654 Journal of Pain and Symptom Management Vol. 54 No.

5 November 2017

Original Article

To Intubate or Not to Intubate: Emergency Medicine

Physicians’ Perspective on Intubating Critically Ill, Terminal
Cancer Patients
Kenneth Kim, MD, Bharath Chakravarthy, MD, Craig Anderson, PhD, and Solomon Liao, MD
Department of Palliative Medicine (K.K., S.L.), University of California, Irvine; Department of Emergency Medicine (B.C., C.A.), University
of California, Irvine, California, USA

Abstract
Context. Emergency physicians (EPs) often need to make a decision whether or not to intubate a terminal cancer patient.
Objective. The objective of this study was to explore EPs’ attitudes about intubating critically ill, terminal cancer patients.
Methods. Fifty EPs at three emergency departments (one university based, one community, and one Health Maintenance
Organization) in Southern California participated in an anonymous survey that presented a hypothetical case of an end-stage
lung cancer patient in pending respiratory failure. Fourteen questions along a five-point Likert scale asked EPs about
prognosis and factors that influence their decision to intubate or not.
Results. A convenience sampling of 50 EPs yielded a 100% survey response rate. Ninety-four percent believed intubation
would not provide an overall survival benefit. If the family insisted, 26% would intubate the patient even with a do-not-intubate
(DNI) status. Ninety-four percent would postpone intubation if palliative consultation were available in the ED. Sixty-eight
percent believed that a discussion about goals of care was more time consuming than intubation. Only 16% believed they had
sufficient training in palliative care. Although 29% who felt they had inadequate palliative care training would intubate the
patient with a DNI, only 13% of EPs with self-perceived adequate palliative care training would intubate that patient.
Conclusion. EPs vary in their attitudes about intubating dying cancer patients when families demanded it, even when they
believed it was nonbeneficial and against the patient’s wishes. Palliative care education has the potential to influence that
decision making. Intubation could be mitigated by the availability of palliative consultation in the ED. J Pain Symptom
Manage 2017;54:654e660. Ó 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Key Words
End-of-life care, palliative care consultation, resuscitation, do not intubate

Introduction and ICU stay, improves outcome and patient satisfac-

The emergency department (ED) is a frequent
destination of cancer patients with uncontrolled
symptoms and unmet needs.1 Approximately 40% of
patients in their final two weeks of life visit the ED.1
Palliative care consultations are often used to
optimize pain and symptom management and to
address the goals of care in the ED.2 Previous studies
have shown that palliative care consultation reduces
distressing symptoms, the total length of hospital
tion, increases direct hospice referral, and reduces
the cost of overall health care.3e6 Across the country,
a number of initiatives to promote palliative care in
the ED have been created to bring palliative care
consultation more upstream.7,8 Many experts believe
that palliative care for critically and terminally ill
patients should start in the ED because these patients
have greater unmet physical, social, psychological,
and spiritual needs that call for immediate
attention.7,9,10

Address correspondence to: Kenneth Kim, MD, 101 The City Accepted for publication: July 18, 2017.
Drive S, Building 26, Suite 1002, Orange, CA 92868, USA.
E-mail: kennyilkim@yahoo.com

