Integrating PC in the ER.pdf

I n t e g r a t i n g P a l l i a t i v e
C a r e i n t h e
E m e r g e n c y D e p a r t m e n t :
A P a r a d i g m S h i f t
Maria Fidelis Manalo, MD, MSc.
Palliative Care
The Medical City

P r e s e n t a t i o n
o u t l i n e
TOPICS TO BE DISCUSSED:
• How can early identification of the end-of-life state
reduce low-value emergency care?
• How can we integrate discussions about goals of
care, shared decision-making, and advance care
planning with the families of resuscitation patients?
• How can we optimize emergency treatment
planning to help reduce inappropriate CPR
attempts?

Choosing And Doing Wisely: Triage Level I Resuscitation A Possible New Field For
Starting Palliative Care And Avoiding Low-value Care –
A Nationwide Matched-pair Retrospective Cohort Study In Taiwan
Methods
• A matched-pair retrospective cohort study was conducted to examine the association between
palliative care and outcome variables using multivariate logistic regression and Kaplan–Meier
survival analyses.
• Between 2009 and 2013, 336 ED triage level I resuscitation patients received palliative care services
(palliative care group) under a universal health insurance scheme.
• Retrospective cohort matching was performed with those who received standard care at a ratio of
1:4 (usual care group).
• Outcome variables included:
• Number of visits to emergency and outpatient departments
• Hospitalization duration
• Total medical expenses
• Utilization of life-sustaining treatments
• Duration of survival following ED triage level I resuscitation
Lin, CY., Lee, YC. BMC Palliat Care, 2020

Choosing And Doing Wisely: Triage Level I Resuscitation A Possible New Field For
Starting Palliative Care And Avoiding Low-value Care –
A Nationwide Matched-pair Retrospective Cohort Study In Taiwan
Results
• The mean survival duration following level I resuscitation was less than 1 year.
• Palliative care was administered to 15% of the resuscitation cohort.
• The palliative care group received significantly less life-sustaining treatment than did the usual care
group.
Conclusion
• Among patients who underwent level I resuscitation, palliative care was inversely correlated with
the scope of life-sustaining treatments.
• Furthermore, triage level I resuscitation status may present a possible new field for starting
palliative care intervention and reducing low-value care.
Lin, CY., Lee, YC. BMC Palliat Care, 2020

People Enter The ED
In Search Of Help
When A Medical Or
Surgical Emergency
Arises
- Boyle S.
https://www.capc.org/blog/palliative-pulse-the-palliative-pulse-december-2018-integrating-
palliative-care-in-the-emergency-department-a-paradigm-shift/
•They arrive suffering from pain, respiratory
distress, with symptoms of a stroke or heart
attack, or as the victim of a motor vehicle
accident.
•These are the patients that ED physicians
and nurses have been trained to stabilize
and resuscitate; this is where the
adrenaline kicks in and the team jumps into
action.
•While ED staff are trained to save lives, all
too often they are also faced with
situations where the usual approach—
do everything and anything to prolong
life—may add to suffering with little to no
likelihood of benefit.

Recognizing
"Actively Dying" or
"Imminent Death"
• It is important for healthcare providers to be
familiar with this process:
– so they know what to expect when providing
direct care to patients during this time
– so they can guide the family in understanding what
to expect during this process and providing support
as needed
• The timeline for each patient is variable.
A patient may experience these signs and
symptoms over 24 hours or for longer than 14
days.
Oates JR, Maani CV. Death and Dying. [Updated 2021 Aug 30]. In: StatPearls [Internet].

• Early stage: Loss of mobility and becoming bed bound; loss of interest or ability to drink and
eat; cognitive changes to include increased time sleeping or experiencing delirium. Delirium
can be a hyperactive or agitated state or a hypoactive state. The trademark point of delirium
is there is an acute change in the level of arousal.
• Middle stage: Further decline in mental status to becoming obtunded or slow arousal with
stimulation and only brief periods of wakefulness. Patients often exhibit the "death rattle"
which a noisy breathing pattern caused by a pooling of oral secretions due to the loss of the
swallowing reflex.
• Late stage: Coma; fever, possibly due to aspiration pneumonia; an altered respiratory
pattern which can be periods of apnea alternated with hyperpnea or irregular breathing;
and mottled extremities due to the constriction of the peripheral circulation
Recognizing "Actively Dying" or "Imminent Death"
Oates JR, Maani CV. Death and Dying. [Updated 2021 Aug 30]. In: StatPearls [Internet].

