End of life care
Why is this important?
- Patients in the last two months of life are frequents visitors to the ED;
- Such patients can receive futile care;
- Time in the ED and in the hospital can cause distress for the patient, their relatives and the health care providers;
- Consider which of the patient’s complaints are incurable and which are reversible and treatable;
- Focus on palliative care: improve substantially quality of life and satisfaction;
- From saving life to providing comfort.
How can we recognise “End Of Life Care” patients?
Patients with rapidly progressing incurable disease (e.g. metastatic cancer), frequent organ failure (e.g. heart failure or COPD exacerbations) or severely frail and bed-bound.
Four main trajectories
- Sudden death: cardiac arrest, stroke, ruptured aortic aneurysm
- 7% of deaths
- Mostly asystole and pulseless electrical activity
- Success of CPR is very low
- Terminal illness: cancer
- 22% of deaths
- Determine goals of care following oncological guidelines
- Organ failure: heart failure, COPD, liver failure
- 16% of deaths
- Patients with heart failure or COPD exacerbations are frequent visitors of the ED
- Frailty: dementia, Parkinson’s disease
- 47% of deaths
- Patients referred from long-term-care facility or functional poor status
What can we do?
- Ask the patient whether he/she has established his/her goals of care with the General Practitioner or organ/hospital specialist. If not: initiate such a discussion. Use positive language about need for comfort care. Use optimally an opportunity of relatively compensated state of the patient.
- Treat pain: Opioids are the main tool (Find out any previous use of opioids!).
- Treat dyspnea Rule out for reversible causes like pleural effusion, fluid overload or anemia. Symptomatic relief with oxygen, opioids and/or benzodiazepines.
- Treat nausea and vomiting: Identify any reversible causes like constipation or side effects of medication.
- Treat anxiety or delirium: Explore possible causes (e.g. urinary retention, faecal impaction or pain). Benzodiazepines or antipsychotics like haloperidol can be used. See also “Delirium and Cognitive Impairment” poster.
GOAL: Prioritize patient comfort by managing their symptoms
Treatment of nausea and vomiting
| Cause | Drug |
|---|---|
| Anxiety | benzodiazepines |
| Bowel obstruction | octreotide, draining nasogastric tube |
| Increased intracranial pressure | dexamethasone |
| Malignancy including side effects of chemotherapy | ondansetron |
| Opioid-induced | dopamine antagonists |
| Vestibular irritation | antihistamines/anticholinergics |
Toolbox
- British Geriatrics Society: “End of Life Care in Frailty: Urgent care needs”
- European Recommendation of End-of-Life care for Adults in Departments of Emergency Medicine
Information
This education material was developed by the European Task Force for Geriatric Emergency Medicine, which is a collaboration between the European Society for Emergency Medicine (EUSEM) and the European Geriatric Medicine Society (EuGMS). For more information, please visit: geriEMEurope.eu and follow us on Twitter: @geriEMEurope.
References
- You JJ, Fowler RA, Heyland DK. Just ask: discussing goals of care with patients in hospital with serious illness. Can Med Assoc J. 2014 Apr 1;186(6):425 LP – 432.
- Mierendorf SM, Gidvani V. Palliative Care in the Emergency Department. Perm J. 2014;18(2):77–85.
- Rosenberg M, Lamba S, Misra S. Palliative Medicine and Geriatric Emergency Care: Challenges, Opportunities, and Basic Principles. Clin Geriatr Med. 2013 Feb 1;29(1):1–29.
- Lunney JR, Lynn J, Hogan C. Profiles of Older Medicare Decedents. J Am Geriatr Soc. 2002 Jun 1;50(6):1108–12.
- Grewal K, Helman A. Episode 70 End of Life Care in Emergency Medicine. Emergency Medicine Cases. 2015.