He barely roused as the paramedics transferred him from the ambulance stretcher to the emergency department (ED) bed. Obtunded and breathing irregularly, he couldn’t tell me his name. As our care team undressed him and started to establish IVs, I took 30 precious seconds to open his chart: late 60’s, terminal cancer, no advanced directive. The most recent oncology note mentioned initiating conversations about hospice, but no formal decisions had been made. For an emergency physician (EP), this translates to “full code.” I called for airway equipment and a respiratory therapist. A nurse from triage burst into the room, announcing that the patient’s wife called and was several minutes away.

In this situation, the routine and indeed easiest thing to do is to intubate, connect him to the ventilator, and admit him to the intensive care unit (ICU). Tell his wife we had to act quickly to keep him alive. Call it a day and move on to the next patient. The relentless onslaught of ED patients awaits.