3.4 (3.3) Palliative Care in the emergency department Flashcards
Palliative patients frequently present to the ED. List two tools for assessing the palliative needs of these patients and define the populations they should be used for
- Initial screen for palliative care needs in stable patients, the Screen for Palliative and End of Life Care Needs in the Emergency Department (SPEED) assessment tool.
- 13-question assessment tool
- addresses five major domains of palliative care needs: physical, therapeutic, psychological, social, and spiritual - ABCD’, which was developed to assist in the approach to patients in critical condition
- P-CaRES (Palliative care and Rapid Emergency Screening) - rapidly identifies patients with unmet pall care needs, and for early referral for inpatient pall care consultation. *This tool includes ALL pall care patients, not only cancer dx. (SEE Fig. 3.4.2)
What are the five domains assessed by the SPEED tool
addresses five major domains of palliative care needs: physical, therapeutic, psychological, social, and spiritual
Describe the four elements of the ABCD tool
A Advance directive: Check available records or reports from paramedics or family
B Better symptom control: Attend to symptoms while avoiding invasive interventions to allow time to evaluate whether more invasive interventions would achieve intended goals
C Caregivers: Provide reassurance to patient, contextualize patient goals and recent functional and medical changes to foster reasonable discussion of medical decision-making.
D Decision-making capacity: Assess patient’s ability to reliably engage in dialogue about medical goals and interventions.
Palliative patients may present to the hospital with a cancer pain emergency and severe pain. What is a proven technique for managing this and list 3 reasons that barriers to optimal pain control in the ED exist
Barriers - lack of training, inadequate assessment, misinterpretation of reasons for seeking care, and disparities in treatment practices among clinicians
- Assessing severity of malignant pain using a standardized pain scale
- Severe pain in malignancy has been referred to as a ‘cancer pain emergency’ and rapid titration of parenteral opioids has been demonstrated to provide effective and safe control of pain while concurrently addressing other diagnostic concerns
Tools to enhance communication in the ED have proven effective for what three common palliative clinical scenarios in the ED
A structured approach can be used to address three important scenarios in the emergency department:
(1) rapidly establishing goals of care
(2) death disclosure
(3) family presence during cardiopulmonary resuscitation (CPR) (if it is assessed as appropriate to initiate CPR)
A patient comes into the ER and a GOC discussion is required. After obtaining background info and taking the family into an appropriate space, what six steps should be taken to establish GOC?
- getting started - start by acquiring sufficient information and limiting environmental distractions in order to conduct the meeting effectively
- assess what is known
- explore expectations and hopes
- suggest goals
- make a recommendation
- confirm understanding
- Make a plan
A patient comes into the ED and dies of cardiac arrest. The family arrives in the ER after 30 min. After meeting them at the door and taking them to a private space, what 8 steps should be taken to disclose the death?
- Preparation - greet at door, move to private space
- Engagement - initial introductions must state the full name of the patient and all involved staff, while unequivocally identifying the primary survivor and the relationship to the patient, sit down close to this person
- Transition - preferred opening communication to a sudden death in the emergency department is to provide information about the immediate circumstances prior to the patient’s death.
- Dead or died - euphemisms be avoided at this stage, use clear direct language
- Reaction tolerance - Understanding and engaging empathic responses
- Information - surviving family hopes for a lack of suffering, speak about pain control etc, gather information about patient’s history if relevant to explain death
- Viewing
- Conclusion - clinician should offer condolences and provide contact information for any additional questions
- Self and staff care - Staff should consider a routine debriefing just after the death disclosure
What four steps are common to all death disclosure models?
◆ attending to survivors on arrival to the emergency department
◆ unequivocal communication of the death
◆ allowing for and reflecting on the emotional response
◆ offering survivors to view the body of the deceased
After disclosing to Elaine that her husband died in the ED from a malignancy associated PE, she becomes very angry. What five steps can be taken to create space for this situation?
◆ Acknowledge:
• ‘This is not what you were expecting.’
• ‘You seem angry.’
◆ Legitimize:
• ‘Many people in this situation would feel angry.’
◆ Explore:
• ‘Can you tell me what you are most concerned about right now?’
◆ Empathize:
• ‘I wish the news were better.’
◆ Commit:
• ‘I will make sure we have a good plan in place before you leave today.’
A patient presents to the ED with a massive GI bleed and resuscitation is initiated. The family members arrive in the ED. After the assigned staff person brings them to the resuscitation bay outline 9 steps you would take to communicate with them during the resuscitation
Step 1: Introduction - the family support person should introduce the family members. The resuscitation team leader should then introduce themselves as “doctor responsible for the care of your ___”
Step 2: Status - Either the resuscitation team leader or a delegate reviews the situation and current status in clear and concise terms
Step 3: Prognosis - Given the high likelihood of death in cardiac arrest, it is prudent to warn the family members of the seriousness of the situation
Step 4: Plan - State the plan of further care, such as, ‘We are giving him powerful medications and electricity to try to restart his heart’.
Step 5: Provide - Provide standard resuscitation as indicated by the situation
Step 6: Review - A. Return of spontaneous circulation: provide a quick summary of the events leading to return of spontaneous circulation and plan
B: No return of spontaneous circulation - provide a brief summary to serve as a warning communication, review steps taken, review recommendations: while continuing resuscitative efforts, the team leader may consider asking for any other recommendations from other team members. This establishes team concordance and assures that all reasonable medical efforts have been performed to the level of comfort of the entire team, as witnessed by the family, transition, pronouncement, condolences
Step 7: Acknowledge - acknowledge with gratitude the difficulty of the event, the skill of the staff, and effort put forth to attempt to save the life of the patient
Step 8: Inform - Either offer to inform the remaining family independently, or offer to bring the family members in the room to the others to inform them of the patient’s death
Step 9: Self and Staff care - Debriefing after attempts at resuscitation is an excellent method of assuring that all concerns about the resuscitation are addressed.
Elaine is watching her husband receive CPR in the ER. After thirty minutes there is no ROSC. What six steps will you take to communicate this and manage the actions of the team?
Provide a brief summary to serve as a warning communication
Review steps taken during resuscitation so far
Review recommendations: while continuing resuscitative efforts, the team leader may consider asking for any other recommendations from other team members. This establishes team concordance and assures that all reasonable medical efforts have been performed to the level of comfort of the entire team, as witnessed by the family
Transition - in a firm but compassionate manner, prepare the family members for the discontinuation of resuscitation
Pronouncement
Condolences