Ó 2017 American Academy of Hospice and Palliative Medicine. 0885-3924/$ - see front matter
Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpainsymman.2017.07.038
Vol. 54 No. 5 November 2017 On Intubating Terminal Cancer Patients
Emergency physicians (EPs) often need to make an
urgent decision whether or not to intubate a critically
ill, terminal cancer patient. Unfortunately, only a small
portion of these patients brings in advance directives
or has discussed their preference of life-sustaining mea-
sures with their family or physicians. In one U.S. study,
only 23% of seriously ill patients had discussed with
their doctors about their preferences regarding cardio-
pulmonary resuscitation.11 A survey study showed that
55.7% of patients with end-stage disease hoped ‘‘not
to be kept alive on life support when there is little
hope for a meaningful recovery.’’12 Unfortunately, too
often, these patients end up dying in the intensive
care unit on life support, although the vast majority of
terminal cancer patients expressed a desire to die at
home.13 Thus, intubating a dying cancer patient can
become a professional and ethical dilemma to many
EPs. Only a limited number of studies have been pub-
lished to help understand the perceptions of EPs about
intubating dying cancer patients in the ED.
Without available advance directive or completed
Physician Orders on Life-Sustaining Treatment
(POLST), we hypothesize that EPs will consider intubat-
ing critically ill, terminal cancer patients in pending
respiratory failure. We conducted a survey to explore
EPs attitudes about intubating critically ill, terminal can-
cer patients and the reasons why.
Methods
Study Design
A survey was created, adapting a format used by Lam-
ba et al.14 The survey achieved face validity through a
revisions process, based on critiques provided by a
group of emergency and palliative medicine specialists
at an academic medical center in Orange, California.
Survey Content, Participant Selection, and
Administration
The survey (Appendix 1) presented a hypothetical
case of an end-stage lung cancer patient showing up
to the ED in pending respiratory failure. We used
the Palliative Performance Scale to create this hypo-
thetical patient so that he would have an expected sur-
vival on the order of days. Palliative Performance Scale
is a prognostication tool that estimates a median sur-
vival, utilizing five domains, ambulation, activity
level/evidence of disease, self-care, intake, and level
of consciousness.15 Fourteen questions along a five-
point Likert scale were asked to assess 1) EPs ability
to prognosticate, 2) the level of comfort and familiar-
ity with practicing, utilizing and understanding pallia-
tive care, 3) willingness to initiate palliative care in the
ED, and 4) perceived barriers to initiating palliative
care instead of intubating the patient.
655
The study took place at three EDs in Southern Cali-
fornia: an academic medical center, a community hospi-
tal, and a Health Maintenance Organization (HMO)
hospital. To be eligible to participate in the study, the
participant needed to be a board-certified emergency
physician and worked at one of the aforementioned
EDs. The academic medical center was an urban, Level
1 trauma center with an ED serving more than 40,000
patients a year. The community hospital was an urban,
Level 2 trauma center, with an ED serving more than
40,000 patients a year. The HMO hospital was an urban,
nontrauma center with ED serving more than 80,000 a
year. The primary author was a resident physician at the
academic medical center and the community hospital
and was a Per-Diem staff physician at the HMO hospital.
The survey was conducted during department meeting
and clinical shifts. All participants verbally consented
to participate and completed the survey. Each partici-
pant completed the survey and then placed it in a
‘‘drop box’’ to ensure anonymity. At each hospital, palli-
ative care consultations were available in the ED. The
survey was conducted from February 2015 to March
2015. The University of California, Irvine Institutional
Review Board approved this study.
Data Analysis
A sample size of 50 gave confidence intervals of

14% over the entire range of possible results. Data
were entered into a spreadsheet (Excel; Microsoft Cor-
poration, Redmond, WA) and analyzed using Stata
(version 13.1; StataCorp, College Station, TX). Factor
analysis was used to internally validate the survey re-
sponses. Polychoric correlation coefficients for the
ordinal survey responses were calculated, and then the
correlation matrix was used to perform a principal-
components factor analysis with varimax rotation.
Kruskal-Wallis equality-of-populations rank test was
used to compare Likert responses for groups that
were not ordered (such as hospital), and Cuzick test
was used to compare Likert responses across ordered
groups (such as age groups and groups based on years
in practice). Fisher’s exact test was used to compare
two subgroups, one with self-perceived sufficient pallia-
tive care training and the other with self-perceived
inadequate palliative care training. A P-value of 0.05
was used as the criterion for statistical significance. An
ordinal logistic regression was used to examine the ef-
fect of experience, gender, and site. Age and experience
could not be examined together because of their strong
correlation. Although the full Likert scale responses
were used in comparisons, for reasons of simplicity
and clarity, the description of the data includes only
dichotomized results. ‘‘Very likely’’ and ‘‘likely’’ were
considered as positive responses, and ‘‘not at all likely’’
and ‘‘not likely’’ were considered as negative responses.
656 Kim et al. Vol. 54 No. 5 November 2017

