Clinical Vignette
A frail 95-year-old woman with multiple medical comorbidities presents to the emergency department with somnolence and confusion. She lives in a nursing home, and staff noticed she was sleepier than usual and not communicating as she normally does. She was also displaying labored breathing.
On arrival, EMS noted minimal responsiveness, a heart rate of 32 beats per minute, and blood pressure of 83/50 mmHg, both of which improved with the initiation of transcutaneous pacing. EMS also recorded an SpO2 of 80% which improved to 92% after initiating 6L oxygen via nasal cannula.
The patient has a past medical history of CHF, atrial flutter, interstitial lung disease, CKD stage IV, vascular dementia with prior stroke, residual left-sided weakness, and dysarthria. She does not ambulate at baseline, and code status at her nursing home is documented as DNR/DNI.
Upon arrival at the ED, an ECG is obtained while pacing is paused. It shows a junctional bradycardia with a heart rate of 30. She becomes hypotensive and somnolent while pacing is paused. External pacing is resumed, and mechanical capture is achieved with improvement in her mental status and blood pressure. Her new onset junctional bradycardia is discussed with cardiology and the patient’s healthcare agent/proxy, her daughter. It is determined that ultimately permanent pacemaker placement would be the only definitive treatment, although there is some concern that she may not tolerate it well.
The patient’s daughter further discusses the situation with additional family, the emergency medicine team, and the cardiology team. The patient’s family decides to terminate transcutaneous pacing and transition the focus of her care to maintain comfort, understanding she is expected to pass away from her current medical condition. Her daughter requests she be transported back to her nursing home to expire because it is more peaceful there. The patient is provided supplemental oxygen for comfort, and cardiopulmonary monitoring is stopped. Intravenous access is currently maintained for medication delivery. After 15 minutes, the patient becomes tachypneic and agitated, which is relieved with1 mg IV lorazepam. After approximately 30 minutes, she begins to appear agitated and restless; her symptoms again improve with an additional dose of IV lorazepam.
What is Palliative Medicine?
Palliative medicine is a medical specialty that focuses on preventing and relieving suffering and emphasizing quality of life for patients who are experiencing a serious and/or life-threatening condition, as well as their families.1 Physicians who complete fellowship training in Hospice and Palliative Medicine develop expertise in symptom management and effective communication skills.
What is Palliative Care?
Palliative care is an interdisciplinary field that focuses on preventing and relieving suffering and emphasizing quality of life for patients with a serious illness, such as a life-threatening or life-limiting condition, as well as their families.1 The disciplines represented within this broad field include social work, spiritual care, nursing, pharmacy, and medicine. Palliative care is not limited to dying patients and may be offered in conjunction with life-prolonging treatment.
Palliative care teams may help support patients and families through symptom management, discussing goals of care, or initiating and establishing adequate resources for patients and their family members to assist in their disease process, as well as coordinating all these aspects among multiple disciplines of medicine, and more.
What is Hospice Care?
It is important to distinguish between hospice care and palliative care. While hospice provides palliative care, palliative care is not synonymous with hospice. Palliative care provides quality of life and symptom management in all patient populations, not just those with a terminal illness with a life expectancy of fewer than six months.
The goal of hospice care is to provide medical care for patients with terminal illnesses. It is also to provide support and care for their family members and other caregivers. It focuses on quality of life rather than attempting to cure disease or prolong life. It has a specific role when patients and/or their families/loved ones decide to cease potentially curative therapies to focus on quality of life. Patients who qualify are those with a life expectancy of fewer than six months.
Palliative Care in the ED
Although most evaluations and interventions focus on providing life-sustaining interventions in the emergency department, emergency physicians must also be prepared to provide proper care to individuals who may not benefit from the introduction of life-sustaining interventions. Therefore, emergency physicians must have knowledge of palliative care and must be able to perform palliative care when indicated. In specific situations, a palliative care consultation may be helpful in initiating and coordinating care for patients who would benefit. The emergency physician may find the following tips helpful when getting a palliative care team involved.
Tips for Consulting Palliative Medicine
1. Know when it is appropriate to consult palliative medicine. The following is a general list of situations when consultation of palliative medicine may be appropriate:
- Difficulty in managing pain or other symptoms
- Symptom management for an actively dying patient
- Rapid consensus for goals of care
- Clarification of provisions in an advance directive
- Withdrawal of non-beneficial treatments
- Bereavement support
- Challenging dispositions requiring care coordination2-4
2. Have a specific question. As with any consult, asking a direct question you would like assistance with is appreciated. “I would like assistance with pain and anxiety medications management for a patient.” This example provides palliative medicine providers with a particular goal, allowing them to begin to formulate a plan.
3. Provide a thorough history to the palliative medicine provider. At this point in the patient’s care, you know much more about the patient and their history than the consultant. Be sure to provide as much history as you can regarding the patient’s presentation and what you have done so far in the emergency department.
4. Introduce the concept of palliative care with the patient/family before consulting palliative medicine. It is important that the patient and family members or any other individuals involved in the decision-making process understand what palliative medicine offers. Many individuals hear the term “palliative care” without a true understanding of what this field of medicine involves. It is important to inform them of what the scope of practice and goals of palliative medicine are so they have better insight into what will potentially be involved in care going forward.
5. Begin the palliative process in the emergency department. Emergency physicians can and should begin goals of care discussions and symptom management when appropriate. These are all things that can and should be done before consulting palliative medicine.
Case Resolution
You discuss with the family the idea of consulting palliative medicine. You explain to them the role they will play and their expertise in symptom management in end-of-life care. They agree with the consultation. You then consult palliative medicine for assistance with symptom management. You review the nature of the patient’s presentation and the goals of care discussions that were already made with the patient’s family. The palliative medicine physician recommends admission to their service and discusses this with the daughter, who agrees to admission for end-of-life care.
Take-Home Points
- When you consult palliative medicine:
- Know when it is appropriate to consult their service.
- Begin the discussion with the family and consider recommending palliative involvement.
- Have a specific question.
- Provide a thorough history to the palliative medicine provider.
- Begin the process of palliative treatment in the ED if appropriate.
- Patients who have a terminal illness and life expectancy of fewer than six months are eligible for hospice.
- Although hospice includes palliative care, palliative care is not hospice.
References
- Sepúlveda C, Marlin A, Yoshida T, Ullrich A. Palliative Care: the World Health Organization’s global perspective. J Pain Symptom Manage. 2002;24(2):91-96.
- Lamba S, Nagurka R, Walther S, Murphy P. Emergency-department-initiated palliative care consults: a descriptive analysis. J Palliat Med. 2012;15(6):633-636.
- Weissman DE. Consultation in palliative medicine. Arch Intern Med. 1997;157(7):733-737.
- Mierendorf SM, Gidvani V. Palliative care in the emergency department. Perm J. 2014;18(2):77-85.