Advance care planning: challenges at the emergency department of a cancer care center

Code status discussions form an important part of advance care planning (ACP) as it enables physicians to respect the patient’s wishes for end-of-life care. However, in some cases, code status discussions can be challenging causing the physician to go against the patient’s wishes and the code of medical ethics. This is especially true in an emergency setting. In this paper, we will discuss three cases of advanced cancer patients, where code status discussions posed challenges to healthcare providers.

In the first case, the patient was a 26-year-old male diagnosed with advanced osteosarcoma. Code status was discussed with him, while he was still functional, wherein he agreed to a do-not-resuscitate (DNR) order. However, at the time of end-of-life care, despite of previous code status agreement, the patient’s mother insisted on full code. As a result, the DNR order was reverted and the patient was intubated. The second case discusses an 83-year-old female patient with metastatic gastric cancer. Code status was extensively discussed with the patient and her son who agreed to sign a DNR order. This case posed a challenge because when the patient’s condition deteriorated, her son demanded cardioversion and other aggressive treatment measures without any chest compressions or intubation. In the third case, the patient was a 40-year-old woman with advanced metastatic adenocarcinoma with neuroendocrine features of the parotid. On admission to the ED, as per the patient’s wishes expressed by her husband, a DNR/DNI order was placed. However, this order had to be reverted when the patient’s aunt and sister opposed vehemently to the DNR/DNI order.

The three cases demonstrate the challenges that can arise in the implementation of code status order in the ED as it pertains for end-of-life care. In any scenario, respecting the patient’s wishes and adherence to the code of medical ethics take precedence over any familial objections arising difficulties with coping.