By Guhan Rammohan, MD, and Alexander Kaunzinger, DO
EXECUTIVE SUMMARY
- Palliative care is focused on relieving symptoms that are interfering with the patient’s quality of life, regardless of the patient’s stage of illness.
- Hospice care is focused on the end of the patient’s life, generally within the anticipated last six months of life after stopping all curative treatment to focus on improving the quality of the end of a patient’s life and to provide support to their family members and caregivers.
- Patients who would benefit from a palliative care consultation generally include those with a serious or life-threatening condition and at least one additional factor, such an uncontrolled symptoms, functional decline, incurable cancer, out-of-hospital cardiac arrest, or advanced dementia.
- Palliative care interventions are more useful in patients experiencing these three disease trajectories: frailty, terminal illness, and organ failure.
- Dyspnea is the most common presenting symptom in the chronically ill patient and generally is described by patients as a subjective sensation that they are unable to get enough air into their lungs.
- Opioid medications are the first-line treatment for the management of dyspnea in chronically ill patients, reducing the sensation of dyspnea via multiple mechanisms.
- Constipation is commonplace in patients with chronic illness, generally because of their opioid pain and dyspnea regimens, and initial treatment should include regularly scheduled stimulant and surface laxatives.
- At the end of life, patients are especially afraid of a painful death, and families often derive comfort from a death where the patient was seemingly at peace, so significant and frequent dosing of opioids, benzodiazepines, and antipsychotics help to control pain, anxiety, and agitation.
Case
A 91-year-old female with a past medical history of essential hypertension, hyperlipidemia, transient ischemic attack, colon cancer in remission, generalized anxiety disorder, and ambulatory dysfunction presents to the emergency department (ED) from a nursing home via emergency medical services (EMS) for altered mental status. The patient history was obtained from EMS at bedside and from family via phone. The patient had initially experienced neck pain, headache, dizziness, and nausea without vomiting at around 9 that morning. The patient’s daughter had last spoken to the patient at approximately 9:30 a.m., when the patient told her daughter that she would take some acetaminophen and lie down to rest. At approximately 11:30 a.m., the patient was found unresponsive on the floor by her husband and nursing home staff. The initial EMS evaluation showed a right fixed pupil, left blown pupil, and agonal respirations. They placed a supraglottic airway and interosseous (IO) line, then transported the patient to the ED. Per nursing home medical records, the patient took aspirin, but no other anticoagulation agents.
On physical examination, the patient is unresponsive and has agonal respirations. Vital signs demonstrate a heart rate of 63 beats per minute, respiratory rate of 16 breaths per minute, blood pressure of 181/105 mmHg, pulse oximetry of 100% on 15 liters per minute via bag-valve-mask. She appears in acute distress and overall is ill-appearing. There are no external signs of head trauma. There are dry mucous membranes, and a supraglottic airway is in place. The pupils are nonreactive bilaterally, with left pupillary dilation. The right pupil is normal size. The patient is tachycardic but with a regular rhythm. There are equal and strong radial and dorsalis pedis pulses. Lung sounds are clear to auscultation bilaterally. Her Glasgow Coma Scale (GCS) score is 3 (1E, 1V, 1M). Gag and corneal reflexes are absent. There is myoclonic jerking present in the right lower extremity. There is an IO line placed in the right proximal tibia.
A noncontrast computed tomography (CT) scan of the head demonstrates extensive multicompartmental hemorrhage, which is predominantly present in the intraventricular space with moderate to severe hydrocephalus. There is a subarachnoid hemorrhage within the right medial temporal lobe. There is a prominent mass effect in the posterior fossa with downward tonsillar displacement and mass effect on the pons, in addition to right-sided uncal herniation.
Based on the patient’s GCS, age, intracerebral hemorrhage (ICH) volume, and presence of intraventricular hemorrhage, her ICH score is 5, with a predicted mortality of 100%.1 An initial goals of care conversation is held with family members via phone to discuss the patient’s code status and non-survivability of the patient’s condition. The family makes the decision to withdraw life-sustaining care and transition to comfort measures at this time.
Introduction
The ED is one of the areas of the hospital best equipped for rapid evaluation, diagnosis, and treatment of urgent and emergent patient conditions. Therefore, a large proportion of non-survivable injuries or worsening medical conditions are first identified in the ED. Some of these conditions occur suddenly, such as in the setting of traumatic injuries or rapidly progressing infections. Other conditions have progressed more slowly, such as non-survivable cancers, and have now led to symptoms unable to be managed effectively as an outpatient. In some circumstances, the patient’s family or other representative is responsible for the patient’s ED visit because of their inability to continue to care for the patient’s increased needs. Some patient conditions even have reached a critical mass so that the patient is now actively dying.
In all these cases, the emergency physician is the first physician during the current presentation to evaluate these patients and interact with their families. Therefore, the emergency physician should seek to establish goals of care, have initial conversations regarding further evaluation and prognosis of critically ill or injured patients, assist families in understanding the patient’s clinical condition, and rapidly and aggressively intervene to support the patient’s needs.2
What Is Palliative Care and Who Would Benefit from It?
Palliative care is focused on relieving symptoms that are interfering with the patient’s quality of life, regardless of the patient’s stage of illness.2,3 Such interventions include caregiver support services, symptom control with medication, and prescription of physical items that improve a patient’s quality of life.2 Patients do not have to be dying to receive palliative care interventions and may undergo non-curative interventions alongside curative therapies.3,4 Palliative care continues to evaluate the patient’s life-prolonging interventions to ensure they align with the patient’s current wishes, especially when such treatments may only be prolonging the patient’s suffering. Palliative care is not the same as end of life or hospice care, which will be discussed later.
Patients who would benefit from a palliative care consultation generally include those with a serious or life-threatening injury and at least one additional factor. (See Table 1.) The evaluating emergency physician would not be surprised if these patients subsequently died in the next months.2,3 They often are bounce-backs, having recently been admitted to the hospital or making multiple ED visits with the same presentation.2,3 They currently may be presenting with emotional and physical difficulties that are unable to be controlled in their outpatient environment.2,4 There may be overall decline in patient function, which may lead to patient or caregiver distress.2 This presentation also may be simply an attempt to obtain more support for an increasingly complex patient.2
Table 1. Triggers for Palliative Care Consultation in the Emergency Department |
Patients meeting the following criteria would benefit from a palliative care consultation:
|
Assessment of the Patient with Functional Decline
The next step of an emergency physician after the initial assessment of a patient’s airway, breathing, and circulation is to determine the reason for the patient presenting to the ED. The physician should determine if this presentation is primarily driven by the patient’s ongoing symptoms from their primary disease process or if there is a new presentation of different disease. This drives both diagnostic workup and therapeutic interventions. In all patients with overall decline, a conversation regarding goals of care should occur with the patient or the patient’s representatives.
