Critical Care Palliation in the ED

We as EM physicians often deal with managing exacerbations of chronic, incurable diseases… CHF, dementia, COPD, ESRD, ESLD, and the like. While we might be amazing at resuscitating the nearly dead, we dont do such a great job of letting go when tubes and fingers in every orifice proves futile. To make matters worse, many of our patients arrive in the ED having never had a conversation about their EOL goals. A recent article in the Atlantic, highlights exactly this: How Not to Die.

The lecture in the video below is from the 2013 EmCrit Conference. Ashley Shreves is an EM doc at Mt. Sinai in NYC, and like our very own MGL, is dual boarded in EM and Palliative Care (unlike our very own MGL, she is not boarded in peds and IM). The talk below is a game changer for how we should deal with EOL care in the ED. This should supplement, not replace MGL’s phenomenal EOL care module available on KPLearn.

From EmCrit… 2 blog posts that deserve a read/listen:


To Summarize:

  • 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.
  • 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 (MSO4= 1mg Q15 min / Dilaudid=0.2mg Q15min).  Double every 15 minutes until decreased suffering.

Resources


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Posted in SDMEDED Blog Posts