Podcast 93 – Critical Care Palliation with Ashley Shreves

As you know, my motto is maximally aggressive care, ALWAYS! Maximally aggressive curative care and maximally aggressive palliative care. I did a podcast episode on critical care palliation a year or so ago.

At this year’s EMCrit Conference, Ashley Shreves gave the ultimate lecture on the topic. Twenty minutes jam-packed with goodness.

A listener, Don Zweig, wrote with this summary:

  • We (as in ED docs) in general deal with End of Life Care and palliative care situations poorly.
  • Our job as physician is to understand the family goals and values and then give a professional recommendation- it is not to give a menu–they have no medical knowledge to reasonably make this choice.
  • Three things we should never say:
  1.  “Do you want us to do everything?”  Of course they do, but if you offer “everything” who wouldn’t want mom to get everything? Could they say….”no, whatever you do , don’t do everything for mom!” This also makes the family feel that everything (whatever that entails) is reasonable or possible. Instead use the ‘Pal Care’ approach and say, “What would be most important to you and your mom now?”  On the basis of what you hear make a reasoned professional recommendation.
  2. “Do you want us to resuscitate her?”  This implies that we think it is possible or reasonable to do this!  Since you ask this it must be reasonable.  “You can just bring her back?  Great, go ahead!” Use natural death language.  So it sounds like your mom would want a natural death?  When her heart stops we will not interfere with that process
  3. ” I am so sorry, there is nothing more we can do”  There is a lot that can be done and it involves maximizing comfort and minimizing suffering. They need palliative care or hospice.    So call a consult and give palliative meds.
  • Try to get private room and take them off the monitor!  There is no place for monitor in the dying patient for which you are providing comfort care.
  • Treat discomfort with morphine or dilaudid in very small doses.  Double every 15 minutes until decreased suffering.

Addendum

This amazing post on the blog Expensive Care is a must read on the topic of the ethics of CPR

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Comments

  1. Great podcast, Doc Weingart!
    It’s reassuring for me to see that you deal with this topic on your blog: it confirms that we also, in Italy, are on a good way (we’re introducing these points in Italian EM by a formative initiative of Italian Society of EM). To deal with end of life is a mandatory competence for the EP.

    I think that, in addition to what is reported by Shreves, we need to introduce some concepts like the right calculation of rescue dose for opiate-treated pts (particularly onco-pts), how to deal with opiate-induced adverse effects, and palliative sedation (that is often misinterpreted as euthanasia).
    A little pearl: Buscopan (Joscine butil-bromure) for bronchial secretion in the terminal ill (but I’m not sure that it’s available in the USA).

    These topics seem to be far from the field of EM but, as Shreves says very well, there are a lot of reasons for a terminal ill to seek for help in the ED!

    Thank you,
    Fabio De Iaco, Italy

  2. Minh Le Cong says:

    Hey Scott, nice one!
    DO you think AShley would be receptive to a PHARM podcast ? Palliative care is in fact one of my other clinical interests particularly in rural medicine.

  3. Ben Dowdy says:

    Minh, also a great need to address this topic in the prehospital arena as well. Thanks for posting this for me to pass on to my paramedic students; sometimes their definition of “help” doesn’t fit with the patient’s!

  4. Lakshay Chanana says:

    Great Lecture !!

    I will never use words like DNI/DNR for such patients…Natural Death is sounds better..

    Thanks..

  5. Another term that makes me cringe is “expire”..

  6. Brilliant,
    I only wish I had seen this before my ICU fellowship a few years back…Although I don’t think I did a terrible job (got more thankful than angry family in EOL patient), this approach would have made my life so much easier…
    I wish the ED folks that called me at the time as part of an institutionnal procedure to limit curative treatments in EOL situation had seen it to… And I’ll make damn sure that they watch it in the future.
    Thanks again… and keep’em coming…

  7. I have to say that this one of the best talks on the practice of Medicine I have ever had the honor of hearing.

    In my practice, it took me a long time to realize that chronically ill people don’t need to have a terminal diagnosis to be dying. It took seeing the same pattern of increasing debilitation, the whole ECF/Hospital Merry-Go-Round, the entire spectrum when we go from functioning beings to bedridden shells of our former selves.

    This talk lays it out in plain talk and emboldens us to BE A DAMN DOCTOR!, not just the piano player in the whorehouse that is medicine.

    I so much enjoy the critical care podcasts you post here and my increasing ability to extend or save life because of the information I gain. But when all is said and done, we have to have the skill, mindset and courage to step up to the plate and say the family “If your mother could be with us now, what would she say?”

  8. David Levy says:

    Great lecture on a truly important and timely topic…one of the best I’ve heard in my 25 years of practice as an EM doc… a game changer…thanks!

  9. Katarzyna Hampton says:

    When dealing with terminally ill patients and their families, in other than ED settings I do often encourage them to bring pictures and albums to the hospital… Quite a few times I’ve seen despair turn into celebration of life a given person lived. They start looking at the dying loved one through the beauty of all the memories they’ve made… Quite a metamorphosis I must say… In the ED, given time constraints I always try to talk to everyone involved and provide them as much privacy as possible, at the very least.
    Awesome lecture! Thanks!

  10. SUPERB lecture by Ashley Shreves (!) – on this tremendously important topic that is applicable (and to be recommended) far beyond the domain of the ED – to include virtually ALL medical providers (physicians plus non-physicians) – medical students – as well as selected families with a loved one nearing the process of dying (so that they too know what can be done for their loved ones).

    On a related note – I’ll mention as potential supplemental material on this topic the excellent book by another full-time emergency physician (Dr. Monica Williams-Murphy) – The book is called, “It’s OK To Die” (http://www.oktodie.com/book ) – and can be recommended to health care providers as well as patients in the process of dying and their families.

    CREDIT to Drs. Weingart, Shreves & Williams-Murphy for their combined important contributions to this previously not-well-covered area.

  11. katrinab135 says:

    Great talk. As a resident I suspect the reason there is not much guidance given on this topic, is because of a lack of comfort and knowledge within our field. Thank you for this brief, high-yield talk.

  12. Scott,

    Thank you so much for putting this up. I’m planning on playing this for the residency this year before my chief time ends, such a powerful talk with language that speaks to the humanism aspect, and gives such a more compassionate and meaningful way to speak with people and their families. Definitely a tool I will be using. Bravo Ashley Shreves, and thank you Scott.

  13. JG in Kalamazoo says:

    Thanks Scott for putting up this lecture!! I always enjoy your podcast. Thanks for Don Zweig for doing the written summary! I have been making short Powerpoints so I can review later and this written summary helped a lot.

  14. Rocky Samuel says:

    Fantastic lecture! I would like to present this information to my fellow residents at Northwestern. Do you have the citation for the article she discussed at 19:00? Thanks.

    • Ashley Shreves says:

      Thanks for listening. There are several studies by Katri Clemens demonstrating the safety and efficacy of opiates at the end of life. The reference for the data I included in the talk is Clemens KE and Klaschik E. Effect of hydromorphone on ventilation in palliative care patients with dyspnea. Support Care Cancer 2008;16:93-99.

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