End of Life Care in the ED

Written by: Savannah Vogel, MD (NUEM ‘24) Edited by: Logan Wedel, MD (NUEM ‘22)
Expert Commentary by: Matt Pirotte, MD

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References

“Discussing Goals of Care.” UpToDate, www.uptodate.com/contents/discussing-goals-of-care

Ganta, Niharika, et al. “SUPER: A New Framework for Goals of Care Conversation.” SGIM Forum, vol. 40, no. 3, 2017.

“Transitions/Goals of Care.” VitalTalk, 9 May 2019, www.vitaltalk.org/guides/transitionsgoals-of-care

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Expert Commentary

This is a nice review of the steps of what can be a very difficult conversation from Drs. Vogel and Wedel; I encourage emergency providers (especially residents) to run towards these situations aggressively and not expect other doctors to begin these challenging discussions.

While their piece is chock full of great tips, let me throw out a few of my own that might help you on your next shift.

1. “I am worried” is a great phrase to open the conversation. These are confusing topics for families and loved ones, our medical jargon is usually not fully suppressed and generally makes things even worse. While a family member can misunderstand a diagnosis or a prognosis, no one can misunderstand another person’s worry. “I am worried that your husband might not survive this illness” is very clear.

2. Be the first step. Remember that you might be the first step in what might be a series of conversations. When you are admitted to a patient who you think is in big trouble, have a frank honest conversation with the family but do not force them to make decisions. Then your conversation becomes part of your handoff to the inpatient team. The care of the patient will benefit from open communication upfront that minimizes false hope. Emergency doctors know intuitively what trajectory patients are on, a chronically ill elderly patient presenting with shock requiring pressors have an extremely high mortality risk and we should be clear with families about that.

3. Reassure and validate at every opportunity. Jim Adams gave me a great pearl when I was training at Northwestern which was that when you see worried first-time parents at 3am in the ED with a benign newborn issue you compliment, reassure, and validate. “This kid looks great, you guys are doing a great job.” Same thing with families. Simple statements like “it’s obvious that you care about them” and “I know you are trying to make the right decision and you’re asking great questions” will go a long way towards helping families process this information.

4. Humanize the body filled with tubes and lines. A few minutes to ask about the patient at the beginning of a tough conversation go a long way. What did they do for a living? What were their hobbies? Families usually end up smiling a little bit here, reminiscing, and telling you some really cool stuff. Sometimes you find yourself laughing with a family that came in the door sobbing. I find these few minutes spent getting to know your patient also helps to steer discussions towards what the patient would have wanted.

5. Anticipatory guidance is not just for well-child checks! After tough goals of care conversations especially those that end in decisions to move towards palliative care goals I always do 2 things. First I tell the decision-maker that they are making a good and loving decision, that it is the decision I would make for a member of my family, and to not let anyone tell them otherwise. Second, I insist that the family especially the decision-maker drink a bottle of water and eat a sandwich. We’ve all seen an end-of-life situation generate a second patient with dehydration mediated syncopal episode at the bedside, let’s try to prevent that.

I am forever grateful to my PD at NUEM Mike Gisondi for sparking my interest in this topic, it has been an unbelievable gift to me in my clinical practice. As I frequently say in the ED, you cannot avoid difficult goals of care conversations and then complain about the lack of beds in the hospital.

Matt Pirotte, MD

Program Director & Associate Professor of Emergency Medicine

Vanderbilt University Medical Center

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Vogel, S. Wedel, L. (2022, Feb 21). End of Life Care in the ED. [NUEM Blog. Expert Commentary by Pirotte, M]. Retrieved from http://www.nuemblog.com/blog/end-of-life-care

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Other Posts You May Enjoy

5 Palliative Care Myths DEBUNKED!

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Written by: Hashim Zaidi, MD (NUEM PGY-3) Edited by: Alison Marshall, MD, (NUEM Graduate 2017) Expert review by:  Eashwar B. Chandrasekaran, MD MSc

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1) “Palliative care is only for people close to death”

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Image Credit: “Reconceptualizing palliative care as a continuum of support”Wang, David H., MD. Published March 31, 2017. Volume 69, Issue 4. Pages 437-443.

