Geriatric Medicine Book

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Emergency Department Transition to Palliative Care

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

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