A few days ago a 70ish-year-old patient arrived by EMS, end-stage liver cancer, sent in by her family because she was “not feeling well”. From home. No advance directives. She was frail and obviously unwell, jaundiced, her abdomen distended by ascites. EMS reported she was vomiting blood on the way in; her pulse was racing, her blood pressure was dropping. I asked her the paramedics to offload her into a Resus Room bed, and I followed in to help EMS lift the patient into the emerg stretcher and to help the primary nurse with the assessment.
The patient looked me in the eye, a look, I think, of astonishment, vomited once, and coded. We did the usual: called the code, started chest compressions (and fracturing ribs in the process), started IVs (the paramedic were unable to get a line), pushed drugs, until the family arrived and the physician went out to speak to them. There was a lot of blood. She was PEA; she had likely bled out from some complication of cancer. A pump needs fluid to work. A few minutes later the physician returned and pronounced death.
It was a bad death. I’ve seen several deaths like this in my years in the emergency department, concerned family sending in people at the verge of death or nursing homes calling EMS for residents at the end of life (at the behest of families or physicians responsible) who end by dying within minutes or hours of arrival. Some of them have elaborate direction for the end of life (but are ignored by well-meaning, or to be less charitable, indifferent family members); others, like this patient, seemed to have no sort of plan at all, despite being considered terminally ill.
I get that families sometimes cannot cope at home with desperately ill family members, or they live in a state of denial, or that they sometimes panic at the end of life; staffing issues in nursing homes make it difficult to carry out end-of-life directives, or institutional hospice care is often limited, or sometimes people near the end of life are unclear about the options available to them, that dying at home, comfortable in familiar surroundings is feasible and even desirable. But the alternative, dying on an emergency department stretcher with cracked ribs and all manner of other pointless physical indignities inflicted, seems grotesque, demeaning and otherwise an unworthy way to end a life.