Results the POLST form (Q#4) had a somewhat weaker loading

Characteristics of Study Subjects on this factor. A question about intubation in response
Table 1 describes the characteristics of the partici- to family demands (Q#6) was paradoxically loaded on
pants. Eighteen were from the academic center, 16 this factor, although with a lower loading. The negative
from the community hospital, and 16 from the loading for the question about the perception of
HMO hospital. All 50 participants were responders greater time required for a discussion compared with
and there were no nonresponders. Participant’s age intubation (Q#7) is consistent with the limitations EPs
was categorized by increments of five years. Partici- face in discussing end-of-life issues in the ED.
pants were also classified into years-in-practice post-
residency. Male physicians made up 79.1%. Main Results
Table 3 lists the EPs’ prognosis determination, willing-
ness to intubate, sense of palliative care training, atti-
Internal Validation tudes toward discussing goals of care, and willingness
Three factors with eigen values greater than 1.5 were toward obtaining code status. Ninety-six percent of
retained. They accounted for 56% of the variance in the physicians felt the patient would likely die during the
data. The rotated factor loadings are listed in Table 2, hospitalization, and 94% believed intubation would be
with the questions grouped by the factor for which nonbeneficial. However, if families insisted, 26% would
they had the greatest loading. For the first factor, still intubate the patient with an existing do not intubate
Poor Prognosis Factor, EPs gave consistent responses (DNI) on their advance directive. Ninety-four percent
to five questions (Q#1, Q#2, Q#8, Q#9, and Q#14) would postpone intubation if a palliative care team
related to the patient’s poor prognosis and the consid- could address the goals of care in the ED, and 94%
eration that intubation is nonbeneficial, with a negative would avoid intubation if a family member requested
loading for the question about the benefit of intubating not to intubate. Although only 16% of physicians felt
this patient (Q#1). The second factor, Obtaining Infor- they received adequate formal training in palliative
mation Factor, included consistent responses to three care, 96% felt comfortable discussing goals of care,
questions (Q#10, Q#12, and Q#13) about obtaining and 76% in interpreting advance directives and POLST.
additional information from the family and a chart Sixty-eight percent of EPs believed that discussing goals
review. The question regarding the level of formal of care was more time consuming than intubating and
training (Q#5) had a somewhat weaker loading on admitting the patient to the intensive care unit.
this factor. The third factor, Comfort Factor, had consis- Seventy-two percent of physicians would initiate a
tent responses to two questions about the level of conversation with the family about code status, even if
comfort in interacting with the family (Q#3) and the the code status were previously a full code. If physicians
paramedics (Q#11). The question about interpreting believed that the patient would likely die during the hos-
pitalization, 90% would talk to the family about not
Table 1 intubating the patient. Ninety-four percent of physicians
Demographics, Length of Experience, and Hospital would ask paramedics about patient’s advance directive.
Affiliation of the Participating Emergency Physicians Eighty-four percent would review the patient’s chart for
Characteristics n (%)a advance directives, but only 66% would call the next of
Age rangeb kin to inquire about advance directives. No notable
30e35 10 (20.8) statistical differences were found among the hospital
36e40 8 (16.7) sites, age groups, lengths of experience, and between
41e45 10 (20.8)
46e50 7 (14.6) genders. No further differences were found in the
51e55 3 (6.3) ordinal logistic regression.
56e60 2 (4.2) Table 4 lists the rates of intubation by EPs based on
61þ 8 (16.7)
Malec 34 (79.1) their perceived level of palliative care training.
Years in practice post-residencyd Although 29% of EPs with minimal-to-no formal palli-
1e5 10 (21.7) ative care training would intubate a patient with a DNI
6e10 11 (23.9)
11e15 10 (21.7) when family insisted on intubation, only 13% of EPs
16e20 4 (8.7) with a self-perceived adequate amount of palliative
20þ 11 (23.9) care training would intubate the patient.
Hospital affiliation
Health maintenance organization hospital 16 (32)
Community hospital 16 (32)
Academic center 18 (36) Discussion
a
b
May not add to 100% because of rounding. This study demonstrated that a vast majority of the
Two participants did not list age range.
c
Seven participants did not list gender.
surveyed EPs appropriately prognosticated the hypo-
d
Four participants did not list experience in years. thetical patient in the survey to be terminal and
Vol. 54 No. 5 November 2017 On Intubating Terminal Cancer Patients 657

Table 2
Rotated Factor Loading for Survey Responses
Poor Prognosis Obtaining Information Comfort
# Survey Item Factor Factor Factor

