ACEP’s Choosing Wisely initiative recommendations state, “Don’t delay engaging available palliative and hospice care services in the emergency department for patients likely to benefit.”20 Identifying patients is the critical first step. After using available assessment tools to recognize patients who may benefit, a referral can be made to the existing in-hospital or community hospice intake case manager for evaluation and further discussion with the patients and their families.
Rapid Assessment in the Critically Ill Patient with a Terminal Condition
In the absence of clear goals for medical interventions as the patient nears EOL from a terminal illness, the nearest emergency department becomes the default destination once the patient begins physiological decline. This is typically brought on by predictable organ failure or infection. In such situations, if the patient or family is unprepared to manage this expected trajectory of decline, the emergency physician becomes responsible for recognizing the situation and its context while simultaneously guiding communications to steer medically appropriate interventions within the context of the patient’s goals for those interventions.
As emergency physicians, we are comfortable identifying surgical situations where there are no reasonable interventions to alter the outcome. Some examples include the patient with metastatic cancer and carcinomatosis who presents with a ruptured viscus and multi-organ failure, the elderly patient with a devastating intracranial hemorrhage with mass shift and herniation, and the person struck by a car and found pulseless in the field with no return of spontaneous circulation by the time of arrival to the emergency department. It may be less clear what interventions are appropriate in a patient who is dying from a terminal medical illness. With a few simple guiding principles, emergency physicians can effectively navigate these critical moments while keeping the goals of the patient a priority.
A rapid approach to communication in such critical situations comes from the Education in Palliative and End-of-Life Care–Emergency Medicine (EPEC-EM) curriculum.21 Most of us were trained to use the “A, B, C, D” approach for initial evaluation of the critical patient, where A=airway, B=breathing, C=circulation, and D=disability. The EPEC-EM approach draws on this model to allow for a simultaneous assessment of palliative considerations to drive intervention decisions. In this model, A=advance care plan (is there one available to review?), B=better symptom control (what can be immediately done to mitigate overwhelming symptoms such as dyspnea or pain?), C=caregivers (is there an available caregiver for information on the patient’s clinical context and recent functional changes?), and D=decision-making capacity (does the patient have capacity to discuss goals, or is the legal surrogate identified and accessible?). The four points may only take minutes to accomplish yet have the potential to dramatically affect the outcome for the patient.
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