endoflife
end of life care
see also:
“it’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.
Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen—that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).”1)
introduction
end of life care is a critical aspect for an ED which must be approached with sensitivity, decisiveness and compassion.
end of life care in this article refers more to the acute situation found in the ED where it is likely the patient will die within a matter of hours or days. See elsewhere for
palliative care of patients with terminal illnesses requiring prolonged care such as provided by hospices.
it is critical to understand that resuscitative procedures such as intubation should NOT be attempted if an ICU department would not consider such a patient for admission, irrespective of the wishes of the family - this would NOT be in the interest of the patient whose suffering would be prolonged, and they would almost certainly never regain consciousness post-extubation - thereby preventing family an opportunity to partake in a final parting while the patient can still communicate.
when a potentially reversible problem is suspected, the ratio of the risk and discomfort of diagnostic and therapeutic interventions needs to be considered in light of the patients projected lifespan, the probability of the therapy being successful and available, and the values, needs and wishes of the patient.
nursing home patients who are not applicable for intubation should have a standing NFR order (advanced care directive).
if they deteriorate with a condition that is not reversible, then, ideally, they should receive their end of life care at the nursing home where they and their family are familiar with both environment and staff. To be transferred unnecessarily to an ED to die is an added stress to all concerned and usually fails both the patient and their family at this important time.
please see the above documents for more details and legal aspects including patient rights to receive or refuse treatments, advanced directives, the doctor's right to with-hold or withdraw treatment which are not in the patient's interests, and the right to give pain killers and sedatives with the prime aim to reduce a patient's discomfort despite the knowledge that doing so may hasten an inevitable death.
deciding when resuscitative care is futile
it can be difficult at times to decide when resuscitation is futile
at times, short term resuscitation even when clinically futile, may still have a role if its benefits outweigh the harm, for example:
the decision must be individualised based not only upon known futility of the benefits of proposed resuscitation (one should ask - will the intervention work?) but also upon the harm this may impose upon the patient and family, in particular, in preventing good clinical management which would allow a “good death”, and instead causing prolonged pain or suffering, preventing family communication (eg. by intubation), and creating false hopes.
one will not be doing the patient or family any favors if one embarks on intubation and critical care pathway in a patient with poor quality of life and a largely irreversible condition such as end stage COPD or cardiac failure, for them to gradually die from multi-system failure whilst mechanically ventilated over the following weeks in an intensive care environment.
interventions which are likely to be futile even in those without prior morbidity
ED management
early decision, preferably by a senior doctor, that the current event will very likely be a terminal event and that resuscitative attempts would not be in the interests of the patient and would only prolong suffering before an inevitable death.
early discussion with family, and patient if possible
document “Not For Resuscitation (NFR) order” to ensure staff are empowered to provide the best end of life care possible
aim to have patient transferred to an appropriate ward bed as soon as possible - the ED is NOT the place for planned births nor for end of life care - the patient and family deserves peace and quiet, and the environment and privacy to allow the final parting and grieving with dignity.
ideally, the patient should be admitted to a palliative care bed or returned to the familiar environment of their nursing home, but if neither of these are possible, then a general medical ward admission is a reasonable compromise.
patient and family should be offered access to pastoral care such as a priest or similar spiritual leader, for last rites, etc.
usual medications to be prescribed
s/cutaneous line should be inserted and any iv line removed
s/c fentanyl 25-50mcg prn for pain, agitation or dyspnoea
s/c midazolam 2.5mg prn for agitation or dyspnoea
s/c haloperidol 0.5mg prn for vomiting or agitation
s/c atropine 0.6mg to control excess retained secretions
glycerine supps
bisacodyl supps
s/c normal saline at a rate of 1L/24hrs for comfort to avoid development of dehydration
consider adding:
fentanyl 100mcg over 24 hrs (or morphine 10mg over 24hrs if not in renal failure)
midazolam 5mg over 24hrs if restless
haloperidol 1mg over 24hrs if agitated
NB. higher doses may be required if patient is already on opiates
NB. lower doses may be adequate in the frail elderly or those with renal failure
end of life care patient observations
patient obs scored on scale 1 to 10
pain
breathing problems
agitation
nausea
family obs on scale 0 to 3
urgent clinical review by care team
Unresolved Pain scores ≥7
Unresolved Breathing problems ≥5 despite routine management
Unresolved Agitation ≥5 despite routine management
Unresolved Vomiting ≥5 despite routine management
Catastrophic events, such as acute airway obstruction or torrential bleeding
Unresolved Family distress
Any other unresolved symptom for which you require support to initiate management
less urgent clinical review criteria
Pain score ≥5 despite repositioning, and administration of medication
Breathing problems ≥5 despite routine management
Agitation ≥5 despite routine management
Nausea ≥5 despite routine management
Vomiting ≥5 despite routine management
Family distress score ≥2 despite routine management
New symptoms perceived to be distressing to patient and or family
bereavement care
endoflife.txt · Last modified: 2019/02/16 11:54 (external edit)