Do Everything! For the Patient,Their Family,or Ourselves? A Surgical Resident's Experience

“Do everything!” All physicians have encountered this plea in their career. Our colleagues in critical care medicine experience this on a daily basis. The ICU service is where most residents develop an approach to the goals of care discussion. We are given many lectures on how to approach acidosis, respiratory failure, renal failure, and increased intracranial pressure; but we receive little formal teaching on conducting family meetings and explaining goals of care.

It was during my time on the critical care service that I experienced how complex “do everything” can be. It was interesting to be involved in these conversations and witness how different physicians with different backgrounds and experiences approach and manage these discussions. Some physicians are clear masters, who we all hope to emulate, while others seem to make an uncomfortable situation worse. The main factors that determined how these difficult discussions were received were physician experience and communication skills.^1,2

It is not surprising that many physicians are uncomfortable discussing goals of care and end-of-life realities. ³ The literature supports that approaching and managing these discussions is a learned skill that improves with specific training and education.^2,4–6 Unfortunately, the literature also indicates that physicians receive little to no formal training and education on the subject.^7,8 I believe that this is particularly true in surgical specialties. Most clinicians believe that end-of-life decision making varies significantly across countries and cultures, but few have formal medical futility laws or guidelines to direct their practice. ⁹ Interestingly, most clinicians believe that their individual faith or religion does not influence the end-of-life decisions provided in their practice, but most feel that their opinion and practice has changed with clinical experience. ⁹ Personally, my experience has been limited to reading the goals of care pamphlet produced by our large health care region, collaborating in family meetings with more senior members of the critical care team, and initiating discussions with patients and family members during consultations. The only related medical school experience that I can recall was on breaking bad news using the SPIKES (Setting up the interview, assessing the patient's Perception, obtaining the patient's Invitation, giving Knowledge and information to the patient, addressing the patient's Emotions with Empathetic responses, Strategy and Summary) approach. ¹⁰

I believe the major barriers are the following:

1. Initiating the conversation with the appropriate audience in the appropriate setting.

2. Defining and negotiating what “do everything” means to the involved persons.

There are three distinct examples from my ICU experience that illustrate my difficulty and frustration with the statement “Do everything.”

1. A code blue was initiated on a medical ward. The code 66 team (pre–code blue) arrived at the bedside as the code was elevated. The patient was an 88-year-old man from a nursing home that was admitted earlier that day with sepsis. The intake history and physical was lacking many important details, but a considerable number of comorbidities were documented. A code status/level of care discussion was not documented in the paper chart. No code status level was in the chart sent from the nursing home. An R1 level of care (full code) was noted in the computer order system, but some code blue team members felt it was a default order in a standard order set.

The patient had an unwitnessed cardiac arrest and was without vital signs for an unknown length of time. The admitting physician was not able to be contacted. CPR had been started but a senior code blue team member suggested that it stop given the likely futility. The bedside nurse stated that because the patient was designated an R1 level of care on the computer we were obliged to “do everything.” The nurse was visibly upset that the code was terminated.

2. The ICU was consulted by the medical teaching unit. A 49-year-old woman with metastatic breast cancer was admitted earlier that day for sepsis. She was now in respiratory failure. There was no code status recorded in her chart. No goals of care were designated on the computer order system. The admitting service had not discussed her level of care during their intake assessment. There were no family or friends available to speak with regarding the patient's wishes. She was intubated and transferred to the ICU. A family discussion occurred approximately 12 hours following her ICU admission. The patient's sister stated that they never had a discussion regarding medical intervention, but she was sure that her sister would want us to “do everything.”

3. The ICU team was consulted by the emergency department. A 72-year-old woman with multiple comorbidities and multiple ICU admissions in the last year for pneumosepsis, urosepsis, and intentional opioid overdose was transferred from a rehab facility with sepsis. The patient had very poor functional capacity at baseline and was unable to complete many of her activities of daily living. There was no code status documented in the chart or in any of her previous discharge summaries from the ICU. A discussion with her family was initiated. The family was shocked and upset that a goals of care discussion was necessary, as it had never been discussed before. The family stated that she always gets better because she is a “fighter” and would want us to “do everything.” The common threads in these clinical examples:

1. No goals of care discussion documented on the current chart/admission.

2. No goals of care designation in previous charts/admissions.

3. “Do everything” requested by someone without specific knowledge of the patient's wishes.

How do we define what “do everything” means? How do we approach what is medically appropriate? How do we find common ground? What if a significant disagreement exists? Goals of care/code status discussions are a critical skill for all physicians. Many physicians are uncomfortable initiating and conducting these discussions because of insufficient education and experience. Evidence confirms that this is a learned skill that is poorly taught in medical school and during residency. Our patients are becoming increasingly more complex, and therefore we more commonly encounter scenarios where determining appropriate goals of care are an absolute necessity. We will inevitably be faced with the request to “do everything.” Most clinicians believe that their opinion and practice regarding end-of-life care decisions and beliefs have changed with clinical experience. ¹⁰ We must ensure that we understand our patients' wishes and respect them to guide our care. We need to have an approach to this sensitive and complex request. More education and mentorship is required in medical school and residency to prepare us for these situations and ensure that when we “do everything” it is what the patient wanted.