Goals of Care Conversations
Before critical procedures, the emergency physician often will run through a mental checklist, anticipating changes in the clinical course and bringing additional equipment or resources to bear depending on that clinical course. Similarly, the establishment of a patient’s goals of care is a critical step, and the emergency physician should treat it with the same gravity. They should set the stage to ensure first-time success and gather resources appropriately, attempting to gather the critical decision-makers for this patient and setting aside time to have this difficult discussion.
Patients and their families often do not have a clear understanding of their disease process, and so the next step in establishing the patient’s wishes is to establish their baseline understanding of the clinical situation. Knowledge gaps often are the cause of misunderstanding regarding patient prognosis, and by establishing baseline knowledge, the emergency physician can address them to the best of their ability.
Patients generally present along one of four common trajectories of disease, which the emergency physician can identify based on the patient’s disease characteristics. The first is a sudden, unexpected death, which often is the hardest for patient families to accept.2 Without ongoing symptoms prior to the patient’s sudden death, there is no role for early palliative intervention from the ED.
Palliative care interventions are more useful in patients experiencing the remaining three disease trajectories: frailty, terminal illness, and organ failure. Frail patients present with a poor functional state at baseline and will slowly deteriorate with time.2 Patients with terminal illness, such as malignancy, may function well at baseline, then quickly deteriorate over a short period of time.2 Patients with progressive organ failure, such as liver cirrhosis, congestive heart failure, or chronic obstructive pulmonary disease, present with slow overall decline, punctuated with frequent exacerbations. These exacerbations will resolve to a certain extent, but each exacerbation will decrease the overall functional baseline of the patient.2 Overall, a patient with a poor functional state on any of these disease trajectories has a decreased chance of survival. They are less resilient to disease exacerbations and are less likely to benefit from both curative and non-curative treatments.
The emergency physician should communicate the patient’s prognosis clearly by explaining the current clinical picture and the expected poor outcome based on the identified disease trajectory. If applicable, it should be communicated clearly that the disease process that the patient is experiencing is not able to be cured. Use simple and patient-centered dialogue regarding the disease process, avoiding complex medical language that may confuse the message that is being given to the patient: “I believe that your disease is non-survivable, and it will continue to get worse. I want to discuss the ways that I believe we can help you to manage your symptoms.” This often is the most difficult part of the goals of care conversation, since patients or families may not acknowledge your statement to be true, and so may be difficult to engage in a conversation regarding their goals of care.
Once the physician initiates the conversation regarding goals of care, the physician should engage the patient or patient representative by asking open-ended questions about their wishes for the remainder of their life. These are questions regarding the patient’s hopes and fears, what they find to be important, and what they consider a good or bad death. When the patient or their representative relays those goals, the physician should discuss a plan to assist in meeting those goals. The words used should be carefully chosen so that the patient does not feel abandoned. These discussions should be framed as a transition between phases of care, from a phase centered around preservation of life to a phase focused on improving the quality of the patient’s remaining life and enhancing the quality of the patient’s death.5
Code status discussion is a critical area when discussing goals of care, since there are many misconceptions regarding cardiac arrest resuscitations in the lay population. Achieving return of spontaneous circulation (ROSC) is by no means guaranteed. In-hospital cardiac arrest has a median rate of ROSC of 70.5%, without considering any patient factors such as age, sex, or clinical condition at the time of arrest.6 Patient age is a significant factor influencing the likelihood of ROSC. Compared to those younger than 50 years of age, patients older than 70 years of age have a reduced rate of ROSC following in-hospital cardiac arrest: patients aged 70-79 years having an odds ratio of 0.89, and patients older than 80 years of age having an odds ratio of 0.70.6
Males tend to have slightly lower ROSC rates than females, with an odds ratio of 0.92.6 Patients with metastatic cancer have significantly decreased ROSC rates, with an independent odds ratio of 0.839. If the patient is at the point where they would require intravenous vasopressors, there is a decreased ROSC odds ratio of 0.76 for ROSC following an in-hospital cardiac arrest.6 If the patient would require intubation and mechanical ventilation, there is a decreased ROSC odds ratio of 0.76.6 In the previously mentioned case, if the patient had gone into cardiopulmonary arrest and had not been designated as comfort care, she would have a combined odds ratio of 0.532, which would put her median percentage of ROSC at 37.5%.
If ROSC is achieved, the patient may experience extensive neurologic complications because of hypoxic brain injury during their downtime. Only approximately 20% of patients in whom ROSC is achieved following an in-hospital cardiac arrest end up surviving to hospital discharge.7 Of all patients who received cardiopulmonary resuscitation and survived until discharge, 28.1% had significant neurologic disabilities.7 One-half of all survivors did not return home.7 Factors that affect likelihood of ROSC are the same factors that affect survival to discharge rates. Specifically, the presence of pulseless electrical activity or asystole is associated in an independent survival to discharge rate of 10%.7 Patients who receive chronic hemodialysis have a survival to discharge rate of 14%; however, only 3% of all discharged survivors survived until six months.7 The presence of metastatic cancer is associated with a survival to discharge rate of 7.8%.7
Furthermore, cardiopulmonary resuscitation is not a benign process. Properly performed compressions fracture ribs, can cause intra-abdominal injuries, and will lead to aspiration prior to intubation, all of which will complicate the patient’s care even if ROSC is achieved.
Therefore, the decision for a patient or patient representative to elect to receive cardiopulmonary resuscitation in the event of a cardiac arrest should be framed as a risk-benefit discussion, as is done for other procedures. The benefits of possible but unlikely survival (especially when considering the patient’s specific risk factors) need to be weighed against the significant likelihood of additional damage to a probably already frail patient. Again, use simple language to describe the interventions that would be performed in a cardiopulmonary resuscitation. As examples, use “press hard and fast on your chest” rather than “compressions,” “electrical shock” rather than “defibrillation,” and “breathing tube” rather than “intubation.” At the end of the discussion, it is hoped that the patient or patient representative will be able to make a fully informed decision regarding code status.