1 How convinced are you that intubating this patient will provide an 0.7 0.15 0.4
overall benefit to the patient’s survival?
2 How likely do you think that this patient is going to die during this 0.73 0.03 0.04
hospitalization?
8 How likely are you to withhold intubation if palliative care could 0.65 0.33 0.34
immediately address goals of care in the ED?
9 If you believe that this patient will likely die during this 0.65 0.01 0.08
hospitalization, how much does it affect your decision to talk with
the family about NOT intubating the patient?
14 How likely would you follow family member’s wishes to avoid 0.68 0.11 0.29
intubation if this patient did not have an advance directive?
10 If the patient described above had Full Treatment and Attempt 0.03 0.72 0.19
Resuscitation orders signed on the POLST form during his last
hospitalization, how likely are you to talk with the family now about
DNR/DNI (Do Not Resuscitate/Do Not Intubate)?
12 How likely would you look through the patient’s chart for an advance 0.08 0.77 0.08
directive before making your intubation decision?
13 If the POLST form or advance directives were not available, how 0.22 0.86 0.09
likely would you call the patient’s next of kin to obtain patient’s
end of life care wishes before making a decision to intubate the
patient?
5 How much formal training (e.g., residency lectures, CME lectures) 0.47 0.52 0.13
do you feel you have had in addressing the end-of-life care issues?
3 How comfortable are you talking with the family members first about 0.25 0.25 0.59
the goals of care before making a decision to intubate the patient?
11 How likely would you ask paramedics about patient’s advance 0.17 0.09 0.84
directive if they brought the patient to the emergency department?
4 How confident are you in interpreting POLST form/advance 0.13 0.26 0.72
directives regarding life-sustaining measures?
6 When a family member without a durable power of attorney insists 0.03 0.38 0.49
on ‘‘doing everything’’ including intubation and the patient
actually has an advance directive, stating, ‘‘Do Not Intubate,’’ how
likely are you to intubate the patient? Of note, you are unable to
reach any other family members.
7 How much more time does an end-of-life discussion take over 0.23 0.05 0.49
intubating the patient and admitting to the intensive care unit?

believed intubating a critically ill, terminal patient to
be medically nonbeneficial. Two main barriers to an
appropriate end-of-life care were identified: 1) family’s
demand for intubation against patient’s wishes, and 2)
a perception that goals of care discussions are time
intensive. Factors that can mitigate these barriers
include utilization of palliative care consultation in
the ED and promotion of palliative care education
for EPs. To help facilitate appropriate end-of-life
care in the ED, we believe that developing a health
care system that allows for a 24/7 palliative care
consultation via phone or in-person and easy access
to the patients’ advance directive and code status are
of paramount importance.
This study showed that family’s demands for intuba-
tion, especially when the patient had previously chosen
a DNI, could act as a strong barrier to providing an
appropriate end-of-life care. Families may request to
override the wishes of the patient and insist on intuba-
tion because they may believe that intubation does little
to no harm and saves lives, as commonly portrayed on
television.12 In reality, intubation can inflict a great deal
of suffering on patients.16 In a situation where a
treating physician believes intubation will not likely
provide survival benefits to a terminal patient, the
physician would feel ethically uneasy to intubate the pa-
tient just to satisfy the demands of the family. Although
EPs strive to do the ‘‘right thing’’ for dying terminal pa-
tients (e.g., allow natural death), not intubating and
going against family’s demands has the potential for
negative consequences, from a simple complaint
affecting satisfaction scores to a potential malpractice
suit.9,17 A survey done of 155 physicians, where EPs
made up 16%, showed that 20% of physicians felt their
job security was threatened by patient satisfaction
scores, and 59% felt their job compensation was linked
to these scores.18 When faced with a clinical dilemma
similar to that described earlier, EPs may find it more
expeditious to comply with the family’s requests to intu-
bate first and then have goals of care addressed during
the later course of hospitalization.
When faced with conflicts related to end-of-life care,
our study results suggest that EPs generally perceive
goals of care discussion to be time consuming. In a
typical ED, an EP sees about 2.25 patients per hour
and EPs are expected to make a timely disposition to
658 Kim et al. Vol. 54 No. 5 November 2017

