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Talking About Goals of Care

Highlights from a rundown on end of life discussions in the ED taken from a lecture by Ashley Shreves:

“…not all dying pt should have CPR. Some evaluation should be made before proceeding. The cardiac arrest should be sudden and unexpected, the patient should not be in the terminal stages of a malignant or other chronic disease, and there should be some possibility of a return to a functional existence”
- JAMA 1961 Jude et al (written by the creators of CPR)

In this country everyone is presumed full code and it is an expectation at the end of life. This has strayed from the original intent of CPR; many ultimately have a ‘highly medicalized death’ though this is only what a minority have been shown to want. Ventilator use is also similar and may artificially prolong the dying process.

-”DNR” tells you what to do when someone has died. This may include things such as a trial of critical care or mechanical ventilation
-”DNI” tells if someone in respiratory distress should be put on a ventilator (as per NY state law)
-Many of us are not trained to have these discussions and do this poorly, potentially confusing the patient/family (ie. may think intubation/CPR will ‘fix’ someone) or having them continue down a path of burdensome/futile care without a peaceful and dignified death

-cardiac arrest outcomes in the following populations are poor, ie. resuscitation is not appropriate:
-out of hospital arrest with no initial ROSC -> survival of 0.4%, all neurologically devastated
-advanced CA in the final stages of illness with death expected -> 0% survival
-ICU with arrest -> 15% survive to discharge, 3% neuro intact
-mechanical ventilation outcomes are more nuanced and depends on baseline disease and the acute disease process being treated:
-30% eventually go home, 30% die, 30% to the nursing home
-consider intubation in reversible causes (COPD, CHF, sepsis, asthma) vs irreversible causes (ICH, advanced dementia, CA). Think: will this prolong their dying or help with the problem?

Target the right patients:
-having an adequate discussion may take some time, time that we don’t always have in the ED. Try to find the appropriate circumstances to initiate these conversations
-consider if cardiac arrest may be imminent. Or advanced illness in respiratory distress with an acute devastating illness

1. locate advance directives or the appropriate decision-maker
2. Listen to understand the family’s perspective
-”how have things been going with your mom? What do you know about her illness?”
-determine what they know about the patient’s current state and quality of life at home (how functional are they?). Fill in their knowledge gaps
-assess the readiness of the family to have this discussion
3. Tell them a medical summary
-”we have been doing this and that…” “… we can’t make this disease better” “we know she is dying”
-”let’s make a plan”
4. Listen to goals and hopes
-”what are you hoping for?” “what would the patient want for themselves?”
5. Give them recommendations
-”given what we know…”
-patients do not need to follow your recommendations, but you are obligated to make and help them understand them
-”normalize” decisions to withhold life sustaining treatment. People may feel guilt for this decision, help relieve their burden. This is the ‘right’ thing to do in this situation, though it may not be conceived of as ‘normal’ given current popular mores/medical understanding
-”life support will only prolong dying”
-use language that is clearer and less loaded. Say “allow natural death” or “we will not interfere with that process”  instead of “we will not attempt resuscitation” (can be misinterpreted)

-as physicians we focus on procedures, this is less relevant to the patient and the discussion at hand ie. CPR, chest compressions
-jargon such as ‘mechanical ventilation’ or ‘intubate’. Speak in lay person terms: ”when the heart stops…”
-20% people thought mechanical ventilation was O2 by nasal cannula, not “life support” or being attached/dependent on machines
-can have paperwork signed, but verbal consent is fine
Link to the lecture:


Tall R in V1 Differential?

My CCU attending asked me to, if nothing else, remember 3 causes of a tall R wave in V1. In my diligence I have indeed remembered nothing else. What’s in your differential?


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Woke Up with Weak Legs

30 y.o. M PMHx hyperthyrodism, who presents c/o b/l leg weakness since this AM. Pt states he awoke with the symptoms and was unable to stand. Feels that his weakness is located in his thighs. Had similar episode 4 days ago, went to OSH and symptoms had resolved. Denies numbness, other neuro complaints, changes in bowel or bladder, trauma, history IVDU or CA, pain, fever, N, V, SOB.
meds: propylthiouracil, propanolol

Exam is significant for 1/5 strength to BL proximal  LE, with 5/5 strength distally. Sensation grossly intact. Somewhat hyporeflexic to lower extremities.

What tests would you order? What could be in the differential?

Cxr Adequacy

CXR’s can be misleading, some common points to be aware of:

Erect vs supine (fluid layering):


AP view can magnify the heart (PA vs AP):


Rotation – are the spinous processes centered between the medial edges of the clavicles? Note how heart width changes with rotation.


Penetration – vertebral bodies should be just visible behind the heart

1penet 1penet2

Inspiration – should be about 9-10 posterior ribs seen

1inspiaration1 1inspiration2

Labeled ribs:




Images from:

Nose Refresher




A resident of ill-repute was minding his own business on the way to his shift when he was assaulted. He complains of nose pain and that conference is too early in the morning. The attending was anxiously awaiting the arrival of said tardy resident, and then was immediately seen as above. What is is happening?

A. the correct approach to “feedback” for tardiness as per departmental policy

B. an attending of ill-repute minding her own business

C. bilateral carotid massage

D. an impending nasal fracture, which today’s pearl will be about

E. all of the above

Continue reading “Nose Refresher” »