Ultimately, create a treatment plan that aligns with the patient’s wishes. Summarize the discussion at this point, ensuring all parties agree on the patient’s goals for this ED visit. Communicate the plan to meet the patient’s goals and the patient disposition associated with those goals. Emphasize the patient or patient representative’s right to advocate for their wishes. Palliative interventions should be flexible, and if the current non-curative and curative therapies are either ineffective or actively leading to increased suffering, the current plan of treatment should be adjusted.
Emergency physicians can be the physicians to first broach these difficult conversations. It is important to have these conversations regardless of the patient’s decision, since these decisions may lead to more reflection by the patient and their representatives and could lead to future conversations regarding goals of care in the inpatient setting with primary teams or in the outpatient setting with their specialists.
The previously mentioned recommendations outline an approach to goals of care conversations with a patient who has the capacity to weigh risks and benefits and express their wishes. But emergency physicians regularly care for critically ill patients who lack capacity for these decisions at baseline or who are temporarily incapacitated because of an acute event. Capacity in the context of medical decision-making refers to the patient’s ability to understand the options of treatment, including the option of no treatment, and choose between them, with the understanding of the consequences of that choice. It differs from medical competency, which is a legal determination made by a court of law. Sometimes a surrogate decision-maker is present, such as a spouse or an adult child, to make decisions for the patient. But it is important that such surrogates consider the clinical situation from the perspective of the patient’s wishes rather than their own.
Advance Directives
All advance directives should be reviewed to understand what the patient’s previously expressed wishes are. Advance directives can include specifications of surrogate decision-makers, orders such as do-not-resuscitate or do-not-intubate (DNR/DNI), or a physician orders for life-sustaining treatment (POLST) form.2,8 POLST forms are a specific set of medical orders that include a larger range of medical preferences regarding the patient’s care, including cardiopulmonary resuscitation, select medical interventions, and artificial nutrition.8,9 Each state in the United States has its own unique POLST, and once signed by the patient and physician, it is a legally enforceable document.
Patients can accept or decline certain specified limited interventions, such as declining intravenous antibiotics but accepting intravenous fluids or intravenous medications intended for symptom control.9 Therefore, patients who have decided not to continue curative treatment for their central medical problem may seek treatment for the complications of that central medical problem or other separate medical issues. For example, someone with lung cancer may no longer be interested in receiving chemotherapy, but they may be interested in receiving intravenous antibiotics for an infection.
Presentation and Palliative Intervention of Common Presenting Symptoms
Patients with chronic illness often present to the ED because of progressively worsening symptoms that are unable to be controlled as an outpatient. Generally, the symptoms stem from the patient’s primary chronic illness and can be treated with symptom-specific non-curative therapy in addition to their already prescribed curative therapy.2 The most common presenting symptoms in chronically ill patients who present to the ED include dyspnea, anxiety, pain, nausea and vomiting, and constipation.2,3,4 While these patients may not be in acute distress, these symptoms are anxiety-provoking and can create significant discomfort. Ideally, many of these regimens for symptomatic treatment can be initiated in the ED and continued by the patient’s outpatient primary care physician or palliative care specialist.
Dyspnea
Dyspnea is the most common presenting symptom in the chronically ill patient and generally is described by patients as a subjective sensation that they are unable to get enough air into their lungs. Sometimes patients state that they feel the need to breathe faster or deeper, or that they feel suffocated. The sensation of dyspnea often is related to the patient’s primary illness, which can be triggered by increased respiratory rate because of disorders of ventilation, decreased ventilation reserve or increased metabolic need for oxygen, disorders of gas exchange, or abnormal activation of the brainstem respiratory centers.10
Dyspnea also can be related to a patient’s anxiety and may become a self-fulfilling cycle as a patient becomes more dyspneic as a result of their anxiety over their ever-increasing dyspnea.11 Patients may fear their next dyspneic episode and develop frustration over limitations of their activities.11
Therefore, with dyspnea being a subjective sensation, vital signs such as respiratory rate and pulse oximetry are not a reliable indicator of the severity of dyspnea. Instead, the emergency physician should rely on a careful physical exam, paying specific attention to the patient’s facial expression, pattern and quality of speech, self-reported level of anxiety, presence of accessory muscle use, and extent of chest rise and fall.12 Dyspnea should be symptomatically treated while also evaluating for reversible causes of dyspnea. If a reversible cause of dyspnea is found, a risk-benefit discussion should occur with the patient to determine if a possible intervention is in line with the patient’s wishes.
Reversible causes of dyspnea include pleural effusion, ascites, pulmonary fluid overload, anemia, and excess secretions.12 Pleural effusions are either transudative or exudative, and can arise from multiple sources, although the most common causes are congestive heart failure, malignancy, and pneumonia. They can present with decreased breath sounds on lung auscultation, and point-of-care lung ultrasound is useful in visualizing the effusion. Pleural effusions are drained via thoracentesis.
Similarly, ascites also can be transudative or exudative, arising generally from cirrhosis, heart failure, or malignancy. It presents with abdominal distension and a positive fluid wave on physical exam and can be visualized with abdominal ultrasound. It is treated via a paracentesis. Fluid overload and pulmonary edema often present in exacerbations of renal failure, such as a missed dialysis session, or in heart failure with insufficient diuretic use. Lung and cardiac ultrasound can identify B-lines in the lungs and evaluate distension of the inferior vena cava. Fluid overload is treated with diuretics or dialysis if the patient is critically unstable or cannot make urine.
Anemia may be caused through acute or chronic blood loss or chronic decreased production of blood cells due to immunosuppression, infection, or chronic sequestration of blood components. Red cell transfusions for treatment of symptomatic anemia generally are considered when the hemoglobin is less than 7 mg/dL; however, a higher transfusion threshold may be considered with concomitant cardiac or pulmonary disease.
Excess secretions also may cause dyspnea through partial airway obstructions and generally occur with pneumonia, malignancy, or when the patient is actively dying. Medications such as glycopyrrolate and scopolamine are used to dry up secretions via their anticholinergic effects.