manage the flow of a busy ED.18 In the midst of a rapid
evaluation, treatment, and critical care, an EP often
finds it difficult to allocate a significant amount time
to have a family conference in the ED to resolve con-
flicts and determine goals of care. In addition, EPs
usually do not have a long-standing relationship with
the patient or family nor sufficient training and prac-
tice in handling conflicts related to end-of-life care.9,19
Our study findings corroborated the latter sentiment
about the inadequate level of training in addressing
end-of-life issues. Despite multiple layers of obstacles
to overcome to initiate palliative care in the ED, a
large number of the EPs in our study expressed intent
to initiate a conversation with the family about not in-
tubating the terminal patient, even if the patient had a
recent POLST with full treatment. This supports an
important premise that EPs want to do ‘‘the right
thing’’ for patient.
Utilizing palliative care consultation in the ED and
providing palliative care training for EPs can help EPs
practice a patient-oriented end-of-life care. When a
conflict arises from contradicting wishes between
what the family wants and the written and reported
wishes of the patient, palliative care team could explore
and compassionately address the emotional and factual
basis of the conflicting wishes and encourage the family
to uphold the wishes of the patient.20 As shown in liter-
ature, having such discussion can potentially reduce
the frequency of nonbeneficial intubation on dying
cancer patients.21 Other potential benefits from
involving palliative care team have been recognized in
several studies and efforts like early Goal-Directed Palli-
ative Therapy, a concept similar to Early Goal-Directed
Therapy for sepsis, has been proposed to move pallia-
tive care consultation more upstream and make it
more reflexive.3e6,22 However, a lack of 24/7 palliative
care staffing makes the timely utilization of palliative
care difficult.7,9,23 Although 72% of all U.S. hospitals
with 50 beds or more have an available palliative care
service, only a fraction of them has the capacity to fully
meet the palliative care needs of the ED, despite that
national guidelines recommending hospitals to offer
24/7 telephone or in-person palliative care consulta-
tion.24,25 Many EPs perceive palliative care consultation
as ‘‘limited’’ because they are often not available during
night hours or weekends.14 The shortage of palliative
care specialists are thought to be, in part, the cause
of the mismatch between the supply and demand of
palliative care services.26,27 Given the shortage, creating
and supporting a system, adapting an existing model
such as British Columbia’s Palliative Care Hotlines
that supports 24/7 hours phone consultation may be
a reasonable step to follow the national recommenda-
tions and to increase prompt accessibility to palliative
care consultation, even for emergent situations during
nights and weekend hours.28 The health system needs
to ensure the availability of palliative care consultation
in the ED to help support EPs to do what they believe is
‘‘the right thing’’ for dying cancer patients.
Given the limitations on the availability of ED palliative
care consultation, enhancing palliative care training and
education focused on conflict resolution and leading
goals of care discussion can empower EPs to handle
end-of-life care issues when no help is available. Educa-
tion in Palliative and End-of-Life Care for Emergency
Medicine has been developed by emergency medicine
and palliative care experts to equip EPs with essential
clinical competencies in palliative care to recognize and
resolve conflicts.29 Our study suggests that possessing
the knowledge to address end-of-life issues can enable
EPs to be more resistant to inappropriate family’s
requests. EPs are interested in learn more about palliative

Table 3
Emergency Physicians’ Responses Regarding Prognosis Determination, Willingness to Intubate, Palliative Care Training,
and Willingness to Obtain Code Status
Survey Questions Positive Response,a n (%) 95% Confidence Interval

