PALLIATIVE CARE COMMITTEE
End of Life in the Emergency Department Maggie Putman, DO FAAEM, Jessica Fleischer-Black, MD FAAEM, and Bruce Gutierrez, MD
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roviding compassionate care for patients in their final hours of life is a critical skill for emergency physicians. This article is the first in a series presented by the Palliative Care Committee on end of life care in the emergency department. We will provide you with a simple framework to relieve suffering and provide dignity to patients dying in the ED. You have already had the hard conversations to understand the patient’s values and goals. The decision to transition to intensive comfort-focused treatment has been made. Here is what you can do next. SETTING. Try to have the patient in a quiet and private space in the ED. Make sure there are chairs for loved ones, tissues, and water. You can either take the patient off the monitor or turn off the screen in the patient’s room. RESOURCES. If you have a social worker, chaplain services, or spiritual care, offer them to the patient and family. They can be a resource for psychological and/or spiritual distress and also aid in next steps.
Symptom Management PAIN. Opioids are the mainstay of pain management. For patients with an IV, 2-5mg IV morphine every 15 minutes as needed is a good starting dose. Hydromorphone 0.4-0.8mg every 15 minutes as needed is preferred if a prolonged prognosis is anticipated and in patients with poor renal function. If analgesia is inadequate with the first dose, increase by 50-100%. In patients without an IV, opioids can be administered subcutaneously. The potency is considered the same as IV (give the same dose) but the time to peak effect is slightly longer, therefore space repeated doses out to every 30 minutes as needed. Reassessment is necessary to optimize symptom control. Nursing staff, social workers, and family members can be helpful to let you know if pain is adequately controlled. DYSPNEA. Treating dyspnea can significantly alleviate suffering in
dying patients and their families. Opioids are first line and considered safe when used appropriately. Lower doses are typically required when compared to treating pain, starting with morphine 2mg every 15 minutes as needed. Titrate until respiratory rate and accessory muscle use are improved. Patients with renal failure will have accumulation so hydromorphone 0.2mg can be used if the patient is expected to live longer than a few hours. Fentanyl is an option if a patient has both liver and renal failure but is very short acting. A fan directed at the patient can improve the sense of dyspnea. Supplemental oxygen fixes hypoxia but not typically symptoms, so you can consider a trial and only continue if it improves the
patient’s sense of dyspnea or work of breathing. Be aware that supplemental oxygen tubing is a tether which may further agitate some patients. Treatment should be aimed at relieving the patient’s symptoms, not correcting numbers on the monitor. NAUSEA AND VOMITING. Consider the underlying cause of nausea and vomiting when choosing the best agent. Serotonin receptor antagonists such as ondansetron are first line for chemotherapy induced nausea and vomiting. Haloperidol, a dopamine receptor antagonist, is also frequently recommended in palliative care, at 0.5-2mg IV. Both serotonin receptor antagonists and dopamine receptor antagonists are effective at treating nausea and vomiting mediated by the chemoreceptor trigger zone and the GI tract. Both have potential to prolong the QT interval so consider the benefit of symptom burden versus risk of adverse effects. DRY MOUTH. We recommend oral care and discontinuing unnecessary medications that may worsen xerostomia. SECRETIONS. Noisy breathing is common at the end of life secondary to the patient’s inability to cough and clear secretions leading to turbulent airflow. This is often referred to as the “death rattle.” There is not clear evidence that medications such as anticholinergics (e.g., glycopyrrolate, atropine, or scopolamine) are useful, and they can cause side effects such as dry mouth and delirium. Consider repositioning, gentle suction, and reassurance to family members and team members. Counseling family members that noisy breathing and secretions are an expected part of the dying process and does not cause the patient any distress may be helpful. ANXIETY/DELIRIUM/AGITATION. These symptoms are
commonly seen in the final days of life. Consider potential causes including dyspnea, pain, and constipation, and offer support for spiritual or psychosocial distress. When medication is needed, haloperidol 0.5-2mg IV is most commonly considered the first line agent. For severe agitation, a patient may also require a benzodiazepine in addition to an antipsychotic. Consider lorazepam 0.5-1mg IV if needed. OTHER CONSIDERATIONS. We recommend discontinuing IV
fluids. IV fluids will not provide symptom relief, may prolong the dying process, and may potentially cause worsening dyspnea secondary to fluid overload. Antibiotics should be considered on a case by case basis. If antibiotics are thought to be providing some symptom relief (for example reducing secretions secondary to pneumonia, providing some pain relief >>
COMMON SENSE JANUARY/FEBRUARY 2023
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