End-of-life care is only one of the many components of palliative care. Palliative care consists of interdisciplinary efforts to decrease the physical, spiritual, and psychological stress related to an incurable or chronic illness. Sound familiar? We do this daily in the emergency department (ED) for a variety of patients with acute on chronic conditions, many of whom would benefit from early palliative care involvement. Despite multiple studies illustrating the benefit of early palliative intervention, palliative care has traditionally been offered late in one’s disease course, thus creating the misperception that palliative care is synonymous with hospice, or end-of-life care. Specifically, hospice is a benefit and program for patients whom providers believe are prognostically likely to live less than 6 months if the disease is to run its usual course and are philosophically inclined with not pursuing further life-prolonging interventions. Many conditions and disease states could benefit from the model proposed below, with palliative care offered in tandem with life-prolonging care in order to ease symptom burden and improve quality of life. As someone’s chronic illness starts to worsen with concern that their time may be getting shorter, palliative care can then transition to planning for end-of-life, including discussions about enrolling in hospice. Within the landscape of modern disease shifting towards long term management of chronic disease, emergency medicine and palliative care are beginning to share increasing common ground. Many of these patients present to the ED on a regular basis, making the emergency department a unique access point for initiation of early palliative services.

2) “Palliative care discussions are really just about establishing code status.”

            As mentioned previously,  palliative care accomplishes much more that just what happens when a patient has cardio-respiratory compromise. The exact actions performed at the very end of life are not as significant as identifying the values that inform patients and surrogate decision making. It is better to avoid jumping into a goals of care discussion with questions such as “Would your loved one like everything done?” or more gore filled specifics of “Do you really want us beating on their chest or shocking them with electricity to try and keep them alive?”  No one would like to approach the context of their goals for treatment and care framed as a series of end of life checkboxes and procedures. Rather, palliative care providers stress the importance of identifying what’s important to patients and families with the worsening of their disease progression, in order to fill the gap between expectations and reality.

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“‘Hello I’m Dr. Emergency please fill out this checklist of invasive procedures that you think sound appealing for your loved one.”

While it is important for us as ED providers to understand how a patients’ wishes relate to medical interventions, we must remember that collaboration and the development of mutual trust are needed to provide excellent care. Trust is achieved through verbal communication style and through non-verbal cues such as sitting with the patient and/or family and giving them time to communicate their wishes without haste or decision-steering conversation. Attempts should be made to identify broad goals that are important to the patient and family. Building on those principles, providers should then propose appropriate goals of treatment based upon expectations.

Once trust and rapport are developed and the goals of care identified, providers should elaborate on a plan as well as timeline just as you do with all ED patients. If your patient's goals are more aligned with comfort and aggressive symptom control at the end of life, future discussions should establish code status as well as discussion of initiating hospice services be it as an inpatient or outside the hospital. . When speaking specifically of code status, a “Do Not Resuscitate” (DNR) specifically comes into play when the patient’s heart stops beating, even though it is often misconstrued as a theme for withholding treatment of any kind at the end of life. Thus, discussions for withholding interventions at the end of life should include discussion of not only code status, but also of discussion issues such as artificial nutrition/hydration and use of antibiotics. If appropriate, most emergency departments have a case-management based approach to initiate a hospice referral. Often, this is done in concert with the admitting team and/or palliative care providers to guarantee a smooth transition and often may require the patient to be admitted for setting up these services. Future directions will look to establish formalized care patterns for the initiation of hospice services in the ED to reduce hospitalizations for individuals at the end of life.

If the patient’s or family’s goals align with ensuring they live as long as possible or continue for hope of curative treatments, then it would be prudent still to offer your perspective of prognosis and document this discussion for future providers that may come in communication with the patient in the future. This certainly does not preclude trying to get palliative care involved with the patient as they can continue to follow the patient even if he is pursuing life-prolonging therapy in anticipation of a change in disease progression in the future.

3) “A patient who is DNR or DNR/DNI should not be admitted to the ICU”

The rough translation of this statement is “if we can’t offer everything in terms of intensive care then the only option is no critical care at all.”

“Wait a minute- if I can’t intubate the patient then how do I get a plateau pressure? Where are we on the CVP monitoring?” - ICU MD

For the emergency physician, identifying the broad goals of care in a criticallyi ill patient helps to delineate what specific interventions should and should not be done in the ED and furthermore during their inpatient stay. Identifying that CPR and intubation aren’t in line with the patient’s goals is critical first step if that intervention could happen in the ED. ICU level of care is not determined by this, but rather based upon the amount of intensive nursing care which will be required for that patient as well as frequency with which medications must be administered. Often times if patients are pursuing life-prolonging therapy, a short ICU stay is necessary to further discussions with inpatient ICU and palliative care providers as they de-escalate use of technology at the end of life and transition to aggressive symptom control. In the end, most ICU doctors have an informal fellowship themselves in palliative care and feel comfortable with admitting these patients knowing that their goals and their disease trajectory may change acutely.  It is important however to be explicit with specific discussions that have already taken place and what decisions may have been made based upon these discussions as to help the accepting service provide better care for these patients.

