Palliative medicine

Palliative Care in the ED

• Palliative care team involvement early in EOL (end of life)
• Can be distressing time for family/providers

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
• Haldol 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

• Pain control

Authors

Allen Bookatz, Claire, Ross Donaldson, Neil Young