Palliative medicine

Palliative Care in the ED
  • Palliative care is defined as specialized medical care for patients suffering from severe illness
  • Focused on alleviating symptoms and psychosocial distress, with truly patient-centered approach
  • Palliative and curative care are not mutually exclusive
    • Given misconceptions that palliative care = hospice, important to introduce role of pall care team to patient/family as specialists in symptom control, communication, and psychosocial support
    • E.g. "Have you ever heard of a specialty called palliative care? I recommend it for all my patients who have a serious disease like [yours]. While your [oncologist focuses on killing cancer, cardiologist optimizes your heart etc.], the palliative care doctors really focuses on symptoms and side effects, and they tend to be great communicators and really good at making sure that what's most important to you and your family is front-and-center during all of your medical care"
  • Consider palliative care team consultation/referral particularly for patients at the end of life, with poor prognosis, or with overwhelming symptom burden

Analgesia

Dyspnea
  • Not a time to reclarify goals of care
  • Reassurance is key to family
  • O2, NIPPV
  • Bedside Fan
  • Morphine; start "low and go slow", 1-2mg IVP Q10-15min until desired effect
    • If opioid tolerant, in addition to standing use - 10% of 24 hour opioid regimen Q10min; or 25% of 4 hour opioid regimen Q10min

Dehydration
  • Anorexia does not cause distress, no evidence for IVF, TPN
  • Normal to decrease PO intake in last weeks of life
  • Swabs on mouth/lips to prevent dry lips
  • Artificial tears for dry eyes

Delirium
  • Reassurance in normal part of dying process, not "going crazy at the end"
  • Common to see deceased relatives
  • Quiet, well lit room, windows preferable, familiar faces present
  • Haloperidol 0.5-1mg IVP show to be useful, benzo as additional adjunct

Disposition at End of Life
  1. All life sustaining care desired
    • Self explanatory
  2. Comfort + limited life sustaining interventions
    • Admit with time limited trial (establish this beforehand) for antibiotics or NIPPV
  3. Comfort measures only
    • Admit to hospice unit/palliative care service or manage acute symptoms in ED then dc with home hospice

External Resources
  • Fast Facts : great quick-reference resource for practical/specific info on myriad palliative care topics

See Also
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