The conversation should not be about end-of-life care or do-not-resuscitate orders. The discussion should follow some simple guidelines:

• Introduction. Introduce yourself and state the reason for your questions.
• What’s happening. Ask patients and their families what they think is going on with their illness. Do they think they are getting better or worse? Simply opening this dialogue first helps you gather more information and may lead to the quick agreement that a person is dying. To our amazement, many patients or family members say, “I think I am dying,” or “I don’t think I will survive this.”
• Goals. The next focus is on exploring patients’ care goals and life goals. This allows you to change the conversation to what you, as a clinician, can do to support patients’ decisions. If they haven’t thought about this, a simple lead-in conversation, such as, “Let’s discuss planning for the worst and hoping for the best,” opens the discussion. Having this type of meeting and discussion is easier than you might imagine.
• Partnering. Rather than focusing on the traditional “all or none” divisive conversation, this changes the tenor of the conversation to a planning exercise with the emergency physician as a partner. Through this approach, the emergency physician in the initial case was able to guide the family to consider hospice and tone down acute aggressive treatment. However, sometimes this conversation may go nowhere due to reasons beyond your control, such as symptom severity or family members not being present. Remember, it is about patients’ goals—not yours.
• Palliative referral. A referral to your palliative services may be all that is needed so a family meeting can take place at a more appropriate time.

Key Element #3: Symptom Management

If patients want everything done, then consider time-limited interventions or therapy. A family meeting to discuss goals of care can be set up for the future.

This is one of the most important areas of palliative medicine in the emergency department and something we do every day. For all patients and families we see, we must be skilled in managing all physical, psychological, and spiritual symptoms, including pain and non-pain symptoms. Pain algorithms and guidelines exist, with conversion tables to control and alleviate pain. Other non-pain symptoms, such as dyspnea, nausea and vomiting, diarrhea, delirium, constipation, and anxiety, frequently need management and stabilization. The emergency physician must master this skill and knowledge.

MORE INFORMATION

TO LEARN MORE ABOUT EMERGENCY DEPARTMENT PALLIATIVE CARE, PLEASE SEE ACEP’S PALLIATIVE CARE SECTION AT
WWW.ACEP.ORG/PALLIATIVESECTION.