Abstract
We have been discussing the ethical problems related to critical care and emergency medicine in our emergency medical center since 2003. In this article, we review the conference records of 15 cases that fulfilled the criteria for terminal stage of life according to the Japanese Association for Acute Medicine guidelines on end-of-life care in emergency medicine and discuss the ethical and social problems related to end-of-life care in the emergency medical center. Except for 7 cases of brain death and end-stage of cancer, the medical assessment for the irreversibility or terminal stage of severe heart failure and respiratory failure was different among the medical staff, making it difficult to agree on withholding or withdrawing treatment. Only 2 of the 15 patients left a living will. We made an effort to understand the end-of-life requests and desires of the remaining 13 patients through discussion between the medical staff, clinical psychologist, and the patient's family. In the 5 cases of difficult weaning from percutaneous cardiopulmonary support (PCPS) or extracorporeal membrane oxygenation (ECMO), for which there was no indication for organ transplantation or left ventricular assist device, withholding or withdrawing treatment was discussed from the medical and social points of view. ICU beds in our emergency medical center were used for all end-of-life care in these cases. Appropriation of an ICU bed for use in end-of-life care was also discussed among the medical staff, and it remained difficult to reach agreement. The problems related to end-of-life care in an emergency medical center are difficult to solve. We believe that a multifaceted discussion on clinical ethics that includes allied healthcare professionals and the patient's family would lead to a better understanding and practical solution for each patient requiring end-of-life care in an emergency medical center.
