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Viewpoint: The Silver Hour

Knepel, Sheri MD

doi: 10.1097/01.EEM.0000418683.02837.0a

Dr. Knepelis an assistant professor of emergency medicine at the Ohio State University College of Medicine.



I got more hugs during my last shift in the ED than I have for as long as I can remember. I didn't help save a life. Instead, I helped transition one.

My patient was a 79-year-old man with end-stage dementia. He and his family had recently established a DNR order with comfort care only. This day, the patient had become suddenly dyspneic, hypoxic, and less responsive. He had been treated palliatively with oxygen, pain control, benzodiazepines, and atropine drops for secretions. That evening, however, the family asked that he be brought to the ED.

It was one of those shifts: a seven-hour wait in the lobby, we were boarding half of our beds, we were short nurses.

The patient arrived unresponsive with an oxygen saturation in the 80s on a nonrebreather. If we were providing typical ED care, he would need to be intubated and resuscitated immediately. Instead, we quickly talked to family. They told us the story, and said if the patient only needed antibiotics to get well, they wanted him to be treated. They also wanted him to be comfortable. Later, they gave me the real reason they were there; they just wanted to make sure they were doing the right thing.

We talked about the patient's wishes and what he would want. We talked about his devout Catholicism. The chaplain was able to find a priest to -administer last rites. The patient eventually left with his family, and I got hugs.

So, palliative care in the ED. Is it an oxymoron or an emerging facet of our practice? It goes against all we have been trained to do in many ways. We are skilled at fighting death but not transitioning to it. We all know about the golden hour of trauma, but how many of us know about the silver hour of palliative care?

Palliative care is “the active total care of patients whose disease is not -responsive to curative treatment,” -according to the World Health Organization. Controlling pain and other symptoms and addressing psychological, social, and spiritual problems is paramount. The goal of palliative care is to achieve the best quality of life for patients and their families.

The most common diagnoses associated with palliative care include cancer, HIV/AIDS, congestive heart failure, chronic obstructive pulmonary disease, end-stage renal disease, liver failure, dementia, and stroke. Chief complaints include dyspnea/-secretions, GI complaints, anxiety and depression, delirium, and pain. The American Board of Emergency Medicine and nine other ABMS boards approved palliative medicine as a subspecialty in 2006, and the term, the silver hour, was coined by Marilyn Smith-Stoner, RN, PhD, three years later to describe the last moments of a patient's life and the first moments of death. (

Why is the silver hour of palliative care important in the ED? First, the patient-based answer. Death is an event; perhaps the most important visit to the doctor that the patient and family will ever make. Death is one of the pinnacle moments of life. There is only one chance to get it right.

Second, the practice-based answer. One in 500 patients who present to the ED die in the ED, and another three percent die following admission. This equals 768,000 patients per year who die during the visit or shortly after their visit to the ED. If you see 2.5 patients per hour and work 156 hours in a month, roughly 12 of your patients will die each month shortly after seeing you. And our population is aging; the first baby boomers turned 65 in 2011, so the number who die in the ED will grow.

Finally, the systems-based answer. A study published in the Archives of -Internal Medicine in 2008 found that patients who received palliative care services cost the hospital $1696 to $4908 less per admission. (2008;168 [16]:1783.) Insurers notice these things. As usual, financial concerns will help shape our practice.

The elephant in the room, of course, is ourselves. We have to deal with our own barriers. This is not an easy patient to pick up. This is not an easy conversation to have. It is emotionally draining, and a lot of us bring baggage from our own previous experiences, fears, beliefs, or denials.

Time is also a barrier because palliative care takes a lot of it, and time is difficult to find in the middle of a busy shift. And the system itself is a major barrier. Physicians cannot do it all. The palliative care process has multiple components: physical (this we can do), psychological, social, and spiritual. We need a team approach, and at a minimum that means a doctor, nurse, social worker, and spiritual advisor. This is often difficult to achieve at 3 a.m.

We need to educate ourselves to practice good palliative care. This is a teachable skill in the same way placing a chest tube or draining an abscess is. Many resources are available; a great one is the EPEC-EM project (Education in Palliative and End-of-life Care for Emergency Medicine;

In the meantime, start with doing what we do now:

  • Evaluate: Assess the situation. Examine the patient. Determine the chief complaint. Find out why he came. Some come for treatment, others for symptom control, IV fluids, thoracentesis, paracentesis, urinary catheters for retention, or antibiotics for pneumonia. Some patients or their families need reassurance. Some come because they do not want to die at home. Some come because they don't know they are dying.
  • Communicate: Have a conversation with the patient and family and deliberately address the topic. Know with whom you are talking. Ask the family members what they know. Approach the conversation with respect, and allow the patient to have dignity. Enlist family support.
  • Plan: Give the patient and family choices. Establish goals of care. Validate their refusal of treatment, if needed. Reassure the family that we can control symptoms and make the patient comfortable. Treat symptoms aggressively. Establish the plan. Confirm the plan. Make the bad less bad.

Remember each situation is unique in its cultural, psychosocial, family, and other issues that we may not understand. Remember that there is no right answer. The difference compared with our usual practice is that we aren't -trying to fix something. The similarity is that we are practicing medicine.

Do what is right for the patient, and you might get a hug.

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The Geriatric Tsunami

How will a burgeoning geriatric population affect EDs? Read Dr. Graham Walker's Emergentology column on p. 18.

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