4) “Having a productive goals of care conversation takes hours; I don’t have that kind of time in the ED”

Meaningful discussions happen between patients and providers every day in the ED on a minute to minute basis. Having a productive and efficient goals of care conversation should be no different. These are critical communication skills that allow us as providers to understand the values of our patients and ensure that they understand their trajectory of care.  ACEP’s Simple Palliative Toolkit includes a framework for a 5-minute goals of care conversation in order to facilitate  meaningful dialogue in a time sensitive manner. Like any procedure, it requires patience, preparation and practice to accomplish well. The initial conversation should focus on defining the current situation and establishing the values of the patient. We’ve found the following question stems useful (shout out to Dr Justin Morgenstern who taught us this and so much more during his EM:RAP segment on Dyspnea in the Palliative Care Patient):

1. What do you understand about your condition?
2. How do you normally spend your days?
3. How much has that changed over the last month?
4.  What is most important to you (your loved one) right now?

Validate the patient and their loved ones continuously; acknowledge their challenges to date and what they have accomplished to get to that point. Utilizing this value framework will allow you to consider treatment options from the patient’s perspective in the current medical context. Discuss these options and then recommend a course of action based on both your medical knowledge and your understanding of the patient’s values. Finally, remember that emergency medicine is a team sport--get your colleagues from social work and pastoral care involved early, so that they can assist in the established care pathway.

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5) “When discussing goals of care for a patient with a dire prognosis, I should avoid partiality in treatment options.”

This myth goes back to the 5 minute goals of care conversation. After establishing wishes and mapping out care goals broadly, it is imperative care providers take the role of adviser rather than host in terms of care. It is key to understand that this does not mean to be irreverent or negligent of a patient or family's wishes. Rather, when the goals of care and treatment have been established and the rapport developed, this is the time you give your professional opinion about the best course of action. If, with the appropriate patient with an incurable disease, you feel the patient would benefit from increased palliative measures and less invasive care you need to communicate that to the patient and family. Connecting their broad reaching goals with actionable palliative interventions such as pain control, dyspnea control, and secretion control will help build the sense that the providers are not “doing nothing” simply. With concerns and care issues validated you can build on issues and also discuss critical invasive interventions that would not help the overall prognosis and lead to prolonged suffering such as intubation, mechanical ventilation, and central line placement. As an ED provider, it is imperative we have discussions about interventions which could directly change the patients trajectory in the hospice such as the procedures detailed above, but more chronic life-prolonging therapy is best guided by the patient’s primary oncologist or in concert with their primary care physician. My recommendation is to make sure you have done due diligence to try to get these individuals in discussion if possible as to have appropriate follow up for future conversations.

Regardless of the patients chronic healthcare conditions, each visit to the ED is an opportunity to assess for palliative care needs

Talking to the oncologist first often reveals a foundation of previous care goals that can be built upon. Instead of saying, “I’m going to talk to your oncologist about stopping chemotherapy and getting you the palliative care that I think is better for you at this stage,” this would be better communicated by saying, “I know you talked about what care and comfort issues were most important to you as this disease progresses with Dr. X. I talked to them as well. I wanted to revisit this issue and talk more about working to make you actively comfortable moving forward with or without cancer therapies.”

While these “myths” being debunked likely didn’t leave any physicians in shock or awe, it’s important to realize many of the underlying concepts get lost in the chaos that is the emergency department. Remember the ED sets the pace and tone for a lot of care delivered in a hospital system and establishes a patients trajectory through the greater hospital system. By taking a step back and remembering the principles and benefits of early palliative care, a substantial impact can be imparted on patients and their families  that will increase patient satisfaction, and provide better resources that align with their wishes.

Expert Review by Eashwar B Chandrasekaran MD MSc

Assistant Clinical Professor Indiana University SOM Dept of EM

Associate Hospice Medical Direct IUH Ball Memorial Hospital

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 How to cite this post

[Peer-Reviewed, Web Publication]  Zaidi H,  Marshall A  (2018, March 12). 5 Palliative Care Myths Debunked.  [NUEM Blog. Expert Review by Chandrasekaran E ]. Retrieved from http://www.nuemblog.com/blog/palliative-care. 

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