Opioid medications are the first-line treatment for the management of dyspnea in the chronically ill patient. (See Table 2.) They reduce the sensation of dyspnea via multiple mechanisms: through decreasing respiratory drive, altering the brain’s perception of air hunger, and decreasing patient anxiety.13 Opioids’ effect on the central respiratory drive occurs through direct interaction with the opioid receptors on the dorsal and ventral respiratory groups in the medulla oblongata and the pneumotaxic and apneustic centers in the pons, reducing their responsiveness to hypercapnia and hypoxia.13
Table 2. Starting Doses for Symptom Management in the Emergency Department: Dyspnea and Pain |
Mild Dyspnea, Opioid-Naïve
OR
OR
Dyspnea, Mild, Opioid-Tolerant
Dyspnea, Severe, Opioid-Tolerant
OR
OR
OR
OR
Dyspnea, Severe, Opioid-Tolerant
Dyspnea with Concomitant Anxiety
Pain
|
PO: orally; IV: intravenous; MME: morphine milliequivalents; PR: per rectum; IR: immediate release formulation |
Under normal physiologic circumstances, these respiratory centers are primarily driven through responses to partial pressure of arterial carbon dioxide, although there is some response to partial pressure of arterial oxygen.13 Slight changes in arterial carbon dioxide partial pressure create immediate changes in tidal volume and respiratory rate to normalize the carbon dioxide partial pressure.13 Through the reduction in responsiveness to hypercapnia, and to a lesser extent hypoxia, there is less change in tidal volume and respiratory rate in response to increased carbon dioxide partial pressure, which in turn reduces the sensation of dyspnea. This effect is directly proportional to the dose of opioids and is the primary reason for bradypnea in opioid overdoses.
Opioid medications also interact with the brain’s central processing of dyspnea. With decreased usage of respiratory muscles, there are decreased corollary discharges to areas responsible for processing sensory information.13 Corollary discharges are signals sent by motor processing centers to sensory processing centers at the same time as the motor processing center is sending an activation signal to a peripheral neuron to move a muscle.14 They allow the brain to compensate for the sensory effects of the muscle movement initiated by the motor processing center. The application of opioids in treating dyspnea is that by causing respiratory depression through the reduction in respiratory center responsiveness, there is a compensatory decreased central sensation of dyspnea through the decreased activation of sensory areas.
Opioids additionally may treat dyspnea through the reduction of patient anxiety related to their existing difficulty breathing.11,13 Anxiety and panic attacks lead to palpitations, faster respiratory rate, and lightheadedness as patients create a respiratory alkalosis via excess respiratory offloading of carbon dioxide. Through the use of appropriately dosed opioid therapy, a patient’s sensation of dyspnea and their anxiety may be treated simultaneously.
While there appears to be a clear benefit to opioid therapy for dyspnea and anxiety, many clinicians are concerned for respiratory compromise secondary to the prescription of opioid medications, especially when discharging patients from the ED. In a prospective nonrandomized study in Germany of 11 patients performed by Clemens and Klaschik, opioid-naive patients with dyspnea ranging from mild to severe were treated with immediate-release opioid medications for dyspnea while the level of dyspnea and respiratory parameters were continuously evaluated at rest and with exertion before and after administration of opioid therapy. The researchers demonstrated no significant change in oxygen saturation, arterial carbon dioxide partial pressure, or heart rate despite repeated therapeutic doses of appropriately dosed opioid therapy.15 The study does show a significant respiratory rate decrease from 41.8 ± 4.7 breaths per minute to 26.5 ± 5.3 breaths per minute 60 minutes after receiving opioid medication.15 This demonstrates that while opioids may reduce respiratory rate, there was no downstream effect on the physiologic parameters that would lead to a poor outcome. There also was a significant decrease in sensation of dyspnea and anxiety based on patient self-reporting.15
The patient with mild dyspnea who is opioid naïve can be started on hydrocodone-acetaminophen (Norco) 5 mg/325 mg per os (PO) every two to four hours.2,4 If the patient is unable to take tablets, a liquid suspension of morphine 2.5 mg to 5 mg PO every two hours or morphine 1 mg to 1.5 mg intravenous (IV) every 15 minutes are reasonable starting doses.2,4 These may be titrated by 25% to 50% every 12 hours for oral dosing and every 30 minutes for IV dosing.2,4
Dosing should be titrated to reduction in dyspnea or respiratory rate of 12 breaths per minute.4 If the patient is opioid tolerant and already on a home regimen, the emergency physician should first prescribe the current home regimen, changing oral formulations to IV formulations as necessary.2 The patient additionally can be administered 10% of total daily morphine milliequivalents IV every 30 minutes as needed for severe or breakthrough dyspnea.2 The dosage or frequency may be titrated to reduction in dyspnea, but should be done one at a time to avoid mental status changes or overt respiratory depression.
The patient with severe dyspnea should start at higher doses, regardless of opioid tolerance.16 Opioid-naïve patients may be started at liquid suspension morphine 5 mg every two hours, IV morphine 1.5 mg every 15 minutes, oxycodone-acetaminophen (Percocet) 5 mg/325 mg PO every two to four hours, hydromorphone 1 mg to 2 mg PO every two to four hours, or hydromorphone 0.2 mg to 0.5 mg IV every 15 minutes.2,4 Dosing should be titrated to reduction in dyspnea or respiratory rate of 12 breaths per minute.
Because of the significant effect of anxiety contributing to a sensation of dyspnea, early use of anxiolytics such as benzodiazepines is beneficial in reducing opioid requirements to adequately treat the patient’s dyspnea. Benzodiazepines do not directly treat the sensation of dyspnea, but they may decrease the anxiety that is exacerbating the dyspnea.17 Lorazepam is a suitable first-line agent because of clinician familiarity and can be given orally, rectally, or intravenously at a starting dose of 0.5 mg to 1 mg every four to six hours.2,17 Emergency physicians should be reassured by a favorable safety profile when combining appropriately dosed opioid and benzodiazepine therapy. In a prospective non-randomized study, 26 patients who received opioid treatment in combination with lorazepam had a significant decrease in dyspnea at rest and with exertion but without decreases in pulse oximetry saturation and transcutaneous carbon dioxide partial pressure measurement.18
Additional adjunctive therapies for dyspnea include supplemental oxygen, pulmonary rehabilitation, and the use of fans. Supplemental oxygen via nasal cannula has only been shown to decrease sensation of dyspnea when the patient is hypoxic.19 Pulmonary rehabilitation can be beneficial; however, it does require patient participation and a baseline functional status to complete the exercise component.12 The use of fans blowing cool air in a patient’s face gives the feeling of freedom of movement and was shown in a randomized controlled trial to be superior to room air without a fan.20
Pain
Patients who present to the ED with uncontrolled pain as a result of their chronic illness usually are already taking outpatient pain regimens, which are not controlling their worsening pain. Emergency physicians should use the patient’s current outpatient regimen as a template to build on when working to create a new regimen for symptomatic relief.2 An outpatient pain regimen may contain multiple medications, which can make judging the relative strength of pain dosing difficult. When working with opioid medications, the physician should convert medication dosage to the morphine milliequivalent and titrate from there.2 It should be communicated to patients and patient representatives that complete cessation of pain is unlikely to occur in the ED, so the primary goal in pain management is to reduce pain to a more tolerable point.
