When to Make the Call

By: Brynn Lawrence

Introduction:
Dr. Shen is an Emergency Department physician in the cardiac intensive care unit at a
Regional Hospital. Dr. Shen is in a dilemma with a patient that has arrived via airlift. Does the
medical team continue with their efforts to save her or do they explain their efforts to the family
when they arrive that she has passed away? The patient is Ms. Danforth, who is a single parent
of one child and is a medical emergency that does not have a great outcome. She was believed
to be a woman who was in good health prior to this event. The purpose for her emergency visit
is that she suffered a massive inferior myocardial infarction. Upon arrival to the hospital she is
requiring ongoing CPR efforts. Dr. Shen has examined and assessed Ms. Danforth to be in a
PEA (pulseless electrical activity) arrest. Understanding that condition the medical team
understands that the outcome is 11-0% survival rate. Her family is on the way to the hospital,
which is 150 miles away from their homes. They are continuing to beg the medical team, to
save her at all costs. Dr. Shens medical team knows and understands that the outcome will not
change if they continue with CPR and medical treatments they have already exhausted. At this
point the team has the opportunity to continue CPR efforts until the family arrive or prepare the
family with the news of her passing.
Thesis:
Medical professionals are faced with making life decisions daily. A family that wants a
different outcome needs to be briefed and prepared for the life ending situations, despite the
efforts of a medical team. The resources in which an Emergency Department can continue to
try to save a patient, which they already know the outcome, could be grim. The efforts of
medical resources may extend to delayed care for others in their care due to the extent of staff it

requires. In the case that a patient cannot communicate their desire for treatment a family
member takes that responsibility. This practice is allowed for them to speak on behalf of the
patient and is allowed in many states (Caroline Pace). The dilemma and question is the quality
of life for the patient. The rhythm of the heart is not functioning and therefore the outcome
ultimately is death for this patient. The patient isnt maintaining any ability to function without
CPR and additional efforts. Dr. Shen is in a position of continuing futile effort to save this
patient (Caroline Pace). The best outcome for the medical staff and the family members would
be to end all efforts to save the life prior to the family members arriving.
Body:
Medical Indications: In the case of Ms. Danforth the medical professionals have
exhausted all efforts to save her life. The result is that she will not survive the heart condition in
which she experienced. Their expertise, training, education, and research at this point assist the
medical team to understand the final outcome. To continue the efforts to save her life is futile
and needs to be called as the time of death. Not only are their efforts not going to give the family
the outcome they desire it is also exhausting the Emergency Departments resources to treat other
patients. Statistics for someone to survive this type of heart attack is less than 9-11% with all
efforts available which was as recent as 2013 (Caradic Arrest Statistics). They are delaying the
outcome because of the request of the family. If efforts are continued by the medical staff and
the family arrives this will give the family members false hope of her surviving. As
professionals they have given their best efforts to save her life. It is the position that emergency
medical staff faces all the time. If they have done all they can, then they need to be prepared to
present those facts to the family. There will be events in medical situations that life cannot be
saved.

Patient Preferences: Family members take the decision making role or proxy, when a
patient is not in a position to give their desires for treatment. Of course it is a dramatic for them
to make those types of decisions in an emergency decision. No one wants to lose a family
member and usually will choose the option to do all you can type of a request.

It should be a

household discussion to present what you want to your loved ones. They rarely give those
desires and express at what point we want family members to terminate the efforts. Emotions
and understanding of their current life situations make it difficult. The case of Ms. Danforth is a
single mother to one child. The family knows and understands the difficulty the child would face
to suffer the loss of their mother. To be a proxy for the patient may make family members
uncomfortable when they need to make the difficult decision to cease efforts to support life for
the patient. These discussions should be being discussed throughout all times of life.
Emergency situations can occur at any age and you should be prepared to make all final life
decisions.
Quality of Life: The quality of life in this case would be to go on a life support system.
The recovery from PEA and the lifelong effects are not usually something a patient can recover
from to continue their normal life. As family members they would be required to take care of
her child and then continue to support the expenses to watch a machine support what little
function her life would be worth. The difficulty her child will go through to watch their mother
survive this way is no way of life for any family members. Ultimately additional cardiac
moments would take place and the family would need to consistently keep making that choice to
continue the efforts. It is okay that life comes to an end. Patients are not here to outlive
everyone. As human bodies are consistently getting older and exhausted from the stress and time

life puts on them. Granted science has extended quality of life to live longer, but the goal is not
meant to leave this world alive.
Contextual Features: Dr. Shen is at an ethical dilemma to the family that has not yet
arrived. They can call the time of death and present those efforts to the family or they can
continue efforts and wait for the family to arrive to call her time of death. Granted that neither of
these situations would be what the family would choose or want for this single mother. Dr. Shen
has no medical history of the patient, no relationship with the family, and no time to get those
types of details. Dr. Shen does not know what type of questions and expectations the family will
have of the medical team. They have to be confident in the decision and efforts they have given
to Ms. Danforth. Futility is easily defined as uselessness. The mistaken appearance that it
cannot be defined is explained by difficulties applying it to particular cases. This latter problem
is a major goal of clinical training and cannot be solved in a pithy statement (Chwang). Dr.
Shen knows that it is futile to continue the efforts. Telling a family member that they have lost a
loved one is never an easy task but, the medical staff is prepared and trained to deliver these
types of messages at any moment.
An additional option for the medical professionals at the Emergency Department would
be to continue with an auto CPR vest and life support efforts until the family had arrived to
discuss the options with Dr. Shen. The effort would not be to save her life, although it would be
the first initial response of the family since it was their objective. To have the discussion would
be sensitive and not an easy discussion to have with anyone when they first find out the results
that their loved one has passed. The only additional option would be to give them the
opportunity if there is an option to allow her to be a donor. This would give them the
opportunity to allow her to give a gift of live to others if they believed in that for her.

Conclusion:
Ethically Dr. Shen is faced with a situation that could go either way. Although the doctor
has the request of the family being considered, they are also faced with the best interest of the
patient. The medical team and staff support the doctors decision in calling the patients time of
death. The efforts have been exhausted and the staff is basically wasting time not treating other
patients. Granted that statement sounds cold hearted, but the fact of the matter is that the patient
will not and has no chance of survival. To extend and continue efforts will only give the arriving
family members a sense of false hope. If the efforts are continuing then they might feel that the
doctor believed or was trying to still get the desired result. In the medical field they are faced
with difficult decisions and are trained to confront them to the best of their ability. The family
will feel that their time to say good-bye was a missed opportunity. At times it is a sense that she
died without being surrounded by loved ones that might cause guilt or issues in dealing with her
death. A physicians role it to try and present those details that they can be comforted along with
being educated in the fact that she was already gone when she arrived or shortly after. Life is not
a guarantee and although people continue to plead for additional time, it isnt always granted. A
physician is practicing medicine and is not a miracle worker. They are men and women doing
the best they can to allow people to have additional time in some medical cases. People need to
find peace in knowing that life will come to an end and thats okay.

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Caroline Pace, M. (n.d.). Make it Okay That This Life is Ending . Retrieved from AMA
Journal of Ethics: http://journalofethics.ama-assn.org/2010/06/ccas11006.html
Chwang, E. (n.d.). Futility Clarified. Retrieved from Wiley Online Library :
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