Common Reasons Palliative Care Patients Present To The ED

Common Reasons Palliative Care
Patients Present To The ED

As an entry point to care, the ED is uniquely positioned to
identify the real needs of the patient and the family
- Boyle S.
https://www.capc.org/blog/palliative-pulse-the-palliative-pulse-december-2018-integrating-palliative-care-in-the-emergency-department-a-paradigm-shift/
Historically, however, ED clinicians have avoided goals of care conversations about
what is most important to the patient and family, assuming these were the domain of
the primary care clinicians or their hospital colleagues.
ED staff, in turn, suffered from varying degrees of moral distress and frustration at
their inability to meet their patient’s true needs in situations where the usual
approach to disease treatment appears to be doing more harm than good—by adding
stress and suffering without meaningful gain in survival, function, or quality of life.

Palliative Care In The
Emergency Department:
An Oxymoron Or
Just Good Medicine?

What is Palliative Care?
• Palliative care is an approach to patient/family/caregiver-centered health
care that focuses on optimal management of distressing symptoms, while
incorporating psychosocial and spiritual care according to
patient/family/caregiver needs, values, beliefs, and cultures.
• The goal of palliative care is to
• Anticipate, prevent, and reduce suffering
• Promote adaptive coping
• Support the best possible quality of life for patients/families/caregivers, regardless
of the stage of the disease or the need for other therapies

What is Palliative Care?
Palliative care can begin at diagnosis; be delivered concurrently with
disease-directed, life-prolonging therapies; and facilitate patient
autonomy, access to information, and choice.
Palliative care becomes the main focus of care when disease-directed,
life-prolonging therapies are no longer effective, appropriate, or desired.

Palliative Care Is NOT Synonymous With
End-of-life Care or Hospice Care
• Whereas palliative can begin at any point along the cancer care
continuum, hospice care begins when curative treatment is no longer the
goal of care and the sole focus is quality of life.
• Palliative care can help patients and their loved ones make the transition
from treatment meant to cure or control the disease to hospice care by:
• preparing them for physical changes that may occur near the end of life
• helping them cope with the different thoughts and emotional issues that arise
• providing support for family members
• Hospice care is always palliative, but not all palliative care is
hospice care.
Image courtesy of http://www.ersj.org.uk/content/32/3/796.full
- https://www.cancer.gov/about-cancer/advanced-cancer/care-choices/palliative-care-fact-sheet

When Is Palliative Care Used In Patient Care?
EARLY IN THE ILLNESS PROCESS

Who Gives Palliative Care?
• Palliative care should be provided by the primary
care team and augmented as needed by
collaboration with an interprofessional team of
palliative care experts.
• Palliative care specialists have received special
training and/or certification in palliative care.
- https://www.cancer.gov/about-cancer/advanced-cancer/care-choices/palliative-care-fact-sheet#when-is-palliative-care-used-in-cancer-care

Palliative Care Skills Relevant to ED Practice
- Quest TE, Lambda S.
https://www.uptodate.com/contents/palliative-care-for-adults-in-the-ed-concepts-presenting-complaints-and-symptom-management

Palliative Care Skills Relevant to ED Practice

Palliative Care Skills
Relevant to ED Practice

M a n a g i n g T h e p a l l i a t i v e c a r e
P a t i e n t W h o P r e s e n t s T o T h e E D

Palliative Care Referral
• Limited treatment options
• Concerns about decision
making capacity
• Need for clarification of goals
of care
• Resistance to engage in
advance care planning
• High risk of poor pain
management
• High non-pain symptom
burden
• High distress score
• Need for invasive procedures
• Frequent ER visits or hospital
admissions
• Need for ICU-level care (multi-
organ failure or prolonged MV
support)

Treat Distressing Symptoms
TOTAL PAIN CONTROL

Pain
Assessment
O P Q R S T
O - Onset
P - Provocative factors, Palliative factors
Q – Quality
R – Radiation, Referral pattern, Location
S - Severity or Intensity
T – Timing: onset, duration, course, persistent, or intermittent
Q – Quality

DYSPNEA CRISIS
COMFORT: Mnemonic Summarizing Key Palliative Management
- An Official American Thoracic Society Workshop Report: Assessment and Palliative Management of Dyspnea Crisis, Mularski RA et al, 2013
C: CALL for help.
Calming voice and
approach among
patient and caregivers
O: OBSERVE
closely and assess
dyspnea for ways to
respond
M: MEDICATIONS
to be tried
(recommendations
from providers for
opioid/other use)
F: FAN to face
may decrease shortness
of breath
O: OXYGEN therapy
as previously found
useful
R: REASSURE
and use relaxation
techniques
T: TIMING interventions
to reduce dyspnea–
work together–
reassess–repeat
Treat Distressing Symptoms