When titrating orally dosed medications, immediate-release (IR) agents should be increased by 25% to 50% for moderate pain and 50% to 100% for severe pain.2 Increasing the frequency of oral medication should cap at once every two hours.2 When titrating intravenous medications, increase the dose by 25% to 100% based on pain severity.2 If using a continuous infusion, administer an additional loading dose of 50% to 100% of the hourly dose for breakthrough pain prior to increasing the infusion rate.2
Some patients may be taking methadone or using fentanyl patches for outpatient pain management. If the patient is already using a fentanyl patch outpatient, the same dose should be administered in the ED.2 Dosing adjustment of fentanyl patches should only be titrated every three days, so the last titration should be verified prior to adjusting the dose of the fentanyl patch.2 Because the conversion rate of methadone changes based on total morphine milliequivalents, pain management or palliative care consultation is helpful to determine proper dosing.2 When increasing the dose of methadone, an electrocardiogram should be obtained prior to titration to evaluate for QTc prolongation.
Nausea and Vomiting
Nausea and vomiting in the chronically ill patient may be related to the primary illness or have a separate cause. Symptomatic treatment should be initiated while evaluating for reversible causes of nausea and vomiting. Once the source of nausea and vomiting is identified, more targeted therapy can be administered. The most common causes of nausea and vomiting in the chronically ill patient are medications, infections, malignancy, intestinal obstruction, vestibular dysfunction, and anxiety.2 All patients with persistent vomiting should be assessed for electrolyte abnormalities.
Medication effects leading to nausea and vomiting predominantly occur as a result of opioid therapy for pain and chemotherapy for treatment of malignancy. D2 dopamine receptor antagonists, such as haloperidol and metoclopramide, and 5HT3 serotonin receptor antagonists, such as ondansetron, work well for both opioid- and chemotherapy-related nausea and vomiting. (See Table 3.)
Appropriate starting doses are 0.5 mg to 4 mg haloperidol PO every six hours, 5 mg to 20 mg PO/IV metoclopramide every six hours, and 4 mg to 8 mg ondansetron PO/IV every four to eight hours. The dose of metoclopramide should be renally adjusted in patients with chronic kidney disease.
Table 3. Starting Doses for Symptom Management in the Emergency Department: Nausea/Vomiting |
Nausea/Vomiting: Medication Effect
OR
Nausea/Vomiting: Infection
Nausea/Vomiting: Increased ICP
Nausea/Vomiting: Malignant Obstruction
OR
Nausea/Vomiting: Vestibular
OR
Nausea/Vomiting: Anxiety
OR
|
PO: orally; IV: intravenous; ICP: intracranial pressure; PR: per rectum |
If using intravenous haloperidol, use one-half of the starting oral dose.2 Avoid haloperidol and metoclopramide in patients with Parkinson’s disease, since these patients are more likely to develop dystonic reactions. If the patient develops a dystonic reaction, administer diphenhydramine 1 mg/kg IV (maximum dose 50 mg IV).
Systemic infections leading to nausea and vomiting should be treated with antibiotics to address the underlying source. Patients likely will need intravenous hydration to additionally support blood pressure. Ondansetron is the agent of choice for infectious or inflammatory processes at 4 mg to 8 mg ondansetron PO/IV every four to eight hours.2
Nausea and vomiting related to malignancy are caused by either the direct effect of tumor burden and increased intracranial pressure impinging on central vomiting centers or gastrointestinal obstructions. The central vomiting centers are located in the area postrema at the floor of the fourth ventricle in the medulla oblongata, which indicates either advanced primary brain tumor or metastatic disease.21
In the case of increased intracranial pressure or direct vomiting center impingement, administer 6 mg to 10 mg dexamethasone loading dose PO/IV with a maintenance dose of 2 mg to 4 mg dexamethasone PO/IV every six to 12 hours until evaluated by neurosurgery.2,21 When administering dexamethasone, obtain frequent blood glucose checks to monitor for hyperglycemia. For malignancy resulting in bowel obstruction, administer 100 mcg to 300 mcg octreotide subcutaneous or 10 mcg/hour to 40 mcg/hour octreotide infusion.2
Vestibular causes of nausea occur through the stimulation of the vestibulocochlear nerve via activity of acetylcholine at muscarinic acetylcholine receptors and histamine at H1 receptors.21 Administer 25 mg meclizine PO every six to eight hours for antimuscarinic effects.2 Consider 0.5 mg to 1.5 mg scopolamine transdermal patch every three days if the patient is unable to tolerate oral intake.2 Administer 25 mg to 50 mg diphenhydramine PO every four to six hours for antihistamine effects.2 The physician should monitor for confusion related to antihistamine and anticholinergic adverse effects from all sources, especially in elderly patients who may develop symptoms rapidly.8
As discussed earlier, a patient’s anxiety and panic can significantly exacerbate existing symptoms and should be treated with benzodiazepines, such as diazepam or lorazepam, along with the concomitant nausea and vomiting.17 Administer diazepam 0.05 mg/kg/dose to 0.2 mg/kg/dose PO/PR/IV every six hours with a maximum of 10 mg or lorazepam 0.03 mg/kg/dose to 0.05 mg/kg/dose PO/IV every six hours, with a maximum of 4 mg.2 Monitor patients for confusion and respiratory depression.