Prognosis determination and willingness to intubate

No survival benefit to intubation 47 (94) 83.2e98.6
Likely die during hospitalization 48 (96) 85.8e99.7
Intubate if family insisted, despite DNI 13 (26) 15.8e39.7
Postpone intubation if PC available 47 (94) 83.2e98.6
Accept DNR requested by family 47 (94) 83.2e98.6
Palliative care training and attitudes towards goals of care
Had adequate PC training 8 (16) 8.1e28.8
Comfortable discussing goals of care (GOC) 48 (96) 85.8e99.7
Comfortable interpreting POLST 39 (78) 64.6e87.4
More time consuming discussing GOC than intubation 34 (68) 54.1e79.3
Attitudes and willingness toward obtaining code status
Ask paramedics for advance directive 47 (94) 83.2e98.6
Review chart for advance directive 42 (84) 71.2e91.9
Call next-of-kin for advance directive 33 (66) 52.1e77.6
Revisit code status if previously full code 36 (72) 58.2e82.6
Initiate code status discussion 45 (90) 78.2e96.1
DNI ¼ do not intubate; DNR ¼ do not resuscitate; GOC ¼ goals of care; PC ¼ palliative care; POLST ¼ physician orders for life-sustaining treatment.
a
Four or five on the five-point scale (e.g., ‘‘very likely’’ or ‘‘likely’’) were considered as positive responses.
Vol. 54 No. 5 November 2017 On Intubating Terminal Cancer Patients
Table 4
Rate of Intubation by Emergency Physicians Based on Their Perceived Level of Palliative Care Training
Group
Emergency physicians with sufficient palliative care training
Emergency physicians with insufficient palliative care training
Note: Group difference ¼ 16.1% (95% confidence interval 10.6% to 42.8%).
a
A positive response was ‘‘very likely’’ or ‘‘likely’’ on the five-point scale to the question #6, ‘‘when a family member without a durable power of attorney insists on
‘doing everything’ including intubation and the patient actually has an advance directive, stating, ‘Do Not Intubate’, how likely are you to intubate the patient? Of
note, you are unable to reach any other family members.’’
care.30 Of surveyed emergency medicine residents and
attending physicians, 79% hoped to have more palliative
care related training and education, and they felt the
need to improve their knowledge base about palliative
care.30 Despite the perception that goals of care discus-
sions would take more time than intubation, our survey
showed that a vast majority of surveyed EPs would initiate
a goals of care discussion before intubating a dying cancer
patient. Resources exist to aid EPs with further devel-
oping palliative care skills. A study by Gisondi demon-
strated that Education in Palliative and End-of-Life Care
for Emergency Medicine adapted materials, consisting
of 14 modules taught in 16 hours by a trained profes-
sional, were effective means to deliver palliative medicine
education to EPs.31 Numerous national guidelines chose
palliative care training and end-of-life care as a standard
recommendation for all physicians.31 Although incorpo-
rating a new topic to an already full EM curriculum poses
a challenge and may be poorly rewarded, techniques
learned from palliative education can be as potent and
effective therapy as intubation and critical care.
In addition to the effort toward mitigating barriers
of providing appropriate end-of-life care in the ED, a
system that facilitates obtaining, storing, and effec-
tively communicating advance directives and code sta-
tus across the medical system is an essential
component to rendering appropriate end-of-life
care. In our study, EPs recognized end-of-life wishes,
expressed in advance directives, as key information
in guiding the trajectory of the care of critically ill pa-
tients, and they demonstrated a strong intent to
retrieve advance directives, most notably by asking
the paramedics. Nearly all EPs would ask the para-
medics for advance directives which implies that the
paramedics play a very important role in the care of
the critically ill. We believe that it is of critical impor-
tance that each Emergency Medical Services mandates
a protocol for paramedics to inquire about and obtain
advance directives or POLST at the scene so as to in-
crease the availability of those documents on patient’s
arrival to the ED. Each ED, hospital, and medical sys-
tem should have a policy that provides EPs easy access
to the patients’ advance directive and code status. The
system needs to be designed so that doing ‘‘the right
thing’’ is the easiest and least time consuming, that
is the path of least resistance.
659
n Positive Response,a n (%) 95% Confidence Interval
8 1 (12.5) 0.1e49.2
42 12 (28.6) 17.1e43.7
Limitations
The survey sample size of EPs was in one geograph-
ical area and was small, which limits the generalizability
of our study results. The results may not apply to EDs
outside Southern California or to EDs where palliative
care service is not available. As a pilot study, the survey
questions have not been validated nor were they in-
tended to be comprehensive. Survey answer choices
were pre-selected and, thus, limited. Some survey an-
swers may include social desirability bias and may not
reflect the true behavior of EPs but only their beliefs.
Further studies need to be conducted to assess how
frequently stated responses are carried out in real life.
Conclusion
Our study revealed that variability exists among prac-
ticing emergency medicine physicians’ beliefs regarding
intubating critically ill, terminal cancer patients.
Although EPs feel responsible to understand the
patient’s end-of-life wishes, perceptions about the time
needed for goals of care discussion, inadequate training
in palliative care, and the family’s demand for intuba-
tion serve as barriers to end-of-life care. Increasing the
availability of palliative consultation in the ED and
improving palliative education for EPs may decrease
the frequency of nonbeneficial and undesired intuba-
tion of dying cancer patients. Future research is needed
to determine if palliative consultation in the ED can
reduce the occurrences of nonbeneficial intubation of
critically ill, terminal cancer patients and whether the
attitudes found in this study reflect national perceptions
among EPs.
Disclosures and Acknowledgments
The authors have nothing to disclose. The authors
thank all who participated in the survey.
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Appendix 1

