EMCrit Podcast 25 – End of Life and Palliative Care in the ED

Aggressive palliative care is just as important as aggressive critical care in the ED. Sometimes we will be the first physicians to talk to a family about end of life issues, even if their loved one is terminally ill. Now that is not how it should be, but it just means that we must be just as skilled at family palliative care discussions as we are at floating a transvenous pacer. In this podcast, I discuss my vision of how to handle palliative care issues in the ED.

Step I-Identify potential comfort care patients

Step II-Establish goals of care

Either aggressive curative or aggressive comfort. Sometimes, you will decide with the family to a “trial” of critical care

Step III-Sign the Paperwork

Step IV-Maximize comfort

start a fentanyl drip

consider glycopyrrolate or a scopolamine patch

Remember the concept of double effect

photo by P Nicholson

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  1. emcrit says

    Dena writes

    hi! thanks for the podcast, just a couple questions- if a patient does
    not have capacity to make decisions or assign a healthcare proxy, and
    a family member is at the bedside, but the family member is saying
    that the patient has a healthcare proxy for example, in california,
    and you cant get in touch with them, can you make the patient DNR>>
    according to the family member at the bedside?

    also, just to clarify, a non-health care proxy can ask that their
    family member be DNR, but not DNI… what if its a friend and not a
    family member who is at the bedside and the patient isnt able to make
    decisions for themselves at that point… what if there is no family
    available? do you go by the friend or do you stick to a 2 attending

    my next question is, does everything have to be officially in writing
    before a patient is DNR? say a patient is rapidly deteriorating and
    the family is telling you that they want DNR but you dont have time to
    get the official DNR signed because the patient is crashing, legally,
    is that ok?

    lastly, on my ICU rotation, i had some issues regarding what i was
    allowed to do over the phone versus what i had to do in person. i was
    told by the AOD that i couldnt do a DNR over the phone with a family
    member unless there was written documentation that the family member
    was the HCP- this patients family was all in burma- so there was no
    way we were going to get anyone in person to do the DNR. what are your
    thoughts on that?

    This all pertains to NY:

    Technically you should find HCP or closest relative if possible. But what many administrators don’t understand is that you, the clinician are obliged to do what you think is best for the patient. If I have a close family member, whose motives I trust, telling me that their loved one would not want aggressive treatment and I can’t find the HCP, I am still going to make them DNR.

    With just a friend and no corroborating evidence from the patient that they would want their friend making decisions, I would probably go down the 2 attending path with the friends opinions as a helping hand.

    You don’t shock a patient just b/c you have not printed out the forms yet. If you just do what the patient wants and there is no disagreement from the family, you’ll never have a problem.

    You can definitely do DNR over the phone with a family member.


  2. Kyle McCammon says

    Dr. Weingart,

    Please comment about “upstream” problematic issues of palliative and end-of-life care in the nursing home and how it may conflict with ED evaluation and care. If the patient is already DNR and would be an appropriate candidate for aggressive comfort care with any acute deterioration, why transfer the patient to the ED? Why hospitalize? Isn’t it most appropriate to carry out all therapies of comfort care (relief of pain and suffering, IV’s, antibiotics) at the nursing home? What about do not transfer and do not hospitalize orders? Once the patient is in the ED, I get the comfort care goals, but what about testing (labs, CT, LP, etc.) as it relates to establishing the cause of an acute illness/condition in the decompensated DNR nursing home patient. How far will you go to establish a diagnosis? Thanks.


    • says


      You are totally correct, in a real health care system these patients would never be transferred and if I had more of a public health bent I would be fighting that fight. Unfortunately, that is not my bag, so I just deal with what comes through the door.

      As to testing, I usually will avoid anything I can and then the admitting team takes it as far as they or their attending deems appropriate.


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