Palliative Care in the Emergency Department
“Death is often seen as a failure to keep people alive rather than a natural dignified end to life” (1)
Coping with death is difficult for anyone, including medical care practitioners. The super-hero mentality (emergency physicians (EP) in particular suffer from this disorder) makes encountering an end-of-life situation confusing, anxiety-inducing and unnerving. Unfortunately with more and more terminally ill patients presenting to the emergency department (ED), EPs need to acquire skills in comfort and palliative care.
Patients diagnosed with life-threatening illnesses should from time of diagnosis be initiated on a treatment path of palliative care. EPs should always be alert for this patient population as they do present to the ED. Commonly they present seeking symptom control or they are brought in by distraught family members in crisis. As an EP you will have to deal with both in a caring, compassionate yet professional manner.
There are many myths surrounding management of these patients. Here are three which I will debunk:
- Palliative care implies doing nothing for the patient
- Palliative care is someone else’s problem (not the EP’s problem)
- Opioids hastens death and should only be prescribed with extreme caution
The WHO’s definition of palliative care is “An approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual” (2)
Palliative care therefore does NOT mean doing nothing for the patient. It is a very active form of care which requires EPs to seek out and attend to those symptoms that may cause patient distress.
Another other common myth is that palliative care cannot or should not be initiated/ implemented in the ED. It’s for the wards, the palliative care clinic or a hospice. WHO deliberately uses the terminology- life threatening illness (see the above definition) – so as to illustrate the point that these patients require palliative care even before they reach the terminal stage of their illness.
Common complaints will be shortness of breath, pain, agitation or delirium which can easily be addressed in the ED.
Treating some of the symptoms may require administering opioids, which leads us to our third myth: Opioids given for symptom control may hasten death. This is the so-called “double effect” (3).
Many practitioners shy away from administering opioids for fear of hastening death therefore leaving patients to suffer. Palliated patients are often on fairly high doses of oral outpatient opioids and tolerate them without life threatening side effects. The goal in the ED is to convert their oral outpatient doses to the intravenous forms, to adjust suboptimal dosage or to supplement current analgeisa.
Ultimately a significant part of palliative care is just talking. Talking to patients and their families.
When the patient arrives in the ED assess the patient as you would any other patient. Provide appropriate initial supportive care until you get a full background history of the patients diagnosis and care plan. Do not be distracted by family members or the mutterings of fellow staff members discouraging initial thorough assessment and care. Providing initial supportive care often buys you time for further information gathering. When you are ready to engage with the patient and/or the family ensure you have the following:
- an appropriate location
- a structured approach to discussing all the pertinent points regarding the patient and their care plan
- a colleague to accompany you
SILVER is an easy mnemonic (there are many others) that I believe provides a structured approach and covers all the pertinent aspects of such a conversation(1).
- How are the people present related to the patient?
- Who can make decisions on behalf of the patient (e.g. spouse or legal representative etc)
- Who will be the family spokesperson? You may not always be able to speak to the whole family and speaking to different people is far from ideal.
- If there’s a relative with a medical background that’s a bonus. Do not let this intimidate you – it’s actually very beneficial.
The initial part of the conversation should allow the family to do most of the talking. Assist them with open ended questions:
What do you know/understand about the patient’s condition? Do you have any medical reports from previous consultations? Previous treatment plans? If they struggle, follow up with even more basic questions: Who stays with the patient? Who brings the patient for their follow ups? That usually gets things going.
The most important information to illicit from the family/patient should be: What are the expectations of this visit?
Patients presenting to the South African public healthcare sector often do not have advanced care directives. For a patient without a directive stimulate conversations which assess their life values or personal wishes. Listen carefully; patients may not articulate themselves in ways which may be culturally recognizable to you. Ask clarity seeking questions. Get help.
If you have access to the patient’s file, read through it for clues. Multiple refusal of hospital treatment forms? A documented discussion with another doctor previously? Include these in your conversation.
At this point you should have some sense of the patients’ background illness, prognosis and wishes. Educate the family about the expected trajectory of the specific diagnosis/ disease. Mind your language. Do not be offensive, antagonistic or patriarchal but provide the family with medical facts. Speak clearly in understandable language. This is a critical stage in the conversation because from here you can establish and implement realistic goals of care.
Things you might say: “From what I have heard (or read in the file), your family member (name) is suffering from a life-threatening illness. An illness that will eventually cause them to die.”
Pause. Assess response. Continue
“In these types of situations the treatment we offer is that which keeps (name of the loved one) comfortable. None of the treatment will be life saving. We cannot reverse the path of the disease. My recommendation is to provide analgesia, sedation etc according to their needs.”
Pause. Assess for response. Ask for questions
Do not be offended or scared if the family asks for a second opinion. In SA it’s part of the patients rights charter to receive a second opinion(4). Secondly let the family satisfy themselves that they did all they could for their relative and that later they do not get stuck in the guilt stage of the grieving process.
Answer their questions as best as you can. Do not get caught up in predicting times or dates of death. Respond to their emotions with compassion and empathy, even if their emotions are fear and/or anger. Do not lose your composure. If things do get out of hand solicit calmer family members to assist with relatives who may be out of control or call in security. (As much as you are empathetic with the family you still have the duty to the safety of yourself, other patients and staff in the unit)
Respond to your own emotions as well. Take a moment to yourself after speaking to the family. If you need to cry privately allow yourself to do so. If you need a quick chat with your own family, do so. Refill your own emotional tank before returning to the patients’ side.
Palliative and hospice care fellowships are available in North America and some European countries. There is so much literature available regarding this type of medical care in the ED. Arm yourself with up to date information and I guarantee that both you and the family will come out of this mental space with some level of satisfaction despite the obvious challenges.
2. WHO. Definition of Palliative Care
3. Fohr SA. The double effect of pain medication:separating myth from reality. J Palliat Med 1998 Winter;1(4):315-283
4. HPCSA.Guidelines for Good Practice in Health Care Professions. Booklet 3. Patient’s Rights Charter
Post by Kamo Molokoane @drhomie