Palliative Medicine and Geriatric Emergency Care: Challenges, Opportunities, and Basic Principles

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Key Points

  • Hospice and palliative medicine, a subspecialty of emergency medicine, concentrates on life-threatening illnesses, whether curable or not.

  • Palliative care is not the same as end-of-life (EOL) care.

  • Arrival of a patient under hospice care to an emergency department (ED) does not automatically equate to hospice care termination nor does it imply that patient seeks aggressive interventions.

  • Challenges to implementation of pre-existing advance planning documents exist, including an unanticipated

Opening remarks

Before starting this article, it is important to have some perspective. Fig. 1, Fig. 2, Fig. 3 define the terms and summarize necessary concepts of care. On initial presentation of a disease, such as lung cancer or heart failure, the goal of care is curative but patients also receive noncurative symptom management. In cancer, this noncurative management may include nausea relief and relief of constipation. This noncurative symptom management is palliative. Palliative care is the relief of

Recognizing unmet palliative needs in the emergency department

Elderly patients with serious, advanced illnesses comprise a particularly vulnerable population in EDs.15, 21, 22, 23 A recent longitudinal study of patients older than 65 years examined the pattern of ED use in their last months of life23: 75% (4518 decedents) visited an ED in the last 6 months of life and 51% in the last month, and repeat visits to an ED were common.23 This is not unique to the United States; a recent Australian study of patients with a known poor prognosis disease, such as

Effective Communication when Caring for Seriously Ill ED Patients

Optimal communication with shared decision making has been identified by patients and families as a crucial aspect of medical care, especially at EOL.45, 46, 47, 48 Effective communication facilitates improved satisfaction with care and a reduction of anxiety and distress, often with even brief interactions.49, 50, 51 Although most patients and family members want to receive support and hope from clinicians, they also value clear and honest information about the medical condition and prognosis.

Palliative emergencies in the elderly

A palliative care emergency is an unexpected change in a patient's medical condition in the context of an underlying known advanced or serious illness, and this emergency often triggers an ED visit.34, 77, 78 The recommended ED assessment and treatment plan should consider patients' overall goals of care as well as the following:

  • What is the acute medical issue and is it potentially reversible?

  • What would most likely be the patient's status after treatment?

  • What is the person's recent performance

Symptom management

The challenge faced by ED physicians who are managing patients with life-limiting illness, specifically EOL patients, is to provide relief of symptoms. Whether a patient is admitted to the hospital or discharged to home should not interfere with this management initiative. A partial list of common symptoms and complaints that may need to be addressed at EOL includes

  • 1.

    Agitation/confusion/delirium—see Table 3

  • 2.

    Anxiety

  • 3.

    Constipation—see Table 4

  • 4.

    Diarrhea

  • 5.

    Dyspnea

  • 6.

    Nausea and vomiting—see Table 5

  • 7.

    Pain—see

Ethical issues at EOL in the emergency department

“Palliative care at the EOL involves meeting the physical, psychological, social and practical needs of patients and caregivers.”81 Ethical issues arise from time to time in EDs when dealing with palliative care patients at the EOL. Ethical dilemmas in the ED setting are likely to include matters related to the use of artificial airways, artificial nutrition, and surrogate decision makers. If available, state-approved advanced directives in the form of do-not-resuscitate (DNR) orders, living

Managing the elderly under hospice care in the emergency department

Patients under hospice care often present to EDs for crisis events, and emergency clinicians who are familiar with the hospice model of care may be better able to guide EOL care for such patients.34 Eligibility for hospice is primarily based on a prognosis of living 6 months or less if the disease were to run its natural course.96 Patients may have any diagnosis to qualify for hospice care, and noncancer primary diagnoses now comprise more than half of all hospice admissions.96, 97

Arrival of a

Referring an eligible emergency department patient to hospice care

Elderly patients with declining health and functional status and advanced disease have frequent ED visits, particularly in the last months of life, presenting a window of opportunity to assess patient needs/goals of care and initiate discussions about hospice in eligible patients.35, 96, 100, 103, 106 Hospice may be considered in eligible patients when the pre-eminent care goal is relief of symptoms, such that they want therapy aimed at maintaining quality of life, without a major focus on life

Managing the actively dying patient in the emergency department

Two distinct death trajectories have been recently discussed in ED literature: the so-called spectacular death—a resource-intensive event, for example, a traumatic, sudden event in a young person where multiple personnel are involved, and the so-called subtacular death, for example, ED death of an older person with a DNR directive who enters the final actively dying phase after a prolonged chronic illness.106 Although it is important to give families a general idea of how long a patient might

Summary

It is impossible to put all aspects of palliative care into one article. The authors' objective is to give readers a broad overview of general principles. Geriatric care in EDs, by the nature of the specialty, must include an understanding of disease trajectory, prognostication, and symptom management in EOL as well as the psychosocial needs of dying patients and their families.

An understanding of palliative medicine is important for several reasons: palliative and hospice medicine is a

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