“There is a dignity in dying that doctors should not dare to deny.” – Unknown
How do you respond when a family member pleas, “do everything”, for a dying patient? What do you do for a patient with profound dyspnea at the end of life? Did you know that hospice bereavement services are available to families of deceased patients even if the patient was never in hospice?
In February 2015, the Advocacy Track hosted a Palliative Care Workshop led by Dr. Lindsay Weaver, Assistant Professor of Clinical Emergency Medicine and Palliative Care Medicine. There was a tremendous turn out for the workshop, and included representation from multiple hospitals and a wide variety of specialties/fields – RNs, faculty/resident EM MDs, NPs, SWs, CMs, CNAs, hospice representatives, and palliative care experts.
A few of the critical topics related to death and dying in the ED were covered, including:
- Withdrawal and end of life of care in the ED
- Code status discussions in the ED
- Hospice resources/information
- Discussing the results of the palliative care needs assessment
- Aiding in the development of an action plan for end of life care in our EDs
Why is this discussion so important, and how does it relate to emergency medicine?
As Dr. Weaver aptly stated in her powerpoint, “The Emergency Department is the safety net for the acutely and chronically seriously ill. As the population ages, ED visits for crisis events in the setting of serious, chronic illness are likely to increase.“ Initiating end of life conversations in the ED allow for a more patient centered, quality of life centered focus that may save the patient from unwanted procedures, avoidance of unnecessary admissions, integration into resources such as palliative care sooner, and decreased overall cost to patients and families that does not ultimately improve end of life care.
Individual patient cases were discussed in small groups, each illuminating key points in caring for patients at the end of life. The overwhelming theme was communication. Taking the time to discuss options with patients and families with the other team members (RNs, CMs, SWs) can prove to be the major factor in providing optimal care. The consensus was that we should start these conversations in the ED, because what we do has a snowball effect for the patient’s management/testing/procedures in the hospital.
What limitations or barriers exist to limit our ability as providers to achieve this in the ED?
- Common responses include TIME. Conversations about end of life take time, and this can be a limited commodity in the ED during a bustling shift. However, sharing with your colleagues in the department that you are going to have a conversation with a family is OK. Some thoughts were to have secretaries hold pages for 10 minutes during this time, and to make a call-back list when you are finished. We often do not like to ask for help, but in some situations, this can prove to be the difference between intubation, central lines, arterial lines, vasopressors, and a week or more on the ventilator, when perhaps all the patient or family really wants is the option to go home with hospice or focus primarily on pain control and do it well.
- Another concern was provider/RN comfort and perceived time required in providing medications for comfort. There seems to be a educational gap regarding goals of comfort measures in the department, because it is not performed often.
- Furthemore, lack of documentation and medico-legal concerns are another factor.
Solutions we discussed to improve Palliative Care in the ED:
- Creating an order set for withdrawal of care/comfort measures in the ED
- Identifying a quiet place in the ED to provide comfort care and/or arrange services, for example, the observation unit
- A bereavement resource basket filled with information for families who have a loved one pass in the ED
- Resource handout available in the ED for easy reference for providers
- Educating staff/residents/RNs/ancillary staff on medications used for comfort measures
- Carrying out discussions and plan of care in the presence of the entire team, if possible, including MDs, RNs, chaplain, SW/CM to ensure communication is consistent
- Holding pages from secretaries and asking fellow ED colleagues for help while you have this important conversation uninterrupted
Some of the above solutions are actively being implemented in the Methodist ED, and other sites are also being considered.
A sincere thank you to everyone who participated in this important conversation, particularly to our guest speakers, our resident leaders Amber Fouts (EM PGY-2) and Anar Desai (EM PGY-3), and to our faculty leader/presenter, Dr. Lindsay Weaver.
Submitted by: Kyra Reed, PGY-3 EM/Pediatrics