Constipation
Constipation is commonplace in patients with chronic illness, generally because of their opioid pain and dyspnea regimens. Constipation is uncomfortable and can lead to severe complications due to ileus, obstruction, and fecal impaction. Colonic distension and inflammation caused by these conditions may present as stercoral colitis, which in turn may lead to bowel ischemia, ulceration, and perforation. Therefore, when a patient presents for constipation or when starting opioid therapy, a patient should be placed on a regularly scheduled and as needed bowel regimen.22 Some patients may previously have been on a bowel regimen, so they may have insight about the most effective regimens for them.
Initial bowel regimens should include regularly scheduled stimulant and surface laxatives.22 (See Table 4.) Stimulant laxatives work by stimulating colonic nerve plexuses, increasing intestinal motility and secretions.23 Surface laxatives, also known as stool softeners, lubricate the stool by lowering stool surface tension, allowing water to penetrate deeper into stool, allowing it to pass more easily from the rectum.23 Administer two to three tabs senna every 12-24 hours as a stimulant laxative and 100 mg to 250 mg docusate every 12-24 hours as a surface laxative.2 Bisacodyl can be used as a stimulant laxative 5 mg to 15 mg PR as needed.2 Patients also should attempt to increase fiber in their diet or add bulk-forming laxative such as psyllium to retain water in the stool, which increases the weight and consistency.23
Table 4. Starting Doses for Symptom Management in the Emergency Department: Constipation |
Constipation, Initial Regimen
AND
Constipation, Refractory
OR
Constipation, Opioid-Induced
OR
|
PO: orally; IV: intravenous; ICP: intracranial pressure; PR: per rectum ; prn: as needed |
If a patient’s constipation is refractory to initial bowel regimens, osmotic laxatives may be used. Osmotic laxatives are poorly absorbed and bring fluid into the intestinal lumen.23 Administer 17 g polyethylene glycol in eight ounces of water every 24 hours.2 If constipation continues, administer a second or third dose daily. Magnesium citrate 120 mL to 240 mL daily is another effective osmotic laxative.24 Tap water enemas also may be used to soften and flush out stool, although these may be uncomfortable for patients.23
Peripherally activating mu-opioid receptor antagonists are useful agents to treat opioid-induced constipation. They selectively block mu-opioid receptors in the gastrointestinal tract, preserving enteric function without reducing opioid receptor activity in the central nervous system.23 Methylnaltrexone is the most common peripheral mu-opioid receptor antagonist and most well-tolerated. The starting oral dosage is 450 mg daily.23 Methylnaltrexone also is available in injection form if a patient is unable to tolerate oral medications; prescribe 12 mg subcutaneous injection daily.23 Patients do not automatically need to be prescribed these peripherally acting medications when being placed on opioid medications; rather, stimulant and surface laxatives still are first-line therapy.
Although laxatives are important adjuncts to hydration and dietary fiber and have a generally well-tolerated safety profile, they may present with adverse effects. Stimulant laxatives may cause abdominal cramping via intestinal stimulation. If not taken with adequate fluid intake, osmotic and bulk-forming laxatives may cause bloating. Osmotic agents additionally may lead to nausea, vomiting, and diarrhea because of the increased fluid in the intestines.
Benefits of Early Palliative Intervention
Chronic illness, especially when severe, accounts for a significant percentage of ED visits, especially in those during the last year of their lives. In a study of patients older than 65 years of age, 75% sought care in the ED in their last six months of life, with 51% receiving care in the last month of life.24
Expedited palliative care intervention allows for earlier transition from life-prolonging treatment to focusing on life-improving treatment, thus making patient quality of life better while also decreasing resource use. Patients who receive early palliative intervention are less likely to receive hospital or intensive care admission, have decreased length of stay when admitted to the hospital by approximately 50% to 75%, and increased use of hospice resources.4 Overall, early palliative intervention is shown to improve patient and family satisfaction while also reducing healthcare cost.
It is important to recognize that the physicians and medical staff caring for these chronically ill patients also incur a cost. In 2017, 65% of responding emergency medicine physicians reported burnout.4 This leads to depersonalization of patients and subsequent compassion fatigue. Through early palliative interventions, physicians help patients take control over their symptoms and place the person back into the heart of medicine.
Disposition of the Declining Patient from the Emergency Department
Disposition of any patient from the ED is always based on shared decision-making following a risk-benefit discussion. It depends primarily on whether symptoms have been adequately controlled in the ED and the resources the patient has in their outpatient living place. Generally, patients and families prefer to be at their normal place of living.25 The hospital is an unfamiliar place with unfamiliar caregivers, so it is unsurprising a patient would prefer to be in a place they know surrounded by the people they know.
If the patient is to be discharged, a referral to palliative care should be provided for an outpatient appointment, and all medications should be prescribed as PO/PR/SC.25 However, if symptoms are unable to be controlled with an outpatient regimen or the patient needs additional resources that will take time to obtain, the patient should be admitted to the hospital and continue to be evaluated by the palliative care team. When discharging patients in need of palliative or hospice care, use available clinical pathways in the electronic medical records to ensure the patient receives appropriate follow-up.
Hospice care is focused on medical care at the end of the patient’s life, generally within the anticipated last six months of life. Its goal is to focus on improving the quality of the end of a patient’s life and to provide support to their family members and caregivers. It requires the patient to have stopped all curative treatment, but it is important to stress to patients and family that care of pain and other symptoms will continue. Hospice care can be provided in the patient’s home, through the hospital, in a specialized hospice facility, or in a nursing home.26
Patients should receive a referral to hospice from the ED if they are being discharged and with a prognosis of less than six months. This often is when curative therapies no longer are of benefit to the patient or when the patient or their family has elected for comfort care. Palliative care consults do not need to be obtained prior to referral to hospice.26 ED case managers and social workers are able to enroll patients who have been referred by any physician.
Practical Implementation of ED-Palliative and ED-Hospice Pathways
Traditional patient entry into palliative care consists of consultation of in-patient palliative care teams made up of physicians, social workers, and case management or referral to outpatient palliative care practices. If a patient is unable to make an outpatient appointment, they may be admitted to the hospital just to establish care with a palliative care team. Palliative care consultation in the ED by a dedicated ED palliative team would facilitate patient entry into these services.
