Patients who live with complex serious illness are a large proportion of the patients we see in the emergency department. The ED is the staging area for patients at all critical points of their serious illness. These difficult patients and their families are often bewildered and defensive, having been to numerous specialists and facilities in an attempt to control their illness. We have a unique opportunity in the ED to make a difference. Palliative care principles can be applied in the ED under many circumstances. Discussing serious illness, guiding future care such as code status and advance care planning, prognosticating, managing symptoms, and dispositioning can all be addressed.
Explore This IssueACEP Now: Vol 34 – No 08 – August 2015
The following actual cases illustrate palliative care principles applied to common ED scenarios: the extreme, the game changer, and the mundane. We hope to convey the significant difference that palliative interventions in the ED can make to families, caregivers, and the overall trajectory of the patient’s care.
Case 1: The Extreme
A 69-year-old man presented with hematemesis, headache, and visual changes. He had a history of metastatic prostate cancer and was currently undergoing chemotherapy. On exam, he was very pale with dried blood around his mouth, lethargic, and in moderate distress. While in the ED, he deteriorated rapidly, became unresponsive, and started posturing. During intubation, the medical team also noticed one of his pupils was blown. His blood work showed pancytopenia, including platelets of 5,000.
- Standard approach: Intubate, resuscitate, computed tomography (CT) scan when stable, and admit to the intensive care unit (ICU).
- Palliative approach: Invite family to witness the resuscitation, initiate prognosis conversations with wife (early), ask about advance directives, discuss the prognosis clearly and realistically explore the possibility of terminal extubation, provide aggressive symptom management, and admit to floor.
More history was obtained from his wife, who was distraught but able to communicate well. The patient was currently receiving chemotherapy for prostate cancer metastatic to bone. He had received a double dose the week before because the couple were supposed to go on a cruise that week. That morning, he started vomiting, and when the wife got home from work, she saw that it was bloody and he was much sicker than he ever had been. He had no advance directives, but she knew that he did not want to be kept alive by machines. His wife was aware that the chemotherapy was palliative, meaning not curative. He had been tolerating it well so far with minimal side effects and was still very functional at home. They were hopeful for more time.
We invited the wife to watch the resuscitation, and together with her, we decided to intubate the patient in order to obtain the CT scan. The scan showed a large left-sided bleed with 2 cm midline shift and herniation. This confirmed the prognosis, which had already been shared with the wife based on our clinical findings: this type of injury to the brain is not survivable. She told us to stop everything that could possibly prolong his suffering. We moved him to a special room in the ED, turned off the monitors, and called the chaplain at the family’s request. The wife called in her family, and when everyone was present, we extubated him. He lived for two more hours, during which time we treated his dyspnea with morphine and his secretions with sublingual atropine drops, plus answered all of his family’s questions. We admitted him to a hospice room on the floor. He died in the ED just as a room became available.
Case 2: The Game Changer
A 59-year-old woman with colon cancer metastasized to the liver, pancreas, lung, and brain presented to the ED with shortness of breath for one day and abdominal pain. On exam, she was in moderate respiratory distress with tachypnea, tachycardia, hypertension, and hypoxia. Her lungs were clear, and her abdomen was diffusely tender with a hard palpable mass. Her daughter was with her at the bedside. Per her daughter, the patient had been feeling short of breath all day and then syncopized (without head trauma) trying to get back to bed from the bathroom.
- Standard approach: Labs, chest X-ray, CT angiography of the chest for possible pulmonary embolism, and admit to ICU.
- Palliative approach: Symptom management, goals-of-care discussion, work-up, and disposition.
On further history, we found that the patient had extensive chemotherapy and radiation, most recently whole brain radiation two months ago that shrank the tumor briefly, but a recent scan showed tumor recurrence. Her oncologist had stated that there were no further chemotherapy options but discussed possible experimental treatment. She suffered constantly from abdominal pain, and she was treated with both long-acting morphine and short-acting morphine. However, upon further questioning, the patient admitted she was not taking any opiates, only the occasional Tylenol because she did not want to feel “drugged.” The patient was essentially opiate naive. She was given 5 mg morphine, 4 mg ondansetron, and 25 mg Benadryl. After a half hour, the patient was resting comfortably and was able to walk with assistance to the bathroom. Her vitals normalized, and her chest X-ray and labs were all essentially normal.
Now that the patient was comfortable and the daughter was calmer, a physician sat down with them and asked gently, “What do you think is going on with your cancer?” The patient replied, “I think I am in the final stage; I think I am dying.” The physician said nothing and just sat with them. Finally, the physician said, “I think you are right. If conditions were ideal, where do you want to be?” Without hesitation she said, “Home.” Her daughter agreed. The daughter handed the physician an advance directive that the patient filled out 10 years ago before she got sick. The medical team reviewed it. No machines, no heroics, no experimental treatments.
