When serious becomes critical

“I′ll do my best because I want to walk on my own again.” These were the words of Mr. S, a cheerful octogenarian receiving treatment for chronic limb-threatening ischemia (CLTI). His medical history was notable for IgG4-related disease, for which he was taking prednisolone, and poorly controlled type 2 diabetes. He was always polite and would update us on the progress of his rehabilitation. Despite the prolonged and difficult treatment course, he viewed the facts of his illness as challenges to overcome. I first met him during this hospitalization, and it was immediately clear that he was medically vulnerable. Long-term prednisolone therapy, suboptimal glycemic control, and persistent CLTI meant that there were several plausible scenarios that could culminate in critical illness. From the early days after his admission, our hospitalist team attempted to engage him in serious illness conversations (SICs) to understand his core values and determine whether he had prepared for a serious illness. When I asked, he simply replied, “I can′t think about that right now.” Not wanting to undermine his motivation for treatment, I didn′t press him further. Several months after admission, Mr. S developed fever and cough with associated hypoxemia. COVID-19 was diagnosed, and dexamethasone and remdesivir were initiated for what was now a severe illness. His condition rapidly deteriorated and by day two of the illness, he had progressed to respiratory failure requiring high-flow nasal oxygenation. Given the gravity of his condition, I sat by his bedside and attempted a SIC, also referred to as crisis communication. Because of his dyspnea, I limited the discussion to about 10 min, paused frequently to allow him to catch his breath. I explained that his condition was now critical. He fully understood that he was critically ill. “For the first time, I realize my life is in danger,” he told me. “I want to survive, even if it requires difficult treatment, but I don′t want to be kept alive if I′m permanently unconscious.” This was the first time he had articulated these specific preferences for his future care. He also designated his daughter as his surrogate decision-maker. His determination to walk again remained undiminished, and in accordance with his wishes, we designed his status as full code. His daughter was subsequently included in the shared decision-making (SDM) process. Our team explained that because her father was in isolation, the medical team would act as mediators. We conveyed his preferences to her and clarified that she would need to assume the role of surrogate if he lost decision-making capacity, a role she readily accepted. After we detailed her father′s core values, she remarked, “Our family has never had a conversation like this with him, but we′ll make our decisions based on his values.” Looking back, I regret that I missed opportunities to have deeper SICs earlier in his hospitalization, which would have allowed me to share those insights with his family. The SIC concept was originally developed as a “just in case” conversation to be held before a patient became critically ill.1 The goal was to prepare for a future serious illness, allowing patients to express their preferences and values with sufficient time for reflection. SICs are likely to be particularly useful for chronic diseases with a foreseeable illness trajectory, such as cancer, heart failure, and chronic kidney disease.2 However, clinicians must also be able to initiate SICs “just in time” for patients, also called crisis communication, even if a patient has had no prior “just in case” preparation. Crisis communication aims to reach consensus on goals of care under conditions of high clinical uncertainty and significant time pressure.3, 4 During the COVID-19 pandemic, we encountered many previously healthy patients whose clinical trajectories were abruptly altered by infection. Given how difficult it had been for Mr. S to imagine a truly critical illness before contracting COVID-19, the 10-min crisis communication may have been his first and possibly only opportunity to articulate his core values. On day 6, his respiratory failure worsened, and he was no longer able to make decisions for himself. After a discussion with his daughter, he was transferred to the ICU and later intubated. He developed acute respiratory distress syndrome (ARDS) and received lung-protective ventilation and prone positioning to facilitate his recovery. Although his family expressed trust in our medical team, they also conveyed their complex emotions about nosocomial infection. His daughter told me, “We never imagined he would get COVID-19 while he was in the hospital. It′s hard to describe our feelings, the regret we feel.” Mr. S′s daughter spoke openly and was able to articulate her views and those of her family. Making decisions about her father′s dying while maintaining communications with our team, she served as a surrogate decision-maker in an unprecedented and emotionally difficult situation. She repeatedly told us, “I want to know the truth, even if it′s bad news.” Nosocomial COVID-19 infection is emotionally distressing for patients and their families but also for the attending physician. Nevertheless, as the primary physician, I felt a strong responsibility to support decision-making that was consistent with the patient′s goals of care. Remaining mindful of the family′s emotional burden, I made deliberate efforts to clearly explain his clinical condition and to offer treatment recommendations that would enable accurate, values-based decision-making. Unfortunately, there was no improvement in his ARDS. Weaning from mechanical ventilation proved difficult, and his condition was further complicated by secondary organizing pneumonia. Poor lung compliance, combined with significant respiratory effort upon lightening sedation, precluded safe performance of a spontaneous awakening trial. Despite this difficult clinical course, his family remained committed to SDM that honored his goals of care. We held repeated conversations, framing the prognosis with an approach of “hope for the best, and prepare for the worst.”5 The family understood the details of his condition and continued to hope for his survival and eventual long-term recovery. Because of the need for prolonged weaning from ventilation, a tracheotomy was subsequently performed. After several weeks of intensive care, he experienced recurrent episodes of sepsis, including ventilator-associated pneumonia and catheter-related bloodstream infections. Communication with him was no longer possible. Multiple organ failure was inevitable, and he was approaching the state he had explicitly wished to avoid—being kept alive while permanently unconscious. After a multidisciplinary conference, the medical team determined that he had reached the end-of-life phase of his illness. After this was discussed with his daughter, she said, “We understand his condition is irreversible. We don′t want to prolong his suffering with more invasive treatments. Because we had the opportunity to understand his values before he was intubated, we feel comfortable making this decision on his behalf.” The patient′s previously expressed wishes were crucial in guiding this surrogate decision-making process. The focus of care shifted to comfort measures, and he died peacefully several days later. As the end-of-life approaches, the preferences of patients and family may change with the clinical situation.6 Concepts such as advance care planning, SDM, and SICs have become widespread. Various approaches have been developped7, 8 and their importance is obvious. However, a patient′s core values can be missed during an outpatient SIC, as such conversations are typically limited to hypothetical questions. In contrast, core values are expressed more clearly when patients perceive a real and immediate danger to their lives. This was precisely what I observed in Mr. S, whose previously unarticulated values emerged only during crisis communication. Ideally, every patient admitted to the ICU would be given the opportunity to engage in SICs before a crisis occurs. In reality, crisis communication often takes place when healthcare providers and family members are meeting for the first time, in the midst of intense emotions. As such, crisis communication requires advanced, high-context communication skills. Through my experience caring for Mr. S, I became firmly convinced of the importance of conducting crisis communication during episodes of acute clinical deterioration. Although it is inherently difficult to broach sensitive topics in high-stress situations, medical teams should not hesitate to initiate patient discussions aimed at understanding their core values, even when time is limited. Crisis communication grounded in the patient′s core values is essential for guiding both the medical team and the family. Because outcomes are always uncertain, physicians must clearly and consistently convey the patient′s values to the family to support shared and informed decision-making. After her father′s death, his daughter told us, “Our family was satisfied with the inpatient treatment and decision-making process with the medical team. We′re really grateful.” The author has no funding to report. The author declares no conflicts of interest. Signed consent for publication was obtained from the patient.