Mar 4 2014

Jumping for Joy in the ER: When Patients Have Clear Advance Directives

This blog post was originally featured at, a blog dedicated to advance care planning. The author, Dr. Monica Williams-Murphy, MD, is a Board Certified Emergency Medicine Physician, who practices in one of the largest emergency departments in the United States at Huntsville Hospital.

Ok, so the ER is not the place where you can usually find ER doctors jumping for joy, but certainly stranger things have happened there…so, why not?

I had just started my afternoon shift in the area we call the “trauma pod” and as I left my first patient’s room, I was spinning around giving a fist pump in the air and exclaiming, “YES! Now that it the way it is supposed to be!!”

Needless to say, this had the attention of all my nursing staff and the doc I was relieving.

“What’s going on out there?” the “leaving” doctor asked me in a curious manner.

Before I answered him, I called out, “You guys come listen to this. This is a success story!”

As you might imagine, a small group of curious Emergency Department staff had crowded around me in attempts to understand the commotion.

Speaking in low but excited tones to maintain HIPPA compliance, I gushed the following story:

“So, I just walked into room 48 to see Mr. Bronson. He’s an 85 year old man with COPD who had arrived in respiratory distress and the respiratory therapists had already started BIPAP because the patient arrived on his own machine and it wasn’t doing any good. So, here’s the kicker… he was too short of breath to even speak a word and when I listened to his lungs, I heard no air movement. There was no one in the room family-wise whom I could turn to for a discussion of next steps (meaning no surrogate decision maker). Just as I started to feel a twist developing in the pit of my stomach, assuming that I might have to intubate him without understanding his own personal wishes, the nurse whips out a piece of paper from behind his home med list and starts waving it at me.”

“Voila!” She said smiling, “I know that you would want to see this.”

With two steps in her direction, I was across the room and pulled it from her hand like a young child getting her first mail.

“ALABAMA STATE DO NOT RESUSCITATE ORDER” were the first words on the document, but up in the right hand corner was something even more surprising than a real-live “actionable” advance directive… up in the corner was my own messy handwriting (barely legible, of course…the only bad grades I ever made in elementary school were in handwriting…fated to be a physician some would say). In my own messy scratch were the words, “Patient wants CPAP and BIPAP but no intubation”. The rest of the document was filled out correctly and dated about one year ago- signed by the patient and myself plus one other physician.

Suddenly, I remembered Mr. Bronson. He had “gently” wrecked his car while shopping because he had become so short of breath last year. I recall that I sat on his hospital bed and we talked about his illness.

“I seem to be getting worse” he said back then and I listened as he described an accelerating course of COPD exacerbations.

I recall identifying that pattern for him bluntly but compassionately, “We see that pattern when someone with COPD begins to approach the end of life. Have you thought about creating an advance directive to prepare yourself and your family for the inevitable?”

He stared at me, expressionlessly (not uncommon when bringing this up).

“Yes,” he said, “I should probably do that. But I want to ask you one thing, young lady (being 42, I was flattered of course). Why hasn’t my lung doctor or family doctor brought this up before?”

“I have no idea,” I replied. “All of your doctors should be educating you about where you are on the map of life. How else can you know or prepare for what lies ahead?”

He sat pensively. Then, surprising me, he said: “Let’s do one of those right now. At this rate, tomorrow could be my last,” he said with a smile. I could tell that he liked shock-value!

Well, that day was not his last, neither was this instance. But, had it been, I would have known EXACTLY what HE wanted me to do or not do—such is the power of a proper Advance Directive.

You may not consider this a reason for me to be jumping for joy in an ER, but after seeing what I have seen, I think that this is as good a reason as any other. My staff agreed.

(Please read the excerpt from “It’s OK to Die” below to understand my rationale…)

(As always, patient names and some details have been changed to protect the privacy of the patient)



Chapter 1: (It’s OK to Die)

Why is an ER Doctor Writing a Book on Death Planning?

I am not a hospice doctor, a palliative care doctor, a cancer doctor, or even a family doctor. I have not spent days at the bedside of my patients, and have not developed intimate relationships with family members. I am an ER doctor. Relative strangers show up in the Emergency Room and die right in front of me, or at least attempt to. If you arrive critically ill, I have about three minutes to find out your name, your medications, your allergies, your preexisting illnesses, your primary care doctor, your specialists, your surgeries and your vital signs—all while establishing myself as someone you and your family can trust, while examining your heart, your lungs and your abdomen, while reading your EKG, while ordering tests and medications, and possibly, while placing a tube in your lungs or an IV in your neck, or while attempting to shock your heart back into a life sustaining rhythm.

If this sounds like a high pressure situation, it is. But there is more. I have to ascertain whether you are dying from an unknown cause, or from an expected source, like advanced cancer. Within that three minutes, I also have to know whether you have a Living Will, the identity and location of your selected health care proxy, and whether you have signed Do Not Resuscitate (DNR) or Do Not Intubate (DNI) orders. If you are like 70% of Americans, you will not even have a Living Will, the minimum plan for end-of-life care. It is likely that you have at least thought about death, but you have yet to make any plans. Trust me, the ER is not the place to set your affairs in order.

You are why we are writing this book. We want to help you and your family long before you roll through the doors into any ER. Too many people are showing up completely unprepared. The reality is that we all are going to die, including you and me. Don’t wait until a near-death crisis to make end-of-life decisions and plans. Dying patients and their families, as a general rule, don’t come to the Emergency Department calm, cool, and collected; after all, this is an EMERGENCY! …

(Emergency room photo courtesy taberandrew)


Advance Medical Directives Dr. Monica Williams-Murphy Emergency Room

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