There’s not nothing more we can do

Ashley Shreeves (from SmartEM) is an EM doctor in NY who took a year to do a palliative care fellowship. Now she practices both. It would, at first, seem to be paradoxical. In EM, we are trained to do something. For us, the end-of-life is a challenge to overcome – not to be met gracefully. This lecture will change the way I approach these situations, I hope you watch. Let me know what you think.


An 82 year-old woman comes in to the ER while your working in respiratory distress. Her vital signs are 90/72, 110, 28, 98.6F and 89%. The family notes she has metastatic lung cancer. She appears in quite a bit of distress and somewhat anxious. You feel the patient needs intubation to secure her airway, but are not sure whether she would want to be intubated.

The three things ER docs should stop saying (this summary is partially lifted from emcrit.org).

  1. “Do you want us to do everything?” This means something different to us than it does to the family. We mean rib-breaking chest compressions, smoke forming shocks and complication inducing intubations. But if you ask a family member if we should do “everything,” what do you expect them to say? The opposite of “everything” is “nothing.” No family is going to say, “do nothing for my mom.” Dr. Shreeves instead recommends we say “What would be most important to you and your mom now?” On the basis of what you hear make a reasoned professional recommendation.
  2. “Do you want us to resuscitate her?” This implies that we can resuscitate her. Again, if this is possible, what family member would say no?! If the doctor thinks it’s possible to get her back, then yes, get her back. Instead, we should ask the question differently, “Would you like your mom to die a natural death?When her heart stops we will not interfere with that process?”
  3. “I am so sorry, there is nothing more we can do.” This is just wrong. There is a lot we can still do, we can provide comfort. We can minimize suffering. We can console the family. Call the chaplain. Place a palliative care consult. The medication of choice here is opioids – even in the face of respiratory depression.
There’s not nothing more we can do

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