We explained that a likely cause for her shortness of breath was that she was not treating her pain adequately and she was trying to live with an incredible amount of pain. Another worrisome alternative was a pulmonary embolus. If this were the case, the treatment would be a blood thinner. Blood thinners are contraindicated in brain metastases because of the high likelihood of bleeding. When we explained this to the family, they agreed that we should not do the scan because it would not change our management or the outcome. Since we were able to control her symptoms with a small dose of morphine, we were confident that this could be easily converted to oral medication to take at home.
How do you honor this patient’s wishes to go home? “I think the best way to get you home is to use the hospice service,” we advised. We explained what hospice is and what it isn’t. In her case, she had a primary caregiver, her daughter, and symptoms that can be controlled with oral medication. Hospice would provide all the medical equipment, including medications, with a nurse on call 24-7. There would be home health aides that come weekly, as well as social workers and bereavement services available. They would help the patient and her family make the most of the time she has. The patient and daughter loved the idea. We called the local hospice agency, and they arranged to meet the family and patient at home later that day. We discharged the patient.
Case 3: The Mundane
A 94-year-old woman was brought from home by her niece, who had been away for several days on business and unable to check on her aunt. On exam, the patient had swollen, red, painful legs that had worsened over the past week. Her current medical history included hypertension, hyperlipidemia, and congestive heart failure (CHF). She was put on antibiotics by her doctor, but they had not improved her symptoms. She was fully oriented and stated she did not want to come to the hospital. Her exam and work-up verified leg cellulitis, resulting in mild sepsis without evidence of CHF.
To think about this case in the broader context of this woman’s life, we needed to think about her illness trajectory. She was 94 with multiple chronic conditions. This event most likely heralded the beginning of a steady decline, punctuated by trips to the hospital and rehab, with possibly a short trip home, only to be repeated until her death.
- Standard approach: Intravenous antibiotics, admit to floor, and default full code.
- Palliative approach: Discuss her prognosis, goals of care, and trajectory of illness and fill out a physician order for life-sustaining treatment (POLST) form with patient and power of attorney (POA).
While we waited for her primary physician to call back, we asked a few basic questions. What had her life been like the past few weeks? Why didn’t she want to come to the hospital? Who will make decisions for her when she is no longer able? Does she have an advance directive or living will? We found out that she had been very independent until the last couple of months when she had required more and more assistance. She did not want to come to the ED because she knew she would be admitted, and she hated being in the hospital. She did not want us to “do anything” to her. Her goals were to remain as independent as possible at home. Her niece was her POA, and she, indeed, had a living will but not with her. We asked what her living will said, and she said that she did not want to be on life support or on any machines.
We explained to her that we would not do anything to her that she did not want us to do and that we would make sure her wishes would be followed in the event she worsened. We gave her our prognosis: she would probably improve from this infection, but she would most likely not be able to function at the level she had before and would likely need more help.
She and her niece were visibly relieved. The patient was admitted with a code status of do-not-resuscitate/do-not-intubate. Although it would probably not be relevant during this admission, we filled out a POLST form and explained that it would follow her to every facility to help ensure her wishes were followed. Our discussion and plan laid the groundwork for her admission and subsequent care because now future providers can see the POLST and take into account her goals of care.
As these three cases illustrate, the context of a patient’s serious illness is extremely important. Finding out where the patient falls on the trajectory of the illness (just diagnosed, end-stage, currently undergoing treatment, bouncing back more frequently to the ED) is crucial in prognostication. Aggressive symptom management ensures patient comfort and family trust in you as the provider and builds a foundation for subsequent conversations. Involving the family early in witnessing resuscitation and communicating prognosis can significantly impact the patient’s course. Exploring the patient’s goals of care, fears, and hopes can also help you make the most appropriate recommendations for the patient and family. The more doctors or providers speak to families and patients about these issues, the more it becomes a normal part of what we do. Even if the family is completely reticent or shut down in distrust or denial, you can suggest a palliative care consult to the primary physician to continue to work with the family and patient beyond the ED.
The authors are members of the ACEP Palliative Medicine Section. Dr. Goett is assistant professor and assistant director for advanced illness and bioethics in the departments of emergency medicine and palliative care at New Jersey Medical School/Rutgers University in Newark, New Jersey. Dr. Fetzer is an emergency medicine attending physician at Advocate Health Care and director of palliative care at Rainbow Hospice and Palliative Care in Mount Prospect and Park Ridge, Illinois. Dr. Aberger is core faculty in emergency medicine and palliative medicine at St. Joseph’s Regional Medical Center in Paterson, New Jersey. Dr. Rosenberg is chairman of emergency medicine at St. Joseph’s Healthcare System and associate professor of clinical emergency medicine at New York Medical College.