• Comfort care is often used in a misleading or
imprecise manner — for example, when such
care is automatically considered equivalent to a
Do-Not-Resuscitate order and, perhaps even
without discussion with the patient, is
extrapolated to mean the exclusion of a full
range of palliative measures appropriate for
the patient.
• Rather than simply writing orders for “comfort
care” (or “intensive comfort measures,” the
term that we prefer), the medical team should
review the entire plan of care and enter explicit
orders to promote comfort and prevent
unnecessary interventions.
- Craig D. Blinderman, CD, Billings, JA, Comfort Care for Patients Dying in the Hospital, N Engl J Med, 2015
U n d e r s t a n d i n g
C o m f o r t C a r e

U n d e r s t a n d i n g
C o m f o r t C a r e
• Infrequently, a focus on comfort care may
include the use of potentially life-
sustaining measures, when these are
consistent with a patient’s goals (e.g.,
when the patient wants to be kept alive
with mechanical ventilation until a loved
one can visit from afar or when
withdrawing a treatment conflicts with
the patient’s religious beliefs or cultural
norms).
• In addition, the use of invasive
interventional procedures, such as
thoracentesis for the treatment of
symptomatic pleural effusions, can
promote comfort.
- Craig D. Blinderman, CD, Billings, JA, Comfort Care for Patients Dying in the Hospital, N Engl J Med, 2015

An Official American Thoracic Society Statement: Update on the
Mechanisms, Assessment, and Management of Dyspnea

O p i o i d s a n d D y s p n e a
• Opioids have been the most widely studied agent in the
treatment of dyspnea.
• Opioids treat dyspnea through many mechanisms:
–Reducing respiratory drive
–Reducing anxiety
–Altering central responses to exertion
–Cough suppression
- American College of Chest Physicians consensus statement on the management of dyspnea in patients with advanced lung or heart disease.
Chest 2010;
- Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline
from the American College of Physicians. Ann Intern Med 2008;
- Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnea. BMJ
2003.

O p i o i d P a i n
M e d i c a t i o n :
S e p a r a t i n g M y t h
f r o m R e a l i t y
• Symptom-titrated opioids do not hasten death.
• With proper titration, clinically significant
respiratory depression does not occur because
pain is a powerful respiratory stimulant and
counteracts the narcotic-induced depression.
• Because pain is a stimulus to respiration,
clinically significant respiratory depression is
rare.
• Pain is nature's own antidote to respiratory
depression.
- Fohr, SA, Journal of Palliative Medicine, 1998

T r e a t D i s t r e s s i n g
S y m p t o m s
Delirium and agitation
Nausea and vomiting
Pruritus and sweating
Cough and hemoptysis
Constipation and malignant bowel obstruction
Chronic wounds, including malodorous or bleeding malignancy-related wounds
Acute urinary retention

If rapid decisions are required
regarding the use of life sustaining
treatments (e.g., intubation for
respiratory failure), whenever
possible, taking a few minutes to
clarify the patient’s goals and
preferences first, before discussing
actual decisions, can help others
engage in decision-making.
M a n a g i n g T h e
p a l l i a t i v e c a r e
P a t i e n t W h o
P r e s e n t s T o T h e E D

G u i d e F o r A n E f f i c i e n t D i s c u s s i o n O f
G o a l s O f C a r e I n T h e E D
1. Determine the legal decision maker.
If the patient is unable to make decisions, identify the appropriate
proxy/surrogate. Review any completed advance directives.
Adapted from: Weissman DE, Quill TE, Arnold RM. The family meeting: End of life goal setting and future planning. J Palliat Med 2010; 13:462.

G u i d e F o r A n E f f i c i e n t
D i s c u s s i o n O f G o a l s O f
C a r e I n T h e E D
2. Explain the prognosis. Discuss the "big picture."
Be clear; avoid vague language. If the condition is
incurable, say so.
•Frame the discussion as "hoping for the best
while preparing for the worst."
•Answer 2 key questions: What is wrong with the
patient? What will happen?

