II. Precautions
-
Loss Aversion
- Patients are not being offered aggressive Resuscitation OR nothing
- Patients are being offered Resuscitation OR aggressive comfort measures
- Swaminathan and Weingart in Herbert (2018) EM:Rap 18(10): 3-4
- Ethicists make no moral distinction between witholding treatment and withdrawing treatment
- Patients often present to the Emergency Department without Advanced Directives and Resuscitation is continued
- As relatives and power of attorney arrive, patient's wishes for no life sustaining measures may become known
- Withdrawing treatment at this time may be the most ethical and humane path, and consistent with patient wishes
- Consider this to be the transition "from cure to care", in the active management of the dying process
- Lin and Barren in Herbert (2019) EM:Rap 19(12): 5-7
III. Management: Family Counseling in Dying Patient appropriate for Palliative Care
- Sit down in a quiet, private space with the family
- Summarize evaluation and patient status
- Baseline status
- Example: Bed-ridden with Dementia
- Underlying condition
- Example: Severe Pneumonia with Hypoxia, Hypotension and unresponsive
- Severity of illness
- Example: Critically ill and will succumb without aggressive therapy
- Describe standard interventions
- Intubation, pressors via Central Line, broad spectrum Antibiotics
- Baseline status
- Listen to the family
- Listen to family concerns and their understanding of patient wishes
- Acknowledge how hard this must be for them
- Understand if other family members not present need to be involved in discussion
- Identify Durable Power of Attorney if one is assigned
- Review advanced care planning (e.g. Advanced Directive, Living Will, Medical Directive) and POLST forms with family
- POLST forms are legally binding directives and can be followed exactly without interpretation
- Advanced Directives are interpretable and should be reviewed as to what they understand patient's wishes to be
- Make it clear, that the decision making is based on what the patient would have wanted
- The family is not making a decision of what they themselves want, which may allow for less sense of guilt
- Recommendations (example)
- Our goal is to respect your loved one's wishes
- She appears to be actively dying
- I have very aggressive, intensive measures to support her (e.g. intubation, pressors, Antibiotics)
- Without these interventions, she will likely succumb to her illness
- Despite these interventions, there is still a very high likelihood of death
- Many families ask us to focus on comfort and decreased suffering instead of aggressive procedures at the end of life
- We can very effectively treat pain and suffering
- Our intensive measures to keep someone alive are frequently at odds with our comfort measures
- We have services dedicated to providing comfort (e.g. Palliative Care, Hospice)
- These measures include Morphine and Ativan for pain and Shortness of Breathing
- Based on life threatening illness at the end of life, and based on my understanding of her wishes
- I recommend we focus on comfort measures and avoid heroic measures which may increase suffering
- This would allow for a natural death
- Discussion
- Decisions may not occur in the emergency department (but rather on the ward)
- Initial treatment trial may be compromise
- Non-invasive support may be used (e.g. CPAP or BIPAP instead of intubation)
IV. Management: Palliative Measures
- See Palliative Care
- Turn off monitor alarms and other noises
- Turn off High Flow Oxygen (may continue 2-4 L by nasal canula for symptom relief)
- Keep room quiet
- Turn down lights
- Family may play music if they wish
- Offer on-call chaplain and other available services
V. References
- Orman and Abbott in Herbert (2014) EM:Rap 14(2): 11-2
- Lin and Romero in Herbert (2018) EM:Rap 18(11): 4-5