PALLIATIVE CARE COMMITTE
caused by an infection) then consider continuing the antibiotic regimen. If antibiotics are not likely improving symptoms then discontinue so as not to prolong the dying process. Consider foley placement, as leaking from an external catheter is uncomfortable and any cleaning can be very unpleasant. If a patient has an internal defibrillator that has not
been turned off, consider placing a magnet over the device to prevent it from delivering a shock in the case of arrhythmia. Families may ask questions about next steps including funeral home arrangements. Consider engaging your chaplain or social worker to help answer these questions.
We hope this resource will help you deliver compassionate care, relieve suffering, and provide dignity to patients dying in the ED. SYMPTOM
TREATMENT
DOSING
Pain
Morphine Hydromorphone
2-4mg IV/SC q15 min PRN 0.4-0.8mg IV/SC q15 min PRN
Dyspnea
Morphine Hydromorphone Fan directed at patient
2mg IV/SC q15 min PRN 0.2mg IV/SC q15 min PRN
Nausea and Vomiting
Haloperidol Ondansetron
0.5-2mg IV/SC 4-8mg IV
Dry mouth
Oral care Discontinue contributing medications
Secretions
Repositioning Gentle suction Reassurance
Anxiety Agitation Delirium Haloperidol Lorazepam
Benefits of using anticholinergic agents are unclear and may have unpleasant side effects like delirium and dry mouth. 0.5-2mg IV/SC 0.5-1mg IV/SC
References 1. Blinderman CD, Billings JA. Comfort Care for Patients Dying in the Hospital. N Engl J Med. 2015;373(26):2549-2561. doi:10.1056/ NEJMra1411746 2. Wang D, Creel-Bulos C. A Systematic Approach to Comfort Care Transitions in the Emergency Department. J Emerg Med. 2019;56(3):267274. doi:10.1016/j.jemermed.2018.10.027 3. Siegel M, Bigelow S. Palliative Care Symptom Management in The Emergency Department: The ABC’s of Symptom Management for The Emergency Physician. J Emerg Med. 2018;54(1):25-32. doi:10.1016/j. jemermed.2017.08.004 4. Loffredo AJ, Chan GK, Wang DH, et al. United States Best Practice Guidelines for Primary Palliative Care in the Emergency Department. Ann Emerg Med. 2021;78(5):658-669. doi:10.1016/j. annemergmed.2021.05.021
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5. Ekström MP, Bornefalk-Hermansson A, Abernethy AP, Currow DC. Safety of benzodiazepines and opioids in very severe respiratory disease: national prospective study. BMJ. 2014;348:g445. Published 2014 Jan 30. doi:10.1136/bmj.g445 6. Wee B, Hillier R. Interventions for noisy breathing in patients near to death. Cochrane Database Syst Rev. 2008;2008(1):CD005177. Published 2008 Jan 23. doi:10.1002/14651858.CD005177.pub2 7. Hosker CM, Bennett MI. Delirium and agitation at the end of life. BMJ. 2016;353:i3085. Published 2016 Jun 9. doi:10.1136/bmj.i3085