Don’t Wait Until the End

How advance directives spare you suffering — and spare your loved ones impossible choices.

Emergency rooms are the worst place to make decisions about life and death.
Unfortunately, it’s where those conversations happen far too often.

I understand why people put them off — advance directives, powers of attorney, “Do Not Resuscitate” orders — these are uncomfortable topics. But waiting until you’re in crisis, or worse, unconscious, means your wishes may never be heard.

When a young trauma patient rolls in, the decision is simple: full code. We do everything. But for elderly or chronically ill patients, there’s no excuse for avoiding the conversation. How you plan to die should be considered, discussed, and documented well before you’re staring death in the face.

As an emergency physician, my goal is to honor a patient’s wishes and minimize suffering. If a patient has chosen a DNR, performing CPR or intubation isn’t “heroic.” It’s assault. Yet all too often, DNR patients are still sent to the ED because a family panics, or a care home doesn’t want to manage the dying process. Those are some of the hardest cases — where my resuscitation bay becomes a place for reaffirming wishes rather than saving a life.

Sometimes, our role isn’t to stave off death at all. It’s to recognize when death is the natural next step and to help a patient leave this world with dignity and comfort. Death is not a failure. It’s part of the life cycle.

The worst cases are when families insist we “do everything,” even when there is no chance of meaningful recovery — when the body becomes a vessel kept alive by machines, not a life being lived. I’ve seen people endure prolonged suffering because no one could bring themselves to let go. True love isn’t keeping someone alive at all costs. Sometimes, it’s setting them free from suffering.

I’ve lived this personally. Last year, my mother-in-law had a sudden catastrophic brain bleed. A few nights earlier, we’d been out celebrating her birthday. In the ICU, we were told she could survive on a ventilator indefinitely but would never regain meaningful brain function. She had been clear: she did not want to live like that. As gut-wrenching as it was, our job wasn’t to choose for her — it was to honor the choice she had already made.

In the ED, we are lifesavers when we need to be, palliative doctors when it’s right, and advocates always. But please — don’t force these decisions on us in your final moments.

Have the conversation. Write it down. Appoint someone to speak for you if you can’t. Because the best way to ensure you die on your terms… is to decide long before you have to.