The Physician Survey

Please read the clinical scenario

A 75-year-old man on chemotherapy for stage 4 lung cancer presents to the ED in respiratory distress. The patient is
tachypneic to 30 breaths per minute, using accessory muscles. His oxygen saturation is 90% on a 15-L non-rebreather
mask. He is altered and is unable to speak nor make decisions for himself. You believe that the patient will likely need
ventilator support in the emergency room.
At baseline, the patient is
1) on oxygen for chronic dyspnea
2) cachectic and tube-feed for chronic dysphagia
3) bed bound
4) demented

The patient does not have a completed POLST form. The family is at the bedside. You consider intubating the
patient.

Answer the following questions

1. How convinced are you that intubating this patient will provide an overall benefit to the patient’s survival?
Not at all convinced Not convinced Neutral Somewhat convinced Very convinced
2. How likely do you think that this patient is going to die during this hospitalization?
Not at all likely Not likely Neutral Somewhat likely Certain to die
3. How comfortable are you talking with the family members first about the goals of care before making a decision to intubate the patient?
Not at all comfortable Not comfortable Neutral Somewhat comfortable Very comfortable
4. How confident are you in interpreting POLST form/advance directives regarding life-sustaining measures?
Not at all confident Not confident Neutral Somewhat confident Very confident
5. How much formal training (e.g., residency lectures, CME lectures) do you feel you have had in addressing the end-of-life care issues?
No training Minimal training Some training Adequate training Extensive training
6. When a family member without a durable power of attorney insists on ‘‘doing everything’’ including intubation and the patient actually has an
advance directive, stating, ‘‘Do Not Intubate,’’ how likely are you to intubate the patient? Of note, you are unable to reach any other family
members.
Not at all likely Not likely Neutral Somewhat likely Very likely
7. How much more time does an end-of-life discussion take over intubating the patient and admitting to the intensive care unit?
Significantly less A little less About the same Somewhat more A lot more
8. How likely are you to withhold intubation if palliative care could immediately address goals of care in the ED?
Not at all likely Not likely Neutral Somewhat likely Very likely
9. If you believe that this patient will likely die during this hospitalization, how much does it affect your decision to talk with the family about
NOT intubating the patient?
None Very little Does not affect me Somewhat Very much
10. If the patient described above had Full Treatment and Attempt Resuscitation orders signed on the POLST form during his last hospitalization,
how likely are you to talk with the family now about DNR/DNI (Do Not Resuscitate/Do Not Intubate)?
Not at all likely Not likely Neutral Somewhat likely Very likely
11. How likely would you ask paramedics about patient’s advance directive if they brought the patient to the emergency department?
Not at all likely Not likely Neutral Somewhat likely Very likely
12. How likely would you look through the patient’s chart for an advance directive before making your intubation decision?
Not at all likely Not likely Neutral Somewhat likely Very likely
13. If the POLST form or advance directives were not available, how likely would you call the patient’s next of kin to obtain patient’s end of life
care wishes before making a decision to intubate the patient?
Not at all likely Not likely Neutral Somewhat likely Very likely
14. How likely would you follow family member’s wishes to avoid intubation if this patient did not have an advance directive?
Not at all likely Not likely Neutral Somewhat likely Very likely
Demographics
Age <30 30e35 36e40 41e45 46e50 51e55 56e60 >60
Gender Male Female
Years in practice after residency 6e10 11e15 16e20 >20
1e5

Thank you for taking this survey.