Palliative Aspects of Emergency Care

Edited by Paul L. DeSandre and Tammie E. Quest

Oxford American Palliative Care Library

The first resource for managing the complex needs of palliative care patients presenting to emergency departments
Concise and practical guidance to promote best practices at time of care
Incorporates the collaborative efforts of multiple national projects in Emergency Medicine to improve care of palliative patients

Palliative Aspects of Emergency Care

Edited by Paul L. DeSandre and Tammie E. Quest

Oxford American Palliative Care Library

Description

The process of patients with advanced illnesses entering the emergency department is fraught with uncertainty for both patients and medical providers. Yet, there is a lack of definitive and accessible resources which provide immediate guidance for the care of these patients. Palliative Care in the Emergency Care is a practical guide designed to fill this void. From the paramedic struggling with difficult and/or conflicting information in the home through the palliative care specialist trying to interface effectively with the emergency department, this user-friendly handbook offers practical help from experts in the interdependent fields of Emergency Medicine and Hospice and Palliative Medicine. This evidenced-based book covers the prognostication and assessment of relevant, advanced-illness clinical problems, the management of symptoms, and the physical and spiritual treatment of palliative patients in the emergency department through their last hours of living. Also included are chapters focusing on hospice care, communication techniques, and the legal and ethical issues of palliative care in the emergency department. This guide is a must-have resource for clinicians looking for concise, point-of-care information, and for hospital administrators working to address palliative care needs in emergency departments through best practice recommendations.

Palliative Aspects of Emergency Care

Edited by Paul L. DeSandre and Tammie E. Quest

Oxford American Palliative Care Library

Chapter 1: Overview
Chapter 2: Trajectories and Prognostication in Emergency Care
· Emergency Department and Functional Trajectories
· Prognostication and Prognostic Tools
o Cancer
o Heart Failure
o Chronic Obstructive Pulmonary Disease
o Dementia
· Communicating the Prognosis
· Creating a Plan of Action
Chapter 3: Rapid Palliative Care Assessment
· The Critically Ill or Unstable Patient
· The Medically Stable Patient
Chapter 4: Cancer Emergencies
· Spinal Cord Compression
o Pathophysiology
o Epidemiology
o Signs and Symptoms
o Diagnosis
o Interventions
§ Corticosteroids
§ Radiation Therapy
§ Surgery
§ Bisphosphonates
· Superior Vena Cava Syndrome
o Pathophysiology
o Etiology
o Signs and Symptoms
o Diagnosis
o Interventions
§ Radiation Therapy and Chemotherapy
§ Endovascular Stenting
o Prognosis
· Hypercalcemia of Malignancy
o Pathophysiology
o Interventions
Chapter 5: Malignant Pain
· The Cancer Pain Emergency
· The Emergent Pain Assessment
o Pain scales
o Classification
o Opioid naïve and opioid tolerant
· Pharmacologic Management
o Choosing an Algorithm
o Using Equianalgesic dosing tables
o Calculating the Initial Dose of an Opioid
o Advanced Age, Renal Impairment, and Hepatic Impairment
o Routes of Administration and Pharmacokinetics
o Pain Reassessment after Treatment
o Opioid Side Effects and Toxicities
§ Sedation and Respiratory Depression
§ Nausea and Vomiting
§ Myoclonus
§ Constipation
· Confrontation of Barriers
· Methadone
· Non-Opioid Pharmacologic Management
o Neuropathic Pain
o Bone Pain
o Other Approaches
Chapter 6: Non-malignant Pain
· Pain Pathophysiology
· Physiologic and Clinical Differences between Acute and Chronic Pain
· Definitions
o Tolerance
o Physical dependence
o Addiction
o Pseudoaddiction
· General Principles for Managing Chronic Pain
· Policies Informing Emergency Department Management of Chronic Pain
· An Emergency Department Approach to Managing Chronic Pain
Chapter 7: Symptom Management
· Dyspnea
o Pharmacologic approaches
§ Oxygen
§ Opioids
§ Anxiolytics
o Complementary and Non-Pharmacologic Approaches
· Delirium
· Anxiety
· Fatigue and Weakness
· Insomnia
· Fluid Balance and Edema
· Nausea and Vomiting
· Constipation
· Diarrhea
Chapter 8: Spiritual Suffering and Bereavement
· Definitions
· Grief: Normal and Complicated
· Spiritual Needs in the Emergency Department
o Role of the Clinician
o Role of the Chaplain
· Rapid Spiritual Assessment
· Responding to Hoping for a Miracle.
Chapter 9: Communication
· Breaking Bad News
· Death Disclosure
· Special Considerations
o Culture
o Requests to Withhold Information
o Telephone Notification
o No Next of Kin Available
o Communicating with Children
· Death of a Child
o Sudden Infant Death Syndrome
o Miscarriage or Stillbirth
· Self-Care and the Care of Other Emergency Department Staff
Chapter 10: Resuscitation, Family Presence, and Last Hours of Living
· Cardiopulmonary Resuscitation and Prognosis in Advanced Illness
· Family Presence During Resuscitation
· Witholding or Withdrawing Interventions
o CPR
o Intubation and Artificial Ventilation
o Artificial Nutrition and Hydration
o Antibiotics
· Care of the Actively Dying Patient
o Environment
o Symptom Control
o Secretions
o Dry Mouth
o Agitation
o Opioid Toxicity
Chapter 11: Hospice
· Understanding Hospice Care
o Eligibility
o Underutilization
o Scope of Services and Reimbursement
o Discontinuing Hospice Care
· Emergency Department Management of Patients under Hospice Care
· Common Presentations
· Initiating New Hospice Referrals from the Emergency Department
Chapter 12: Legal and Ethical Issues of Palliative Care in the Emergency Department
· The Interrelation of Law, Ethics, and End-of-Life Care
· Informed Consent
· Limitation of Treatment
· Determination of Decision-Making Capacity
· Decision-Making for the Incapacitated
· DNR Orders and Physician Orders for Life-Sustaining Treatments
· Opioids and End-of-Life Care
· Suicide and Physician-Assisted Suicide
· Futility

