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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Review-Palliative Care in the ED
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Scott Weingart
[…] This post was mentioned on Twitter by Scott. Scott said: Good end of life and palliative care is the mark of a skilled ED intensivist. Learn how in EMCrit Podcast 25. http://su.pr/AMDBgi […]
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 approach? 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,… Read more »
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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.
Kyle
Kyle,
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.
Scott,
How do oral/nasal airways and SGA’s fit into the picture w/respect to DNI?
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