Issues that naturally arise during
conversations about goals of care
include the following:
Resuscitation
orders/code status
Use of invasive and noninvasive
diagnostic tests or treatments
(e.g., mechanical and
noninvasive ventilation,
hemodialysis, intravenous [IV]
vasopressors, surgery, blood
products, antibiotics)
Prognosis and
trajectory of illness
Approach and
commitment to
controlling symptoms
Disposition and discharge
options, to include home,
hospice care,
hospitalization, initiation of
critical care
https://www.uptodate.com/contents/palliative-care-for-adults-in-the-ed-goals-of-care-communication-consultation-and-patient-death

G u i d e F o r A n E f f i c i e n t
D i s c u s s i o n O f G o a l s O f
C a r e I n T h e E D
3. Elicit patient values. Engage the patient or
surrogate with open-ended questions:
"What is most important to you in your (or your
loved one's) life right now?"
"What kind of results are you hoping for?"
"What do you hope to avoid at all costs?"
If appropriate: "Have you been with someone
who had a particularly good death or a
particularly bad death? Tell me about it."

G u i d e F o r A n
E f f i c i e n t D i s c u s s i o n
O f G o a l s O f C a r e I n
T h e E D
4. Use appropriate language.
•Avoid negative statements, such
as: "Do you want us to withhold
aggressive treatment?"
•Frame the discussion positively:
•"We want to ensure that you receive
the kind of treatment you want."
•"Let us discuss how we can work
towards your wish to..." (e.g., stay at
home).

G u i d e F o r A n E f f i c i e n t D i s c u s s i o n
O f G o a l s O f C a r e I n T h e E D
5. Reconcile the goals of care.
Sometimes a "time-limited trial" of therapy is needed to help the patient and family
cope with circumstances or reach a consensus about goals. If so:
• Outline the proposed treatment plan clearly.
• State the goals that you are hoping to achieve with the plan.
• Clarify how you will determine that these goals are being met.
• Establish a period of time for determining if the intervention works and is consistent with
goals of care.
Clinicians may need to set limits on unrealistic goals without making the patient feel
abandoned: "I understand your goal is not to be a burden to your family and you want
an assisted death. Unfortunately, I cannot do that. However, I can help you manage
distressing symptoms, and I can find ways to help you not be a burden."

When decisions are made about
initiation of life-sustaining
interventions, it is often helpful
to present treatment options as
time-limited trials to see if they
will meet the care goals; if they
do not, this may set the stage
for possible withdrawal later
when they no longer meet the
patient’s care goals.
R a p i d
g o a l s o f c a r e
d i s c u s s i o n s

Another productive tactic is to
portray life-sustaining
treatments as “bridges to
recovery,” thus implying that
life-sustaining treatment is not
intended to be indefinite therapy
and is only appropriate when the
patient has the potential for
recovery at some future time.
R a p i d
g o a l s o f c a r e
d i s c u s s i o n s

G u i d e F o r
A n
E f f i c i e n t
D i s c u s s i o
n O f G o a l s
O f C a r e I n
T h e E D
6. Recommend a care plan based on the patient's goals.
a. Summarize the patient goal (e.g., "From what I
understand, your goal is to...")
b. Outline the plan (e.g., "In order to meet this goal,
we can...")
c. Be specific whenever possible ("I would/would not
recommend...")
•Discuss discontinuing interventions and therapies that
will not help meet the patient's goals.
•Diagnostic, treatment, and disposition plans are best
formulated and discussed with the patient's goals of
care in mind.

P a t i e n t W h o P r e s e n t s
T o T h e E D

P a t i e n t W h o

M a n a g i n g T h e p a l l i a t i v e c a r e P a t i e n t
W h o P r e s e n t s T o T h e E D

M a n a g i n g T h e p a l l i a t i v e
c a r e P a t i e n t W h o

“There is nothing more that can be
done” does not exist in the lexicon
of palliative medicine.”
We do not abandon dying patients
and their families.
W e c o n t i n u e t o
p r o v i d e
c o m p a s s i o n a t e
c a r e e v e n w h e n
c u r e i s n o
l o n g e r p o s s i b l e

1) To see the patient & the family through
the physical & emotional stages of terminal illness
2) To ease their burden along the way
to walk alongside, not to give orders from above
3) To be there
when symptoms arise, when hard questions
have to be faced, when fear & loneliness threaten
T A S K S O F T H E
M U L T I D I S C I P L I N A R Y C A R E
T E A M

T A S K S O F T H E
M U L T I D I S C I P L I N A R Y
C A R E T E A M
To apply to the care of
the seriously-ill,
the terminally-ill, and
the dying
the same high standards of clinical
analysis & decision-making as are
demanded in the care of patients
expected to get well

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