ED targets end-of-life patients
Program offers 'comfort, control and choices'
[Editor's note: ED Management awards the "Gold Star" to ED teams that go above and beyond the expected to dramatically improve performance through unique and creative approaches. To nominate your ED or another one for a Gold Star, contact Joy Daughtery Dickinson, senior managing editor, at [email protected].]
An ED program designed to serve the terminally ill? It makes perfect sense to Mark Rosenberg, DO, MBA, FACEP, chairman of emergency medicine at St. Joseph's Regional Medical Center in Paterson, NJ. So much so, in fact, that his department recently introduced Life-Sustaining Management and Alternative (LSMA) services. The program is designed to provide comfort, control, and choices for chronic and terminally ill patients and their loved ones.
"St. Joseph's has a large peds ED and a very active ED in downtown Paterson with a fairly large geriatric population that had been continuing to grow," Rosenberg says. "We decided to develop full-circle care in the ED."
Rosenberg says his ED had been seeing 40-60 geriatric patients a day, but it had not really met its goal of providing complete care because it did not have a program to help most of them who had a life-limiting disease.
"In January [2010] we decided to start the program and take care not just of geriatric patients but anyone who had life-limiting illness," says Rosenberg. "We felt management of these patients could be better if it was initiated in the ED and then followed through to the community or the hospital."
The ED leadership was particularly qualified to develop such a program because both Rosenberg and ED nurse coordinator Ramazan Bahar, RN-BC, had been involved in palliative care over the years. "When a patient has a terminal illness they know they are dying, but often no one wants to discuss it with them," notes Bahar. This approach takes control away from the patient, she says.
Bahar recalls the case of an elderly Dominican woman with metastatic brain cancer. "The children were told she had three weeks to live, but they had not wanted to tell her," she says. "I said, 'I'll tell you something: She knows. Let's let her decide how she wants to spend that time."
The daughters gave their permission, and the ED physician in charge of the case told her. Her response? "I knew." The provider team and the family asked her what she wanted to do. "She wanted to go back to the Dominican Republic," says Bahar, "And we made arrangements for hospice and palliative care." (Rosenberg takes a non-traditional approach to one specific type of palliative care. See the story, below.)
A different approach
A program such as this one runs counter to the traditional ED approach to care, says Rosenberg.
"We are usually focused on curing, and sometimes you need to focus on caring," he explains. "We have now created that model in the ED, where you can provide care without curing and give control back to the patient."
A "treat, stabilize, cure, and discharge" approach might work for most patients, Bahar says, "but there is a different type of treatment for these patients. We are here to advocate for them and make sure their wishes are translated to the next level of care."
Rosenberg and Bahar provide a consulting service and are available 24/7 along with another ED physician. Rosenberg says, "Any time a patient is in need of palliative care or has to deal with end-of-life issues, rather than them having to deal with it, they call us. We take the burden away from the emergency physician."
The ED physicians simply have to call his or Bahar's extension. If they're out, it goes to their cell phones, notes Rosenberg. "We've created a whole new level of care for these individuals," he says. (For an example of a recent case, see the story, below.)
Source
For more information on treating terminally ill patients in the ED, contact:
- Ramazan Bahar, RN-BC, ED Nurse Coordinator, and Mark Rosenberg, DO, MBA, FACEP, Chairman of Emergency Medicine, St. Joseph's Regional Medical Center, Paterson, NJ. Phone: (973) 754-2000.
Case shows hospital met patient's request A recent case in the ED at St. Joseph's Regional Medical Center in Paterson, NJ, shows the value of its new Life-Sustaining Management and Alternative (LSMA) services, says Mark Rosenberg, DO, MBA, FACEP, chairman of emergency medicine and co-creator of the program. The patient was 56-year-old male with stage IV lung cancer who was having difficulty breathing. He had been through chemotherapy, but it was no longer efficacious. His oncologist had told the family there was nothing more he could do. Rosenberg met with the patient and his wife and reviewed his history. He also presented them with alternatives. "The hospitalist was going to admit him, probably drain the malignant effusion in his chest, and put him in the ICU, where he may have died," he said. When Rosenberg explained the circumstances to the patient, "he was excited ... happy. He knew he was dying and just wanted somebody to say it and know what was in store for him," he says. The patient decided he would rather go home. Rosenberg arranged for hospice care. "We also got him to tape record messages for his nieces, who were 1 and 3, and for others, so he could leave a legacy for them," he notes. "We also had family meeting, and to this day the family couldn't be more thankful that we let him have a choice and reach his goals." The patient died at home three weeks later without medical support. |
Some EOL care is not adequate Shortness of breath in terminally ill patients is often managed poorly, says Mark Rosenberg, DO, MBA, FACEP, chairman of emergency medicine at St. Joseph's Regional Medical Center in Paterson, NJ, and co-creator of its new Life-Sustaining Management and Alternative (LSMA) program. "The tendency is to put a breathing tube in, but a very good treatment is giving morphine," Rosenberg says. "A lot of people think this will shorten life, but studies show it will actually lengthen life. Rosenberg adds that ED managers and their staffs have a lot to learn about treating these patients. "My feeling is there is great opportunity for emergency doctors to provide better care by better understanding EOL [end of life] initiatives," he says. "From a clinical point of view, it's a better opportunity to learn how to manage acute chronic pain, narcotics like morphine, methadone, and dilaudid in particular. You can get very skilled." There are several recommended drugs for EOL care that can help mask symptoms such as dizziness, nausea, vomiting, constipation, and diarrhea, Rosenberg adds. |
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