a “baby boomer” and he’s not, Daniel G. Murphy, MD, MBA (Hofstra Business School, May 2003) our Vice-Chair and Medical Director for nearly eight years has given much more thought than I to this theme. So let me turn this month’s column over to Dan.

Perhaps I use too many metaphors explaining my thoughts, but one bantered about in Boston this October at various Quality Improvement and Patient Safety Section, Geriatric Section and Benchmarking Alliance meetings during the recent ACEP Scientific Assembly needs sharing among us:

“A tsunami is coming!”

For years, we have worked hard to make our emergency departments more efficient. Best practices, data driven CQI, customer service, error reduction, computerization, decision support, streamlined bed control and standardized peer review processes are just a few of the successful efforts and new paradigms. It’s a good thing too, since the role of emergency departments in America grows more crucial and more burdened annually.

But a tsunami is coming, already visible on the horizon, presaged by choppy and rough surf today (crowding), and it may wipe us out before we retire. The tsunami is the aging ‘baby boomer’ generation and emergency departments and hospitals are (to complete the metaphor) the coastal villages lying directly in its path. It provides a dispiriting backdrop for today’s EM CQI tinker. Input may soon overwhelm a process already lamenting its inability to transfer admitted output (inpatient boarders).

One way to prepare for and assuage this impending disaster is to reconsider how we die in America. We need to die better, with our families, perhaps at home, with no one doing chest compressions and no one putting a tube down our throat. Hand holding, praying, crying and feeling is much better. We just need a major culture change and then implement better end-of-life education and better communication.

I know the following: a) more of my patients are very close to or at the end of life, b) emergency departments and hospitals are horrible places to spend the end of one’s life and c) we do a poor job of caring for patients and guiding families at the end of life.

We need to help identify that point in a person’s (person, not patient) life where there is more value and reward in focusing on planning, comfort, dignity, family and ritual. Life is a terminal condition. Palliative care is a desirable choice for almost all people at some point prior to death, whether it is hours, days, weeks or months before their final breath.

In the July-August 2003 SAEM newsletter, Drs. Quest and Abbott summarized the World Health Organizations definition of palliative care.[2] :

• Active, total care of patients whose disease is not responsive to curative treatment.
• Control of pain and other distressing symptoms.
• Address psychological, social and spiritual problems.
• Achieve the best quality of life.
• Affirm life and regard dying as normal.
• Neither hasten nor postpone death.
• Offer a support system for patients to live as actively as possible before death and to help families cope and then bereave.

But what can we do in the emergency department? The nursing home keeps sending them. The families can’t handle it! There is little expertise and ability at home. Sometimes there seems to be little end-of-life expertise in the nursing home. By the time the dying elder is in the ER, the opportunity for privacy, tranquility and even dignity are lost. If we don’t ignore you, we may intubate you! Our comfort with natural death and dying is notoriously fragile in the ER. We will almost certainly stick some tube into an orifice. It’s our nature.

Some of us in the United States are comfortable with impending death only when paperwork is current and pristine. The documentation includes ‘do not resuscitate’, ‘do not intubate’, other advanced directives, living wills and health care proxies. Is the need for certified, renewed and impersonal contracts reflecting some difficulty of the American healthcare system to connect with our patients at the humane and primary care levels? Do we fail to see the forest, only some frustrating tree, confounded and frightened by medico-legal risk?

As Mildred Solomon, EdD[3] and Linda Kristjanson, PhD[4] explain of the Australian healthcare system, “Long-term relationships between general practitioners, patients and families, coupled with the existence of palliative care services, solve many of the communication problems that, in the United States, advance care directives are intended to ameliorate. Once the decision to accept palliative care is made, people accept that certain things won’t happen, the resuscitation matter dissolves, and patient, family and health care team address each end-of-life question, such as tube feedings or the use of antibiotics, as these issues arise.” Kristjanson continues, “You know your patient, the relationship is very individualized, thus an advanced directive would be seen as a legalistic document that would be incongruent in the context of the relationship.”

Such holistic, generalist, and humane approaches are unusual where we practice. Indeed, too many elders seem to have a neurologist, cardiologist, podiatrist, cardiothoracic surgeon and dermatologist, but no one who takes responsibility for the care of the person instead of an organ system. I witness nursing home admission procedures where patient-physician relationships that have endured decades are terminated just as end-of-life planning is most crucial. As long as our federal healthcare reimbursement model encourages procedures instead of humane, generalist care, form will follow finance and poorly integrated, intrusive and wastefully expensive end-of-life care may predominate.

But I ask again, what can we do in the emergency department? What can we do as emergency physicians?

I believe that our contribution could be significant. We are, after all, generalists. We are capable of seeing the big picture and treating or palliating every sort of ailment and organ system. Are there desired end-of-life services that we are uniquely qualified to provide? Perhaps there is a significant pre-hospital or ED need and market eager for our care, advice and skills.

In the House of God,[5] the term GOMER was first publicized. How ironic to consider the phrase as prescient, desirable and sophisticated. Look out to sea. A tsunami is coming. There may still be time to build an adequate sea wall and save the village. If we work hard and fast, we will just get bumped around and wet like we always do.

[1]McCaig, LF and Burt, CW: National Hospital Ambulatory Medical Care Survey: 2001 Emergency Department Summary in CDC Advance Data from Vital and Health Statistics. No. 335, June 4, 2003.

[2]Quest TE and Abbott J for the SAEM Ethics Committee: Palliative Care and the Emergency Physician: Finding our Way. The SAEM Newsletter XV(4): 14, July-August 2003.

[3]Solomon MZ. Why are Advance Directives a Non-Issue Outside the United States? In: Solomon MZ, Romer AL, Heller KS, eds. Innovations in end-of-life care: practical strategies and international perspectives. 1st ed. Larchmont, NY: Mary Ann Liebert, Inc, 2000: 13-18.

[4]Kristjanson L. Advance Care Planning in the Australian Context. In: Solomon MZ, Romer AL, Heller KS, eds. Innovations in end-of-life care: practical strategies and international perspectives. 1st ed. Larchmont, NY: Mary Ann Liebert, Inc, 2000: 43-46

[5]Shem, S: The House of God. Dell, 2003

Heard Bruce Schneier

imgp0153_cropped2Heard Bruce Schneier speak in the Kohn Lecture last evening at the 92nd Street Y.

Schneier’s five steps to security analysis make sense to me and I enjoyed his examples. The five steps:
1. What assets are you trying to protect?
2. What are the risks to those assets?
3. How well does the secuirty solution mitigate the risks?
4. What other risks does the security solution cause?
5. What costs and trade-offs does the security solution impose?

He was wonderfully clear about the trade-offs in security, but a bit blurry on threat and risk at times despite his efforts to avoid conflating the two. Nonetheless, I was a bit disappointed by the rigor in the discussion. I suppose I’m lamenting the substitution of the political for the technical in the lecture though Schneier was quite clear that he’s not running for office. I’ve not yet had the chance to read the entirety of the book, Beyond Fear, in which from what I’ve already read he’s clearly more technical.

Still, Schneier is not addressing risk as conceptually nor as thoroughly as Peter L. Bernstein does in Against the Gods, The Remarkable Story of Risk which takes a historic, mathematical and conceptual view of risk, ultimately discussing risk in modern financial market terms. While not directly on point to Schneier’s discussion in terms of security, nor operational risk as I conceive of it from my time in the field in EMS, Bernstein’s historical, mathematical and conceptual discussion would enrich strategic planning in the entire emergency management field.