Palliative Aspects of Emergency Care

Edited by Paul L. DeSandre and Tammie E. Quest

Oxford American Palliative Care Library

Author Information

Edited by Paul L. DeSandre, Assistant Professor, Emergency Medicine; Assistant Chief, Section of Palliative Care - Atlanta VAMC, U.S. Department of Veterans Affairs Medical Center; Emory University School of Medicine, USA, and Tammie E. Quest, Roxann Arnold Professor in Palliative Medicine; Director, Emory Palliative Care Center; Associate Professor, Emergency Medicine; Chief, Section of Palliative Care - Atlanta VAMC, U.S. Department of Veterans Affairs Medical Center; Emory University School of Medicine, USA

Assistant Professor, Department of Emergency Medicine and Center for Palliative Care; Associate Fellowship Director, Hospice and Palliative Medicine, Emory University School of Medicine, Atlanta, Georgia

Contributors:

Jean Abbott, MD, MH
Attending Physician, Anschutz Medical Center
and
Professor Emerita, Emergency Medicine &
Faculty, Center for Bioethics and Humanities
University of Colorado School of Medicine
Aurora, Colorado

Eric Bryant, MD
Department of Emergency Medicine
Exempla Saint Joseph Hospital
Denver, Colorado

Garrett Chan, PhD, APRN, FAEN, FPCN, FAAN
Associate Adjunct Professor Department of Physiological Nursing
University of California, San Francisco
and
Lead Advanced Practice Nurse & Associate Clinical Director Clinical Decision Unit
Stanford Hospital & Clinics
Stanford, California

Arthur R. Derse, MD, JD, FACEP
Director, Center for Bioethics and Medical Humanities
Julia and David Uihlein Professor of Medical Humanities
Professor of Bioethics and Emergency Medicine
Institute for Health and Society
Medical College of Wisconsin
Milwaukee, Wisconsin

Paul L. DeSandre, D.O.
U.S. Department of Veterans Affairs Medical Center
Assistant Professor, Emergency Medicine
Assistant Chief, Section of Palliative Care - Atlanta VAMC
Emory Palliative Care Center
Emory University
Atlanta, Georgia

Kirsten G. Engel, MD
Research Assistant Professor
Department of Emergency Medicine
Northwestern University
Chicago, Illinois

Sangeeta Lamba MD
Associate Professor of Emergency Medicine and Surgery
Director of Medical Education
Director of Palliative Care
Department of Emergency Medicine
University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Newark, New Jersey

Ryan Paterson, MD
Associate Professor, Emergency Medicine
University of Colorado, Denver - Health Science Center,
Denver Health and Hospital
Denver, Colorado

Jan M. Shoenberger, MD
Associate Professor of Clinical Emergency Medicine
Keck School of Medicine of the University of Southern California
Residency Director, Emergency Medicine
Los Angeles County + USC Medical Center
Los Angeles, California

Susan C. Stone, MD, MPH
Clinical Associate Professor of Medicine
David Geffen School of Medicine, UCLA
Director of Home Visits and Outpatient Palliative Care, Region 2
Health Care Partners
Los Angeles, California

Jessica Stetz, MD, MS
Department of Emergency Medicine
Assistant Professor of Emergency Medicine
SUNY Downstate Medical Center / Kings County Hospital Center
Brooklyn, New York

Audrey Tan, DO
Chief Resident, Department of Emergency Medicine
SUNY Downstate Medical Center / Kings County Hospital Center
Brooklyn, New York

Lynne M. Yancey, MD, FACEP
Associate Professor, Department of Emergency Medicine
University of Colorado School of Medicine
Denver Health Residency in Emergency Medicine
Denver, Colorado

Palliative Aspects of Emergency Care

Edited by Paul L. DeSandre and Tammie E. Quest

Oxford American Palliative Care Library

Reviews and Awards

"This is the only book of its kind, and fills a critical need" - Doody's Notes

"It was a pleasure to read this book, which taught me a number of things. There is a move afoot (at least in the USA) to allow trainees in Emergency Medicine to also train in Palliative Medicine, allowing the caring of the latter to be mixed with the technological expertise of the former, and probably unthinkable 25 years ago. As outlined in this book, there is a push for more appropriate treatment (in terms of holistic palliative medicine) for patients with life-limiting disease, as well as identifying the much larger number of patients who present to the ED who are in need of/eligible for palliative care services. This all sounded like good news to me... Hopefully this book will be a useful resource and inspiration for people who work in ED. I would also recommend it to trainees in palliative medicine, as it provides a good picture of what is happening on the other side of the wall." - Roger Woodruff for IAHPC News, July 2013

"From the paramedic struggling with difficult and/or conflicting information in the home through the palliative care specialist trying to interface effectively with the emergency department, this user-friendly handbook offers practical help from experts in the interdependent fields of Emergency Medicine and Hospice and Palliative Medicine... This guide is a must-have resource for clinicians looking for concise, point-of-care information, and for hospital administrators working to address palliative care needs in emergency departments through best practice recommendations." - Anticancer Research, August 2013