In a feasibility study running from August 2020 through April 2021, an ED-embedded palliative care consult service with a single physician was launched at a moderate-volume ED.27 Of the 565 palliative care consults by emergency physicians, 260 patients downgraded code status, 45 patients were not admitted to the intensive care unit (ICU), 51 patients avoided hospital admission altogether, and 73 patients were referred to hospice care, all without increased ED length of stay (LOS).27 Of the patients who were admitted, median hospital LOS decreased from 10.8 days to 3.3 days (70% reduction).27 Median direct costs decreased by 75%, saving approximately $13,000 per hospitalization.27
Another feasibility study introduced an electronic medical record pathway designed specifically to guide emergency physicians on which patients would be appropriate for hospice. Through the clinical pathway, more patients were identified as appropriate for hospice, with resultant increased consultation for hospice evaluation.28 The identified patients had a decreased median ED LOS of 2.9 hours.28 Of the identified patients who were admitted to the hospital, more were admitted to observation rather than inpatient status, and admission median LOS decreased by 18.4 hours.28
Emergent End-of-Life Care for the Actively Dying Patient
The primary goal with an actively dying patient is to relieve suffering and improve the quality of the patient’s dying process, both in reducing the burden of physical and emotional suffering on the patient and in reducing the emotional suffering felt by the family and physician caring for the patient.
It may be appropriate to pursue initial resuscitative efforts if the patient’s goals of care are not immediately apparent, since these efforts may be used to obtain time to speak with the patient or their representatives or review any advanced care documents.2 In addition, the emergency physician may need to obtain imaging and blood testing to fully understand the patient’s prognosis so that it may be communicated to the patient and their representatives.
The decision to initiate comfort care starts with the language the physician uses to introduce the patient’s transition to the dying process.2,4,26 A patient and their family need to be told clearly and gently that the patient is going to die and that the dying process is different for every person in terms of progression of symptoms. Comfort care should be introduced as a transition from focusing on quality of life to now ensuring the quality of a patient’s death.
The patient and their family should be assured of support throughout the process to avoid feelings of abandonment. The reaction to this by patients and their families varies and will have to be managed appropriately with gentle but clear explanations. Spiritual support, such as on-call chaplains or the patient’s own spiritual representative, also may be helpful to the patient and their family to understand and accept the dying process.29
Families should be encouraged to share stories among themselves and with the patient, bringing comfort to the patient and other members of the family. During this process, families will want to know what to expect; have empathetic communication between hospital staff, the patient, and the family; and have a space dedicated to the dying process.29 Ultimately, death is a unifying human experience, and we should not forget the humanization of the dying process in a world of medicine where so much is dictated by procedures and algorithms.
Symptoms should be managed aggressively to improve the patient’s quality of death, but the underlying causes do not need to be addressed at the end of the patient’s life. To ensure adequate treatment, reliable intravenous access should be obtained. Patients may experience decreased oral intake and increased secretions, pain, anxiety, delirium, and dysfunctions of the respiratory, cardiovascular, and nervous systems.2,30 Symptoms and treatments should be explained clearly to patients and families to reduce anxiety.
Patients may have decreased solid and liquid intake over the last several hours of their life. In a patient who has elected comfort care, there is no need for intravenous hydration, since the patient’s progressing dehydration and starvation lead to natural endorphin release.2 The symptoms of dehydration, such as dry mucous membranes, may be addressed by applying petroleum jelly or artificial saliva to soothe cracked lips.2 If applicable, patients should be allowed to pleasure feed as wanted. Patients also may develop an accumulation of fluids in the throat and upper airways, causing gurgling or the “death rattle.”2,30 This can be very distressing to families. Control secretions through antimuscarinic medication, such as glycopyrrolate 0.4 mg SC/IV every three hours or scopolamine 1 mg transdermal patch.2,26,30
At the end of life, patients are especially afraid of a painful death, and families often derive comfort from a death where the patient was seemingly at peace. Significant and frequent dosing of opioids, benzodiazepines, and antipsychotics helps to control pain, anxiety, and agitation. These medications should be scheduled and titrated to indications of discomfort: facial grimacing, agitation, moaning, writhing, tachycardia, and tachypnea.
For opioid medication, administer fentanyl 50 mcg to 100 mcg bolus for initial pain control, followed by either 2 mg to 4 mg morphine IV every 30-60 minutes or 1 mg to 2 mg hydromorphone IV every 30-60 minutes.2,26 Morphine metabolism is erratic in patients with renal disease; therefore, hydromorphone is the preferred agent in these patients. For benzodiazepines, administer 1 mg to 2 mg lorazepam IV every 15-30 minutes.2,22 For antipsychotics, administer 2.5 mg to 5 mg haloperidol every one to two hours.2,22 A transition to infusions rather than bolused medication may be advisable if frequent dosing is difficult with ED staffing levels.
These are strong dosages for opiates, benzodiazepines, and antipsychotics, and in the normal course of clinical care, might cause harm to a patient with adverse effects such as respiratory depression and death. However, because of the ethical principle of the doctrine of double effect, it is permissible to undertake this risk as a potential consequence of achieving the intended beneficial result, with the sole intention to adequately treat the patient’s pain and suffering.31
Ultimately, the patient will experience respiratory, cardiovascular, and neurologic dysfunction as their organs begin to fail. The patient’s breathing will become irregular and develop into agonal breathing. They may experience air hunger, which can be treated with the recommended dosage of opioid medications as discussed earlier. For the actively dying patient, opioid dosing can be rapidly titrated to patient comfort, and continuous opioid infusion should be considered early for refractory dyspnea. Oxygen therapy may prolong the dying process, and air hunger should instead be treated with medication.2
Patients may become more confused and disoriented, unable to follow commands, or verbalize incomprehensible speech. They may be unable to keep their eyes closed and so should be administered artificial tears.2 Agitation should be treated with haloperidol or lorazepam.2,26,30 These changes generally are more frightening for the patient’s family and should be explained prior to the patient developing symptoms. Frequent reassurance may be necessary as well.
As the patient’s cardiovascular system begins to fail, they will become cold, and their heart rate and oxygen saturation will begin to drop. The patient should be swathed in blankets and kept comfortable. The patient should be on a cardiac monitor, but the screen should be turned off in the room. Therefore, the patient can be monitored for the moment of death from outside the room, and the family can focus on the patient rather than the monitor. When the patient expires, the physician should enter the room, explain gently to the family that the patient has likely died, and perform a brief and respectful death exam to pronounce the patient.
