Heuristics serve us well in emergency medicine. During our busy, decision-dense shifts, a term Pat Croskerry, MD, PhD, coined, we make diagnostic and treatment decisions in quick succession in a hectic and unique environment that has been equated to managing spinning plates. (Pediatr Emerg Care 2014;30:104.) Algorithms are useful in providing guidance through decision points to avoid omissions and to ensure that we consider specific recommended treatments.
My word of caution is that overreliance on these patterns often fail to account for differing circumstances such as comorbidities, disease trajectory, prognosis, and most importantly, goals of care. The 39-year-old healthy man with a fever of 102°F, cough, and respiratory distress and the 92-year-old bedbound patient with advanced Alzheimer's dementia, a fever of 102°F, cough, and respiratory distress clearly represent cases of sepsis. Protocols outline interventions that may include large bore intravenous lines, obtaining blood cultures and initiating antibiotics, blood transfusions, and mechanical ventilation. But I suggest that these two patients are different, and, in fact, deserve a very different approach.
But how do we figure out how to navigate those next steps? That is where palliative care comes in. We emergency physicians have a broad skillset that borrows from all other specialties, and palliative medicine should be no different. Developing expertise in communication strategies during these important and sometimes difficult conversations about next steps is an important tool to add to our armamentarium.
Breaking It Down
The first step is to stop. You may consider initiating diagnostic studies and interventions that are relatively low burden when the patient first arrives and while performing a chart review or waiting for family members to arrive, even an intravenous line and basic labs, a small bolus of normal saline, and noninvasive positive pressure ventilation, if necessary, to stabilize the patient.
The next step is to ask. Start by determining what the family knows. Ascertaining this information lets you know where you need to start the conversation. Then inform them of the gravity of the current situation: “Your mother is critically ill. I believe she has an infection in her lungs and because of her advanced age and serious disease, I am concerned about her.”
Next, determine if and what previous conversations have been had about advance care planning. I often start with, “We need to talk about next steps. And those next steps depend on you and your family. Had you ever spoken to your mom about advance directives? Does she have a health care proxy?”
You will need to explore the patient's and family's values. Determine what is most important to the family. Often, I get pieces of information that give me a jumping-off point. “She never wanted to go to a nursing home” leads me to ask, “It seems like being at home is important for your mother. Can you tell me a bit more about that?”
The final step is to make a recommendation. Families are lost and confused in this moment when their family member's condition has clearly changed. Based on what you have learned about the patient, guide the patient and family through next steps. You might say, “Based on what I've learned, I'd suggest that we look for reversible processes that we can potentially treat such as the infection and dehydration. Also, given that you've told me that being at home is paramount for your mother, some families would consider allowing her a natural death and avoiding aggressive interventions such as mechanical ventilation that would commit her to a hospitalization in the ICU.” They may agree or they may not be ready or willing to make this decision. You have at least notified them that their mother is critically ill and they need to start thinking about these difficult decisions.
Not All or Nothing
It is also important to remember that there is not an all (e.g., intubation, pressors, antibiotics, ICU admission) or nothing (e.g., comfort measures) situation. This is a unique journey for each family and patient.
I often hear the argument that initiating these discussions is not appropriate in the emergency department. I argue that the emergency department is the perfect (but perhaps not ideal) place for palliative care. It is our job as the physicians who initiate these aggressive measures and set the treatment trajectory to ensure that the goals of our treatments are consistent with the goals of our patients. At this point where the patient's disease course has worsened, it is an opportune time to introduce a conversation about the direction of care.
I also encourage emergency physicians to consider palliative care not only for the elderly or the imminently dying patient. End-stage renal patients who continuously have complications with their hemodialysis, advanced congestive heart failure patients who present to the ED week after week, and oxygen-dependent COPD patients with declining functional status would benefit from symptom management and assistance in navigating treatment decisions provided by a palliative care team. This may necessitate time and skills that are beyond the scope of emergency medicine and, if available, involving palliative care specialty services would be appropriate.
Palliative care is not about dying. It is about living the best life possible. Forging a stronger partnership between emergency medicine and palliative care will help us to help our patients toward this goal.
Palliative Care Steps in the ED
- Consider starting diagnostic studies and interventions that are relatively low burden, such as ordering an intravenous line and basic labs, initiating a small bolus of normal saline, and even start noninvasive positive pressure ventilation to stabilize the patient.
- Determine what the family knows.
- Inform them of the gravity of the current situation.
- Determine if and what previous conversations have been had regarding advanced care planning.
- Explore the patient's and family's values.
- Make a recommendation.
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