Anna knew she needed to stop drinking or suffer the consequences of liver failure. At 53, Anna came to the emergency department having a decreased level of consciousness, low blood pressure and bleeding from her nose and mouth. Her abdomen was the size of a basketball due to ascites, which is fluid in the abdominal cavity. Anna’s family members were not aware of her final wishes, but they knew she had no intention to give up drinking.  

My skilled colleague inserted a breathing tube and central line to manage Anna’s blood pressure and to transfuse blood products. His plan was to admit her to the Intensive Care Unit. I asked if he needed backup. Specifically, "Do you want me to cosign that Anna’s condition is terminal and medical care is futile?" He replied that this wasn’t necessary, but he later announced to the nursing staff that Anna’s family agreed to her receiving comfort care. Anna died two hours later in the ICU.

Many physicians have more medical knowledge than common sense. They attempt to save lives and offer family caregivers hope rather than engage the tough conversations that concern letting a patient die. Terminally ill patients have little or no hope of ever improving, yet they develop infections, dehydration or difficulty breathing that physicians can treat. The Golden Rule in emergency medicine is that any patient who comes into the Emergency Department – terminal or otherwise – is never refused treatment.

Why do family caregivers entrust the care of a terminally ill loved one to physicians who tend to inflict harm through ICU admission?  Terminally ill patients are easily recognized, but they are not definitely diagnosed. Family caregivers often need some nudging to understand that their loved ones will not get better and that doing everything to save terminally ill patients is abusive. Beware!  Most physicians do not think of patients as terminal until every possible measure and medical intervention have been discussed and exhausted.