At this time, it may be appropriate to offer bereavement resources to the family. Much of the current literature regarding bereavement resources from the ED are related to sudden pediatric deaths as opposed to patients at the end of their life due to chronic illness; however, similar principles apply. Offer to contact the family’s religious or spiritual leader.29 The family should be given the option to spend time with their deceased loved one prior to leaving the hospital.29 It may be appropriate to inquire if there is a preferred funeral home that the deceased patient’s body should be released to. Referral to outpatient bereavement support groups also may be helpful.
Palliative Sedation to Manage Refractory Symptoms at the End of Life
Many terminally ill patients experience a relatively uncomplicated dying process. However, some present with distressing symptoms that are refractory to the interventions recommended earlier. When all appropriate therapies have been exhausted and the patient continues to experience intolerable suffering in the terminal phase of dying, palliative sedation may be indicated.
Palliative sedation involves the intentional reduction of consciousness to relieve intractable, unbearable symptoms and is distinct from brief or intermittent sedation used for agitation or procedures.32 Importantly, its intent is symptom control — not to hasten death — differentiating it ethically and legally from euthanasia or physician-assisted suicide.31,32
If palliative sedation is to be initiated in the ED, it should be done only in consultation with palliative care specialists. Symptoms must be deemed unmanageable with available treatments or associated with unacceptable risks or time frames, since palliative sedation truly is an intervention of last resort. A careful conversation regarding risks and benefits should be undertaken with patients and their families, citing the benefit of symptom management against the loss of social interaction with family.
Midazolam is an appropriate first-line sedation agent but may require dose escalations as tolerance occurs.32 A paradoxical excitation reaction is possible but rare, with approximately 2% occurrence.32 Phenobarbital should be used when benzodiazepines no longer are effective in controlling agitation; however, it requires individualized dosing because of variable metabolism.32 Propofol is the sedating agent of last resort because of a high chance of apnea when dosed at appropriate levels for deep sedation.32
If initiating palliative sedation and the patient is not imminently dying, the patient should be admitted to an inpatient palliative care unit, since caregivers outside these units may not be comfortable with monitoring a patient with this level of sedation. Or alternatively admit to the ICU if the hospital does not have a unit dedicated to palliative care. Monitoring should focus on comfort and safety, initially with 20-minute checks until adequate sedation is achieved, then reduced to three checks daily.32 Adequate sedation is a -3 or -4 on the Richmond Agitation-Sedation Scale, which is commonly used for palliative care although not validated for its use.32 In addition, patients under palliative sedation are fully dependent and often will require more nursing care than the ED can provide.
Healthcare providers, especially nurses, report moral and emotional distress related to palliative sedation, often because of confusion about its definition and ethical boundaries.32 Clearly communicating that the intent is symptom relief as opposed to physician-assisted suicide or a desire to hasten the patient’s death may mitigate this.
Overall, palliative sedation is a carefully considered intervention for terminal suffering, requiring individualized medication use, ethical sensitivity, close monitoring, and strong communication with both families and healthcare providers.
Case Conclusion
The supraglottic airway is removed. At 12:27, the patient receives an additional 200 mcg of IO fentanyl. At 12:47, the patient receives another 200 mcg fentanyl IO and 1 mg lorazepam IO. During this time, the patient has become increasingly tachycardic and tachypneic, with continued agonal respirations, indicating agitation.
The patient’s husband, daughter, and other family members arrive in the ED and are prepared in the family conference area. The patient’s clinical condition and imaging are reviewed in additional detail and all questions are answered to the family’s satisfaction. They are specifically prepared regarding the patient’s agonal respirations. Clinicians discussed the purpose of the comfort care medications: to aggressively treat pain from her ongoing intracerebral hemorrhage, nausea, secretions, and anxiety/agitation resulting from dyspnea and air hunger. They are then brought to the patient’s room to be present with the patient during her dying process.
Over the next hour, the patient is administered an additional 3 mg lorazepam IO, 0.5 mg haloperidol IO, and 25 mcg fentanyl IO. Despite these medications, the patient’s heart rate and respiratory rate remain elevated, indicating ongoing agitation and increased sympathetic drive, probably due to continued herniation. Thus, there is a need for increased frequency and potency of comfort care medication dosing. Over the next 90 minutes, a total of 8 mg lorazepam IO, 5 mg hydromorphone IO, 6 mg haloperidol IO are administered, with approximately 30 minutes between dosing. An additional 0.2 mg glycopyrrolate IO is given for increased secretions during this time. Also, during this time, family members are offered admission to the hospital for continued comfort care management; however, they decline because of concerns the patient would expire during transport to another location within the hospital, away from family.
The patient continues to exhibit increased sympathetic drive with tachycardia and tachypnea. She continues to maintain agonal respirations. Her oxygen saturation by this time has decreased to 60% to 70% on room air. An intravenous line is placed because of concern of IO line infiltration to ensure successful delivery of comfort care medication. The patient is placed on a continuous hydromorphone infusion at 10 mg/hour in conjunction with palliative care input to provide continuous pain relief and to reduce burden of frequent medication injections on nursing staff. Thirty minutes later, the patient is given a phenobarbital infusion of 20 mg/kg for refractory terminal agitation. The patient expires and is pronounced dead at 17:39, surrounded by family members.
Conclusion
Emergency physicians play a critical role in recognizing the need for and initiating early palliative care interventions, often at the most pivotal moments in a patient’s illness. By addressing symptoms such as dyspnea, pain, nausea, and constipation early and effectively, and by guiding conversations around goals of care, emergency providers can greatly enhance the quality of life for patients with serious or terminal illnesses. Understanding the distinction between palliative and hospice care allows for more appropriate and compassionate medical decisions, particularly at the end of life. Timely initiation of comfort-focused treatment in the ED not only alleviates suffering but also supports families through the emotional challenges of losing a loved one, ultimately promoting a more dignified and peaceful death.
Guhan Rammohan, MD, is Assistant Chief, Emergency Medicine/Critical Care Faculty, St. Luke’s University Health Network, Bethlehem, PA.
Alexander Kaunzinger, DO, is an emergency medicine resident, St. Luke’s Bethlehem Emergency Medicine Residency, Bethlehem, PA.
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Emergency physicians play a critical role in recognizing the need for and initiating early palliative care interventions, often at the most pivotal moments in a patient’s illness. By addressing symptoms such as dyspnea, pain, nausea, and constipation early and effectively, and by guiding conversations around goals of care, emergency providers can greatly enhance the quality of life for patients with serious or terminal illnesses.
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